A modified, improved, easy and fast technique for split-thickness skin grafting.

BACKGROUND: 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. OBJECTIVES: To describe a modified technique of split-thickness skin grafting that can be considerably faster than alternative methods. 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. RESULTS: 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. CONCLUSIONS: 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.

Micrometastasis of a sentinel lymph node in cutaneous melanoma is a significant prognostic factor for disease-free survival, distant-metastasis-free survival, and overall survival.

OBJECTIVE: Sentinel lymph node biopsy (SLNB) has been proposed as a minimally invasive procedure for the histopathologic staging of the regional lymph node basin. The aim of this work was to investigate the prognostic value of detection of micrometastasis by SLNB. METHODS: In the period from January 1996 to March 2000, a sentinel lymph node (SLN) was identified in 283 patients at the Department Dermatology, University of Tuebingen. In the case of 38 patients (13.4%) histopathologic examination led to the detection of micrometastasis in at least one SLN. The median follow-up period was 29 months. RESULTS: Thirty-one of 245 patients (12.7%) suffered a tumor recurrence following a negative SLNB, and 19 of 38 patients (50%) following positive SLNB. In the case of disease-free survival the remaining significant independent prognostic factors of the multivariate analysis were tumor thickness (p=0.011), ulceration (p=0.026), and the detection of micrometastasis in SLNB (p=0.021). With respect to distant-metastasis-free survival the significant independent prognostic factors of the multivariate analysis were tumor thickness (p=0.0022) and the SLNB results (p=0.0068). For overall survival the tumor thickness (p=0.013) and the SLNB results (p=0.034) were significant independent prognostic parameters in the multivariate analysis. CONCLUSION: The study examined patients with melanomas of all tumor thicknesses and SLNB for which the prognostic significance of SLNB was tested. Recurrences were more frequent in patients with a micrometastatic SLN. Patients with a negative SNLB are still at risk for tumor recurrence. The histopathologic result of SLNB is, after tumor thickness, the most significant prognostic factor for disease-free survival, distant-metastasis-free survival, and overall survival.

Clinical risk factors and prognostic significance of local recurrence in cutaneous melanoma.

BACKGROUND: True local recurrence (LR) means clinically detectable regrowth of parts of the tumour which were not completely excised. In the literature the term 'LR' has been used in a vague and inconsistent manner that may include satellite and in-transit metastasis. OBJECTIVE: The aim of this study was to establish clinical, histological and surgical risk factors for the manifestation of LR and to evaluate the prognostic significance of LR. STUDY DESIGN: Data from 3960 Stage I and II melanoma patients who visited the melanoma clinic of the Department of Dermatology at the University of Tuebingen from 1980 to 1999 were documented in a prospective manner. A retrospective comparative analysis of patients with and without LR was performed. RESULTS: Of all patients 1.4% had a LR as a first recurrence and 1.7% had a LR in the course of the follow-up period. LR were most frequent after previous clinical or histological misdiagnosis and inadequate therapy. In the univariate analysis significant risk factors for LR-free survival were age, tumour surface area, locality, tumour thickness, level of invasion, histological type, associated naevus, surgery (one step vs. multiple steps) and compliance with recommended excision margins. In the multivarate analysis the factors locality (P < 0.0001), tumour thickness (P = 0.0086) and compliance with recommendations on excision margins (P = 0.014) were significant independent risk factors for the manifestation of LR. The overall survival of patients with LR as first progression did not significantly differ from the overall survival of the other patients with melanoma (P = 0.60). CONCLUSION: True LR is a rare event for which tumour locality, tumour thickness and surgery are independent risk factors. The occurrence of LR might not impair the prognosis of melanoma patients. However, in the published literature numerous definitions of 'LR', including lymphogenic metastasis, complicate comparison.

Is sentinel lymph node biopsy of therapeutic relevance for melanoma?

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 compare patients with SLNB (or with selective lymph node dissection in the case of positive SLNB) and patients without SLNB who received only a 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 did not show an independent significant advantage with regard to survival when SLNB had been performed (p = 0.37). Compared with patients in clinical stage I and II with close follow-up only (n = 2,617),patients in stage I and II with negative SLNB (n = 238) had no significantly lower melanoma-related mortality (p =0.36) but significantly fewer recurrences in the regional lymph node area (p = 0.0015). With regard to survival without distant metastases and disease-specific survival, 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 =0.89 and p = 0.38, respectively). CONCLUSION: In the relatively short follow-up period after SLNB, patients for whom SLNB had been performed did not have - 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 [corrected]

[Prognostic parameters and surgical strategies for facial melanomas]. / Prognostische Faktoren und operative Strategien bei Melanomen des Gesichts.

