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 Langer’s  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 .

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 B.

.

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

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 .

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

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 .

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 .INFLAMMATORY CONDITIONS -  Virulent or massive infection together with low patient resistance.

Cellulitis .

Cellulitis .

Cellulitis .

Cellulitis .

Furuncle .

Furuncle .

Carbuncle .

AMNIOTIC membrane .INFLAMMATORY CONDITIONS Management  Debridement and delayed skin grafting  Biologic dressing such as HOMOGRAFT.

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 .

Epidermal inclusion Cyst  Epidermal cells are trapped in subcutaneous tissue. Desquamation leads to the creation of a cavity 2.are fluid filled cavities in subcutaneous tissue which may resemble solid tumor 1. Cyst. Sebaceous Cyst .NEOPLASTIC CONDITIONS Benign conditions B.

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 .

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

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

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

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

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

Lipoma .

Axillary Mass .

Mass Nape .

Another View .

Ready for Surgery .

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

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

Neuro Fibroma .

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.PREMALIGNANT SKIN LESION 1. Actinic Keratosis  Rough. excision or cryotherapy  5-fluorouracil for patients with many keratosis .

Actinic Keratosis .

no potential for metastasis  4th to 6th decade of life  Arsenic ingestion and viruses implicated as etiologic agents Treatment same as actinic keratosis .PREMALIGNANT SKIN LESION 2. Bowen’s 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.

Bowen’s 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 ¼ 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 .

Junctional Nevi  Dark. flat.BENIGN PIGMENTED LESIONS 1. 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 . smooth.

Compound Nevi  Brown to black.BENIGN PIGMENTED LESIONS 2. 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 .

Blue Nevi  Smooth. hairless lesion about 1 cm  Arise from the dermis  Malignant degeneration 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.

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

BENIGN PIGMENTED LESIONS 6. 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 .”Spitz Nevi” Benign (juvenile melanoma)  Smooth round. pink.

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

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

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

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 .MALIGNANT LESIONS Malignant Melanoma C.

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 .

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

.

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

Lentigo Maligna .

Lentigo Maligna .

MALIGNANT LESIONS Malignant Melanoma CLARK’S 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 1.7 are at low risk for metastasis  Patients w/ level 1V or V and w/ a depth of invasion greater than 1. 11.5 mm are at high risk for distant metastasis . 111. lesion w/a depth of invasion that is less than 0.

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 .

 when tissue preservation is important  depigmentation and atrophy can occur . Curettage and Electrodessication  95% cure rate  for lesions less than 0. Radiation Therapy  90% cure rate. BIOPSY IS MANDATORY 1.2cm 2.BASAL CELL CARCINOMA Treatment involves complete removal of the tumor to achieve cure.

BASAL CELL CARCINOMA Treatment 3.5 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 . Excision with primary Closure A 0.

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 .

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 2.

these require radical excision 4. lips  Not used when bone and cartilage are involved.SQUAMOUS CELL CARCINOMA Treatment Methods 3. Moh’s Surgery . Radiation Therapy  Usually reserved for advanced lesions in areas where surgical excision leaves a cosmetically unacceptable defect the nose. the eyelid.

.

.

.

.

.

.

.

.

.

.

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 .