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Background and Objectives After local flaps, it may be necessary to reconstruct the contour of the nasal ala. This is possible with a single-stage all-layer shaping suture. In the present study, the functional and aesthetic results after single-stage reconstruction of the nasal ala were prospectively evaluated. Patients and methods Patients who underwent surgery for skin tumors of the nose between 06/2019 and 06/2020 who required reconstruction of the nasal ala as part of the defect closure and had an all-layer suture used were prospectively included in the study. A standardized evaluation of aesthetic and functional outcome was conducted by the patient and a physician at discharge as well as 4 weeks later. Patients additionally underwent a follow-up survey 6 months later. Results Thirty-seven patients were included in the study. Four weeks postoperatively, all flaps were found to be fully healed and vital. Aesthetic outcome at 4 weeks was rated as very good or good by physicians in 73% and by patients in 78.4%. Persistent complications due to reduced blood flow were not observed. Conclusion The reshaping of the nasal ala as part of the defect reconstruction with an all-layer suture demonstrates very good aesthetic as well as functional results and can be performed in a single-stage procedure.

Background Sentinel lymph node biopsy (SLNB) is useful for staging of patients with melanoma. Although SLNB is mostly performed under general anesthesia (GA), tumescence local anesthesia (TLA) can also be used. However, less data are available regarding feasibility of SLNB under TLA. Here we present a post-operative follow-up of 150 patients. Patients and methods We prospectively analyzed data from 150 patients with primary cutaneous malignant melanoma. We assessed pain, post-operative complications and patients' satisfaction after SLNB under TLA. Results 32 % of the patients reported post-operative pain within the first 48 h after SLNB. Seroma was the most frequent complication, as 29 seromas after SLNB were observed. Wound infection was observed in 3.3 % of the patients. 98.7 % of the patients were satisfied with SLNB under TLA. Conclusions SLNB under TLA is a safe and feasible option and should be considered for patients with melanoma. Especially with multimorbid or elderly patients, the risks of GA can be avoided.

The local recurrence rates of malignant skin tumors after micrographic controlled surgery using complete circumferential peripheral and deep margin assessment (CCPDMA) are reported to be low. However, in daily practice, tumor entities with a significantly higher recurrence rate are found.The aim of the investigation was to identify these high-risk tumors to develop approaches for risk stratification.We included different malignant tumors that were surgically treated and examined with CCPDMA using paraffin sections and HE staining. Re-excisions were performed until the tumor was completely removed.Ninety-nine thousand three hundred seventy-two tumors were included in the study; the follow-up period was 4 years (median). Eight tumor entities were identified as high-risk entities, showing a significantly higher local recurrence rate of over 20%: desmoplastic squamous cell carcinoma, desmoplastic melanoma, Merkel cell carcinoma, microcystic adnexal carcinoma, pleomorphic sarcoma, liposarcoma as well as angiosarcoma, and extramammary Paget's disease.Complete circumferential peripheral and deep margin assessment allows complete control of the resection margins and enables skin-sparing resections with low recurrence rates for basal cell carcinomas, nondesmoplastic squamous cell carcinomas, lentiginous melanomas, and dermatofibrosarcoma protuberans. However, other tumors show significantly higher recurrence rates and therefore need to be classified as high-risk tumors.

Perusal of the literature of cutaneous squamous cell carcinoma (SCC) reveals that the role of the desmoplastic subtype is indistinct. Data on local infiltration and recurrence are inconsistent dependent on surgical technique, histological method, and investigated collective.The aim of the study was to analyze local infiltration and locoregional recurrence of the desmoplastic subtype under a uniform procedure.Between 2005 and 2015, 320 SCCs were analyzed and histological sections of all tumors were examined. Data collection included locoregional recurrence, metastasis rate, and tumor-specific death. The median follow-up was 36.5 months.The desmoplastic subtype required significant more re-excisions (70.0% vs 23.9%, p.001), more interventions until tumor-free margins were achieved (maximal 6 vs 2; p.001), showed more widespread tumor infiltration with larger excisional margins (median 9 mm, 2-51 mm vs median 4 mm, 1-10 mm; p.001), and a 5-fold higher local recurrence rate (26.7% vs 5.0%, p.001). The metastasis rate (16.6% vs 2.3%, p.001) was increased.The desmoplastic subtype is characterized by a widespread local infiltration associated with perineural infiltration. It seems to be a marker for decreased histological detectability with a high rate of locoregional recurrence and metastasis.

