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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.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.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 (p0.05 and p0.001).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.

Surgical treatment of acral lentiginous melanomas with wide excisional margins as recommended often requires amputation of distal extremities. The current study analyzes, if smaller excisions in combination with a complete histological evaluation of the excisional margins (3D histology) have a negative impact on the prognosis.304 patients were retrospectively evaluated. 192 patients with reduced excisional margins followed by 3D histology (group A) were compared with 112 patients treated with conventional wide margins (group B). The outcome of both groups was compared.The median tumor thickness was higher in group A (p = 0.022) and ulcerations occured more frequently (p = 0.017). The median excisional margin was 8 mm in group A and 20 mm in group B (p0.0001). 10.9 % (4.2 % invasive) of group A und 8.9 % (4.5 %invasive) of group B (p = 0.577) developed a local recurrence in a median of 40 months.The melanoma specific 10-year survival was 66.8 % in group A und 63.4 % in group B(p = 0.531). Survival of patients with or without local recurrence showed no difference(p = 0.643).Excision with small margins followed by 3D histology is not inferior to conventional surgery with wide margins concerning the rate of local recurrences and has no negative impact on prognosis or the further course of the disease. Local recurrences are rare and do not influence the survival.

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.

The elevated ambulatory pressure in the peripheral venous system of chronic venous insufficiency (CVI) patients manifests itself not only in the form of disturbed macrocirculation but also and particularly in microangiopathic changes. For this reason, it is closely correlated with trophic disorders of the skin and can ultimately lead to ulceration. Using microcirculation research techniques, we are able to provide clear evidence of a typical microangiopathy in chronic venous insufficiency. Fifty CVI in Widmer stages I, II, and III were examined with fluorescence video microscopy, intravital video capillaroscopy, transcutaneous oxygen partial pressure measurement, TcpO2 and laser Doppler flowmetry. The effects of compression therapy with individually fitted compression stockings on capillary morphology were studied over a period of 4 weeks in 20 CVI patients in Widmer stages I and II. The capillary pressure was measured during simulated muscle contraction using a servo-null micropressure system. We periodically drew blood from the dorsalis pedis vein and a brachial vein of 11 healthy test persons and 8 patients with stage III CVI during experimental venous hypertension in order to evaluate the expression pattern of leukocyte adhesion molecules involved in inflammation: LFA-1 (CD11a), Mac-1 (CD11b), p150,95 (CD11c), CD18, VLA-4 (CD49d), and L-selectin (CD62L). In the same patients, we used immunohistochemical methods to examine clinically unaffected skin and the skin near an ulcer, focusing on the adhesion molecules ICAM-1, VCAM-1, and E-selectin. The microangiopathic changes observed with worsening clinical symptoms include a decrease in the number of capillaries, glomerulus-like changes in capillary morphology, a drop in the oxygen content (tcpO2) of the skin, increased permeability of the capillaries to low-molecular-weight substances, increased laser Doppler flux reflecting elevated subcutaneous flow, and diminished vascular reserve. These microangiopathic changes worsen in linear proportion to the clinical severity of chronic venous insufficiency. In patients with venous ulcerations, the baseline expression of LFA-1 and VLA-4 on lymphocytes, Mac-1 expression on the myeloid cell line, and L-selectin expression on all three cell lines was not significantly different form that in healthy controls. During orthostatic stress, there was a significant reduction in the expression of L-selectin in blood cells collected at foot level in the controls (p=0.002), but not in the patients. Clinical improvement by compression therapy was accompanied by an increase in the number of nutritive capillaries, while the diameter of the capillaries and the dermal papillae was reduced. When ulcers healed in a short period (

For compression treatment to be effective in patients with chronic venous insufficiency, it is vital that leg circumference be measured accurately. If compression stockings are custom fit and appropriate for the medical indications, patient compliance will be high. Exact measurements of circumference and length are prerequisites for a good fit. The aim of the present study was to compare an opto-electronic device for the contact-free measurement of calf circumference with the conventional manual method using a tape measure. We investigated the differences between the results obtained with the two methods, and also their reproducibility. Circumferences were measured at defined heights on an anatomically shaped non-yielding leg model and on the leg of a healthy volunteer by 10 different experimenters both with the tape measure and with the opto-electronic device. The calf circumferences measured manually with the tape measure varied significantly more than those measured opto-electronically, both in the leg model and in the leg of the volunteer. A systematic error in the opto-electronic method appears unlikely, since the manual measurements on the leg model were both larger and smaller than those obtained with the opto-electronic device. Reproducibility was exceptionally high with the opto-electronic device (standard deviation 0.11-0.42 cm). The opto-electronic method yields rapid accurate measurements of circumference with excellent intra- and inter-operator reproducibility.

