SKIN and SOFT TISSUE

Celso M. Fidel, MD,FPSGS,FPCS

Diplomate Philippine Board of Surgery

Introduction
SKIN
Considered as a single anatomic
physiologic
unit
1 to 1.5 sq. m in area
Protects the body bearing the brunt of
injurious effects of external
environment
SOFT TISSUE
Comprises about 50 % of the total body

SKIN INCISIONS
Choice of known skin lines of relaxed tension
Applying principles of effective concealment
and camouflage
Considers dynamic muscle action and effect of
gravity on skin and subcutaneous tissue
Junctions of body planes
Lines of elevations of facial features
Lines of Langers
Contour Lines of junctions of body planes
Lines of Dependency
Elective Lines that show when patient smiles

Skin

Skin
Prevent

fluid loss
Temperature control
Elasticity and support

LESIONS OF SKIN AND SOFT TISSUE

CONGENITAL
TRAUMATIC
INFLAMMATORY
NEOPLASTIC
BENIGN
MALIGNANT
OTHER LESIONS
METASTATIC SKIN LESION
FOREICN BODY GRANULOMA

LESIONS OF SKIN AND SOFT TISSUE

CONGENITAL
A. Dermoid Cyst
Originate from tissue entrapped during
fusion of embryonic processes
Lined by squamous cells and may
contain
Straw colored Fluid
Cheesy material
Lanugo Hair
Generally cyst in the head is operated
at OR

LESIONS OF SKIN AND SOFT TISSUE

Dermoid
Frequently occurs in the
midline over the :
Occiput
Nasal dorsum
Mid-frontal region of scalp
Sacral area
Abdominal areas

Dermoid

Dermoid

LESIONS OF SKIN AND SOFT TISSUE

CONGENITAL

B. Pilonidal Cyst and Sinus

Originate from the NEURENTERIC
canal
and appear as dimpling in
sacrococcygeal
region
Due to unidirectional migration of hair
with micro barbed configuration
When infected cyst becomes an
abscess
mucus and hair maybe discharged

LESIONS OF SKIN AND SOFT TISSUE

CONGENITAL
C. Branchiogenic sinuses
Are located anterior to medial edge of
sternocleidomastoid muscle
Arise from either Ist,2nd or 3rd branchial
arch
Located anterior to ear if coming from Ist
TRAUMATIC
A. Wounds
Abrasions
Lacerated wounds
Punctured wounds Incised wounds
Avulsion

Avulsion

Incised Wounds

LESIONS OF SKIN AND SOFT TISSUE

TRAUMATIC

B. Pneumatic tire injury

Special type of laceration
Rotating tire chews up soft tissue and tears it off from
underlying deep fascia transecting the investing blood
vessels.
Common error of merely suturing the wound and failing to
recognize massive avulsion of skin and subcutaneous
tissue would result in more extensive necrosis.

LESIONS OF SKIN AND SOFT TISSUE

TRAUMATIC
B. Pneumatic tire injury
Management
Damage area cleaned
Divitalized tissue debrided
Extremity splinted
Raw area skin-grafted

LESIONS OF SKIN AND SOFT TISSUE

TRAUMATIC
C. Burns
Thermal
Open flame
Boiling water
Smoke inhalation injuries
Chemical
Electrical

Partial Thickness Burns

Occlusive Dressing w/ Duoderm

OTHER LESIONS
KELOIDS
Fibrous proliferation
More extensive with insidious spread
into surrounding tissues .
Keloid prone areas: sternal, deltoid,
and scapular areas.
Most disappointing surgical problem
because recurrences are frequent.
End results leaves much to be desired .

OTHER LESIONS
KELOIDS
Accepted form of treatment
Surgery with post op radiation
Surgery with intra op steroid
injection
Triamcinolone>> promising
steroid

OTHER LESIONS
Hematoma
Due to rupture of a blood vessel
Bluish or purplish swelling of skin and
subcutaneous tissue
May occur as postoperative complication
Treated conservatively
Surgical evacuation ligate bleeders

INFLAMMATORY CONDITIONS
-

Virulent or massive infection together with low

patient resistance, results in skin and soft
tissue loss

Skin grafting indicated once infection is

controlled and granulation tissue has
developed
Tissue loss often seen in malnourished infants
and children where ordinary pyogenic
infection produces massive skin necrosis

