1. SKIN and SOFT TISSUE Celso M. Fidel, MD,FPSGS,FPCS Diplomate Philippine Board of Surgery

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

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

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

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

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

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

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

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

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

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