Publications (47)87.15 Total impact
- [Show abstract] [Hide abstract] ABSTRACT: Objectives: Dalbavancin, a semi-synthetic lipoglycopeptide, is characterized by a long plasma half-life, which allows weekly dosing. Dalbavancin may be a good treatment option for patients with deep sternal wound infections owing to its improved pharmacokinetic profile and antibacterial activity compared with currently used antibiotics. Here we evaluated the efficacy of 7 or 14 days of treatment with dalbavancin, compared with vancomycin and with saline, in reducing sternal bone MRSA counts in a rat Staphylococcus aureus deep sternal wound infection model. Methods: A mid-sternal wound was surgically induced in anaesthetized rats. A clinical strain of MRSA was injected into the sternum to establish infection. Rats were treated intraperitoneally for 7 or 14 days with dalbavancin, vancomycin or saline. The number of cfu per gram of sternum or spleen tissue was determined using viable counts. The antibacterial efficacy was determined by the reduction in bacterial counts per gram of sternum or spleen tissue in each treatment group. Results: Treatment with dalbavancin was superior to treatment with saline for 7 days (0.75 log reduction in bone cfu) or 14 days (>3 log reduction in bone cfu) and similar to treatment with vancomycin. Additionally, dalbavancin was also effective in reducing systemic dissemination of MRSA. Conclusions: Dalbavancin is effective in the treatment of MRSA rat sternal osteomyelitis.
- [Show abstract] [Hide abstract] ABSTRACT: The fibula flap serves as the workhorse for many mandibular defect types. For massive defects that include the mandible, floor of the mouth, and tongue, reconstruction might mandate a 2-flap approach. This report describes a systematic yet flexible design of a single composite osseocutaneous fibula flap for such cases. From 2003 through 2011, 5 patients underwent surgery for T4 squamous cell carcinoma and adenoid cystic carcinoma. They underwent wide resection of the mandible and floor of the mouth with hemi- to subtotal glossectomy. A large skin paddle was designed on the leg using a customized template consisting of 3 components matching the alveolar, floor-of-mouth, and tongue segments. The round tongue component was folded using its thickness to provide 3-dimensional volume and form in place of the missing tongue. The other 2 components had a crescent shape and were adjusted intraoperatively to match the resected defect. All 5 flaps survived, with 1 case of flap loss that was successfully replaced. Delayed healing of the leg donor site was encountered in 4 patients. The proposed single 3-dimensionally folded flap design provides ample tissue to replace bony and soft tissue elements for major anterior or lateral segment defects. There was morbidity owing to donor-site complications but these were treatable, with recorded functional restoration. Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
- [Show abstract] [Hide abstract] ABSTRACT: Background: Oncoplastic breast reduction in women with medium to large breasts has reportedly benefitted them both oncologically and cosmetically. We present our experience with an oncoplastic breast reduction technique using a vertical scar superior-medial pedicle pattern for immediate partial breast reconstruction. Methods: All patients with breast tumours who underwent vertical scar superior-medial pedicle reduction pattern oncoplastic surgery at our centre between September 2006 and June 2010 were retrospectively studied. Follow-up continued from 12 months to 6 years. Results: Twenty women (age 28-72 yr) were enrolled: 16 with invasive carcinoma and 4 with benign tumours. They all had tumour-free surgical margins, and no further oncological operations were required. The patients expressed a high degree of satisfaction from the surgical outcome in terms of improved quality of life and a good cosmetic result. Conclusion: The vertical scar superior-medial pedicle reduction pattern is a versatile oncoplastic technique that allows breast tissue rearrangement for various tumour locations. It is oncologically beneficial and is associated with high patient satisfaction.