Cellulitis

Cellulitis

Cellulitis

Cellulitis

Furuncle

Furuncle

Carbuncle

INFLAMMATORY CONDITIONS
Management

Debridement and delayed skin

grafting
Biologic dressing such as
HOMOGRAFT, AMNIOTIC
membrane

NEOPLASTIC CONDITIONS
Benign conditions
A. Common Warts
Verrucae Vulgaris Occurs in 2nd decade of life
Maybe transmitted by direct or indirect contact
Caused by a member of the papovavirus
Invades stratum spinosum epidermidis causing
papillomatosis
Located in hands and feet
Rough, grayish papillomatous nodular or
elevated plaques

Verruca Vulgaris

Verruca Vulgaris

Verruca Vulgaris

NEOPLASTIC CONDITIONS
Benign conditions
A.Common Wart
Verrucae Vulgaris Can become tender
Will resolve spontaneously
Problematic lesions can be treated
by:
Curettage and electrodessication
Freezing with liquid nitrogen
Chemotherapy with caustic agent

NEOPLASTIC CONDITIONS
Benign conditions
B. Cyst- are fluid filled cavities in

subcutaneous tissue which may

resemble solid tumor
1. Epidermal inclusion Cyst
Epidermal cells are trapped in
subcutaneous
tissue. Desquamation leads to the
creation
of a cavity
2. Sebaceous Cyst

Sebaceous Cysts

Application of Anesthesia

Start of Excision

The final outcome

Sebaceous cyst in eyelids

Stellate Suturing of Ganglion

Cyst

Stellate Suturing of Ganglion

Cyst

Lines of Langers

NEOPLASTIC CONDITIONS
Benign conditions
C. Vascular Tumors
1. Capillary Hemangiomas
(Port wine- Stain)
found in the
face,
chest,
extremities

NEOPLASTIC CONDITIONS
Benign conditions
C. Vascular Tumors
2.Immature Hemangioma
Found in the head, neck, chest and
extremities of infants
Elevated, red, soft, compressible tumors;
frequently enlarges during 1st year of life
Undergoes spontaneous regression during
the next 2-7 years

NEOPLASTIC CONDITIONS

Benign conditions
C. Vascular Tumors
3. Cavernous Hemangiomas
Compressible & shows a wide channel
w/ loose connective tissue septae
lined by embryonal endothelium
Lesions maybe nodular, lobular or polypoid
Surgery is the treatment of choice

NEOPLASTIC CONDITIONS

Benign conditions
C. Vascular Tumors
4. Spider Nevi ( Telangiectasia )
occur in all age groups & common
in the face, chest & extremities
Arise during pregnancy & in cirrhosis
Central arteriole with vessel
resembling venules radiating from
the center

NEOPLASTIC CONDITIONS
Benign conditions
D. Lipoma
Benign encapsulated subcutaneous
lesion, single but maybe multiple
Are most common on the neck,
shoulder, back, thigh
Occasionally fluctuates under the
palpating finger
Visible lobulation upon stretching the
skin

Lipoma

Axillary Mass

Mass Nape

Another View

Ready for Surgery

NEOPLASTIC CONDITIONS
Benign conditions
E. Nerve Tumors
1. Neurilemomas
Originates from Schwanns cells of
peripheral nerve sheaths and may
not adhere to nerve
Treatment is by excision

NEOPLASTIC CONDITIONS
Benign conditions
E. Nerve Tumors
2. Neurofibroma:
May occur as single or multiple as in
Von Recklinghausens disease
Fibromas of the dermis
Neurofibromas (multiple)
Widespread skin pigmentation at
back(coffee- colored spots
(pathognomonic)

Neuro Fibroma

PREMALIGNANT SKIN LESION

1. Actinic Keratosis
Rough, scaly epidermal lesion in areas of the
body subjected to chronic sun exposure
3rd and 4th decade and 10% to 20% will
undergo malignant transformation
If benign, excision or cryotherapy
5-fluorouracil for patients with many
keratosis

Actinic Keratosis

PREMALIGNANT SKIN LESION

2. Bowens Disease
Intraepidermal squamous cell carcinoma or
Carcinoma in situ of the skin
Well defined erythematous plaque covered
by an adherent scaly yellow crust
No lymphatics in the layer affected, no
potential for metastasis
4th to 6th decade of life
Arsenic ingestion and viruses implicated as
etiologic agents
Treatment same as actinic keratosis

Bowens Disease

PREMALIGNANT SKIN LESION

3. Keratoacanthoma
Locally destructive skin lesion found in
the head, neck, & upper extremities
Fast growing with:
smooth rounded borders & keratitic
center plug
It may regress within six months
Excision is treatment of choice
Squamous cell cancer is found in of
the lesions biopsied

