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The study objectiveis to describe the available techniques of microscopically controlled surgery for skin cancer with histological control of tumor resection margins (three-dimensional (3D) histology). This approach almost completely eliminates the risk of recurrence and allows preserving healthy tissue. It is a standard treatment for skin cancer in Germany; however, in Russia and other CIS countries, this method is not in use.Materials and methods.We reviewed German standards for skin cancer treatment and currently available research literature on the treatment methods used for skin cancer.Results.Automated subcutaneous tumescent local anesthesia (ATLA). Since ATLA contains a highly diluted (up to 100 times) anesthetic, we can inject a 100-fold larger volume, thus, increasing the anesthetized area. The use of naropin or ropivacaine in ATLA ensures long lasting effect (10 h on average), while the incidence of side effects is two times lower due to mixing of anesthetics and reducing their doses. The anesthetic solution is injected slowly; therefore, the patient has neither pain nor oppressive feeling. Moreover, the sodium chloride solution was replaced by ionosteril, which eliminates burning sensation. Microscopically controlled surgery (MCS). Before excision, the tumor is topographically marked (with indicating the 12 o’clock position) in order to determine the tissues that should be additionally excised after finding a tumor infiltrate in the resection margin. The tumor is excised by circumscribing an ellipse of skin; the scalpel blade should be tilted toward the tumor, making an acute angle with skin surface. The defect is closed by wound closure strips; then a compression bandage is placed over the strips. When the complete removal of tumor infiltrates is histologically confirmed, the wound is sutured or closed with a flap (if necessary). MCS ensures complete removal of the tumor and preservation of healthy tissues, which is particularly important for patients with head and neck cancer. Three-dimensional histology. In the case of small tumor specimens (up to 2 cm), the margins and the basis of the specimen are folded to a one plane by incisions (“Muffin” technique). Larger specimens require the “Tubingen cake” technique: a narrow (2–4 mm) lateral strip is cut vertically around the full perimeter of the tumor border (marginal fragment). Then a narrow section is cut from the bottom of the specimen (basal fragment); the remaining tissue is cut by diameter (medial fragment). The marginal and basal fragments are examined to identify tumor infiltrates, whereas the medial fragment is used for the diagnosis. The 3D-histological examination allows revealing twice as many tumor infiltrates as conventional histology in Germany, tumor recurrence is the lowest in the world. 3D-histology does not require additional labor costs. Defect closure using intracutaneous 3D-sutures for high tension. Absorbable butterfly and double butterfly sutures withstand strong skin tension, which allows avoiding reconstructive surgery with local tissues and skin transplantation and allows avoiding expander using. This improves functional and aesthetic results, reduces the duration of surgery, the incidence of postoperative complications, and treatment costs.Conclusion.MCS, 3D histology, ATLA, and defect closure with intracutaneous 3D-sutures for high tension preserve healthy tissues, reduce the frequency of complications and relapses, improve functional and cosmetic results, and decrease the duration of surgery and treatment costs. This technique has proven its efficacy in Germany; so we recommend its implementation in the Russian Federation and in CIS countries.

A performance comparison of an interleaved boost converter (IBC) using Si and SiC diodes for photovoltaic (PV) energy conversion systems is presented in this paper. The performance attributes under investigation include the semiconductor device behavior, thermal requirement, system efficiency, and power density. The IBC is designed to sustain the dc-link voltage in the energy conversion system and to provide the maximum power point tracking in the PV system. Due to the absence of reverse recovery current in SiC Schottky diodes, low switching losses are generated in diodes and switches. This benefit results in a higher system efficiency and smaller cooling system design requirement. As a benefit, the volume and weight of the heatsink can be further reduced. Furthermore, behaviors of the power semiconductors, which will impact the performance in the system, are discussed in the paper. The validity of the analysis is confirmed experimentally with a 2.5-kW IBC prototype with relatively wide power and input voltage operating range. The overall performance of the IBC prototype using Si and SiC diodes is summarized in a table for easy comparison.

The implementation of an interleaved boost converter (IBC) using SiC diodes for photovoltaic (PV) applications is presented in this paper. The converter consists of two switching cells sharing the PV panel output current. Their switching patterns are synchronized with 180° phase shift. Each switching cell has a SiC Schottky diode and a CoolMOS switching device. The SiC diodes provide zero reverse-recovery current ideally, which reduces the commutation losses of the switches. Such an advantage from the SiC diodes enables higher efficiency and higher power density of the converter system by reducing the requirement of the cooling system. This paper presents also an optimization study of the size and efficiency of the IBC. Based on 1) the steady-state characteristic of the topology; 2) the static and dynamic characteristics of the switching cells; 3) the loss model of the magnetic components; and 4) the cooling system design, the paper provides a set of design criteria, procedures, and experimental results for a 2.5 kW IBC prototype using SiC diodes.