- [Show abstract] [Hide abstract] ABSTRACT: Introduction Endoprosthetic reconstruction is considered the mainstay of limb salvage in periarticular bone tumours. However, this procedure has limited durability especially when performed in young patients. The free fibula head flap including the proximal articular surface represents one option for hemiarthroplasty reconstruction. Patients and methods All patients between 2000 and 2006 who underwent hemiarthroplasty procedures using the free fibula head flap were included in the study. Functional assessments were performed using the American Musculoskeletal Tumor Society (AMTS) classification. Results There were 5 males and 2 females (mean age: 22.6 ± 15.9 years). Five patients underwent reconstruction following resection of malignant bone tumours and two for chronic osteomyelitis of the distal humerus. In 3 patients, the fibula was used for distal radius and wrist joint reconstruction, and the remaining 4 patients for reconstruction of the distal humerus and elbow joint. A vascularised growth plate transfer based on the lateral geniculate vessels was performed in 2 patients. A technetium-bone scan confirmed viability of all flaps 10 days after surgery, and radiographic bony union was confirmed on average 5 months following surgery. There were no complications with the recipient or donor site after a median follow-up of 71 months (range: 12 monthsto 10 years). All patients achieved reasonable return of function and were able to perform all activities of daily living. Conclusions We demonstrate the hemiarthroplasty procedure using the free fibula flap with its proximal head is a safe procedure with good functional results. Performing autologous arthroplasty using a free fibula head flap may be a promising alternative to an endoprothesis or alloplastic reconstruction with a low risk of complications and morbidity.
- [Show abstract] [Hide abstract] ABSTRACT: Distal tibial tumor ablation results in combined soft tissue and bone defect that involves the ankle joint. This area is unique and problematic because it combines low caliber limb size, relatively soft tissue deficiency, suboptimal bone and soft tissue healing ability, and the need to sustain increased mechanical loads. The management is difficult, controversial, and traditionally was treated by primary amputation. We present our experience with a limb sparing surgery using biological reconstruction.Between 2004 and 2007, 5 patients with malignant bone tumors of the distal tibia underwent tumor resection and reconstruction with free vascularized osteoseptocutaneous fibula flap. The average age was 33.2 years (range, 11-62 years). In all cases, a skin island was harvested and used for wound closure. Arthrodesis of the ankle joint was preformed in all patients. Double fixation system was used to provide stability and avoid flap rotation.All flaps survived. There were no major complications. One patient had partial loss of the skin paddle that was treated conservatively. Callous formation was documented after an average time of 4 months, partial weight bearing after an average time of 4 months, and full weight bearing after an average time of 11.5 months. All patients regained almost normal ambulation within a year.
- [Show abstract] [Hide abstract] ABSTRACT: Methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis after median sternotomy is a major complication of cardiac surgery with significant morbidity and mortality rates. We evaluated the efficacy of ceftobiprole medocaril in a new rat model of mediastinitis and compared it to vancomycin. The model was induced in 92 rats. Infection was induced immediately after median sternotomy by the injection of MRSA (strain 3020, 1 × 10(7) cfu/rat) into the sternal bone. After 24 h, rats (groups of 6-8) were treated intraperitoneally for 5 days or 14 days by either: (i) saline (control, q8h), (ii) ceftobiprole medocaril (70 or 100 mg/kg, q8h), or (iii) vancomycin (50 mg/kg, q12h). Efficacy was determined by a reduction in bacterial cfu in the sternum and spleen tissues. Comparisons were performed using the Mann-Whitney test. A 5-day treatment course of ceftobiprole at both doses tested lead to a significant reduction in MRSA load in the sternum (p < 0.01) as compared to the control group and compared to 5-day vancomycin treatment, which lead to a non-significant reduction (p = 0.07). Longer treatment (14 days) with ceftobiprole lead to a complete clearance of MRSA from the sternum, similarly to vancomycin. Ceftobiprole also showed a significant effect on eliminating MRSA dissemination to the spleen compared to saline-treated rats. Ceftobiprole was effective in treating MRSA mediastinitis in the rat model. In the 5-day course, ceftobiprole showed a significant reduction in sternal MRSA counts and was superior to vancomycin. After 14 days, both ceftobiprole and vancomycin showed clearance of MRSA from the sternum in more than 50 % of rats and almost complete clearance in the remainder.