Tumescent local anesthesia (TLA) plays an important role in dermatosurgical procedures. TLA has several benefits such as long-lasting anesthesia, reduced bleeding during surgery and the avoidance of general anesthesia-associated complications. Convenience and a favorable risk profile along with a broad spectrum of indications are further reasons why TLA is increasingly applied in infants as well. There are not only a variety of indications for surgical excisions in infancy, such as congenital nevi, but also substantial benefits when performing these excisions at an early age. These include the smaller size of the lesions as well as the unproblematic wound healing and tissue regeneration in infancy. Nevertheless, several aspects need to be considered when applying TLA in infants including dosing, altered plasma protein binding and the need for adequate and long-lasting pain control.

Background Defect coverage following tumor excision requires a case-by-case decision as regards the optimal reconstruction technique. In the head and neck region in particular, the cosmetic outcome is of major importance. The objective of the present study was to compare various reconstruction methods in terms of their functional and aesthetic outcome based on patient age, defect size and site. Patients and methods Overall, 1,827 patients (age: 18-92 years, median age: 56 years) were contacted. Using a standardized questionnaire, they were asked to assess postoperative complications, cosmetic and functional outcome, and the overall result of the surgical procedure. In addition, patient records were used to collect data on defect size and site as well as the type of surgical procedure employed. Results Rated as very good or good (86 %), defect closure by advancement flaps received the highest scores in terms of overall result. Other flaps and skin grafts were rated less favorably. Postoperative complications were significantly more common after local flaps. Irrespective of defect size ( 300 mm2 ), older patients considered the visibility of the scar to be less prominent than younger individuals. Scars in the central facial region were perceived to be more visible. Gender and smoking habits had no impact on the results of the survey. Conclusions Scars in the central facial region were perceived to be more prominent. Overall, older individuals considered their scars to be less conspicuous. Even though they are initially associated with greater tension, advancement flaps resulted in very good aesthetic and functional results and a high level of patient satisfaction.

Background Early paediatric dermatosurgery reveals excellent cosmetic results due to high skin-elasticity and pronounced capacity to recover from trauma. Furthermore, the size of skin lesions increases during life proportionally to skin growth and therefore early removal is of major importance. Selected local anaesthetics like prilocaine can cause methaemoglobinemia. However, in contrast to general anaesthesia many other local anaesthetics do not bare any major risks for infants. Objective In this retrospective study, we analysed infants aged less than 7 months receiving tumescent local anaesthesia (TLA) followed by dermatosurgery at our department between 2005 and 2015. The analysis is mainly based on our records. Additional information for a subset of patients was gained by a postoperative survey. Methods 92 infants (39 male, 53 female) with a median age of 4.2 months (range: 1.5 months; 6.7 months) were included in this study. Additional postoperative information was available for 33 of the 92 studied patients (35%). Results Infants were mainly operated for removal of a melanocytic nevus (n=54), followed by haemangioma (n=23), nevus sebaceous (n=6) and other lesions (n=9). The lesions were located on the scalp or neck (n=31), on the extremities (n=31), on the trunk (n=21), in the face (n=6) or on the buttocks (n=3). The median size of excision was 509mm2 (range: 16mm2; 3600mm2). Primary defect closure was performed by intracutaneous (n=68) or extracutaneous (n=24) suture techniques. No side effects of local anaesthesia were observed in any patient. Postoperative complications include pain (1/33; 3%), wound healing disorder (1/33; 3%) and visible severe scarring (2/33; 6%). Conclusions The combination of TLA and dermatosurgery in infants is a suitable outpatient treatment option for small lesions without any major risks or side effects and the benefit of prolonged postoperative analgesia. This article is protected by copyright. All rights reserved.

Rhinophyma is a deforming soft tissue hyperplasia of the nose and surgical removal represents the treatment of choice. Comprehensive data on surgical therapy and the impact of rhinophyma on patient quality of life are lacking. Patients who received surgery for rhinophyma between 2006 and 2015 were retrospectively evaluated for postoperative complications, clinical outcome, recurrence of rhinophyma, and the impact of rhinophyma on daily life. A total of 143 patients were treated with superficial tumour decortication by scalpel under tumescent anaesthesia. Outcomes were determined by clinical review, clinical files, and a patient questionnaire. Of 143 patients, 70 answered the questionnaire and were included in this study with a mean follow-up time of 54 months. Cosmetic results were evaluated as very good or good in 77% of patients. The majority of patients (87%) were very satisfied or satisfied with the postoperative result. Surgical treatment of rhinophyma improved patients' quality of life in 67% of patients. Recurrence of rhinophyma was detected in 38% of patients. Surgery is an effective therapy for rhinophyma with excellent outcome.