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.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.There were no anesthetic complications. Short-term negative postoperative occurrences (72 hrs.) were swelling (42%), problems with suture material (22%), pain (19%), hematoma and paresthesia (each 13%), erectile dysfunction (12%), small-area skin necrosis after wound healing without requiring further surgery (13%), micturition disorders (7%), and wound infection (6%). Two patients on anticoagulation therapy had postoperative bleeding requiring revision surgery. 5% of the patients were given further analgesic sedation. 19% complained about postoperative pain. Persistent complaints (maximum 6 months) were disturbances of skin sensation (7%), swelling (4%), and redness and micturition disorders (3% each).Supplementing a local anesthetic with epinephrine in penis operations has many advantages, including high patient satisfaction, relatively painless infiltration, low complication rates, improved view of the operating field, and an extended effect of anesthetics with a prolonged reduction in pain. Because of the anatomy of the organ, there is no risk of necrosis related to using a subcutaneous penile ring block. Thus the view that epinephrine should not be used in penis procedures is obsolete.

We conducted a longitudinal cohort study on the quality of life of infertile male patients measured at baseline and after 5 years with a specific quality of life instrument for male patients who are involuntarily childless. It was distributed to patients who were seen at the andrology and gynaecology clinics for infertility diagnoses and treatment. At baseline (T1), 275 patients took part in the study. A subset of these patients (N = 133) had released two semen samples, and the results of the semen analysis had been communicated to them before they received the questionnaire. Semen quality of this subset was assessed according to WHO recommendations. After 5 years (T2), the questionnaires were mailed again and were sent back by N = 101 patients. No significant quality of life difference was found between the semen quality groups. After 5 years, an improvement was found for the dimensions 'desire for a child' [mean score 1.92 (T1) versus 1.72 (T2)] and 'gender identity' [mean score 1.56 (T1) versus 1.42 (T2)] while no change was found for 'partnership' and 'psychological well-being'. We did not find significant differences between patients who had fathered a child in the meantime and patients who did not become fathers.

The microinjection method used for the first time in this study makes it possible to measure in vivo the endothelium-dependent vasomotion in the nailfold capillaries of systemic scleroderma patients. Aceylcholine (blood concentration of 10(-5) M) and sodium nitroprusside (blood concentration of 1.6 microg per kg per min) were used as test substances to examine capillary vasomotion. Defined quantities of medication in the range of microliters were administered as a bolus using the Panomat V-3 medicine pump. The boluses were injected into the capillaries at the capillary loop in 10 scleroderma patients and 10 randomized healthy volunteers. Blood flow velocity and the diameter of the skin capillaries at the venous loop were measured and tested for correlation with the effects of injections of test substances. The intracapillary administration of sodium nitroprusside brought about a significant decrease in capillary blood flow velocity and a significant increase in vascular diameter in comparison with baseline values, both in systemic scleroderma patients (p0.005 and p0.0001) and in the healthy volunteers (p0.001 and p0.0001). The intracapillary administration of acetylcholine led to a significant decrease in blood flow velocity (p0.001) and increase in vascular diameter (p0.0001) only in the healthy volunteers. In systemic sclerosis patients capillary diameter and blood flow velocity were unaffected. In two systemic scleroderma patients this procedure was repeated in identical fashion at the end of a 1 wk infusion therapy cycle with prostacyclin. The infusion therapy led to a normalization of endothelium-dependent vasomotion in the two scleroderma patients. The microinjection technique used in this study for the first time made it possible to establish in vivo that endothelium-dependent vasomotion is disturbed in systemic scleroderma patients.

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.

Recently the "Union for International Cancer Control" (UICC) and the "American Joint Committee on Cancer" (AJCC) changed their TNM (tumor, node, metastasis) classification of cutaneous carcinomas.We compared these classifications, tested their practicability with 615 prospectively collected, unselected, primary cutaneous squamous cell carcinomas, and introduced additional classification criteria.Neither classification contains information about prognosis. Non-metastasizing types of cutaneous carcinoma should be excluded. The vermilion border of the lower lip and the eyelids should be included. Both systems have been improved, but in part they are irreproducible. The AJCC has introduced six "high-risk features" to differentiate between T1 and T2. However, this does not seem reasonable. Only rare cases are classified as T4. Both systems have different N classifications. A clinical cT classification based on tumor size 2 cm seems reasonable but not sufficient. It should be complemented by a postoperative p (pathologic) T classification based on tumor thickness: "no risk"≤ 2 mm thickness (0% risk of metastasis), "low risk"2 mm to 6 mm thickness (4% risk of metastasis), and "high risk"6 mm thickness (16% risk of metastasis). Immune suppression, poor differentiation/desmoplasia, and the ear as tumor site are additional risk factors for metastasis, currently not evaluable.The classifications are unsuitable for a realistic estimate of the risk of metastasis which is possible using a combination of tumor size and thickness. The N staging system should consider histopathologic findings.