- [Show abstract] [Hide abstract] ABSTRACT: bjective: To compare the efficacy and safety of negatively-charged polystyrene microspheres (NCM) with controls (saline soaks) in the treatment of hard-to-heal wounds of various aetiologies. Method: Patients with one or more hard-to-heal wounds, defined as refractory to healing for at least 4 weeks, or those with exposed bone, tendon or ligament, were eligible for inclusion and were randomised to either NCM (PolyHeal; MediWound Ltd.) or controls, both applied twice daily for 4 weeks. Patients were monitored bi-weekly for an additional 8 weeks, while treated by standard wound care, at the investigators’ discretion, and were re-evaluated 2 years after inclusion. The primary endpoint was defined as coverage of > 75% of the wound area by light-red granulation tissue after 4 weeks of treatment. Results: Fifty-eight patients completed the study, 32 in the NCM group and 26 in the control group. The two most common wound types were those with primary etiologies of venous insufficiency and post operative/post trauma. In the NCM group 47% of patients achieved > 75% light red granulation tissue after 4 weeks compared with 15% of patients in the control group (p=0.01). The mean wound surface area in the NCM group was reduced by 39.0% after 4 weeks compared with 14.9% in the control group (p=0.02). The achievement of > 75% light red granulation tissue and reduction of mean wound surface area was also observed in the two main sub-groups (venous insufficiency and postoperative/post trauma), although it was not statistically significant, possibly due to the small sample size in each sub-group. Conclusion: This study demonstrates that compared to control treatment, NCM treatment of hardto-heal and chronic wounds improves formation of healthy granulation tissue and reduces wound size thus in fact ‘kick-starting’ the healing process and ‘dechronifying’ chronic wounds.
- [Show abstract] [Hide abstract] ABSTRACT: Proper wound care includes the use of adequate dressings, nutritional support and topical care. However, some wounds, such as those occurring in diabetic or obese patients, those associated with comorbidities or with poor peripheral circulation or oedema, and pressure ulcers and varicose veins, can fail to heal in a timely manner, despite such treatment, and become stagnant or chronic. Furthermore, some acute wounds, especially those with exposed bone, ligaments or foreign materials, such as orthopaedic implants or suturing materials, are prone to become infected and stagnant.1 Wounds that are refractory to treatment for 2-4 weeks are referred to as hard-to-heal wounds.2.
- [Show abstract] [Hide abstract] ABSTRACT: Background: Skin cancer detection is based on the macroscopic and microscopic appearance of the lesions and the experience of the surgeon. The final diagnosis is done by pathological analysis, based on established criteria. Currently, there is no serum marker that can be used for the diagnosis of skin cancer. CD24, a mucin-like glycoprotein, is overexpressed in a variety of cancers including skin malignancies. Objective: Evaluate the potential utility of CD24 expression in peripheral blood leukocytes (PBLs) for the detection of nonmelanoma skin cancers (NMSC). Methods: Twenty-nine consented individuals attending Tel Aviv Sourasky Medical Center for excision of suspected skin lesions, and 21 age- and gender-matched subjects were prospectively recruited. The resected lesions were examined by an expert dermatopathologist. PBLs were isolated from blood samples and protein extracts were subjected to sulfate polyacrylamide gel electrophoresis (SDS-PAGE) and immunoblotting. The study was double blinded. Results: CD24 expression in PBLs distinguishes between NMSC and healthy subjects, with high sensitivity (81%) and specificity (67%) for basal cell carcinoma, and 100% and 71%, respectively, for squamous cell carcinoma. Conclusion: The CD24 test can successfully distinguish NMSC from healthy subjects. CD24 may serve as a new potential and promising diagnostic biomarker for the detection and surveillance of NMSC.
- [Show abstract] [Hide abstract] ABSTRACT: Different etiologies may lead to total auricular and external auditory canal wall ablation. These include burns, tumors, trauma, and malformations. Reconstruction of the canal wall and maintaining its patency pose as a great challenge in plastic surgery. Inability to do so may lead to a serious hearing impairment. To date, different procedures aim at restoring this patency and include skin grafts and local flaps. Unfortunately, skin grafts are associated with a high contracture rate. Local flaps are associated with donor site morbidity. We present a case of an 85-year-old man who underwent auricular ablation due to squamous cell carcinoma which included the external auditory canal. Sparing the tragal and lobular areas within the surgical margins using frozen section-controlled margins, we were able to reconstruct the canal wall. The tragal lobular wrap flap provides a valuable and consistent long-lasting method for auricular canal reconstruction and postauricular amputation wound coverage. Level of evidence: Level V, therapeutic study.
