Reconstruction of Full Thickness Defects on the Scalp With Artificial Dermal Regeneration Template: Analysis of Long-Term Results in 68 Cases.

BACKGROUND: Artificial skin substitute templates have been shown to be a reliable solution for the reconstruction of large scalp defects with exposed skull bone, but there is a lack of long-term data. OBJECTIVE: The aim of this retrospective study was to investigate the long-term outcome of the procedure in a large cohort of 68 cases. MATERIALS AND METHODS: In total, 58 patients with 68 full thickness scalp defects with exposed skull bone, were included. Mean follow-up time was 24 (±19) months. RESULTS: The mean size of the defects was 63 (±54) cm2. During the follow-up period, no local recurrences occurred. Complications were observed in 13% of the cases including template necrosis (4%), infections (4%), ulcerations (3%), and autograft necrosis (2%). During the final follow-up, 26 patients had died due to internal diseases not associated with the surgery. Cosmetic results were rated good by the patients and an independent observer. CONCLUSION: The use of a dermal regeneration template for the reconstruction of large, full thickness defects of the scalp with exposed skull bone is a reliable method regarding the complication rate, safety of the procedure, and cosmetic outcome. Limitations of this study are the retrospective and single center design.

[Personal preference, experience, intuition and school of surgery dominate the use of wound drainage in dermatosurgery]. / Persönliche Präferenz, Erfahrung, Intuition und operative Schule dominieren die Verwendung postoperativer Wunddrainagen in der Dermatochirurgie.

BACKGROUND: The use of drainage systems in dermatosurgery has so far been carried out without evidence-based data. The indications, complications and contraindications are traditionally passed on from surgeon to surgeon but have so far not been defined. METHOD: An Internet-based survey was created and sent out to members of the German Society for Dermatosurgery (DGDC). The questions were on the general treatment approach in German language countries with reference to the use of wound drainage following dermatological operations as well as the utilization habits and experiences with drainage-associated complications. RESULTS: Of the DGDC members contacted 12.73% completed the questionnaire. Drainages were predominantly used in the clinical environment and all drainage systems in question were used. The extent and complexity of the intervention were essential criteria when evaluating the indications. The use of drainages was dependent on the age of the participant and mostly carried out in patients where complications in the postoperative course were to be expected (e.g. obesity, nicotine use, diabetes). CONCLUSION: In summary, the majority of the participants used wound drainages and mostly intuitively. Uniform and fixed evidence-based parameters for the use of wound drainages are lacking. In the assessment of the necessity for a wound drainage, an individually expressed need of safety seems to play a large role for some dermatosurgeons and an eminence-based action for others.

Reconstruction of Nasal Defects With Dermal Skin Substitutes-A Retrospective Study of 36 Defects.

OBJECTIVES: It is uncertain whether dermal regeneration templates (DRTs) are helpful to reconstruct nasal defects. The aim of this study was to assess whether the aesthetic subunits determine the outcome. METHODS: In this unicentric, retrospective study, the surgical procedures and outcomes of patients who received DRTs to reconstruct nasal defects were assessed and compared with the involved aesthetic subunits. RESULTS: DRTs were used for reconstruction of 36 nasal defects in 35 patients with involvement of 76 aesthetic subunits: nasal sidewall (n = 21), nasal ala (n = 13), nasal tip/columella (n = 12, n = 1, respectively), nasal dorsum (n = 12), and extranasal aesthetic areas (n = 17). Fifty-eight nasal and 8 extranasal aesthetic subunits were reconstructed with DRTs, 10 subunits with a flap. Twenty-nine of 36 defects healed without any complications (80.5%). All reconstructed nasal tips/columella and the nasal dorsa healed without any complications. Region-specific complications were retraction of the ala rim (4/12; 33.3% of the patients with involvement of the nasal ala) and the formation of a fistula in the nasal sidewall (1/21; 4.8%). Region-specific complications of extranasal subunits were the development of an ectropium (2/3; 66.7% of the patients with involvement of the lower lid). CONCLUSIONS: DRTs can be helpful to reconstruct nasal defects. However, if the defect involves the aesthetic subunits nasal ala or the infraorbital region, different techniques should be preferred.

Sentinel node metastasis mitotic rate (SN-MMR) as a prognostic indicator of rapidly progressing disease in patients with sentinel node-positive melanomas.