Removal of the deep fascia is recommended in therapy for dermatofibrosarcoma protuberans, but its necessity in the context of micrographic surgery is unclear. A retrospective clinicopathological analysis of 48 patients with dermatofibrosarcoma protuberans treated by micrographic surgery was performed, to determine in which tumours fascia preservation was feasible and safe. Histologically, 93% of tumours on the trunk and extremities and 14% of tumours in the head and neck region were fully located above the fascia. Localization on the head and neck was the only significant risk factor for tumour extension beyond the subcutis (p

When using procedures that enable complete examination of surgical margins (3D histology), microscopically controlled surgery (MCS) represents a safe and proven method to confirm R0 resection of infiltrating tumors, especially at problematic sites, while preserving the adjacent tissue. This allows for excellent or good aesthetic results that are superior (cryosurgery, short-range irradiation) or equivalent (PDT) to nonsurgical and less safe procedures (PDT).

Summary Background An increasing number of patients are being treated with anticoagulants and platelet inhibitors. Whenever surgical procedures of the skin are required, questions arise regarding the perioperative management of anticoagulation. Methods Development of S3 guidelines following the requirements of the Association of Scientific Medical Societies, systematic literature search and analysis, use of GRADE methodology, structured consensus conference using a nominal group process. Results During cutaneous surgery, treatment with acetylsalicylic acid (ASA) should be continued if medically necessary. In procedures with a higher risk of bleeding and a positive bleeding history, INR should be determined preoperatively. Surgical procedures of the skin with a higher risk of bleeding should not be performed if the INR is above therapeutic range. Bridging from vitamin K antagonists (VKA) to heparin should not be performed just because of the surgery of the skin. As to direct-acting oral anticoagulants, the last dose should be taken 24 h preoperatively. Conclusions The recommendations issued by the German guidelines group are mostly in line with recommendations provided by other guidelines. The American iChest-Guidelinei recommends continuing VKAs and acetylsalicylic acid during minor dermatologic procedures. In their guidelines, the German College of General Practitioners and Family Physicians considers an INR of 2 to be adequate in surgical procedures on the skin.

Cutaneous squamous cell carcinoma (cSCC) is an increasing health burden in white populations. We prospectively assessed risk factors for tumor-specific and overall survival in 1,434 patients who underwent surgery for cSCC between January 24, 2005, and May 29, 2015. A total of 2,149 invasive cSCCs were analyzed. Univariate and multivariate survival analyses included tumor thickness, horizontal size, body site, histological differentiation, desmoplastic growth, history of multiple cSCCs, and immunosuppression. The primary endpoint was time to tumor-specific death. During a median follow-up period of 36.5 months (range = 0-137 months), 515 patients died; 40 because of cSCC (2.8%). Of those, 12 died because of visceral metastases and 28 because of tumor growth by local infiltration. On multivariate analyses, prognostic factors for tumor-specific survival were increased vertical tumor thickness (hazard ratio = 6.73; 95% confidence interval = 3.47-13.08; P0.0001), desmoplastic growth (hazard ratio = 4.14; 95% confidence interval = 2.68-9.83; P0.0001), and immunosuppression (hazard ratio = 2.07; 95% confidence interval = 1.04-4.12; P = 0.039). Defining a point list out of those factors and grouping them into four cohorts resulted in comprehensively separating survival curves (P0.001). Using a cut-off for tumor thickness of 6 mm or greater, the presence of desmoplastic growth and immunosuppression identifies patients at high risk for tumor-specific death.

Summary Background The continuous evaluation of the edges of a tumor by means of three-dimensional (3D) histology often appears complicated and require the surgeon and dermatopathologist to work together closely. We present clear rules that allow communication between all parties involved and then verify their application in daily routine. Methods Tissue processing, interpretation of results, as well as communication between the surgeon and the dermatopathologist are based on an algorithm with the aid of exact times and embedding cassettes, which allow precise topographic orientation. We evaluated the use of this method in daily clinic practice, taking into account 947 operated basal cell carcinomas in regard to the development of recurrent tumors. Results At a median follow-up of 47 months, 10 of the 947 operated basal cell carcinomas (1.1 %) recurred. Sclerodermiform basal cell carcinomas and basal cell carcinomas which could not be curatively resected (R0 resection) during the initial surgery showed a significantly higher recurrence rate (p < 0.05 and p < 0.001). Conclusions Standardized rules for dealing with excised tissue allow an effective application of 3D histology in daily clinical practice. 3D histology results in low recurrence rates. Sclerodermiform basal cell carcinomas which could not be curatively resected (R0 resection) were identified as a risk group for the development of recurrent tumors.