SummaryOur goal was to document changes in venous drainage function ΔV and venous refill times to and th achieved with venous surgery and compare them with preoperative measurements acquired using a variety of venous function tests. Preoperative measurements were performed with two pressure cuffs to predict postoperative outcome; they were compared with actual postoperative measurements made without a pressure cuff. In addition we also analyzed whether the postoperative improvement in venous haemodynamics was correlated with an improvement in clinical findings and symptoms. Patients, methods: 64 patients (14 men and 50 women) were enrolled into the study. Inclusion criteria were Doppler sonographic evidence of insufficiency of the saphenous veins and impaired venous haemodynamics, which form the medical indication for venous surgery. Before and after surgery a variety of diagnostic tests of venous function were carried out simultaneously with the patient in a seated position and performing dorsal extensions: mercury strain gauge plethysmography (MSGP) at the forefoot and calf, phlebodynamometry (PDM), light reflection rheography (LRR), digital photoplethysmography (DPPG) with Elcat measuring head and with Laumann Elcat measuring head, universal light reflection plethysmography (ULP). Results: All the examined methods are suitable for monitoring progress and evaluating therapeutic success after the selective surgical removal of insufficient vein segments. All examination methods showed that refill times t0 and th were significantly improved 6 weeks after venous surgery. The postoperative results of ΔV, t0 and th were most reliably predicted by MSGP (forefoot). ΔV, to and th values determined with MSGP at the calf differed significantly from those acquired with PDM, so MSGP (calf) should not be used for preoperative screening. Conclusions: A close correlation between improvement of clinical symptoms and improvement in venous haemodynamics was found. Selection of the suitable preoperative measurement method makes it possible to accurately predict postoperative outcome.

Resume Nous decrivons ici deux methodes de chirurgie micrographique (ou histologie 3D) permettant un controle des berges et de la base d’exerese des tumeurs cutanees. Le protocole que nous proposons ici est une adaptation pour le systeme francais du protocole develope en Allemagne a l’Universite de Tuebingen.

Microcystic adnexal carcinoma (MAC) belongs to the spectrum of locally aggressive adnexal carcinomas and most commonly occurs in the head and neck region. Recently it has been proposed that MAC is an apocrine tumor. It is characterized by slow, but locally aggressive growth with infiltration of subcutaneous fat tissue, muscles, perichondrium, periosteum, or perineurium. As a result, surgical treatment often leads to ablation defects, which are many times the size of the clinical lesion. In 1982, Goldstein and colleagues first reported MAC to be a distinct histologic entity characterized by a combination of keratinous cysts in the upper dermis, islands and strands of small basaloid, benign-appearing keratinocytes or squamous cells in the deeper dermis within a dense desmoplastic stroma, and areas of ductular differentiation. The authors report the case of a 78-year-old woman in whom a diagnosis of MAC was made when a tumor on the right cheek recurred for the second time. Previous histopathologic diagnoses were squamous cell carcinoma and desmoplastic trichoepithelioma. Local recurrences of the tumor occurred, despite histographic surgery because in hematoxylin and eosin stains, small islands of the deceptively benign-appearing small basaloid cells of MAC were not recognized as tumor cells. The reported case demonstrates the difficulties in diagnosing MAC and indicates that MAC should always be considered in the differential diagnosis of slowly growing tumors in the head and neck region. If MAC is diagnosed too late, it can be inoperable because of its infiltrative growth.

Der Pilonidalsinus ist eine Hauteinstulpung uber dem Os sacrum, welche sich durch Reibung und mechanischen Druck an Haarbalgen vergrosert, die symptomatisch wird, wenn eine Infektion des Ganges eintritt. In 23% ist er mit der Acne inversa vergesellschaftet. Die Acne inversa ist eine Entzundung der Talgdrusen und Terminalhaarfollikel, vorzugsweise in den intertriginosen Arealen. Die Erstmanifestation kann von der Pubertat an bis ins hohe Alter erfolgen. Uber 90% der Patienten sind Raucher. Sie beginnt mit Riesenkomedonen und derben, subkutan gelegenen indolenten Knoten, die im Verlauf in der Tiefe zu wulstartigen, mit Epithel ausgekleideten abszedierenden Fistelgangen konfluieren und sich immer weiter ausbreiten. Konservative Behandlungsmasnahmen oder Inzisionen und/oder Abszess- und Fistelspaltungen bringen keinen Erfolg. Methode der Wahl ist die fruhzeitige operative komplette Exzision pathologisch veranderter Haut im Gesunden sowohl lateral als auch zur Tiefe. Eine Sekundarheilung der Defekte ist meist vorteilhaft.