Risk stratification of sentinel lymph node biopsy (SNB)-positive patients with malignant melanoma differs among current classification systems. To improve classification of patients with rapidly progressive disease who may profit from adjuvant therapy with novel immune or targeted treatment modalities, a single-center retrospective analysis was performed including all melanoma patients diagnosed with a positive SN at a university-based skin cancer center over a 10-year period (2002-2012) (96 of 419 patients). Sentinel node metastasis mitotic rate (SN-MMR) and further histologic parameters were determined by blinded histological re-evaluation and correlated with clinical follow-up (overall [OS], melanoma-specific [MSS], and disease-free survival [DFS]). Median follow-up was 53 months. In univariate analyses, SN tumor penetrative depth (TPD), maximum tumor diameter (MTD), number of positive SN, SN-MMR and the S-, Rotterdam, RDC, Hannover I and II classification systems correlated with OS, MSS and DFS. Multivariate Cox regression analyses showed that a binary classification system based only on the SN-MMR (<1 vs. ≥1 mitoses/mm2 ) was the strongest independent prognostic indicator for all endpoints analyzed. Kaplan-Meier analyses confirmed binary SN-MMR to be superior to stratify patients into high- and low-risk groups (45.45% vs. 87.92% 5-yr MSS). The general prognostic validity of the published SN classification systems was confirmed. The novel SN-MMR classification system may improve discrimination of patients with slowly and rapidly progressive disease. We therefore propose its implementation into clinical practice as the SN-MMR can be easily and reliably determined in routine pathology reports. Its prognostic value for the selection of patients amenable to adjuvant therapies should be studied in clinical trials.

S3 guidelines for the management of anticoagulation in cutaneous surgery.

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

Delayed closure of complex defects with serial tightening of loop sutures - clinical outcome in 64 consecutive patients.

BACKGROUND: Direct wound closure, flaps or grafts are considered to be gold standards for the reconstruction of defects. However, these techniques may not be applicable in all cases, especially for the challenging closure of large defects. OBJECTIVE: We developed a technique to close large defects, of varying size and shape, using serial tightening loop sutures. In 64 consecutive patients, loop sutures were applied to defects from 3 cm(2) up to 173 cm(2) for a maximum of 42 days with tightening every 2-7 days. RESULTS: The median size of the defects was 20 cm(2). In 58 patients (91%) the defects were closed by direct approximation of the wound edges within a median time of 11 days (range: 4-42 days). Two patients received a skin transplant after a significant reduction of the defect size and four remaining defects healed by secondary intention. The skin stretching of defects located on the trunk was faster compared with defects on the extremities. Defects located on the scalp were closed hair bearing with little scarring. Overall, aesthetic results were satisfying. CONCLUSION: The use of loop sutures allows the delayed closure of large defects avoiding the need for skin flaps or grafts in most cases.

Lip cancer: retrospective analysis of 181 cases.

BACKGROUND: In Germany little data on the epidemiology and histology of lip cancers are available, as lip cancers are commonly pooled together with head and neck tumors. PATIENTS AND METHODS: Retrospective analysis of 181 patients with malignant tumors of the lips with respect to gender, location, histology, risk factors and comorbidity. RESULTS: There were 90 women and 91 men with a mean age of 71 years. 98 had a tumor on the upper lip and 83 patients on the lower lip. Tumors of the upper lip showed a slight female preference (61%). In contrast lower lip cancer was more common (64%) in men. Histological analysis revealed that in both regions nodular basal cell carcinomas as well as squamous cell carcinomas (NOS) are the most common subtypes. Vertical tumor thickness of squamous cell carcinomas was in most cases smaller than 6 mm (n = 71) and only in 4 cases was a tumor thickness of >6 mm detected. Altogether, 57% of the patients reported a high to very high sun exposure. CONCLUSIONS: In comparison to previous studies we found a weaker preference for women for tumors of the upper lip and also a weaker preference for men for tumors of the lower lip. The causes remain unclear, but could be causally related to an increased life expectancy and/or changed risk profile.

Liposuction - a surgical procedure in dermatology.