Summary Background It is widely accepted that local anesthetics with epinephrine should not be used in areas served by terminal vessels. There is no evidence in studies for this in penile surgery, and given the anatomy of the penis, perfusion complications are highly unlikely. The goal of this study was to show that a penile block using a local anesthetic with epinephrine is safe. Patients and Methods In a follow-up study between 2005 and 2010, we analyzed 95 patients who got a penile ring block with subcutaneous infusion anesthesia (SIA). The SIA solution consisted of ropivacaine and lidocaine (0.11% and 0.21%) plus epinephrine. Results There were no anesthetic complications. Short-term negative postoperative occurrences (

In current dermatological practice lymphatic mapping and sentinel lymph node biopsy (SLNB) are frequently used in patients with cutaneous cancers, like malignant melanoma, squamous cell carcinoma and Merkel cell carcinoma. However, those tumors are often located on the head and neck, regions with notoriously variable lymphatic drainage patterns. Consequently, the incidence of successful SLNB in the head and neck is considerably lower compared to the SLNB on the trunk and extremities. Thus, there is a need to improve the hit rate of SLNB in this special area. Therefore, in the current study we analyzed SLNB of 149 patients treated for cutaneous tumors at the Department of Dermatology, University of Tuebingen, Germany. By mapping SLN (sentinel lymph node) locations to their specific tumor sites on the head and neck, we were able to calculate the frequency of SLN distribution to defined tumor locations. Furthermore, our analysis revealed that approximately 7% of tumors on the head and neck drain to contralateral SLN, which is of relevance for the classification in the current cancer TNM system. Thus, our mapping can predict SLN location in patients with cutaneous head and neck tumors and might help to further increase the rate of successful SLNB.

To confirm a local R0 resection of tumors with infiltrative growth at problem sites and for sparing of tissue, microscopically controlled surgery represents a safe and proven method, particularly when there are no gaps between the tissue taken at the incision margins.

Objective For reasons of their outdoor work, mountain guides (MG) are heavily exposed to ultraviolet radiation during their work. Methods A standardized interview and examination were performed on 283 male MG (median 41 years) from Germany, Switzerland and Austria and 309 age-matched controls. The median occupation time as MG was 17 years; 39.9% were working full-time. Results The incidence of skin cancer and precancerous lesions was obtained. Precancerous lesions as solar keratosis (SK) were significantly more frequent in MG (25.4% vs. 7.4%). There was no skin cancer [BCC, SSC, melanoma (MEL)] in the control subjects. Basal cell carcinoma (BCC) was diagnosed in 20 MG (7.1%) and SSC in four MG (1.4%). There were 10 highly suspicious melanocytic lesions; one MG had a histologically confirmed malignant MEL. Risk factors for SK in the multivariate analysis included occupation (P

Summary Background: Accurate pre-operative or intra-operative labeling of the skin is often necessary to mark exactly the surgical excision lines. Pre-operative “unsterile” permanent skin labeling systems are needed for example for vein and sentinel lymph node surgery; here the dyes must resist two surgical skin disinfection procedures. In contrast, excision borders are labeled during surgery using a “sterile” skin marking system. Methods: Many commercial and non-commercial pre- and intra-operative skin-labeling systems are available, such as autologous patient blood, fluorescence triphenylmethane dyes and commercial skin markers. The available skin marking systems have specific advantages and disadvantages. We review the different labeling systems, offering guidelines to help choose a cost-effective system appropriate for a given surgical procedure. Results: The Edding® permanent markers 400 und 3000 are well suited for preoperative skin labeling and less expensive than commercial skin labeling systems. Autologous patient blood and eosin are well suited for intra-operative labeling and are most cost effective. Eosin Y is widely used and well suited for labeling of dark skin, bone, cartilage, and muscle tissue and spares the expense of expensive commercial skin markers. Conclusion: Knowledge of the many commercial and non-commercial pre- and intra-operative skin labeling systems and their advantages and disadvantages helps to reduce the use of relatively expensive commercial skin markers.