BACKGROUND: 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). PATIENTS AND METHODS: 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. RESULTS: 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 thickness < or = 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. CONCLUSION: 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.

[Stripping operations of the parva and magna saphenous veins. Long-term study in relation to pre- and postoperative dysfunction]. / Strippingoperationen der V. saphena magna und parva. Langzeituntersuchung in Beziehung zu prä- und postoperativen Funktionsprüfungen.

BACKGROUND AND OBJECTIVE: 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. PATIENTS/METHODS: 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. RESULTS: 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. CONCLUSIONS: Stripping operations can produce long-lasting improvement of venous ulceration and the above-mentioned complaints in a high percentage of patients.

[Questionable effectiveness of autologous platelet growth factors (PDWHF) in treatment of venous ulcers of the leg]. / Fragliche Wirksamkeit autologer thrombozytärer Wachstumsfaktoren (PDWHF) in der Behandlung venöser Beinulzera.

Chronic venous insufficiency (CVI) can cause ulcers of the lower limb having the character of a full thickness wound involving the subcutaneous tissues and fat. Healing requires wound contraction, connective tissue formation and finally reepithelialization. To induce wound healing, on an underlying disturbed environment due to longterm effects of CVI, artificial stimuli may be needed. In a placebo controlled study we tried topical application of autologous PDWHF (platelet derived wound healing factors), to achieve ulcer healing and improve the microangiopathy surrounding of the ulcer area, as there are decreased number of skin capillaries and reduction in cutaneous vascular reserve. Alterations of cutaneous circulation during the course of the study were documented by capillaroscopy, transcutaneous oxygen pressure and laser Doppler flux (LDF) measurements. We were able to recruit 15 patients a I suffering from chronic nonhealing venous stasis ulcers. Eleven of the 15 patients agreed to participate in a placebo-controlled double blind study, whereas 4 patients agreed to participate only if they would be treated with PDWHF. The median age and duration of ulceration of the 6 patients (3 male/3 female) treated with placebo were 71 years and 1089 days. The median age and duration of ulceration of the 9 patients (1 male/8 females) treated with PDWHF were 66 years and 732 days. Duration of therapy for the PDWHF group was 91 days, as compared to 154 days for the placebo group. Despite 2 completely healed ulcers, the expensive treatment did not reveal any significant clinical advantage. In den PDWHF group an ulcer area of 26.9 cm2 was measured at the beginning, of 26.2 cm2 at the end; in the placebo group, 34.7 cm2 and 35.5 cm2. The nonsignificant increase of the capillary density at the ulcer border in the active group as well as the increase in the tcPO2, in contrast to little change in both parameters in the placebo group, suggests neoangiogenic abilities to PDWHF, secondarily leading to a better blood distribution with higher oxygen tension.

Anaphylactic reaction to bovine serum albumin after embryo transfer.

OBJECTIVE: To increase the awareness of bovine serum albumin (BSA) sensitivity as a potentially lethal complication during ET. DESIGN: Case report. SETTING: Routine ET in university hospital. PATIENT(S): A 26-year-old woman who was undergoing her first ET. INTERVENTION(S): ET with BSA containing standard fluid medium. MAIN OUTCOME MEASURE(S): Specific immunoglobulin (Ig) E antibodies and skin tests. RESULT(S): The patient demonstrated increased levels of specific IgE antibodies to BSA and a clearly positive scratch test for BSA. CONCLUSION(S): Anaphylactic reactions to BSA can occur during ET. The risk can be reduced substantially if a detailed medical history is obtained.

[Desmoplastic squamous epithelial carcinoma of the skin and lower lip. A morphologic entity with great risk of metastasis and recurrence]. / Das desmoplastische Plattenepithelkarzinom der Haut und Unterlippe. Eine morphologische Entität mit hohem Metastasierungs- und Rezidivierungsrisiko.

The desmoplastic type of the squamous cell carcinoma (DSCC) of the skin is an entity which is readily distinguished by light microscopy. The DSCC has fine branches surrounded by a desmoplastic stroma and shows in some cases typical perineural, perivascular and widespread intradermal invasion (maximum 6 cm!). This type accounts for 8.2% (n = 44) of our collective of 594 squamous cell carcinomas (SCC) of the skin and vermilion border. Clinically DSCC look like other malignant epithelial tumors of the skin. All tumors were followed up for at least 3 years (maximum 10 years). The local recurrence rate was high (24.3%) even though micrographic surgery was carried out. The rate of local or regional metastasis was also very high (22.7%). In comparison the recurrence rate and the rate of metastasis of the remaining common 91.8% SCC's (n = 550) was low: 2.6% and 3.8%, respectively. The DSCC seems to be identical with the so called neurotropic SCC, the fine stranded SCC or the SCC with perineural invasion which have a high rate of local recurrence and metastasis as well, but DSCC is a better generic histopathologic term for the entire group. The DSCC is best treated with micrographic surgery and wider safety margins than any other type and should be followed up very frequently.