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.

Does controlled vascular training influence plasmaviscosity and the pain free walking distance in patients with peripheral arterial occlusive disease (paod) Fontaine stage II? 37 patients, 24 men and 13 women with a mean age of 64.5 years SD 8.5 took part in ambulant vascular training over a period of 12 months. Before, after 6 months and after 12 months, pain free (pfwd) and maximum walking distance (mwd) was measured using a standardized treadmill program. Also ankle-brachials systolic pressure index (a-bspi), transcutaneous oxygen tension (tcP02) and plasmaviscosity (pv) were measured. Pfwd increased from 212 SD 143 m to 371 SD 249 m (p < 0.02). TcP02 increased during training, but without statistically significance. A-bspi increased between the first 6 months of training statistically significant. Before training pv was 1.31 mPa s SD 0.10, after training period of 6 months it was 1.27 mPa s SD 0.11 (p = 0.06) and 12 months later it was 1.28 SD 0.11 mPa s (p = 0.35). The improvement of pfwd and the decrease of pv correlates (r = -0.39, p = 0.05). In most patients, arterial vascular training improves pfwd and mwd. Simultaneously to the increase of the walking distances plasmaviscosity decreases and crurobrachial indexes increases. We found a coupling between improvement of pfwd and pv. Pv seems to participate in improvement of leg hemodynamics in patients with paod.

Vascular effects of local anesthetics are especially important in dermatological surgery. In particular, adequate perfusion must be ensured in order to offset surgical manipulations during surgical interventions at the acra. However, the use of adrenaline additives appears fraught with problems when anesthesia affects the terminal vascular system, particularly during interventions at the fingers, toes, penis, outer ears, and tip of the nose. We studied skin blood flux at the fingerpads via laser Doppler flowmetry over the course of 24 hours in a prospective, double-blind, randomized, placebo-controlled study with 20 vascularly healthy test persons following Oberst's-method anesthetic blocks. In each case, 6 ml ropivacaine (7.5 mg/ml) (A), lidocaine 1% without an additive (B), and lidocaine 1% with an adrenaline additive (1:200,000) (C) was used respectively as a verum. Isotonic saline solution was injected as a placebo (D). Measurements were carried out with the aid of a computer simultaneously at D II and D IV on both hands. Administration of (A) led to increased blood flux (+155.2%); of (B) initially to a decrease of 27%; of (C) to a reduction of 55% which was reversible after 40 minutes and of (D) to no change.(A) resulted in sustained vasodilatation which was still demonstrable after 24 h. (B) had notably less vasodilative effect, although comparison with (D) clearly showed that (B) is indeed vasodilative. (C) resulted in only a passing decrease in perfusion; this was no longer measurable when checked after 6 and 24 h. This transient inadequacy of blood flux also appeared after administration of (D). These tests show that adrenaline additive in local anesthesia does not decrease blood flow more than 55% for a period of 16 min. Following these results an adrenaline additive can be safely used for anesthetic blocks at the acra in healthy persons.

Laser Doppler flowmetry (LDF) is frequently used to study the microcirculation. Usually LDF time series are analyzed by conventional linear methods, mainly Fourier analysis. The aim of this study was to observe dynamic blood perfusion of the skin in malignant and benign melanocytic skin lesions. Wavelet transformation was performed on each LDF time series in order to calculate a vasomotion field. First, the differences in vasomotion between healthy and pigmented skin were evaluated visually on six different time scales of the vasomotion field. In order to quantify the findings, vasomotion scale variance (VSV) was calculated for each scale plane of the vasomotion field. These VSV were compared using contrast ΔVSV to determine the difference between healthy skin and a pigmented skin lesion in the same patient. After the measurements, the skin lesions were excised and examined histologically. We found that wavelet analysis of LDF time series is a specific, sensitive method for the in vivo identification of malignant melanoma. It is a non-invasive procedure and takes minimal time to be carried out.

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.