SummaryThe elevated ambulatory pressure in the peripheral venous system in patients suffering from chronic venous insufficiency manifests itself not only in the form of disturbed macrocirculation but also and particularly in microangiopathic changes. Laser Doppler fluxmetry is a well established method to measure cutaneous blood flow. Aim of the study was to investigate the cutaneous vasomotion at the inner ankle in patients suffering from chronic venous insufficiency in the clinical stadium C6 compared to healthy subjects. Patients, methods: In 38 patients suffering from venous ulcer and in 33 healthy subjects continous time series of Laser Doppler fluxmetry (LDF) data were recorded with a sampling frequency of 50 Hz over a period of 15 min. The patients were supine and LDF was measured at the inner ankle. Time series were analyzed using newly developed methods (wavelet analysis and biorthogenal decomposition). Results: There was a statistically significant difference in mean LDF between patients and healthy controls (94 SD 65 AU [C6] vs. 28 SD 13 AU (C0), p < 0.001). There also were statistically significant differences in the scaling levels using wavelet analysis corresponding to sympathetic activity, corresponding to myogenic activity in the vessel wall and corresponding to the heart beat. Conclusion: There are changes in vasomotion between patients with venous ulcers and healthy controls. We found a vasale neuropathy and a high degree in dysregulating skin perfusion. The new innovative strategies are suited for describing microcirculation and controlling therapies.

Aims To evaluate the microscopic growth pattern of dermatofibrosarcoma protuberans (DFSP) and malignant fibrous histiocytoma (MFH) and the long-term outcome using 3D-histologic surgery with paraffin sections to cover complete margins and to detect subclinical spreads very sensitively. Methods One hundred and one patients have been included comprising 70 DFSP, 31 MFH. Data from 87 patients treated since 1992 were collected prospectively. Results Mean clinical tumor-size was 45 mm, mean histological tumor size 65 mm. A mean excision margin of 19 mm achieved negative margins. The histological infiltration shows an asymmetrical pattern with horizontal or vertical extension either cord-, sector- or multiple-like up to 70 mm in length, detectable by 3D-histology. Age and localization differed significantly between DFSP and MFH lesions. MFH tumors had a significantly deeper infiltration than DFSP. The mean follow up was 60 months. In 70 patients with DFSP one local recurrence after 62 months occurred, but no metastasis. 31 patients with MFH developed 8 local recurrences, and 4 metastases (lymph nodes and/ or lungs); 3 of them died of the disease, all 3 had a postoperative status of R1 ( p = 0.001). Conclusions There are significant differences in growth pattern and clinical outcome between DFSP and MFH. DFSP can be cured by surgery following 3D-histology with paraffin sections. MFH is significantly more malignant. After local R0-resection proofed by 3D-histology higher cure rates can be achieved.

Rhythmical changes in microvascular perfusion of the skin depend on various influences, which appear continuously but not in a predictable manner. For identifying and quantifying different physiological influences the authors used wavelet transformation, analyzing continuously and simultaneously measured data.A total of 34 healthy volunteers were included in the study. At the dorsum of the left hand, skin perfusion was measured by laser Doppler fluxmetry (LDF) and skin temperature was measured. Simultaneously, the electrocardiogram and the respiration were recorded. The recorded time series were analyzed with wavelet transformation and scale correlation (S-correlation).Semilinear analysis with wavelet transformation allowed a visualization of temporal changes in LDF frequency and amplitude in a color-coded quasi three-dimensional diagram. The authors found that tissue perfusion over an observation period of 327.68 s is governed by 6 closely connected, overlying waves with different degrees of freedom. The major determinants are low frequencies in LDF, which correlates with changes in skin temperature, responsible for 68.5% of the influence. Surprisingly, though indispensable for blood flow, respiration and heartbeat contributed to less then 2.5% of the rhythmic changes.When wavelet transformation is used in analyzing LDF time series, the different rhythms of cutaneous blood flow are made visible and quantifiable and can be assigned to different physiological origins. The application of this novel analysis method allows identifying mechanisms regulating skin perfusion, which will greatly facilitate the diagnosis of a variety of important vascular diseases, such as chronic venous insufficiency, diabetes, or neurotrophic disorders.

Summary Aim: Haemodynamic effectivity of 13 compression stockings in correlation with its physical characteristics. Patients, methods: In a prospective study, 42 patients in clinical stage C1–4 were examined with dynamic mercury strain gauge plethysmography to determine the effects of 13 different compression stockings in compression classes 2 and 3 (CEN) on venous haemodynamics. At the same time that venous function measurement was monitored, the pressure exerted by the compression stockings was measured under resting conditions and during standardized exercises by the patients. Results: Resting pressure measured while the patient was reclining corresponded to the in vitro textile data for the corresponding compression class in all of the stockings. The compression stockings improved venous refill times t0 and t1/2 to a statistically significant degree. The differences in the improvement in refill times t0 and t1/2 was found to depend on the quotient of maximum working pressure during movement over resting pressure (pW/pR) while standing (r = 0.90, p < 0.01 ). The improvement of the expelled volume correlated with decrease of resting pressure from ankle to calf (r = 0.86, p