[Subclinical spread of dermatofibrosarcoma protuberans and resulting treatment modalities]. / Die subklinische Ausbreitung des Dermatofibrosarkoma protuberans (DFSP) und daraus resultierende Behandlungsmodalitäten.

Dermatofibroma protuberans is a rare malignant tumour with a high rate of local recurrence. This is attributable to the tumour's characteristic of forming subclinical, pseudopodium-like outgrowths. Between 1981 and 1991 we treated 23 cases of dermatofibrosarcoma (9 primary tumours, 14 recurrences of tumours following initial treatment elsewhere) using the method of micrographic surgery with paraffin sectioning. Tumour size and localization were taken as parameters, along with the excision depth and the safety margin required for elimination of all tumour cells. The safety margin required for complete extirpation ranged from 5 to 60 mm. On average, recurring tumours infiltrated twice as far beyond the clinically visible tumour margin (22.4 mm) as primary tumours (10.0 mm). Up to now, no localized recurrences have been found in any patient. The therapy used here can be designated as the method of choice.

[The margin of safety and depth of excision in surgical treatment of basalioma. Use of 3-dimensional histologic study of 2,016 tumors]. / Untersuchungen zum Sicherheitsabstand und zur Exzisionstiefe in der operativen Behandlung von Basaliomen. Anwendung der dreidimensionalen histologischen Untersuchung bei 2016 Tumoren.

During the treatment of 2016 basal cell carcinomas (BCC), 1757 of which were primary tumours and 259, recurrences, every operation was followed by a check on radicality by means of histological evaluation of the margins of the excised tissue (three-dimensional histology). The average safe margin at first excision was 3.8 mm, and excision normally extended to the lower subcuticular border in depth. After first excisions, tumour tissue was found in 31.6% of histological sections prepared from the marginal sections at the circumference and/or on the underside of the excised material. Tumour material was far more frequent in the marginal area (28.3%) than on the underside (7%). With a 2-mm safe margin around the primary BCC there were still 46.7% tumour-positive marginal sections; with 4 mm, 20.3%; and with 6-8 mm, 14.7%. Fibrosing BCC and tumours with diameters over 20 mm, and recurrent BCC in particular had a significantly larger share of tumour-positive marginal sections and considerably more frequently required two or more reoperations until the final radical excision than did the solid and superficial types of BCC. An average safe margin of 4.5 mm plus standard deviation to give 7 mm (standard deviation 2.5 mm) was necessary for radical excision of primary BCC, but often even larger margins, up to a maximum of 3.2 mm were necessary. Hence, when surgical treatment of BCC does not include three-dimensional histological evaluation generous safe margins are necessary. Surgery with histological monitoring is the only justifiable method of treating tumours of the fibrosing type, recurrent BCC and BCC over 10 mm in diameter.(ABSTRACT TRUNCATED AT 250 WORDS)

[Combined use of the dermatome and high-speed fraise in the treatment of a generalized verrucous nevus (Jadassohn)]. / Die kombinierte Anwendung von Dermatom und hochtouriger Fräse bei einem generalisierten verrucösen Naevus (Jadassohn).

Since her birth, a 24-year-old woman had suffered from an extensive epidermal verrucous nevus on her left trunk. Because of its severe disfigurement and resulting negative psychosocial impact, the nevus was first removed in 1980 by means of a high-speed fraise; the cosmetic results, however, were not altogether satisfactory. Excision was attempted again in 1983 using both dermatome and high-speed fraise; this time, the cosmetic outcome was excellent.

[Value of scintigraphic examination methods with 99mTechnetium in injuries of the epiphyseal cartilage (author's transl)]. / Der Wert szintigraphischer Untersuchungsverfahren mit 99mTechnetium bei Epiphysenfugenverletzungen.

The value of scintigraphic examinations of injuries involving the epiphyseal plate is to be seen to ensure the correct diagnosis of the lesions type I and type V according to Salter and Harris. Further on the results of these scintigraphic examinations allow a better planning of the therapeutic procedure. Experimental findings in rabbits succeeded to predict the seriousness and an early prognosis. The disturbances of the epiphyseal blood flow can be diagnosed by 99m Tc-O4 labeled erythrocytes and 99m Tc-O4 labeled albumin microspheres. 99m Tc-MDP skeletal scintigraphy gives the information at which time the repair is done and full weight bearing is possible.