NEVI (MOLES)

Pigmented lesions of skin that frequently

concern the patient because of the fear
of malignancy

Average white male has 15 to 20 nevi so total

excision is unreasonable
Clinical diagnosis is of prime importance
because malignant transformation can occur
Well circumscribed lesions with uniform color
rarely progress to malignancy

Epidermal Nevus

Halo Nevus

BENIGN PIGMENTED LESIONS

1. Junctional Nevi
Dark, flat, smooth, lesions about 1mm
to 2cm diameter
Occasionally hairy and develop from
the basal layer of epidermis
Nevi that are located in the palms and
soles are usually junctional
Can develop into malignant melanoma
but this rarely occurs before puberty

BENIGN PIGMENTED LESIONS

2. Compound Nevi

Brown to black, well circumscribed

lesions
Usually less than 1 cm in diameter
Maybe elevated and are frequently
hairy arising from epidermaldermal interface and within the
dermis
Malignant transformation is rare

BENIGN PIGMENTED LESIONS

3. Intradermal Nevi
Are light colored well circumscribed
lesion less than 1 cm in diameter
Hairs are usually present and the cell
distribution is in the dermis
Malignant transformation is rare
4. Blue Nevi
Smooth, hairless lesion about 1 cm
Arise from the dermis
Malignant degeneration is rare

BENIGN PIGMENTED LESIONS

5. Giant Pigmented Nevi
Brown to black, hairy lesions with an
irregular nodular surface
Frequently involve more than 1 sq. inch
foot of body surface and arise from the
dermis and junctional areas
Frequently described in terms of distribution
as bathing trunk vest, sleeve or
stocking
Malignant degeneration is 10%
Excision with margin of normal tissue

BENIGN PIGMENTED LESIONS

6.Spitz Nevi Benign (juvenile melanoma)
Smooth round, pink, to black lesion about
1-2 cm in diameter
Increased cellularity and occur in vest
within the upper dermis
Have no malignant potential
TREATMENT
A. Indicated for junctional & giant pigmented
nevi because of their malignant potential

BENIGN PIGMENTED LESIONS

TREATMENT
B. Indications for excision of any
pigmented lesion include:
1. Changes in color, size, shape, or consistency
2. Pain
3. Satellite nodules
4. Regional adenopathy
C. Excisional biopsy w/ normal margins
D. For large lesions, a full thickness
wedge biopsy including a small area
of normal skin should be taken

MALIGNANT LESIONS

Malignant Melanoma
A. Epidemiology
1. incidence is 13 new cases/ 100,000/year
representing an increase of 50%
2. occurs in 5th decade, rare in children
3. some 20% to 30% arise in head &
neck
4. incidence is equal in males and in
females

MALIGNANT LESIONS
Malignant Melanoma
Exposure to sunlight. Fair skinned
whites with frequent direct
exposure to the sun often affected
In men chest, back, upper extremities
In women affects back upper and
lower extremities
Detection of melanoma is determined
by changes in the color, size and
shape of a nevus

MALIGNANT LESIONS
Malignant Melanoma
C. Classification based on Gross and
Histologic appearance
1. Superficial Spreading Melanoma
Accounts for 70% of all melanoma
Can be present on any part of the
body but more at the back & legs
5th decade of life
Irregular borders, varied color
Upper dermis w/ lateral junctional spread
Generally prognosis is good

Superficial Spreading Melanoma

MALIGNANT LESIONS
Malignant Melanoma
2. Nodular Melanoma
Accounts for 15% of all melanoma
6th decade of life
Blue black lesion on any part
of body
Vertical spread rapid dermal
invasion
Prognosis is poor

Nodular Melanoma

MALIGNANT LESIONS

Malignant Melanoma
3. Acrolentiginous & Mucosal Melanoma
Comprise 10% of all melanoma
5th decade of life
mucous membrane, palms and soles
Irregular borders; black maybe
amelanotic
Slow growth in radial direction
Cells in upper dermis occasional
deeper invasion
Prognosis between superficial and
nodular melanoma

MALIGNANT LESIONS
Malignant Melanoma
4. Lentigo Maligna ( Melanotic freckle of
Hutchinson)
The least common; 5th decade
Brown black w/ elevated nodules w/in a
smooth freckle
Frequent in the head, neck, & hand
Slow growth in radial direction w/ cells in
the upper dermis
Vertical extension is frequent
Prognosis is excellent