Summary Introduction: Local anesthetics supplemented with epinephrine are generally regarded as contraindicated for surgical procedures involving the fingers, toes, penis, outer ear and the tip of the nose [1], but epinephrine is essential if automated tumescence local anesthesia (Auto-TLA) is used. Materials and methods: Infiltration anesthesia supplemented with 1 : 200,000 epinephrine was used from 1985 – 1997 in our department, while Auto-TLA supplemented with 1 : 1.000,000 epinephrine was introduced in 1997 for all surgical procedures involving the ear or nose. During this period, 10,201 patients underwent surgery at these locations. In addition, dermal blood flow was analyzed by acral photoplethysmography (APPG) and laser Doppler flowmetry (LDF) in the right ear lobe of five normal volunteers and during epinephrine supplemented Auto-TLA. Results: Epinephrine-induced complications were not observed in a single patient. Cosmetic skin flap surgery was performed in 4,953 of these patients. Even in patients with extended surgical procedures that took up to one to two hours and that included extensive skin flaps or skin grafts, we observed no increase in complications when compared to procedures performed either under general anesthesia or local anesthesia without epinephrine supplementation. Measuring blood perfusion of the earlobe showed a 69 % reduction of LDF and a 42 % reduction of arterial inflow (APPG) immediately following anesthesia. Conclusion: Epinephrine supplementation of local anesthetics does not block blood perfusion in the ear and did not induce organ, tissue or flap necrosis. Local anesthesia with epinephrine supplementation is therefore safe for acral areas such as the ear or nose. Despite the relatively small influence on blood perfusion, epinephrine supplementation results in a relatively bloodless operating field and longer effectiveness of local anesthesia. The relative absence of blood in the operating field of the ear and nose significantly reduces the duration of surgery and increases the healing rate, as less electrocautery is needed. Zusammenfassung Einleitung: Ein Adrenalinzusatz ist allgemein kontraindiziert bei Anasthesien im Endstromgebiet, insbesondere bei Eingriffen an Fingern, Zehen, Penis, Ohrmuscheln und Nasenspitze [1]. Er ist aber notwendig, wenn man eine automatisierte Tumeszenzlokalanasthesie (Auto-TLA) durchfuhrt. Material und Methode: Seit 1985 wird an der Universitats-Hautklinik in Tubingen bei jedem operativen Eingriff an Ohr und Nase eine Infiltrationsanasthesie mit Adrenalinzusatz 1 : 200 000 bzw. ab 1997 als (Auto-TLA) mit Adrenalinzusatz 1 : 1 000 000 durchgefuhrt. Seit dieser Zeit wurden 10 201 Patienten an diesen Lokalisationen anasthesiert und operiert. Bei funf gefasgesunden Probanden wurde der dermale Blutflus mittels akraler Photoplethysmografie (APPG) und Laser-Doppler-Fluxmetrie (LDF) am rechten Ohrlappchen vor und nach Auto-TLA objektiviert. Ergebnisse: Beim Einsatz der Lokalanasthesie mit Adrenalin kam es zu keiner einzigen adrenalinbedingten Komplikation an Ohr und Nase. Bei diesen Patienten wurde bei 4 953 Fallen eine regionale Hautlappenplastik durchgefuhrt. Auch hier zeigte sich trotz zum Teil mehrzeitiger Operationstechnik und Teil ausgedehnten Hautlappenplastiken oder Hauttransplantationen kein Unterschied hinsichtlich der Komplikationsrate gegenuber einer Narkose oder einer Lokalanasthesie ohne Adrenalinzusatz. Die Objektivierung der Blutperfusion am Ohrlappchen ergab eine Reduktion des LDF um 69 % und des arteriellen Einstromes (APPG) um 42 % unmittelbar nach der Anasthesie. Schlusfolgerung: Durch den Zusatz von Adrenalin in dem Lokalanasthetikum wird die Blutperfusion am Ohr nicht komplett unterbunden. Eine Lokalanasthesie mit Adrenalinzusatz kann daher an Ohr und Nase eingesetzt werden. Der Adrenalinzusatz fuhrt zu einem blutarmen Operationsfeld und zu einer langeren Wirkungsdauer der Lokalanasthesie. Das blutarme Operationsfeld an Ohr und Nase bietet Vorteile hinsichtlich der Zeitdauer des operativen Eingriffes und des Heilungserfolges wegen einer reduzierten Anwendung der Elektrokoagulation von Blutgefasen am Hautrand.

