SKIN & ITS APPLIED

ANATOMY

Snehal Kharche
Contents
 INTRODUCTION
 BASIC STRUCTURE OF SKIN
 BASIC LESION OF SKIN
 SURGERY OF SKIN
◦ BIOMECHANICAL PROPERTIES OF SKIN
◦ SKIN LINES
◦ COSMETIC UNIT OF FACE
◦ PRINCIPAL OF INCISION AND SUTURING OF FACE
◦ WOUND DRESSING
◦ SCAR AND SCAR REVISION (OVERVIEW)
◦ ADVANCES IN SKIN SURGERY
Introduction
Skinis the largest organ of the body
which forms 8% of total body mass

Covers entire external surface of body

Is continuous around body orifices

Basic structure of skin
• Skin may be viewed as a double-layered
sheath, cushioned by underlying
subcutaneous fat,
the layers are

 Epidermis
 Dermis
Epidermis
Epidermis is a continually renewing,
keratinizing, stratified, squamous
epithelium
Layers of epidermis
 Stratum basale
 Stratum spinosum Malpighian layer
 Stratum granulosum
 Stratum corneum
The cells present in skin are
keratinocytes(80%), melanocytes,
langerhans cells & merkel cells
Dermal-epidermal junction
Firmly attaches epidermis to dermis
Mechanical support to epidermis
Acts as a semi-penetrable membrane
Epidermal appendages
Epidermal Appendages
Hairfollicle: is main component of pilosebaceous unit
which is composed of sebaceous gland, arrector pili
muscle & sensory end organ

Sebaceous gland: it is unilocular or multilocular st. which

connects hair follicle by a sebaceous duct

Eccrine sweat glands: reticular dermis, duct opens directly

on skin, innervated by cholinergic nerve fibres

Apocrine sweat gland: adregenic innervation, duct

connects to hair follicle above sebaceous duct
Dermis
Connective tissue between epidermis &
dermis
It is divided into papillary & reticular
dermis
It is composed primarily of collagen,
elastin & ground substance
Regional skin variation
Glabrous skin(non hairy skin)
Non glabrous skin(hair bearing skin)
Vascular supply of skin
It originates from three main sources
 Direct cutaneous: main arterial trunk
 Musculocutaneous: arise from intramuscular
vasculature, pass through surface of muscle,
pierce deep fascia to reach skin
 Fasciocutaneous: perforating branches from
vessels deep to deep fascia, pass along
intermuscular septa, fan out at level of deep
fascia
Plexi
 Subpapillary
 Reticular dermal
 Deep dermal
Basic lesions of skin
Macules (1 - 2cm, different color, flat)
Patches (large macule)
Papule (elevated, less than 1 cm)
Nodule (dome shaped, more than 1 cm)
Wheals (round pale red)
Vesicle (contains fluid, less than 0.5cm)
Bullae (more than 0.5cm)
Erosion (break in epidermis)
Pustules (raised, purulent)
Fissures (cracks in skin)
Burns wound
Burns cause damage in no. of diff. ways, but
most common affected organ is skin
Assessing size (for treatment plan & morbidity)
 Pt. Whole hand is 1% TBSA and is useful
guide for small burns
 Rule of nine(wallace’s) UL-9%, LL-18%,
Torso-18% each side, H&N-9%, GR-1% only
for initial approx.
 Browder chart for large burns
Wallace chart(rule of nine)
BROWDER CHART
Classification of burns
Superficial partial thickness (papillary)

 Deep partial thickness (reticular)

 Full thickness (whole dermis)

Biomechanical properties of skin
Nonlinearity:

1.Flat section- considerable extension with little force
2.Intermediate section- rapid transition
3.Terminal section- little or no extension despite increased
forces
Anisotropy:

variation in skin tension at
diff. sites of body
directional considerations
for skin movement
Viscoelasticity:

At high stresses skin shows viscoelastic

properties, two time-dependent properties of
skin are
Creep: (permanent stretching)increase in length of
skin compared to original length when placed
under const. stress
Stress relaxation: decrease in stress when skin is
held under tension at a const. strain as relaxation
occurs as tissue creeps
Skin lines
Relaxed Skin tension lines (RSTL)
 correspond to the directional
pull when skin is relaxed
 do not always correspond
to wrinkle lines
 result from orientation of
collagen fibre of skin
 used for incision making
 Lines of maximum
extensibility
Wrinkle line – caused by contraction of
underlying muscle, perpendicular to their
axis of shortening
Kraissl’s line – exaggerated wrinkles lines
Langers line- lie at right angle to RSTL
Aesthetic regions of face
Covered by skin having common
characteristics
Principle aesthetic regions of face are
 Forehead
 Cheek (five subunits)
 Eyes & eyebrow
 Nose (nine subunits)
 Lips & chin
Esthetic units of nose
Principals of incision
Incisions placed on exposed surface of
face must follow some basic principles so
the scar is inconspicuous
 Avoid imp. Neurovascular structures
 Use as long incision as necessary
 Place incision perpendicular to surface of
nonhair-hair bearing skin
 Place incisions in line of minimal tension
 Seek for other favorable sites for incision
placement
Commonly used skin incision
Suturing
Optimizing outcome of sutured wound
 Should be at even level to prevent “step off deformity”
 Prior to placement of top stitch all tension should be off
the wound edges
 To reduce wound tension buried absorbable suture
should be used
 Everted wound edges for thinner and flatter scar
 In cosmetic areas fine caliber suture or subcuticular
suture are used
Post operative care
Suture left for long promotes infec.
Remove suture at appropriate time to prevent
“Rail Road” scar
Recommended suture removal time
Eyelid – 2 to 4 days
Face – 4 to 6 days
Neck and scalp – 5 to 7 days
Extremities – 10 to 14 days
Wound dressing
Functions:
 Maintain a moist wound healing environment
 Absorb exudate
 Provide a barrier against bacteria
 Reduce edema
 Eliminate dead space
 Protect against further injury from trauma, pressure and
sheer
Scar and scar revision
The trace of healed wound sore, or burn. A fault
or blemish remaining as a trace of some former
condition or resulting from some particular cause