In recent years it has been found that local anesthesia, which often suffices for surgery of the skin and superficial structures, can be adequately administered using large amounts of highly diluted anesthetic solutions combined with epinephrine. This has considerably increased application of local anesthesia in plastic surgery. Using one or more conventional infusion pumps for slow subcutaneous infusion anesthesia (SIA), we injected mixed anesthetic solutions painlessly and automatically into the subcutaneous layer. The local anesthetics used were equivalent mixtures of prilocaine and ropivacaine (Xylonest and Naropin); these were diluted with original Ringer’s solution containing epinephrine (1:1,000,000) in 500-ml bottles. The concentrations of the mixtures varied between 0.3% and 0.06% depending on the requirements of surgery. Routinely available 18- to 30-gauge needles were used. The speed of injection varied between 30 ml and 1500 ml per hour depending on the location, the requirements of surgery, and the needle size. Volumes usually ranged from 2 ml to 1000 ml depending on the concentrations. The maximum dose was approximately 4 mg of prilocaine and 2 mg/kg of ropivacaine, which is the maximum tolerated dose. Regardless of secondary disorders, all patients scheduled for skin and lymph node operations under local anesthesia underwent surgery using this kind of anesthesia, including those for the nose and ear region. No suprarenin was added for nerve blocks of the fingers and penis. This technique was used in 20,310 major and minor skin operations in 11,810 patients ranging in age from 0.5 years (510 children under 14 years) to 95 years (mean age 55 years; 49% females, 51% males), including all types of local flaps and grafts. There were no complications whatsoever from local anesthesia. The technique proved safe and comfortable even for children and very sensitive patients. The median duration of postoperative anesthesia was 4.3 h (maximum 23 h). We found that experience is required for correct selection of the needle position, the flow rate, and the volume.

Introduction: It is still unclear whether sentinel lymph node biopsy (SLNB) has an effect on the survival or recurrence-free survival of patients. It would be necessary to draw comparisons between patients with SLNB (or with selective lymph node dissection in the case of positive SLNB) and patients without SLNB who underwent only close clinical and sonographic follow-up. To date no results from prospective, randomized studies of SLNB are available. Material and Methods: Patients with SLNB (n = 283) and patients in clinical stage I and II with close follow-up examinations only (n = 3,514) were studied retrospectively in this investigation with regard to prognostic factors established in the literature: sex, age, tumor thickness, histological tumor type, ulceration and localization. Results: Multivariate analysis showed an independent significant advantage with regard to survival when SLNB had been performed (p = 0.017). Compared with patients in clinical stage I and II with close follow-up only (n = 2,617), patients in stage I with negative SLNB (n = 238) had a significantly lower melanoma-related mortality (p = 0.0042) and, especially, fewer recurrences in the regional lymph node station area (p = 0.0026). With regard to survival without distant metastases, patients with positive SLNB (n = 33) did not significantly benefit by comparison with patients who developed lymph node metastasis identified clinically or sonographically later during follow-up examinations (n = 246; p = 0.0084). Conclusion: In the relatively short follow-up period after SLNB, patients for whom SLNB had been performed had on the whole a prognostic advantage over patients who were subject only to close follow-up monitoring. Patients for whom subclinical lymph node metastases had been removed as the result of a positive SLNB did not have a better prognosis than patients without SLNB who had developed lymph node metastases within the follow-up period.

Die Behandlung von Kindern und jugendlichen Patienten mit vaskularen Anomalien im Kopf- und Halsbereich erfordert die interdisziplinare Zusammenarbeit von Padiatern, Mund-, Kiefer- und Gesichtschirurgen, Dermatologen und Radiologen. Grundlage der gemeinsamen Therapieentscheidung ist eine international anerkannte Klassifikation vaskularer Anomalien. Danach werden Hamangiome als proliferierende Neubildungen von vaskularen Malformationen als anlagebedingte Fehlbildungen unterschieden. Nach Hamodynamik und Gefasbett teilen wir letztere in langsam durchstromte kapillare, lymphatische oder venose Malformationen und in rasch durchflossene arteriovenose Malformationen ein. In dieser Arbeit wird ein Algorithmus zur klinischen und bildgebenden Diagnostik vaskularer Anomalien vorgestellt. Die Indikationen zur Behandlung werden diskutiert und die Therapieoptionen erlautert.

PURPOSE: In patients with extended vascular anomalies in the head and neck, therapeutic decisions may pose a challenge to maxillofacial surgeons, dermatologists, and interventional radiologists. We analyzed the value of an interdisciplinary classification and treatment concept. PATIENTS AND METHODS: The classification distinguishes hemangiomas and vascular malformations. Whereas hemangiomas are endothelial proliferations, vascular malformations are considered to be developmental anomalies, which are further classified into high-flow or low-flow lesions and according to the vascular channels into capillary, venous, or lymphatic malformations. Since 2000 we have provided interdisciplinary consultation for patients with vascular anomalies. In patients with hemangiomas and venous malformations, the clinical diagnosis is confirmed by color-coded duplex sonography and magnetic resonance imaging; angiography is performed as part of the treatment planning for patients with arteriovenous malformations. Patients with hemangiomas are treated surgically by cryosurgery or laser surgery or conservatively according to lesion size and behavior. In patients with venous malformations, percutaneous sclerotherapy is combined with surgical reduction; patients with arteriovenous malformations undergo transarterial embolization prior to surgical excision of the nidus. RESULTS:A total of 73 patients attended the interdisciplinary consultation. This group included 53 patients with facial hemangiomas, 7 with venous malformations, 2 with capillary malformations, 5 with lymphatic malformations, and 6 with high-flow arteriovenous malformations. CONCLUSIONS: The interdisciplinary protocol increases diagnostic accuracy and helps to establish individual treatment plans for patients with extended vascular anomalies.