Liposuction is an integral part of the wide range of surgical procedures in dermatology. Dermatologists established tumescent local anesthesia in combination with the use of micro-cannulas; especially dermatologists from Germany and Austria actively designed and developed these new techniques. In this position paper, we discuss the history, various interdisciplinary aspects, the significance, and the treatment indications for this procedure as well as its role within dermatologic training programs and research. For quality reasons, members of the Germany Society of Dermatologic Surgery and the Austrian Society of Dermatologic Surgery discuss several fundamental professional aspects as well as the historical development of liposuction.

Functional and aesthetic reconstruction of full-thickness defects of the lower lip after tumor resection: analysis of 59 cases and discussion of a surgical approach.

BACKGROUND: Carcinoma of the lower lip is a common cancer of the head and neck region. The accepted standard of care is surgical resection and reconstruction. The delicate location poses a challenge to surgeons because they have to aim for conflicting goals: complete oncological resection and functional and aesthetic restoration. For over a century, this challenge led to the development of more than 100 different reconstructive procedures. OBJECTIVE: To develop a standardized surgical approach to simplify selection of an adequate reconstructive procedure. MATERIALS AND METHODS: We performed a review of the literature and a retrospective analysis of 59 patients treated according to a standardized surgical approach over the past 5 years. RESULTS: By taking into account the anatomic location, the width of the defect, and the amount of tissue loss, three flowcharts have been developed to guide the physician to a selection of suitable reconstructive procedures for each case. CONCLUSION: This surgical approach facilitated the successful reconstruction of all encountered defects, and over a mean period of 31 months, no recurrences or major complications were seen.

Medicinal leeches for the treatment of venous congestion and hematoma after plastic reconstructive surgery.

BACKGROUND: Leeches were used for medical purposes as long as 2 000 years ago in ancient Egypt. In recent years the use of medicinal leeches became rather popular again, e. g. to improve blood circulation in ischemic tissue after reconstructive plastic surgery. PATIENTS AND METHODS: In a single center, retrospective study 23 consecutive cases were analyzed in which medicinal leeches had been used therapeutically after plastic reconstructive surgery. All cases were categorized regarding the indication for leech therapy, the onset, the duration, the number of leeches and the number of sessions. RESULTS: Among the group of patients there were 7 female and 16 male patients with a mean age of 73 ± 14 years (48-94 years) altogether. The main indications were venous congestion (12/23; 52 %) and hematoma (9/23; 39 %). Two cases were diagnosed with a necrosis of the tip of the flap and therefore received leech therapy (2/23; 9 %). The average number of leeches was 2.6 leeches/session, the number of sessions was 1.7 ± 0.8. 20/23 patients (87 %) showed a restitutio ad integrum after leech therapy, in 3/23 patients (13 %) a necrosis of the tip of the flap could not be prevented. A clinical improvement was noticed after an average of 1.1 ± 0.3 days. CONCLUSIONS: The early application of medicinal leeches can improve local hemodynamic conditions. Leech therapy is a simple and effective method; the cost efficiency of the treatment is high.

Analysis of treatment costs for complex scalp wounds.

BACKGROUND: Two stage reconstructions of deep scalp wounds with exposed calvarial bone require a vital granulation tissue. By evaluating different surgical approaches functional and cosmetic results as well as economic aspects have to be taken into account. PATIENTS AND METHODS: 52 patients undergoing three different surgical procedures for soft tissue reconstruction of complex scalp wounds with exposed bone were included into a retrospective study. All patients underwent a two stage procedure with 3D histologic control, soft tissue reconstruction and final split thickness skin grafting. Soft tissue reconstruction was carried out using allogenic fascia lata, an artificial skin substitute or a negative pressure wound therapy (NPWT). The costs for all used materials as well as personnel and infrastructure were calculated. RESULTS: Comparing the costs for the different treatments, the fascia lata group was least costly (4,475 €) followed by the artificial skin substitute group (4,557 €). The highest expenses occurred in the NPWT group (7,.521 €). The artificial skin substitute group had the fewest dressing changes and the shortest treatment time. CONCLUSIONS: Although dermal regeneration templates are expensive, their use may be economic. NPWT causes high treatment costs due to high daily rental rates and frequent and time-consuming dressing changes.

Impact of the surgeon's experience on the postoperative outcome--a retrospective analysis of non-melanoma skin cancers of the head and neck region.