Objective: To study the microcirculation of the skin of the leg in patients with chronic venous disease of the lower limb, and to assess the effect of compression treatment. Patients and Methods: Patients were recruited from the vascular clinic and investigated by direct capillary pressure, transcutaneous oxygen tension, intravital video capillaroscopy and fluorescence video microscopy. The microcirculation was observed over the healing period in patients with venous leg ulcers. The effects of compression therapy on microcirculatory changes were studied in patients with Widmer stage I and II chronic venous disease. Results: In patients suffering from lipodermatosclerosis or venous leg ulcers retrograde pressure waves were detected in the nutritive capillaries of the skin by the ‘servo nulling’ pressure measurement during simulated calf muscle contraction. A close correlation was found between the degree of trophic skin change and the microangiopathy observed. Healing of venous ulcers occurred only if the cutaneous microcirculation in the ulcer area improved. Capillary density in base of the ulcer and at the border predicted venous ulcer healing. Conclusions: Cutaneous microangiopathy precedes the development of trophic skin alterations due to chronic venous disease and microcirculatory changes are closely related to the clinical stage of the disease as well as to the outcome of treatment.

In order to evaluate the correlation between the pressure exerted by compression stockings and a resulting improvement in venous hemodynamics, we carried out an open, randomized, prospective study on 22 patients (11 women and 11 men with an average age of 55.1 [10.3]) with chronic venous insufficiency (CVI) in the clinical stages C1-4, Ep, AS, Ap, PR. Dynamic strain gauge plethysmography was used to measure the acute effect on venous hemodynamics of 9 different compression stockings in compression class 2 (A-D). At the same time when venous function parameters were monitored, we also measured the pressure exerted by the compression stockings during rest and exercise. With all compression stockings the average resting pressure fulfilled in reclined patients the specifications for compression class 2 (25-35 mmHg at the ankle, CEN). The compression stockings lengthened venous refill time t0 in a statistically significant degree. The improvement in venous function was correlated with the ratios of maximal working pressure to resting pressure while standing (r = 0.97, p < 0.001). Compression stockings belonging to the same compression class vary in their acute effect on venous hemodynamics. The efficiency of the different therapeutic compression stockings was largely dependent on the amount of fabric stretch, which can be characterized in vivo with the ratio of maximum exerted pressure during movement to that while standing still. A knowledge of the hemodynamic effectivity of the various compression stockings allows the optimal stocking selection for each patient and his individual clinical situation.

Objective Supplementing a local anaesthetic with epinephrine has advantages in hand surgery: faster onset of anaesthesia, extended effect of anaesthetics with prolonged pain reduction, decreased bleeding into the operative field, and abandoned need for tourniquet. We hypothesized that the use of ropivacaine with epinephrine additive in digits allows good skin perfusion rates with prolonged pain reduction. Design In this prospective, double-blinded, randomized study with 20 volunteers (80 fingers, without operation) the chronological course of changes in digit blood flow, post injection pain status and complication rates after two-injection dorsal technique anaesthetic block with ropivacaine (group 1: ropivacaine 0.75%, group 2: ropivacaine 0.75% and epinephrine 1 : 1.000.000, group 3: local tumescent anaesthesia 0.15% TLA: ropivacaine, lidocaine, saline solution plus epinephrine 1 : 1.000.000) were examined. As a control group, injection of 2% lidocaine in the way with 20 minutes tourniquet (group 4) was used. Main outcome Group 1 showed increased skin perfusion with a maximum of 160.2%, group 2 showed no significant changes with a following significant increase of skin perfusion (+66.6%). In group 3, a significant reduction (-54.1%) was followed by an increase of skin perfusion (+45.7%). In the control group (group 4) the skin perfusion was decreased (-66.2%) and increased significantly after opening the tourniquet (+248.1%). The longest pain reduction was shown for ropivacaine 0.75% and epinephrine with 18.0 hours (group 2); the other groups were between 4.6 to 8.1 hours. Conclusion Using ropivacaine with epinephrine additive in digits could improve the intra-, and postoperative terms.

Primary closure in dermatologic surgery is state of the art in small lesions at the head, but also in larger lesions at the trunk or the extremities. Microcirculatory effects on the skin blood flow near to the wound edges affected by primary closure. Forty three patients were investigated. Before and after surgery, skin blood flow was measured using Laser Doppler Fluxmetry (LDF). During primary closure, tension in the suture was measured and the tension on the wound edges was calculated. Times series were analyzed using continuous wavelet analyses, before, after 2 h and 24 h after surgery. After three months, the cosmetic results were requested. Median horizontal diameter was 22 mm (quartiles 20/48 mm), median vertical diameter was 44 mm (quartiles 26/60 mm). Mean string force was 12.0 SD 10.2 N. During the whole course of investigation, we found no change of microcirculatory parameters such as mean LDF or any scaling level following wavelet analysis caused by primary closure. Average of the cosmetic result was 1.8. It is a relative small number of patients and the defects are located in different areas. Skin blood flow and the microcirculatory pattern is not affected in the area by the tension on wound edges and provides therefore a fast healing process without any vegetatively induced complications even if the string force is high. In dermatosurgery, wounds can be closed directly without changing the microcirculatory pattern in the direct area of the wound margins.