- [Show abstract] [Hide abstract] ABSTRACT: Background: Clinical infection of breast implants occurs in 7 to 24 percent of breast reconstructions. It may persist over time in the form of biofilm without overt manifestation and is extremely difficult to eradicate. The authors' aim was to establish a novel model for biofilm infection of silicone breast implants in rats. Methods: Fifty-six rats underwent implantation of miniature silicone breast implants and/or methicillin-resistant Staphylococcus aureus (MRSA) bacteria. Group A received implants covered with MRSA biofilm. Group B received implants and free planktonic MRSA. Group C received free planktonic MRSA without implants. A control group received sterile implants without MRSA. Each group was divided to receive either saline or vancomycin injections between days 4 and 11. Clinical evaluation, bacterial counts, and scanning electron microscopy were performed. Results: The mortality rate in group B (implants infected with free planktonic MRSA) was significantly higher than that in all other groups [37 percent versus groups A and D (0 percent) and group C (7 percent)]. Treatment with vancomycin lowered temperature in groups B and C (p < 0.05) and improved wound healing in group B (p < 0.01). Vancomycin treatment reduced wound bacterial counts in free planktonic MRSA groups B and C but had no significant effect on biofilm MRSA-infected group A. Conclusions: The model successfully induced persistent breast implant infection. Free planktonic MRSA produced in situ biofilm on silicone implants. Biofilm infection has milder manifestations than free planktonic MRSA infection, which has higher rates of systemic infections and death when compared with either isolated biofilm infection or free planktonic MRSA infection without implant. Vancomycin has limited effect against mature biofilm.
- [Show abstract] [Hide abstract] ABSTRACT: Breast symmetry is a key factor in deep inferior epigastric perforator (DIEP) flap breast reconstruction, which necessitates in many cases contralateral breast adjustment, traditionally done at a second stage. We present our experience with simultaneous contralateral breast adjustment in unilateral DIEP breast reconstruction. We retrospectively reviewed all consecutive unilateral DIEP breast reconstructions done in our institution. The patients were divided into three groups according to contralateral breast surgery performed: simultaneous adjustment, late adjustment, and no contralateral breast adjustment surgery. The groups were compared by aesthetic outcome and patient satisfaction using the BREAST-Q questionnaire. A total of 77 unilateral breast reconstructions were performed using the DIEP flap. Fifty-one eligible patients agreed to respond to the questionnaire by telephone and were enrolled in the study; 33 underwent simultaneous contralateral breast adjustment, eight underwent late adjustment procedure, and 10 had no contralateral surgery performed. Aesthetic outcome and patient satisfaction was comparable in the simultaneous and late adjustment groups, but was reduced during the latent period. Simultaneous contralateral breast adjustment in unilateral DIEP breast reconstruction is a safe and a worthwhile procedure that should be offered to the patient when appropriate.
- [Show abstract] [Hide abstract] ABSTRACT: Reconstruction of large bony gaps of the femur poses a surgical challenge, the most common etiology being primary long bone malignancy. In defects larger than 4 cm reconstruction, using a a vascularized fibular graft in adjunct to an autograft or bony allograft, is indicated. We would like to present our experience with this procedure and the lessons we have learned along the way. Patients and methods: Between the years 2000 and 2011 44 patients (18 female, 26 male), underwent free vascularized fibula graft for femur reconstruction. Demographic data, comorbidities, indications, adjuvant treatments, surgical procedure, early and late complication as well as long term radiologic and functional outcomes were retrospectively recorded. Results: Average age at the time of surgery was 20.4 years (range 8-45). In 72% the indication was long bone malignancy, osteosarcoma and Ewing sarcoma the most prevalent pathology. Avascular necrosis of the femoral head was leading non-oncologic etiology in 13% of the cases. In 76% a bone allograft was used to bridge the resection defect engulfing the vascularized bone, in 14% a single straight segment was used, while in the remaining 10% the nonvascularized portion of the fibula served as a bone graft side by side to the vascularized segment. The average boney defect was 16cm (± 6.2, range 9-27 cm). The descending branch of the lateral circumflex femoral artery was used as a recipient vessel in 41% of the cases, while branches of the superficial femoral in 23.5%, deep femoral vessels in 11% and popliteal in 11%. Long term functional scores on a scale of 1 to 4 averaged 3.53, 61% of the patients achieving an excellent score. Conclusion.: During the years we developed a routine, instead of searching for an occasional branch in the surrounding tissues, to aim for the descending branch of the lateral circumflex femoral vessels as the recipient vessels. These vessels are of reliable flow, large caliber, long arch of rotation if required, and usually away from the main zone of resection. This in turn orchestrates positioning of the allograft's concavity laterally, the fixating plate medial to it, and orthotopic or heterotopic orientation of the fibular flap to facilitate vascular anastomosis. Vascularized fibula graft in combination with bone allograft or autologus graft is an excellent method for reconstruction of wide defects of the femur, achieving long term good functional outcome.
