15 Skin And Soft Tissue 1

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  • 1. SKIN and SOFT TISSUE Celso M. Fidel, MD,FPSGS,FPCS Diplomate Philippine Board of Surgery
  • 2.  
  • 3. 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 bulk  Acts as padding and Shock Absorber
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  • 7. 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
  • 8. Skin
  • 9. Skin
    • Prevent fluid loss
    • Temperature control
    • Elasticity and support
  • 10. LESIONS OF SKIN AND SOFT TISSUE  CONGENITAL  TRAUMATIC  INFLAMMATORY  NEOPLASTIC  BENIGN  MALIGNANT  OTHER LESIONS  METASTATIC SKIN LESION  FOREICN BODY GRANULOMA
  • 11. 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 (Possibility of intracranial extension
  • 12. 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
  • 13.  
  • 14. Dermoid
  • 15. Dermoid
  • 16. 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 and branching of the many sinus tracts may require skin closure by Z or W-plasty
  • 17.  
  • 18. LESIONS OF SKIN AND SOFT TISSUE CONGENITAL C. Branchiogenic sinuses  Are located anterior to medial edge of sternocleidomastoid muscle  Arise from either Ist,2 nd or 3 rd branchial arch  Located anterior to ear if coming from Ist TRAUMATIC A. Wounds  Abrasions  Lacerated wounds  Punctured wounds  Incised wounds  Avulsion
  • 19. Avulsion
  • 20. Incised Wounds
  • 21.  
  • 22. 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.
  • 23. LESIONS OF SKIN AND SOFT TISSUE TRAUMATIC B. Pneumatic tire injury  Management  Damage area cleaned  Divitalized tissue debrided  Extremity splinted  Raw area skin-grafted
  • 24. LESIONS OF SKIN AND SOFT TISSUE TRAUMATIC C. Burns  Thermal  Open flame  Boiling water  Smoke inhalation injuries  Chemical  Electrical
  • 25. Partial Thickness Burns
  • 26. Occlusive Dressing w/ Duoderm
  • 27. 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 .
  • 28. OTHER LESIONS KELOIDS Accepted form of treatment  Surgery with post –op radiation  Surgery with intra –op steroid injection  Triamcinolone>> promising steroid
  • 29. 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
  • 30. 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
  • 31. Cellulitis
  • 32. Cellulitis
  • 33. Cellulitis
  • 34. Cellulitis
  • 35. Furuncle
  • 36. Furuncle
  • 37. Carbuncle
  • 38. INFLAMMATORY CONDITIONS Management  Debridement and delayed skin grafting  Biologic dressing such as HOMOGRAFT, AMNIOTIC membrane  Skin auto graft as soon as patient is in a better condition
  • 39. NEOPLASTIC CONDITIONS Benign conditions A. Common Warts Verrucae Vulgaris-  Occurs in 2 nd 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
  • 40. Verruca Vulgaris
  • 41. Verruca Vulgaris
  • 42. Verruca Vulgaris
  • 43. 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
  • 44. 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 3. Ganglion Cyst  areas of weakened retinaculum with out pouching of underlying synovial structures
  • 45. Sebaceous Cysts
  • 46. Application of Anesthesia
  • 47. Start of Excision
  • 48. The final outcome
  • 49. Sebaceous cyst in eyelids
  • 50. Stellate Suturing of Ganglion Cyst
  • 51. Stellate Suturing of Ganglion Cyst
  • 52. Lines of Langers
  • 53. NEOPLASTIC CONDITIONS Benign conditions C. Vascular Tumors 1. Capillary Hemangiomas (Port wine- Stain)  found in the face, chest, extremities 
  • 54. 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
  • 55. 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
  • 56. 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
  • 57. 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
  • 58. Lipoma
  • 59. Axillary Mass
  • 60. Mass Nape
  • 61. Another View
  • 62. Ready for Surgery
  • 63. 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
  • 64. NEOPLASTIC CONDITIONS Benign conditions E. 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- colored spots (pathognomonic)
  • 65. Neuro Fibroma
  • 66. PREMALIGNANT SKIN LESION 1. Actinic Keratosis  Rough, scaly epidermal lesion in areas of the body subjected to chronic sun exposure  3 rd and 4 th decade and 10% to 20% will undergo malignant transformation  If benign, excision or cryotherapy  5-fluorouracil for patients with many keratosis
  • 67. Actinic Keratosis
  • 68. 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, no potential for metastasis  4 th to 6 th decade of life  Arsenic ingestion and viruses implicated as etiologic agents  Treatment same as actinic keratosis
  • 69. Bowen’s Disease
  • 70. 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
  • 71.  
  • 72. 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
  • 73.  
  • 74. Epidermal Nevus
  • 75. Halo Nevus
  • 76. 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
  • 77. 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 epidermal- dermal interface and within the dermis  Malignant transformation is rare -
  • 78. 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
  • 79. 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
  • 80. 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
  • 81. 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
  • 82. MALIGNANT LESIONS Malignant Melanoma A. Epidemiology 1. incidence is 13 new cases/ 100,000 /year representing an increase of 50% 2. occurs in 5 th decade, rare in children 3. some 20% to 30% arise in head & neck 4. incidence is equal in males and in females
  • 83. 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
  • 84. 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  5 th decade of life  Irregular borders, varied color  U pper dermis w/ lateral junctional spread  Generally prognosis is good
  • 85. Superficial Spreading Melanoma
  • 86. MALIGNANT LESIONS Malignant Melanoma 2. Nodular Melanoma Accounts for 15% of all melanoma  6 th decade of life  Blue black lesion on any part of body  Vertical spread rapid dermal invasion  Prognosis is poor
  • 87. Nodular Melanoma
  • 88. MALIGNANT LESIONS Malignant Melanoma 3. Acrolentiginous & Mucosal Melanoma  Comprise 10% of all melanoma  5 th 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
  • 89.  
  • 90. MALIGNANT LESIONS Malignant Melanoma 4. Lentigo Maligna ( Melanotic freckle of Hutchinson)  The least common; 5 th 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
  • 91. Lentigo Maligna
  • 92. Lentigo Maligna
  • 93. MALIGNANT LESIONS Malignant Melanoma CLARK’S CLASSIFICATION Level 1 Tumor confined to epidermis Level 11 Tumor invades papillary derm is Level 111-T umor fills the papillary derm is bu t d oes not invade reticu lar derm is Level 1V-Tu mor invades the reticular dermis Level V – Tumor invades subcutaneous tissue ( Fat )
  • 94. 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
  • 95. 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 )
  • 96. MALIGNANT LESIONS Malignant Melanoma Treatment : A. Excision B. Resection C. Adjuvant Therapy  Regional hyperthermic perfusion  Chemotherapy  Immunotherapy  Radiotherapy
  • 97. 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 12 months
  • 98. 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
  • 99. Basal Cell Carcinoma
  • 100. 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  Present as an ulceration w/ rolled edges
  • 101. 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
  • 102. 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
  • 103. 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
  • 104. Squamous Cell Carcinoma
  • 105. 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  Incisional Biopsy can be performed for larger lesions and those in the face
  • 106. SQUAMOUS CELL CARCINOMA Treatment Methods 1. Electrodessication For lesions less than 1cm in diameter For older individuals In patients with recurrence of tumors
  • 107. 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 with the primary tumor because they will resolve in time if the adenopathy is inflammatory
  • 108. 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. Moh’s Surgery  Precise mapping and frozen-section control of the entire resection bed  Allows early reconstruction because of reliable surgical margin
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  • 122. 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  Overall 5 year survival rate approaches 40%
  • 123. Thank You