BACKGROUND:To date, there is still a debate how to deal with patients receiving antithrombotic agents prior to surgical procedures on the skin.OBJECTIVE:To prospectively assess complications after dermatosurgical interventions, especially bleeding, depending on anticoagulation therapy.METHODS:Patients underwent surgery consecutively as scheduled, without randomization, whether or not they were currently taking anticoagulants. Nine institutions of the DESSI (DErmatoSurgical Study Initiative) working group documented patient data prospectively on a standardized study sheet prior to and after 9154 dermatosurgical interventions.RESULTS:Bleeding complications were observed in 7.14% of cases (654/9154 surgeries). A severe bleed requiring intervention by a physician occurred in 83 surgeries (0.91%). In multivariate analysis, INR, length of the defect, perioperative antibiotic treatment, current treatment with anticoagulation therapy, age and surgery on hidradenitis suppurativa/acne inversa (HS/AI) were significant parameters independently influencing the risk of bleeding. Discontinuation of phenprocoumon therapy and subsequent switching to low molecular weight heparin was associated with the highest risk of bleeding (9.26%).CONCLUSION:Bleeding complications in skin surgery are generally rare. Even if slightly increased complication rates are found in patients taking anticoagulants during skin surgery, platelet inhibitors should not be stopped prior to surgery. If a surgical procedure in patients on a combination therapy of 2 or more antiplatelet cannot be postponed, it should be conducted with the patient remaining on combination therapy. Discontinuation of DOACs is recommended 24 h prior to surgery. Bridging of phenprocoumon should be terminated. In patients with a bleeding history, the INR value should be within the therapeutic range.

Die Inzidenz von Hautkrebs steigt seit Jahren an. Ob es in dem Patientenkollektiv von Hautkrebspatienten, die durch eine Operation behandelt wurden, in den letzten Jahren zu einer Veränderung gekommen ist, wurde bisher noch nicht untersucht.

Background. The incidence of skin cancer continues to increase. However, little is known about the dermatosurgical characteristics of the patients. Patients and mathods. In this single center, retrospective study, dermatosurgical reports of all patients treated because of basal cell carcinomas (BCC), squamous cell carcinomas (SCC), and malignant melanoma (MM) between 2004 and 2013 were analyzed. Results. During the observed period, the number of operated BCC rose by a factor of 1.86 and the number of MM by a factor of 2.3. In comparison to BCC/MM, there was a disproportionately high increase of SCC by a factor of 4.02. The average age was 71.5 +/- 13.4 years (minimum: 14 years; maximum: 104 years), whereupon a significant increase of male age and a significant decrease of female age occurred. Almost 70% of all tumors were located in the head and neck area. The nose was most commonly treated. Conclusion. During the last 10 years, the cohort of dermatosurgical patients changed in the tumor center. This should be verified in multicenter studies.

In der Dermatochirurgie erfordert der Verschluss größerer Exzisionsdefekte ein differenziertes Vorgehen. Defekte bis 5 cm Durchmesser sind je nach Lokalisation in der Regel durch einfache Dehnungsplastiken gut verschließbar, während sich für größere Defekte VY- oder doppelte WY-Plastiken bewährt haben. Entscheidend für den Erfolg des Verschlusses ist die spannungsarme und korrekte Adaptation der Wundränder durch eine Coriumsnaht. Während sich bei dünner bis mittelstarker Dermis die horizontale Schmetterlingsnaht anbietet, hat sich bei dicker und unflexibler Dermis die hier beschriebene vertikale „Flaschenzugnaht” bewährt. Durch eine doppelte vertikale Schleifenführung mit zentraler Verknotung entsteht ein Flaschenzugeffekt, der zu einer schonenden Annäherung der Wundränder führt, minimales Fremdmaterial in der Wunde belässt und durch Platzierung des Knotens in der Tiefe der Wunde ein optimales kosmetisches Ergebnis produziert. Die Flaschenzugnaht vereint die Vorteile einer fortlaufenden Coriumsnaht mit der höheren Sicherheit der Einzelknopfnähte.

Weichteildefekte am Capillitium erfordern abhängig von ihrer Tiefe und Größe verschiedene Versorgungsformen. Während kleinere und oberflächliche Defekte häufig der Sekundärheilung überlassen oder direkt verschlossen werden können, erfordern größere und tiefere Defekte in der Regel Lappenplastiken oder Hauttransplantationen. Bei ausgedehnteren Defekten kommen kombinierte Lappenplastiken oder eine assistierte Sekundärheilung mit einer Vakuumversiegelung infrage. Bei Periostdefekten muss der exponierte Schädelknochen kurzfristig versorgt werden, um knöcherne Komplikationen zu vermeiden. Hierzu muss in der Regel der Knochen durch Bohrlöcher oder auch eine flächige Abtragung der Tabula externa konditioniert werden. Auf den präparierten Knochen lässt sich mit einer Vakuumversiegelung, Kollagensheets oder auch Dermisersatzmaterialien aufbauen. Neue Entwicklungen im Bereich des Tissue Engineerings werden das Spektrum zukünftig noch erweitern.

Soft tissue defects of the scalp can be closed with varying techniques depending on size and depth of the defect. While small and superficial defects can be closed primarily or be left open for secondary intention healing, larger and deeper defects may need flaps or skin grafts. Extensive defects may require combined flaps or vacuum assisted closure techniques. Defects of the periosteum with denuded skull bone must be treated immediately to avoid bony complications. Usually, the tabula externa is fenestrated with holes or abraded totally to create better healing conditions. Granulation tissue may be induced on the properly prepared skull with vacuum-assisted closure, by using collagen sheets or with dermal skin substitutes. New developments in tissue engineering will surely provide new techniques for dealing with deep and extensive soft tissue defects.

The closure of larger incisional defects in dermatosurgery requires different techniques according to the localization of the defect and the texture of the skin. Depending on the localization, defects up to 5cm diameter can easily be closed by extension plastic while larger defects often require VY-or double WY-plastics. A crucial point for the esthetical outcome of the procedure is the choice of the corial suture technique. Defects in localizations with thin to moderately thick corium can be closed with the horizontal butterfly suture. However, in localizations with thicker corium, the corial pulley suture is more advantageous. Two vertical suture loops, knotted centrally produce a block and tackle effect which allows atraumatic approximation of the wound margins, leaves minimal foreign material in the wound and places the knot in depth of the wound thus avoiding granuloma formation. Altogether the cosmetical results of this simple technique are excellent. The advantages of a corial running suture are combined with the increased security of a multiple knot approach.

A 71-year-old woman presented with an asymptomatic growing dermal tumor on her thumb. Clinical picture, ultrasound, laboratory investigations and histology were consistent with the diagnosis of gouty tophus. Pathogenesis, risk factors and therapy of tophaceous gout are discussed.