- [Show abstract] [Hide abstract] ABSTRACT: We present a case report of a 59-year-old patient with a giant lipoma of the left breast, extending to the left arm. She sought medical consultation because it had become heavy and caused pronounced breast asymmetry. The lesion was excised by means of an oncoplastic technique using the superior-medial pedicle wise-pattern breast reduction approach. We concluded that the use of the oncoplastic reduction pattern technique after removal of a giant breast lipoma is highly rewarding, resulting in a smaller-sized breast that is aesthetically more pleasing, has better symmetry with the contralateral breast, and provides relief from functional mass deficit. This technique minimizes the potential for a breast deformity once the tumor is resected.
- [Show abstract] [Hide abstract] ABSTRACT: PURPOSE The deep inferior epigastric artery perforator flap is increasingly used for autologous breast reconstruction. Preoperative imaging of the donor site vasculature with Compute Tomography angiography (CTA) is used to improve operative outcome. The purpose of our study was to correlate CT and surgical findings and to demonstrate the impact of pre-operative CT on surgery. METHOD AND MATERIALS A prospective study was undertaken on 36 consecutive patients between November 3rd 2008 and March 17th 2010 planned for DIEP flap breast reconstruction surgery. Two patients diagnosed with metastatic disease were excluded from the study. Arterial perforators were mapped on a 3D abdominal wall model generated from the axial CT images with actual surgical findings correlation. The volume of the flap was calculated on a workstation in 20 patients and was correlated with the flap weight after it was resected. Operative times and post operative complications were evaluated in a control group of 36 consecutive patients operated by the same surgeons without pre-operative CT planning before the study was initiated. RESULTS Computed tomography angiography identified 219 perforators in 34 patients , 212 of whom were identified intraoperatively. The CT sensitivity for mapping perforators was 96.8% .The average difference between the flap volume calculated at CT and actual flap weight was 16.2%. Operative times were reduced following the use of computed tomography with operative time of 543 minutes and 428 minutes before and after the introduction of CTA pre-operative evaluation ,respectively. CONCLUSION CTA of the abdominal wall is highly accurate in identifying and mapping DIEA perforators before breast reconstruction surgery and enables accurate estimation of the flap volume resulting in reduced operative time. CLINICAL RELEVANCE/APPLICATION CTA of the abdominal wall plays a crucial role in pre operative planning of DIEP flap breast reconstruction surgery , affecting surgery procedure and post operative outcomes.
- [Show abstract] [Hide abstract] ABSTRACT: Aquacel Ag((R)) (ConvaTec, Princeton, NJ, USA) is a new hydrofiber wound dressing consisting of soft non-woven sodium carboxymethylcellulose fibers integrated with ionic silver. It is a moisture-retention dressing, which forms a gel on contact with wound fluid and has antimicrobial properties of ionic silver. We present a current literature review on Aquacel Ag((R)), of both in vitro and in vivo efficacy and clinical applications. In vitro and in vivo studies have demonstrated the wide antimicrobial properties of Aquacel Ag((R)), and additionally demonstrated the cytotoxicity of ionic silver to keratinocytes and fibroblasts that cause delay in wound re-epithelialization. Clinical studies confirmed that Aquacel Ag((R)) is an effective and safe dressing for a variety of wound types, both acute and chronic. Incorporation of ionic silver into the hydrofibers does not cause undue alteration in the performance properties of the base dressing, which continues to provide favorable wound moisture and exudate management. The addition of ionic silver reduces local pain and dressing changes, and provides significant broad-spectrum antimicrobial properties, with no delay in wound healing.