The prognostic value of the type of anaesthesia used for the excision of malignant tumours has been a subject of controversy. Cell-mediated as well as humoral immune responses can be compromised after general anaesthesia, and recurrences may therefore occur more frequently. On the other hand, excision of primary tumours under local anaesthesia might also influence the prognosis unfavourably. The aim of the present study was to determine the prognostic impact of general and local anaesthesia for the primary excision of cutaneous melanoma. Follow-up data of 4329 patients on the Central Melanoma Registry of the German Dermatological Society were analysed. Cox proportional hazards analysis was performed to evaluate the independent significance of the prognostic factors, and survival probabilities were calculated for matched pairs using Kaplan-Meier estimates. Statistical analysis revealed an independent significant effect on survival for tumour thickness, ulceration, level of invasion, anatomical site and gender. General anaesthesia for primary excision of melanoma was associated with a decrease in the survival rate (relative risk 1.46, P

Tumescent local anesthesia (TLA) means an effective anesthesia with about 100 fold lower concentrated solutions than usual. Therefore it is possible to apply 100 fold more volume of the solutions. This extended the indications for the use of local anesthesia. In 1892, C. L. Schleich had experimented successfully with this principle of dilutions using Cocaine and performed huge operations in local anesthesia. But this good idea was not further supported because of the more and more used inhalation anesthesia. About 90 years later in 1987, J. Klein again had this idea in the use of local anesthesia for liposuction using Lidocaine, which was introduced in 1942. G. Sattler introduced the method again in Germany in 1994. He used a roller pump for injection. A controverse discussion took place about the maximal doses which could be applied without danger. Soon a lot of new application fields for operations in local anesthesia were created, such as vein stripping and large skin-operations. In 1998, H. Breuninger developed the subcutaneous infusion anesthesia with flow and volume controlled infusion automats (auto-TLA). In 1999, he combined the solution with the new long-lasting and very safe local anesthetic ropivacaine which was introduced in 1994. The long lasting anesthesia allowed the division of the application and operation. Nearly all surgical procedures could be performed in local anesthesia, even in children. In 2006, H. M. Haefner showed that epinephrine can be used without danger at all acres. The development of TLA is not yet finished.

Background: Tension on surgical wound margins frequently results following the excision of skin lesions such as tumors, naevi or scars. This tension is commonly counteracted with buried, intracutaneous, interrupted sutures of absorbable or non-absorbable material anchored vertically in the corium. Method: A horizontal, buried, intracutaneous suture has now been developed which can be more firmly anchored in the corium. It adapts and everts wound margins nearly as broadly as two vertical sutures, particularly, when the wound edges are cut obliquely with a longer rim of epidermis. When finished, the suture has a butterfly shape, whence its name. It can also be laid as a double suture (double butterfly suture). In creating this sutures, the surgeon changes the customary direction of the needle holder from horizontal to vertical. Materials: Since 1985, this suture has been made with polydioxanon in more than 30000 skin lesion excisions with very good results. In most cases the resulting narrow and smoth scars were narrow and flat in the most cases. During the study, the following suture materials were tested prospectively in 1325 patients: polyglactin 910 (Vicryl®) (n=390), polytrimethylcarbonate (Maxon®) (n=95), poliglecaprone 25 (Monocryl®) (n=175), and (PDS®) (n=665). Results: The results were unsatisfactory in only 8% of procedures. Polyglactin 910 was accompanied by somewhat more inflammation and scar dehiscence, poliglecaprone 25 by a high rate of scar dehiscence. Polytrimethylcarbonate caused skin reactions in 23% and was discontinued. Suture perforation occurred in 9%. Polydioxanon yielded the best results (p-value of the difference

Squamous cell carcinomas of the skin and their precursors, actinic keratosis as well as basal cell carcinomas are classified as non-melanocytic skin cancer and belong to the group of epithelial skin tumors. This tumor entity is one of the most common forms of malignant cancer in western countries with an incidence of approximately 100-170 per 100,000 inhabitants per year in Europe. In German-speaking countries no exact numbers are available on the early forms of squamous cell carcinoma, actinic keratosis (carcinoma in situ); however, results from Great Britain show that at ages over 70 years old the prevalence of actinic keratosis is 34 % in men and 18 % in women. Because invasive epithelial cancer is very common and most commonly occurs in the head region, a safe but skin-sparing approach to surgical treatment is desirable. The safest procedure with respect to local recurrence is surgical excision with subsequent complete 3-dimensional histological preparation (micrographic surgery). With this method it is possible to excise tissue affected by tumor tissue in small steps. This facilitates defect coverage and leads to very good results as well as good esthetic results. The local recurrence rates are extremely low compared to alternative treatment methods, such as photodynamic therapy, topical application of imiquimod or cryosurgery and for the treatment of basal cell carcinoma, for example is 0.7 %. Dermatological operations are therefore interventions with a very high guarantee of tumor-free survival and functional and esthetic results.

