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patient name: Rudy Kash

age: 11

condition: giant congenital melanocytic nevi

seen in: plastic and reconstructive surgery

providers: Salim Mancho, DO, FACS

In 2011, Rudy was born with a very large birthmark on his arm. Since the birthmark had a high risk of being cancerous, they began the removal process when Rudy was two months old at the hospital where he was born. Removing the birthmark required several surgeries.

By the time Rudy was six years old, his mom, Molly, realized that the "fix" for the birthmark was causing a lot of mobility issues. She could tell this was going to be a major problem and it had to be fixed.

The repair of Rudy's arm would require a series of complex surgeries involving tissue expanders and flap reconstruction. Molly wanted a surgeon who was experienced in this specific series of surgeries. She interviewed eleven different surgeons in Chicago, Boston, Cleveland, New York City and beyond. While Molly believed each surgeon was capable and she knew they would have done a good job, she didn't feel the connection she was looking for.

Just when Molly felt like she had exhausted all possibilities, someone suggested that she reach out to their local pediatric hospital, Dayton Children's Hospital. They had heard of a new, extremely skilled surgeon who had joined the plastic and reconstructive surgery team.

"I didn't think there was any way our local hospital would be able to do it," said Molly. "But then I met Dr. Mancho and was absolutely shocked by his skill level and his interactions with me and with Rudy."

treatment at Dayton Children's

In October 2017, Rudy started his treatment with Dr. Mancho. Rudy's first procedure was tissue expansion. Dr. Mancho placed an empty implant known as a tissue expander under the skin of Rudy's back. The goal over time was to fill the implant with saline to stretch the skin and cause it to grow. The new skin would be used to reconstruct the area on Rudy's arm that was causing mobility issues. The process was complex, and they ran into a lot of unforeseen issues.

On Christmas Day, 2017, Rudy developed an infection and Dr. Mancho had to remove the expanders with zero progress. Although they knew this was a possibility, it was disappointing.

Molly remembers Dr. Mancho sitting on the sofa in Rudy's hospital room after removing the expanders. His head was in his hands, and it was evident to Molly that he was just as invested in Rudy's journey as their family was.

Over the next year, Rudy allowed his body to focus on recovering and held off any additional surgeries. In October 2018, they restarted the tissue expander process again. This time around the process was successful and in April 2019 Rudy had flap reconstruction surgery. During this surgery, Dr. Mancho removed the healthy, new skin Rudy grew with his tissue expander and relocated it to the area on Rudy's arm that required reconstruction.

The surgical placement of the flap was successful, but in time, the flap started to die. This was another complication Rudy's family knew was possible. Dr. Mancho wasn't ready to give up on the flap. It took months of work, but he managed to save it and he was able to repair Rudy's arm.

Although Rudy's arm was repaired, he now had a void on his back where the skin had been removed and relocated to his arm. Rudy's back reconstruction was not an urgent matter, and it would be a much easier process than that of his arm, so they decided to give his body time to heal before any more surgeries.

In October 2022, Rudy was growing so fast that his back needed to be repaired. Rudy had just turned 11 that summer and he was well into fifth grade. He really wanted to have his back repaired before he started junior high, so the timing felt right.

Once again, Dr. Mancho approached Rudy's reconstruction by starting with tissue expanders. Rudy's care team and his family took the knowledge they gained from the last few years and applied it to reduce complications. Unfortunately, the reconstruction of his back did develop a few complications. However, Dr. Mancho realized that being able to swim by Memorial Day weekend was super important to Rudy so he managed to get him patched up in time.

going above and beyond for Rudy

As an active little boy and the youngest of four kids, Rudy loves to be in the mix with his older siblings. Throughout the entire reconstruction process, it was really important to Molly that Rudy be able to maintain a typical life even with tissue expanders and a wound vac in place. She wanted him to be confident and happy with minimal restrictions on his day-to-day activity.

Dr. Mancho listened to Molly and made sure Rudy's active lifestyle was not affected by the reconstruction of his arm. He would make casts that allowed Rudy to climb trees and dig in dirt while keeping him protected. As a result, Rudy is super confident with his scars. So confident, he wears a tank top every single day.

The most amazing part of the whole experience according to Molly is the relationship that developed between Dr. Mancho and Rudy. Although visiting hospitals is not new territory for Rudy, he has never spoken a word to a single one of his doctors.

Despite not speaking, Rudy and Dr. Mancho developed a close bond. They play Nerf guns at every appointment and so much laughter fills the clinic when they are together.

Rudy finally spoke his first words to Dr. Mancho in October 2022 when he said, "Hi, how are you?" like nothing was going on. Dr. Mancho's eyes widened in shock, but he just played along.

grateful for specialty care, close to home

Rudy has been in the operating room 46 times in his life, yet he has zero fears about going to the hospital thanks to Dr. Mancho and the entire surgery department. Dayton Children's is no longer a place he is afraid to visit.

"I am beyond grateful that we found Dr. Mancho and Dayton Children's," said Molly. "Our community is so lucky to have the expertise and resources of Dayton Children's right here in our own backyard."