Ideal scar:
 Imperceptible
 Not cause distortion of adjacent structure
 Lie in aesthetic borders or in RSTL
 Flat and in level with surrounding tissues
 Same color and texture as surrounding skin
Adverse scar:
 Wrong direction
 Poor alignment
 Stretched scar
 Contracted scar
 Pigment alteration
 Contour deformity (trapdooring)
 Tattooing
 Stitch mark (after 7 days)
 Hypertrophic scar
 Keloid scar
 Hypertrophic scar  Keloid scar
 Not familial - May be familial
 Not race related - Black > White
 Female = Male - Female > Male
 Children - 10 – 30 yrs
 Remains with wound - Outgrows wound
 Subsides with time
- Rarely subsides
 Flexor surface
 Tension related
- Sternum , shoulder
- Unknown
Scar revision
Reconstructive ladder
Timing of scar revision
Scar should be mature

Collagen remodeling and reorientation

takes upto 18 months

If scar is grossly deforming revision is

recommended 2-3mnths- dermal scar
serves as wound base
Techniques for scar revision

Non surgical methods

 Massage (1month post operative)
 Silicone gel (topical application)
 Intralesional steroids
 Lasers
 Vitamin E
 Vitamin A
 Herbal extract (allium cepa)
 Make up (camouflage)
Surgical Methods

 Scar excision
 Scar irregularization
• Z-plasty
• W-plasty
• Geometric broken line
Scar excision
 Most common excisional tech. is elliptical excision
 Reserved for scars that are parallel to RSTL, less than
2cm in length or short straight wide depressed or raised
scars
 Fusiform shaped incisions made parallel to RSTL
 Angle<30 degree to prevent skin rebundancy & l:w ratio
– 3:1
Scar irregularization
Z- plasty:
• Classic z-plasty is 60 degree
transposed flap

• Used for scar not along RSTL

• It alters the direction of scar to be parallel with RSTL

• Two points in Z- plasty are critical

(a) Angle size (tissue lengthening )
(b) Length of common diagonal (scar)

• In larger scar multiple z-plasty is done

W- plasty:

• Based on principle that

irregular line is less visible
than straight line

• Used for scar not along

RSTL

• Zigzag incision on one side

and its mirror image on
opposite side
Geometric broken line:
• used for longer scar

• outline is made on one side

using geometric designs (circles,
triangles)

• undermine and suture

V-Y & Y-V advancement flap:
 V-Y adv. Flap is unique in that V shaped flap is not
stretched or pulled into recipient site
 It is particularly useful when a structure or region
requires lengthening or release from contracted scar
 Y-V advancement is similar to V-Y flap except that V
shaped flap is stretched or pulled

 The maximum wound closure tension is at apex of flap

Dermabrasion
Superficialinjury to papillary dermis
Deposition of new organized collagen
Improves surface irregularities & pigmentation
Technique
Skin preparation (1 month prior) (optional)
- 4 % Hydroquinone (depigmentation)
- retinoic acid & tertinoin
Entire scar & adjacent skin is dermabraded

Abrasion is carried to the level of upper to

midreticular dermis

End point of abrasion is appearance of pinpoint

bleeding – indicates invasion of dermal papillae
Armamentarium
Electric powered rotary Hand piece

Diamond Fraise & Files (round, wheel)

Derma abrasion is carried out at 10,000 to

15,000 rpm
Advances in skin surgery
 LASERS – Light amplification by stimulated emission
of radiation

- Principles :A quantum of electromagnetic energy called

photon can stimulate an EXCITED atom to emit another
photon with same energy and wavelength

- Key word is EXCITED atom, as resting atom will

simply absorb the photon
Parts of a Laser system
 A gas, solid or liquid medium that can be excited to
emit laser light
 Mirror, reflects light back and forth, increases intensity
 A source of energy to excite medium
 Delivery system (fibro-optic cable)

Type of Laser
 Continuous laser
 Pulsed Laser
 Chromophores – medium that absorb light
 Three primary chromophores in skin:
(a) Water
(b) Hemoglobin (blue, green)
(c) Melanin (Broad spectrum)
 The laser light absorbed by the tissue is converted into
HEAT
 Time required by the tissue to loose half its heat to
surrounding tissue is thermal relaxation time (TRT)
SELECTIVE PHOTOTHERMOLYSIS
- When pulse duration is shorter than TRT of
target – localized heating

CO2 laser and Er:YAG laser for skin resurfacing

(wrinkle , scar)

 Argon laser for vascular lesion

Skin grafts
Two main forms
 Split-thickness (Thiersch graft)
 Full-thickness (Wolfe graft)
- Composite graft – Contains skin plus other
structure eg. cartilage
SPLIT-THICKNESS (STSG) FULL-THICKNESS (FTSG)

DONOR SITE DONOR SITE

-large area -smaller area
-heals spontaneously -site must be closed
-site reusable -site scars

RECEPIENT SITE RECEPIENT SITE

-contracts more -contracts less
-easily abraded -abrasion resistant
-poor color match -good color
-inferior cosmetics -good cosmetics
-reliable ‘take’ -less reliable ‘take’
-inelastic -normal texture, elastic
-over large areas -used over face