Microscopically controlled surgery with three-dimensional histology, tumescent local anesthesia and intracutaneous sutures for high tension in the treatment of skin cancer
Authors: Breuninger H. , Belova I. A. 
Published: November 2018

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.