Large nonhealing ulcers and wounds frequently pose a great therapeutic challenge to clinicians and often require skin grafting. Various skin grafting methods are available to cover large skin defects that fail to epithelize. These methods include the use of small pinch grafts, full-thickness punch grafts, large-sized full-thickness grafts and split-thickness grafts. Large-sized full-thickness and split-thickness skin grafting requires expertise to produce cosmetically acceptable results and prevent cobblestoning, unlike small pinch and full-thickness punch grafts.To describe a modified technique of split-thickness skin grafting that can be considerably faster than alternative methods.We describe a method for split-thickness skin grafting using tumescent anaesthesia at the donor site and an electrodermatome and a polyurethane membrane without sutures at the site of the skin defect.Since 1997, we have practised a modified, improved, quick and easy split-thickness skin grafting method to cover large skin defects at the extremities. Complete healing is usually achieved 4-6 weeks after the split-thickness skin transplantation, and long-term results are aesthetically successful.We provide a sophisticated modified split-thickness skin graft procedure that has been practised for many years and provides cosmetically acceptable results while saving time.

The implementation of an interleaved boost converter using SiC diodes for PV applications is presented in this paper. The converter consists of two switching cells sharing the PV panel output current. Their switching patterns are synchronized with 180 degree phase shift. Each switching cell has a SiC Schottky diode and a CoolMOS switching device. The SiC diodes provide zero reverse recovery current ideally, which reduces the commutation losses of the switches. Such advantage from the SiC diodes can make the converter system achieve higher efficiency and higher power density by reducing the requirement of the cooling system. This paper presents also an optimization study of the size and efficiency of the interleaved boost converter. Based on 1) the steady-state characteristic of the topology, 2) the static and dynamic characteristics of the switching cells, 3) the loss model of the magnetic components and 4) the cooling system design, the paper provides a set of design criteria, procedures and experimental results for a 2.5 kW interleaved boost converter using SiC diodes prototype.

Acral lentiginous melanomas (ALM) represent 4-10% of cutaneous melanomas in white populations. Patients with ALM seem to have a poor prognosis, often due to late diagnosis. Micrographic surgery (3D-histology) is not seen as surgical procedure but more as histopathological technique. With micrographic surgery, continuously spreading ALM can be excised with smaller excision margins and good functional and cosmetic outcomes. In a recent study, 244 patients with ALM were compared using conventional histology versus 3D-histology. Clinical and surgical risk factors influence the prognosis of ALM. Tumor thickness and ulceration are the most important prognostic factors. 3D-histology with paraffin technique (optionally combined with immunohistological methods) can reduce excision margins and avoid local recurrences. Subungual melanomas represent only 2-3% of cutaneous melanomas in Caucasian and 20% in African or Asian skin type and are often clinically misdiagnosed. They are often localized on the thumb or great toe, which are most important for the function of the affected limb. The excision of subungual melanoma with 3D-histology and tumor-free excision margins including the nail matrix can be seen as a safe surgical strategy, which does not hazard the prognosis of the patient. Function and cosmesis of the finger or toe are preserved. Amputation in subungual melanoma is not recommended and should be reserved only for infiltrating melanomas with affection of the bone or joint.

Special knowledge is required to treat acral skin tumors. These lesions are encountered relatively often by dermatologic surgeons. A tissue-sparing operative approach is essential. Especially when dealing with malignant tumors, complete excision must be strived for. One must also consider the methods of local spread of the different tumors. Highly-sensitive 3D histology allows one to combine complete removal and tissue sparing. This helps in preserving function. The operative approach is made simpler by automatic subcutaneous infusion anesthesia with epinephrine added to the local anesthetic; this can also be employed without concern in acral regions.

LBTI is a thermal imager and a nulling interferometer to be installed on the Large Binocular Telescope (LBT). Here, we present the distributed component architecture model and its simple yet powerful software structure designed to complement the LBTI hardware model that comprises pyramid wave front sensors with its control electronic universal beam combiner, phase sensor, science imager, and all housekeeping duties to run the cryogenics, compressors, vibration monitors and the interface to the telescope control systems.

We present 2 techniques of micrographic surgery (3D-histology) useful to control lateral and deep limits of cutaneous tumors. We have adapted the protocol created in Germany, at the University of Tuebingen, for French pathologists and dermatologists.

Current adaptive optic systems are limited by the read noise and sensitivity of their wavefront cameras. Recent advances in substrate thinning are producing focal plane arrays with high quantum efficiencies and extended spectral response over 0.5 to 1.6 microns. Infra Red Laboratories have developed and tested a new ultra-low noise readout integrated circuit (ROIC) that has a performance of 2 electrons (r.m.s.) per pixel read. We combine these two technologies to produce a new detector capable of dramatically increasing the number of available natural guide stars across the sky (and hence increased sky coverage), even in heavily obscured regions near the Galactic plane.