BACKGROUND: Treatment of choice for non-melanoma skin cancers is surgical excision. No study has analyzed the impact of the dermatologic surgeon's experience on the postoperative outcome. PATIENTS AND METHODS: In a single center, retrospective study, 196 cases of non-melanoma skin cancer of the head and neck treated with micrographically-controlled surgery were categorized with regard to type of tumor, location, size of defect, number of stages, complications, recurrence rate and cosmetic result. These data were analyzed in respect of the surgeon's experience (dermatology attendings [AT], senior residents with experience in dermatosurgery [SR], junior residents with less experience in dermatosurgery [JR]). RESULTS: AT and SR excised tumors in toto at roughly the same rate (AT: 42/75; SR: 59/104), JR less frequently (3/6). The patients graded 97% of the scars as very good to satisfactory. The grading of smaller defects (< 4 cm(2)) was not influenced by the surgeon's experience. Larger defects were graded equally in the two groups AT and SR. The complication rate was similar in all three groups, even though larger defects were treated by the attendings (AT). CONCLUSIONS: Micrographically-controlled surgery followed by plastic reconstruction is the treatment of choice for non-melanoma skin tumors of the head and neck area. Cosmetic results are excellent. Minor procedures can be performed by residents during their training; larger defects require more experience in dermatosurgery.

Ex vivo expanded haematopoietic progenitor cells improve dermal wound healing by paracrine mechanisms.

BACKGROUND: Although dermal wounds are common, treatment remains limited and largely ineffective. Recent studies suggest that therapeutic application of progenitor cells is useful for tissue regeneration. OBJECTIVE: We here investigated the effects exerted by the recently characterized immortalized haematopoietic progenitor cell line DKmix and their conditioned medium in a murine wound healing model. METHODS AND RESULTS: Injection of both DKmix cells and their conditioned medium accelerated wound repair between days 3 and 10 compared with PBS-injected control mice (n = 8, P < 0.01 DKmix cells vs control, P < 0.01 conditioned medium vs control at day 6). The treated groups exhibited more CD31(+)-capillaries at day 6 after injury compared with the control group (n = 4, P < 0.01 DKmix cells vs control, P < 0.001 conditioned medium vs control), whereas there was no change in infiltrated CD68(+) macrophages. Conditioned medium of DKmix cells induced tube formation of human endothelial cells in Matrigel assays (n = 4-6, P < 0.05 conditioned medium vs control) as well as migration (n = 4, P < 0.01 conditioned medium vs control) and proliferation of murine 3T3 fibroblasts (n = 5, P < 0.05 conditioned medium vs control). Abundant levels of matrix metalloproteinase -2 and -9 in the supernatants were detected. Protein arrays of the supernatants revealed a strong secretion of cytokines and growth factors, such as monocyte chemoatractant protein-1 and GM-CSF from DKmix cells. CONCLUSION: DKmix cells improve skin-substitute wound healing by promoting angiogenesis as well as migration and proliferation of fibroblasts. These data suggest that immortalized haematopoietic progenitor cells significantly improve dermal wound healing by paracrine effects.

Removal of the outer table of the skull for reconstruction of full-thickness scalp defects with a dermal regeneration template.

BACKGROUND: The reconstruction of large defects of the scalp after wide excisional surgery of cutaneous malignancies is challenging. When the pericranium must be resected due to safety considerations, the exposed bone complicates reconstructive approaches. OBJECTIVE: The objective was to develop an improved technique for reconstructive surgery of full-thickness scalp defects. METHODS: Full-thickness scalp defects of up to 126 cm(2) in size with exposure of denuded bone were treated by partial removal of the outer table of the skull. The diploic space exposed by this treatment showed petechial bleeding and was covered with a dermal regeneration template (Integra, Integra Lifesciences Corp., Plainsboro, NJ). After transformation of the template by vascularization and by proliferation of fibroblasts, an ultrathin skin graft was transplanted onto the neodermis. RESULTS: Thirteen patients with cutaneous malignancies of the scalp were treated using this technique. The defects were transplanted within a median postoperative time period of 29 days (+/- 4 days) and showed good cosmetic results and stable scars. After a follow-up period of 6 months, no local recurrences were observed. CONCLUSION: This reconstructive procedure allows closure and rapid healing of large scalp defects in which the pericranium had to be resected.