In a prospective study, a large number of patients with basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) underwent surgery using three dimensional (3D) histology and were evaluated with respect to local recurrence. The excised tumours were treated using 3D-histology with a routine paraffin procedure until the surgical margins were clear of tumour. Prospective evaluation of recurrence-free survival and overall survival of 5227 primary BCCs in 3320 patients and 615 invasive primary SCCs in 600 patients was conducted in the form of a letter-based follow-up with feedback from the patients and the referring physicians. The mean follow-up period was 5 years. In the BCC collective, 36 out of 3320 patients developed local recurrence (1%, calculated as a percentage of treated BCCs: 0.7%). In the SCC collective, 20 local recurrences appeared (3%). The recurrence rate for SCCs with desmoplasia was 24%, whilst the recurrence rate for common types of SCC without desmoplasia was 1%. Surgery followed by 3D histology results in very low recurrence rates for BCC and SCC with no additional effort compared with the normal histopathological procedure.

The dominance of the radial or ulnar artery at the forearm level and their contributions to the circulation of the hand remain a matter of contention. Therefore, the authors proposed to investigate the predominance of one of these arteries first by anatomic studies on 40 fresh cadaver upper extremities, and then by dynamic studies. The dynamic studies included color Doppler sonography in 22 individuals (44 hands) and five-channel plethysmography in 40 individuals (40 right hands). It was found that the ulnar artery is dominant at the elbow, but after originating its collateral branches, the radial artery becomes the dominant artery in the distal forearm and, consequently, constitutes the major source of vascularization to the hand. The ulnar artery is rarely dominant at the forearm level and is physiologically less important. Therefore, there is no hemodynamic reason to prefer the radial artery to the ulnar artery for any invasive maneuvers.

We studied the patterns of dominance in the palmar digital arteries of the fingers in 39 fresh cadaver arms which had been injected with coloured latex solution. We also performed photoplethysmographic studies in 20 hands. The ulnar digital artery in the index finger and the radial digital artery of the little finger were usually dominant, and their counterparts were slim and often hypoplastic. The findings are relevant to digit revascularization and might influence the planning of digital island-flaps or toe transfers.

Objectifs Pendant longtemps l’artere cubitale a ete consideree comme l’artere dominante pour la perfusion de la main et pour cette raison le lambeau chinois a ete prefere au lambeau cubital pour la reconstruction de pertes de substances au niveau de la main. Nous avons effectue une etude anatomique et clinique que remet en question ce concept qui nous vient de l’anatomie classique. Le but de cette etude est aussi de mieux comprendre quelles sont les arteres dominantes au niveau de la main et des doigts. Materiels et methodes Dans une premiere partie de notre etude nous avons disseque a l’aide d’un microscope operatoire 35 membres superieurs de cadavres frais prealablement injectes par du latex colore. Nous avons disseque l’artere brachiale, la cubitale, la radiale et les interosseuses de chaque preparation et mesure leur diametre. La deuxieme partie reporte le resultat d’un travail clinique sur la perfusion dynamique. A l’aide d’un photoplethysmographe nous avons demontre chez 50 personnes en bonne sante qui se sont benevolement soumises a l’examen que des differences significatives de la perfusion etaient retrouvees au niveau de la main apres compression de l’artere cubitale ou radiale. La troisieme partie du travail reporte le resultat d’une dissection anatomique de 200 doigts de cadavres apres injection du latex colore ainsi que la meme etude de perfusion dynamique pour les arteres collaterales digitales. Resultats Les resultats de notre etude ont mis en evidence que l’artere radiale est l’artere dominante pour la perfusion de la main. Ils mettent aussi en evidence qu’il y a une dominance de l’artere cubitale pour l’index et de l’artere radiale pour l’auriculaire. L’etude dynamique montre que la perfusion peut devenir critique dans certains de ces doigts suite a une compression de l’artere dominante. Conclusions Dans le prelevement d’un lambeau en ilot retrograde au niveau de l’avant-bras ou des doigts la dominance des axes vasculaires doit etre tenue en compte. La connaissance de ces variations peut aussi etre de grande utilite lors de l’execution d’interventions microchirurgicales telles que les replantations ou les lambeaux libres.