Conventional surgery for lentigo maligna melanoma (LMM) is based on normal histological evaluation. However, such evaluation leaves diagnostic gaps. In contrast, complete three-dimensional (3D) histology of excision margins permits accurate detection of continuously spreading tumour strands like those of LMM. These can be specifically excised in tumour-positive areas with smaller excision margins, and better cosmesis and function. To date there have been no controlled studies of micrographic surgery of LMM.Clinical parameters and surgical strategies influencing the prognosis of patients with LMM were evaluated in a prospective study of melanoma patients in the Department of Dermatology of the University of Tübingen (1980-99).The 292 LMMs comprised 7.4% of 3960 primary stage I and II melanomas treated during this period. One hundred and thirty-six patients in this group (46.6%) underwent surgery on the basis of 3D histology.The geometric mean excision margins were significantly smaller in the 3D histology group (P0.0001). Patients with micrographic surgery had fewer recurrences. Multivariate analysis of clinical, histological and surgical variables was carried out, and tumour thickness and 3D histology proved to be independent, significant factors for the prognosis of recurrence-free survival (relative risk, RR 2.08, P0.0001 and RR 2.11, P = 0.0037, respectively). There were no melanoma-related deaths in the 3D histology group. All 16 melanoma-related deaths were observed among the 156 patients of the conventional histology group (10.3%).Excision of LMM using 3D histology resulted in a twofold lower probability of recurrence and twofold smaller excision margins. 3D histology is a valuable diagnostic tool and can be used in the management of LMM because of the latter's pattern of continuous tumour spread.

The ear's specific anatomical and lymphatic characteristics impose special requirements on the treatment of melanoma of the ear.The aim of this prospective study was to define prognostic factors for melanoma of the ear and to evaluate surgical strategies for excision margins, histological evaluation and sentinel lymph node biopsy (SLNB) in order to achieve better cosmetic and functional results.One-hundred and sixty-one patients with stage I/II melanoma of the external ear were treated in the Department of Dermatology, University of Tuebingen, from March 1976 to March 2004 (median follow-up 62 months). Malignant melanoma of the external ear represented 3% of the stage I/II cutaneous melanomas and 20% of the stage I/II head and neck melanomas recorded in the Melanoma Registry of the Department of Dermatology at the University of Tuebingen. Twenty of 42 lentigo maligna melanomas (LMM) underwent conventional histological evaluation, 22 underwent complete three-dimensional histology of excision margins (3D histology) in a paraffin-technique, i.e. micrographic surgery. SLNB was performed in 28 patients with melanomas thicker than 1.0 mm. Clinical, histological and surgical risk factors were evaluated by univariate and multivariate analysis.The median thickness of the tumours in the present study was 1.08 mm (mean 1.51 mm; range 0.18-8.50 mm), and the median excision margins were 11.0 mm (mean 12.61 mm; range 2.0-31.0 mm). The 3-year disease-specific survival rate was 98%, and the 3-year recurrence-free survival rate was 83%. Tumour thickness and invasion level were the only risk factors significant for disease-specific survival. Tumour thickness, location of the tumour and extent of excision margins were independently significant risk factors for recurrence-free survival. LMMs removed surgically with accompanying 3D histology were thicker than those examined by conventional histology (median 0.93 mm vs. 0.83 mm). The use of surgery with 3D histology, i.e. micrographic surgery, made it possible to reduce the excision margins (median 5 mm vs. 10 mm) without an increased risk of recurrence. Two of 29 SLNBs were positive (6.9%). There were six preregional recurrences after negative SLNB and one after positive SLNB. None of the patients who underwent SLNB died of melanoma-related causes during the observation period.This is the largest series of ear melanomas reported so far. The overall survival depended only on the tumour thickness and Clark level of invasion. Local recurrence was more frequent with smaller excision margins, but this did not influence the overall survival. Smaller excision margins under 3D-histological control did not carry an increased risk of local recurrence. Our results do not permit conclusions regarding the prognostic impact of SLNB for patients with melanoma of the ear.

Clio is an adaptive-optics camera mounted on the 6.5 meter MMT optimized for diffraction-limited L' and M-band imaging over a ~15'' field. The instrument was designed from the ground up with a large well-depth, fast readout thermal infrared (~3-5 micron) 320 by 256 pixel InSb detector, cooled optics, and associated focal plane and pupil masks (with the option for a coronograph) to minimize the thermal background and maximize throughput. When coupled with the MMT's adaptive secondary AO (two warm reflections) system's low thermal background, this instrument is in a unique position to image nearby warm planets, which are the brightest in the L' and M-band atmospheric windows. We present the current status of this recently commissioned instrument that performed exceptionally during first light. Our instrument sensitivities are impressive and are sky background limited: for an hour of integration, we obtain an L'-band 5 sigma detection limit of of 17.0 magnitudes (Strehl ~80%) and an M-band limit of 14.5 (Strehl ~90%). Our M-band sensitivity is lower due to the increase in thermal sky background. These sensitivities translate to finding relatively young planets five times Jupiter mass at 10 pc within a few AU of a star. Presently, a large Clio survey of nearby stellar systems is underway including a search for planets around solar-type stars, M dwarfs, and white dwarfs. Even with a null result, we can place strong constraints on planet distribution models., Comment: 10 pages, 4 figures, SPIE Astronomical Telescopes and Instrumentation 2006 Conference Proceedings, in press

Reconstruction of the umbilicus after tumor excision is of great aesthetic importance for the patient. Methods for umbilical reconstruction have been described but do not provide elegant solutions to the problem. The method presented permits reconstruction using two opposing trapezoidal skin flaps at the excision margin. The umbilical cavity is restored by anchoring these flaps at the linea alba. This reconstruction was carried out on seven patients after melanoma excision of the umbilical area.

