Rami D. Sherif

An Evidence-based Approach to Nonsynostotic Plagiocephaly

This article provides an evidence-based review of the literature concerning the cause, diagnosis, manifestations, and treatment of nonsynostotic plagiocephaly, with a particular focus on recently published studies of helmet therapy. It is designed to serve as an overview of this very common abnormality and a stimulus for discussion about management paradigms and future research priorities.

Use of antibiotic beads to salvage infected breast implants

PURPOSE When an implant becomes infected, implant salvage is often performed where the implant is removed, capsulectomy is performed, and a new implant is inserted. The patient is discharged with a PICC line and 6-8 weeks of intravenous (IV) antibiotics. This method has variable success and subjects the patient to long-term systemic antibiotics. In the 1960s, the use of antibiotic-impregnated beads for the treatment of chronic osteomyelitis was described. These beads deliver antibiotic directly to the site of the infection, thereby eliminating the complications of systemic IV antibiotics. This study aimed to present a case series illustrating the use of STIMULAN calcium sulfate beads loaded with vancomycin and tobramycin to increase the rate of salvage of the infected implant and forgo IV antibiotics. METHODS A retrospective analysis was performed of patients who were treated at Mount Sinai Hospital for implant infection with salvage and antibiotic beads. RESULTS Twelve patients were identified, 10 of whom had breast cancer. Comorbidities included hypertension, smoking, and immunocompromised status. Infections were noted anywhere from 5 days to 8 years postoperatively. Salvage was successful in 9 out of the 12 infected implants using antibiotic bead therapy without home IV antibiotics. CONCLUSIONS The use of antibiotic beads is promising for salvaging infected breast implants without IV antibiotics. Seventy-five percent of the implants were successfully salvaged. Of the three patients who had unsalvageable implants, one was infected with antibiotic-resistant Rhodococcus that was refractory to bead therapy and one was noncompliant with postoperative instructions.

Use of both antegrade and retrograde internal mammary vessels in the bipedicled deep inferior epigastric perforator flap for unilateral breast reconstruction

BACKGROUND Autologous abdominal tissue transfer is a well-established method of breast reconstruction. The deep inferior epigastric perforator (DIEP) flap has the additional benefit of minimal donor site morbidity as it spares the muscle and fascia. Conventional DIEP flaps may not provide adequate volume in cases where the patient is thin, has midline abdominal scars, and/or has a large volume of tissue to replace. One solution is to use a bipedicled DIEP flap, incorporating all the available abdominal tissue. Bipedicled DIEP flaps have been described in a number of different configurations. The literature appears to favor intra-flap anastomosis, with a minimal exposition of two recipient vessels. It has been demonstrated that both the antegrade internal mammary artery (aIMA) and retrograde internal mammary artery (rIMA) are adequate recipient vessels. Here, the authors present a single-center experience with bipedicled DIEP flaps to both the aIMA and rIMA, showing their feasibility and safety. METHODS A retrospective review of patients who underwent unilateral breast reconstruction using bipedicled DIEP flaps was performed to assess outcomes. RESULTS A total of 20 patients who underwent unilateral breast reconstruction using a bipedicled DIEP flap were selected for this study. All of them were previously diagnosed with cancer. There were zero flap failure and zero instance of abdominal hernia or issue with abdominal wall functionality following the surgeries. CONCLUSIONS The series of surgeries described in this study resulted in successful breast reconstruction in 20 women using a bipedicled DIEP flap. The results show that this approach allows for reconstruction in places where a conventional DIEP does not provide adequate volume, achieved safely, and does not increase morbidity. The bipedicled DIEP flap is a viable option for large-volume autologous breast reconstruction, providing ample tissue for successful reconstruction while also allowing for shorter recovery and limited donor site morbidity.