- [Show abstract] [Hide abstract] ABSTRACT: Earlobe keloids can form after cosmetic ear piercing, trauma, infection, or burns, or spontaneously. These keloids are highly resistant for treatment and are followed by severe cosmetic implications. There are various surgical and nonsurgical treatment modalities for earlobe keloids, with no universally accepted treatment policy and a wide range of reported recurrence rates. The authors present their experience of treating earlobe keloids using the "sandwich" technique protocol; extralesional excision and external-beam radiotherapy are given a day before and a day after the operation. The authors retrospectively reviewed all patients with earlobe keloids treated by the "sandwich" technique between the years 1996 and 2005. Patients were categorized into two groups: a high-risk group for previously treated patients and patients with a tendency for hypertrophic scars and keloids, and a low-risk group for the others. All patients underwent extralesional excision of the keloid and local radiotherapy before the excision and following it. Follow-up was a minimum of half a year and included a patient satisfaction questionnaire and documentation of keloid recurrence or cure. A total of 23 patients were treated by this protocol; 57 percent were male. Patients had an average age of 24 years. The most common keloid etiology was earlobe piercing. Recurrence rates for the low-risk and high-risk groups were 25 and 27 percent [percent of the patients], respectively. Overall patient satisfaction was high. The combined excision and "sandwich" radiotherapy technique is a simple and effective method for treating earlobe keloids, with high patient satisfaction and low recurrence and complication rates.
- [Show abstract] [Hide abstract] ABSTRACT: Facial paralysis presents diverse functional and aesthetic abnormalities. Reconstruction may be achieved by several methods. We reviewed the management and outcome of facial paralysis patients to establish principles on which a comprehensive reconstructive approach may be based. Records were reviewed of all patients operated for facial paralysis at our institution between 1998 and 2007. Ninety-five patients were included, of which 15 patients had static reconstruction alone, and 80 patients had dynamic reconstruction. Presented is our experience in reconstruction of facial paralysis over the past decade, delineating a comprehensive approach to this condition. Various surgical techniques are described.
- [Show abstract] [Hide abstract] ABSTRACT: Malignant melanoma (MM) was considered a hormone-sensitive tumour, and pregnancy was thought to increase its risk and cause faster progression and earlier metastasis. Several controlled studies demonstrated similar survival rates between pregnant and non-pregnant patients and concluded that early reports of advanced MM of pregnancy were probably due to late diagnosis. We retrieved information from our database between 1997 and 2006 on all patients diagnosed as having MM during and up to 6 months after pregnancy (n=11) and compared them to age-matched, non-pregnant, MM patients (n=65, controls) treated by us during that period. The mean Breslow thickness was 4.28mm for the pregnant patients and 1.69mm for the controls (p=0.15). The sentinel nodes were metastatic in five pregnant patients compared to four controls (p<0.0001). Two patients in the pregnancy group and one control died of MM (p=0.0532). Our results indicate a negative effect of pregnancy on the course of MM.
- [Show abstract] [Hide abstract] ABSTRACT: Forty-three women had reduction mammaplasty during the period 1992-2000 and the cosmetic outcome was evaluated using subjective and objective measures. The inferior pedicle technique was used in all cases. The mean (SD) weight of resected tissue was 1121 (415) g. All objective measurements were within the ideal range except for breast volume and nipple-to-inframammary-line distance, which were more than ideal. Overall, the median difference in measurements between the two breasts of each woman was less than 10%. However, the subjective evaluations given by both clinicians and the patients for overall symmetry and for general aesthetic appearance fell below the preset threshold. The shape of the breast correlated best with the grades of symmetry and general appearance. There was no correlation between the objective and subjective evaluations of symmetry. The disappointing subjective scores, which may be attributed to the specific characteristics of our sample group, are heavy breasts and overweight patients, a double team approach, and the inevitable pseudoptosis that develops with the inferior pedicle approach. These direct us to recommend searching for an alternative operative technique and to evaluate its long term results, as well as placing the nipple-areola complex lower than the standard inframammary fold projection.
Tel Aviv University
Tell Afif, Tel Aviv, Israel
- • Sackler Faculty of Medicine
- • Department of Epidemiology
Tel Aviv Sourasky Medical Center
Tell Afif, Tel Aviv, Israel
- • Division of Surgery
- • Dermatology