In treated facial melanomas, the safety margins generally applied in other body sites cannot be achieved for functional and esthetical reasons. To date there are no controlled studies on safety margins for facial melanomas. Clinical parameters and surgical strategies influencing the prognosis of patients with a facial melanoma were evaluated in a retrospective study of melanoma patients in the Department of Dermatology of the University of Tuebingen (1980-1999).The 368 melanomas of the face comprised 9.3% of 3960 primary stage I and II melanomas and 63% of the melanomas in the head and neck area.Multistep procedures, excisional biopsy for histological diagnosis followed by a subsequent resection of a clinical safety margin or re-excision when the tumor extended to the margin, were associated with a higher probability for recurrence-free survival (p = 0.0007), but had no statistical influence on overall survival. In a multivariate analysis, level of invasion (p = 0.0049), ulceration (p = 0.011), 3D-histology (p = 0.027) and defined safety margins (tumor thicknessor = 1.00 mm: 10 mm;1.00 mm 20 mm; lentigo maligna melanoma 5 mm with 3D-histology) (p = 0,033) were independent significant risk factors for recurrence-free survival. Level of invasion (p = 0.032), ulceration (p = 0.029), 3D-histology (p = 0.0047) were identified as independent significant risk factors for overall survival. Multivariate analysis did not show that the histological type of melanoma was of prognostic significance.Reduced safety margins can be employed in melanomas of the face. 3D-histology allows further reduction of safety margins, detects subclinical tumor strands and is correlated with an improved prognosis in patients with facial melanomas.

Sentinel node biopsy (SNB) is increasingly being used as a minimally invasive staging procedure in patients with malignant melanoma. For decades elective lymph node dissection (ELND) was performed in many centers on patients at risk for lymph node metastasis but without clinically detectable lymph node involvement. Today, selective lymph node dissection (SLND) is offered only to patients with histologically proven metastasis in a SN (10-29%). A positive SN is one of the most important prognostic parameters. Ten years after the introduction of the technique, the role of SNB in the treatment of cutaneous melanoma still remains controversial. Issues include the usefulness of highly sensitive evaluation of SN using molecular biology or cytology techniques, as well as the therapeutic impact of the SNB per se and the associated combined surgical or medical adjuvant therapies.

Bei der Behandlung von Basaliomen, Plattenepithelkarzinomen sowie einer Reihe weiterer Tumoren der Haut zeigen Falle, die mittels einer dreidimensionalen, luckenlosen histologischen Aufarbeitung der Schnittrander untersucht und bis zum Nachweis tumorfreier Rander nachoperiert wurden (mikrographische Chirurgie), eine um eine Zehnerpotenz geringere Rezidivrate wie Patienten, deren Tumorexzisate mit parallelen Serienschnitten beurteilt wurden. Dies konnte auch in unseren Untersuchungen an uber 5900 Fallen demonstriert werden. Die Rezidivrate liegt dabei unter 1 %. Der Unterschied last sich durch das typische subklinische Wachstumsverhalten von epithelialen Hauttumoren erklaren. In der folgenden Arbeit werden 2 einfache Methoden der technischen Aufarbeitung beschrieben, welche auch fur Einsendehistologien gut geeignet sind.

The treatment of paediatric patients with extended vascular anomalies in the head and neck requires a multidisciplinary approach involving paediatricians, maxillofacial surgeons, dermatologists and radiologists. Therapeutic strategies are based on an internationally accepted classification of vascular anomalies, which distinguishes haemangiomas and vascular malformations. Whereas haemangiomas are endothelial proliferations, vascular malformations are considered to be developmental anomalies which are classified into high-flow or low-flow lesions and, according to their vascular channels, into capillary, lymphatic or venous malformations. In this review we present guidelines for the diagnostic assessment of paediatric patients with vascular anomalies in the head and neck region. The indications for treatment are discussed and therapeutic options are outlined.

We have studied the prevalence of anti-microbial resistance of Streptococcus pneumoniae in Southwest Germany. One hundred seventy-four clinical isolates of pneumococci collected from hospitalized patients between October 1992 and April 1994 were used for MIC determinations. MICs for penicillin, ceftriaxone, erythromycin, and rifampicin were assessed by the E test. Eleven of the 174 strains (6.3%) were intermediately resistant to penicillin (MIC between 0.1 and 1.0 microgram/ml) and four of the 174 strains (2.3%) were intermediately resistant to ceftriaxone (MIC between 0.1 and 1.0 microgram/ml). All four isolates with a reduced susceptibility to ceftriaxone also demonstrated intermediate resistance to penicillin. Six of the 174 strains (3.5%) were highly resistant (MICor = 8 micrograms/ml) to erythromycin. Resistance to rifampicin was not observed. Our results demonstrate that pneumococcal resistance to penicillin and erythromycin has increased markedly in Germany over the last decade. Our findings underline the need for continuous surveillance of antimicrobial resistance of Streptococcus pneumoniae.