Lentigo Maligna

Lentigo Maligna

MALIGNANT LESIONS
Malignant Melanoma
CLARKS CLASSIFICATION

Level
Level

1 Tumor confined to epidermis

11 Tumor invades papillary dermis

Level 111-Tumor fills the papillary dermis but

does not invade reticular dermis
Level 1V-Tumor invades the reticular dermis
Level V Tumor invades subcutaneous
tissue ( Fat )

MALIGNANT LESIONS

Malignant Melanoma

BRESLOW CLASSIFICATION

Involves measuring the deep invasion

precisely in millimeter
Patients with Clark level 1, 11, 111,
lesion w/a depth of invasion that is
less than 0.7 are at low risk for
metastasis
Patients w/ level 1V or V and w/ a
depth of invasion greater than 1.5 mm
are at high risk for distant metastasis

MALIGNANT LESIONS
Malignant Melanoma
In order to complete the staging
Thorough histological and physical
examination are necessary
Include ancillary work-up like
complete blood count
urinalysis
chest x-ray
12 test sequential multiple
analysis ( SMA -12 )

MALIGNANT LESIONS
Malignant Melanoma
Treatment:
A. Excision
B. Resection
C. Adjuvant Therapy
Regional hyperthermic perfusion
Chemotherapy
Immunotherapy
Radiotherapy

MALIGNANT LESIONS
Malignant Melanoma
Prognosis:
Disease confined at primary site 5
year
survival is 80%-90%
If regional lymph nodes are involved
survival goes down to 30% to 50%
Patients who have distant or visceral
metastasis are usually dead within

BASAL CELL CARCINOMA

A malignant skin tumor

characterized by slow growth

and very rare distant
metastasis
Generally occurs in the head
and neck
Found most commonly in
individuals of Northern
European Descent

Basal Cell Carcinoma

BASAL CELL CARCINOMA

Etiology
It has been associated with:
Xeroderma pigmentosum
Basal cell nevus syndrome
Nevus sebaceous
Unstable burn scar
Dermatitis subjected to radiation therapy
Clinical Findings
Lesion has pearly translucent edges
Smooth elevation with telangiectatic
surface

BASAL CELL CARCINOMA

Treatment
involves complete removal of the tumor to
achieve cure. BIOPSY IS MANDATORY
1. Curettage and Electrodessication
95% cure rate
for lesions less than 0.2cm
2. Radiation Therapy
90% cure rate;
when tissue preservation is important
depigmentation and atrophy can occur

BASAL CELL CARCINOMA

Treatment
3. Excision with primary Closure
A 0.5 cm margin from the grossly detectable
limit of the lesion adequate for cure
95% cure rate
LN should be excised in continuity
if they are clinically positive
Reconstruction can be performed
in one setting

SQUAMOUS CELL CARCINOMA

It is more malignant in clinical behavior
than basal cell carcinoma
Fast growing and tends to metastasize to
regional LN plus wider local spread
Etiology
Exposure to sunlight
From pre-malignant lesion
Old burn scar
Exposure to arsenicals, nitrates and
hydrocarbons

Squamous Cell Carcinoma

SQUAMOUS CELL CARCINOMA

Clinical Manifestations
May appear as a satellite nodule or a central
area
of ulceration that may become encrusted
obscuring
deeper invasion
Common in the lips, paranasal folds and axilla
Treatment:
is based upon examination of the biopsy
specimen
Excision Biopsy for lesion less than 1cm

SQUAMOUS CELL CARCINOMA

Treatment Methods
1. Electrodessication
For lesions less than 1cm in diameter
For older individuals
In patients with recurrence of tumors

SQUAMOUS CELL CARCINOMA

Treatment Methods
2. Excision with Primary Closure
Advantage of available histopath of
lesion
With clinical evidence of nodal disease
regional LN dissection is performed
Adenopathy accompanying an
ulcerated
lesion is not excised at the same
time

SQUAMOUS CELL CARCINOMA

Treatment Methods
3. Radiation Therapy
Usually reserved for advanced lesions in
areas
where surgical excision leaves a
cosmetically
unacceptable defect the nose, the eyelid,
lips
Not used when bone and cartilage are
involved;
these require radical excision
4. Mohs Surgery

Sweat Gland Tumors

Rare lesions arising from the
eccrine or
apocrine gland
Occur in later life as a soft tissue
mass
that has been present for years
Metastasis to regional lymph nodes are
common;

consider dissection at time of initial

excision