Lingual Pressure During Dingman-Assisted Cleft Palate Repair: An Investigatory Case Series

Background: A variety of palatoplasty techniques are used for cleft palate repair, almost all involving a device called the Dingman-Grabb mouth gag (“Dingman”) to push the tongue and cheeks out of the way of the operating field. There have been numerous case reports of complications hypothesized to be due to the gag, such as lingual edema and airway obstruction. The purpose of this study is to introduce a technique for monitoring lingual pressure during Dingman-assisted palatoplasty and present preliminary data from a small series. Methods: Patients with a cleft palate who underwent palatoplasty with the assistance of a Dingman-Grabb retractor at the Mount Sinai Hospital were eligible. Patients underwent a palatoplasty while having their lingual pressure monitored using a 23-gauge needle inserted into the tongue and connected to a pressure monitor. Results: Three patients were included. Patients 1 and 2 experienced a rapid rise in lingual pressure over the course of the first 45 minutes of the palatoplasty before plateauing until the conclusion of the operation when the Dingman was released. Patient 3 plateaued almost immediately by minute 1 and then had a rise in lingual pressure during the latter half of the operation, reaching a peak pressure immediately before the end of the operation. Conclusions: The present study describes an easy method to monitor lingual pressure that succeeded in measuring such changes throughout 3 palatoplasties and confirming the acute rise in lingual pressure and the potential danger posed to the tongue and the airway through the use of the Dingman.

Abstract: The Use of Antibiotic Beads to Salvage the Infected Breast Implant

INTRODUCTION: Tissue expander(TE) and implant infection is the most common cause of surgical readmission following breast reconstruction. The goals of this study are (1) to characterize a cohort of patients who were treated with IV antibiotics for suspected infection after prosthetic breast reconstruction, (2) to identify local microbiome and (3) elucidate an optimal antibiotic treatment protocol (4) to identify risk factors for explantation.

Sweet Syndrome After Bilateral Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Case Report

Abstract We describe a case of Sweets Syndrome after bilateral deep inferior epigastric perforator flap breast reconstruction in a patient with ductal carcinoma of the left breast.

Reconstructive Surgery in Times of Conflict.

Background:Smile Train is a charitable organization that partners with and trains surgeons in developing countries to provide surgical care to patients with cleft lip/palate deformities. The organization supports surgeries in several countries that experience high levels of regional conflict and violence. Nigeria, a country where Smile Train is very active, has undergone numerous periods of extreme violence over the past 12 years. The purpose of the present study is to analyze how local violence and conflict have impacted the ability of surgeons partnered with Smile Train to provide care in Nigeria. Methods:The authors retrospectively reviewed Smile Train Express, the organizations database, from 2003 to 2015 for cleft lip/palate repairs performed in Nigeria. The data was chronologically mapped against a detailed timeline of incidents of violence in Nigeria to compare how violence affected the work of Smile Train-affiliated surgeons. Results:Smile Train-affiliates facilitated 11,499 surgeries in Nigeria from 2003 to 2015. During the same period, 46,370 people were killed in Nigeria in acts of terrorism and violence. Major drops in the frequency of cleft surgeries were preceded by spikes in violence. Conclusions:Violence in Nigeria has had a clear impact on the ability of Smile Train-affiliated surgeons to provide adequate cleft care. The international medical community needs to take steps in an attempt to continue to provide essential medical care in areas of conflict and instability.

Treatment of large calvarial defects with bone transport osteogenesis: a preclinical sheep model.

Background Bone transport osteogenesis (BTO), distraction of a free portion of bone across a defect, offers an autologous solution to large cranial defects that may allow treatment without permanent hardware implantation. This study establishes a sheep model to evaluate the feasibility and distraction kinetics of BTO. Methods Subtotal cranial defects (3.5 × 3.5 cm) were created in 10 young adult sheep and a transport segment (3.5 × 2 cm) traversed the defect at varying distraction rates (0, 0.5, 1.0, and 1.5 mm/day) using semi-buried cranial distractors. After a 6-week consolidation period, sheep were euthanized and the resultant bone was analyzed by CT, histology, and mechanical testing. Results Gross examination, histology, and 3D CT revealed that control animals had fibrous nonunion whereas distraction animals had ossified defects with fibrous nonunion at the distal docking site. There was one premature consolidation in the 0.5 mm/day group. The volume of bony regenerate in the 0.5, 1.0, and 1.5 mm/day distraction rate groups was statistically indistinct (P = 0.16). The mean flexural moduli (MPa) of non-decalcified samples from the control cranium, transport segment, and bone regenerate were found to be 4.50 ± 4.9, 6.17 ± 2.1, and 4.14 ± 4.8, respectively (P = 0.24). Conclusions This experiment provides proof of concept for BTO for large calvarial defects in a sheep model. Distraction at a rate of 0.5 mm per day may place individuals at higher risk for premature consolidation, but distraction rates did not have significant effects on regenerate quantity or quality. Future work will include the use of curvilinear distraction devices for 3-dimensional contour.