In patients with extended vascular anomalies in the head and neck, therapeutic decisions may pose a challenge to maxillofacial surgeons, dermatologists, and interventional radiologists. We analyzed the value of an interdisciplinary classification and treatment concept.The classification distinguishes hemangiomas and vascular malformations. Whereas hemangiomas are endothelial proliferations, vascular malformations are considered to be developmental anomalies, which are further classified into high-flow or low-flow lesions and according to the vascular channels into capillary, venous, or lymphatic malformations. Since 2000 we have provided interdisciplinary consultation for patients with vascular anomalies. In patients with hemangiomas and venous malformations, the clinical diagnosis is confirmed by color-coded duplex sonography and magnetic resonance imaging; angiography is performed as part of the treatment planning for patients with arteriovenous malformations. Patients with hemangiomas are treated surgically by cryosurgery or laser surgery or conservatively according to lesion size and behavior. In patients with venous malformations, percutaneous sclerotherapy is combined with surgical reduction; patients with arteriovenous malformations undergo transarterial embolization prior to surgical excision of the nidus.A total of 73 patients attended the interdisciplinary consultation. This group included 53 patients with facial hemangiomas, 7 with venous malformations, 2 with capillary malformations, 5 with lymphatic malformations, and 6 with high-flow arteriovenous malformations.The interdisciplinary protocol increases diagnostic accuracy and helps to establish individual treatment plans for patients with extended vascular anomalies.

Little data is available on the log-term effects of stripping the greater and lesser saphenous veins in combination with pre- and post-operative function tests. The goal of this study was to record the long-term course after surgery based on the function data.Drain-off capability was measured preoperatively and postoperatively by light reflection rheography in 203 patients (58 men, 145 women) between 17 and 79 years. Questionnaires were used about 9 years after surgery to determine the nature of the post-operative complaints.Nine years after surgery 58% of the patients still had no discomfort, and 78% had fewer problems with venous ulcers. About 60% reported improvement of swelling and skin changes. The results tended to be better in men. Freedom of complaints was longer-lasting where venous drainage had been good before surgery.Stripping operations can produce long-lasting improvement of venous ulceration and the above-mentioned complaints in a high percentage of patients.

Various histopathological techniques have been developed in order to improve the detection of micrometastasis in the regional lymph nodes of patients with malignant melanoma. Our standard histopathological examination of lymph nodes included haematoxylin and eosin (H & E) staining and immunohistochemistry (IH) using antibodies to HMB-45 and S-100 proteins of three paraffin sections at one level. In addition, lymph nodes were examined by molecular biological methods using tyrosinase reverse transcription-polymerase chain reaction (RT-PCR). In this study, we investigated the use of step sections and IH in lymph nodes regarded as negative by standard histopathology but positive by tyrosinase RT-PCR, suggesting the presence of tumour cells. In a series of 76 consecutive patients with stage I and II cutaneous melanoma, a total of 156 regional lymph nodes were examined by H & E staining, IH and tyrosinase RT-PCR. All lymph nodes were bisected along their long axis for separate evaluation. In 21 patients, at least one lymph node in the regional nodal basin reported as tumour-negative by standard histopathology was demonstrated to express tyrosinase (total number of nodes = 33). These 33 lymph nodes were re-examined by H & E and IH at 10 additional levels of the paraffin block. Only one lymph node from one patient had occult melanoma cells in deeper levels detected exclusively by IH. Six out of 20 patients with positive findings exclusively on tyrosinase RT-PCR developed tumour recurrences during a median follow-up of 34 months. We therefore conclude that additional step sectioning with IH does not significantly increase the detection of tumour-positive lymph nodes. Patients with melanoma cells detected exclusively by RT-PCR, however, were shown to be at increased risk for tumour recurrence.

Reliable, long-acting local anesthetics reduce postoperative pain and make it easier to plan surgery. This is especially true when slow infusion anesthesia (SIA) is used. The anesthetic agent ropivacaine appears to meet the requirements of SIA especially well.1. Venous bloodlevels of ropivacaine after subcutaneous infusion of the maximum dose of 300 mg ropivacaine containing adrenaline 1:1,000,000 were measured in 10 volunteers, time not mentioned in German abstract! We agreed they would match. 2. 30 healthy volunteers received 30 ml of three solutions of lidocaine alone, lidocaine mixed with ropivacaine, and ropivacaine alone, all containing adrenaline 1:1,000,000. The local anesthetic effects were studied. 3. Ropivacaine was used clinically both alone and with different mixtures of ropivacaine and prilocaine, each containing adrenaline 1:1,000,000, in a total of 4,670 cutaneous surgical procedures of all kinds in 3,015 patients. No patient was excluded from this kind of anesthesia. Patient ages ranged from 0.5 to 95 years (median: 54.5). No adrenalin was added for nerve blocks of the fingers and penis.The venous blood levels after administration were low. Ropivacaine acted more than twice as long as lidocaine (p0.001). Clinical application of the mixtures was completely free of side-effects and complications and involved a very low rate of postoperative bleeding. The patients remained free of pain as a rule for many hours.We regard ropivacaine as a major step forward in the use of local anesthesia.