This document provides information on various surgical short cases including lipoma, sebaceous cyst, dermoid cyst, keloid, and basal cell carcinoma (BCC). It describes the presentation, diagnosis, and treatment of each condition. Lipomas are benign fatty tumors that can occur in different parts of the body. Sebaceous cysts and dermoid cysts are cysts lined by keratinizing squamous epithelium that may contain skin appendages. Keloids are fibroproliferative scars that can form after skin injuries. BCC is the most common type of skin cancer, arising from basal cells, with various clinical subtypes and risk factors described. Surgical excision is a common treatment approach for many

1. SURGICAL SHORT CASES
1.LIPOMA
2. SEBAECEOUS CYST
3.DERMOID CYST
4. KELOID
5.BCC
BY
DR.A.SASIDHARAN MBBS

3. Introduction
 Commonest tumor of s/c
tissue.
 Benign
 Arising from yellow fat
 Universal tumor
 Karyotype 12q change
 Hibernoma

4. Types
Encapsulated s/c lipoma
Diffuse variety
Multiple lipomas- Dercum’s
d/s

6. Histological types
Fibrolipoma
Neurolipom
a
Naevolipom
a

7. location presentation d.d. Significance
s/c Mobile, lobular,
edge slips under
palp.fingers
Neurofibrom
a
Most common
variety
subfascial Diff. to appreciate
edge & lobulation
Implantation
dermoid ,
Tbtenosynovitis
In scalp- erodes
bone
Subsynovial,
intra-articular
Knee/elbow
sweling
Bursa,
Baker’s cyst
Intra-articular is
rare
Intermuscular Swelling Fibrosarcoma
Hematoma
More chance of
devpg
liposarcoma
Parosteal Feels hard Bony tumor Very, very rare

8. Contd..
location presentation d.d. Significance
Submucus Asymptomatic/
stridor
Intestinal/laryngea
l tumor
Intussusception
Subserosal Retroperitoneal
swelling
Hydronephrosis,
retroperitoneal
cyst
Liposarcoma
Extradural Very rare - -
Intraglandula
r
Breast, pancreas Cystic lesions Very rare

9. Clinical features
 Localized, lobular, non-
tender
 Semi-fluctuant
 Mobile
 Slip sign
 Skin free
 Pedunculated +/-

11. Complications
 Myxomatous degeneration
 Saponification
 Calcification
 Infection
 Ulceration
 Intussusception & intestinal
obstruction

12. Liposarcoma
 Common in retroperitoneum, thigh &
back
 Rapid growth
 Warm & vascular
 Dilated veins
 Restriction of mobility
 Skin fixation & fungation
 Hematogenous spread to lungs

13. Treatment
 Excision
 Liposarcoma- wide
excision, reconstruction, adjuvant chemo-
& radiotherapy

15. DISEASES OF SEBACEOUS GLANDS
sebaceous gland: Holocaine glands in the skin that secrete
sebum
usually through the hair follicles.
• Sebaceous hyperplasia
• Adenoma sebaceum (Sebaceous adenoma)
• Sebaceous cyst (Epidermoid cyst)
4 Acne
5 Sebaceous gland carcinoma

16. SEBACEOUS CYST (EPIDERMOID CYST)
• Epidermoid cyst originates in the epidermis and a pilar cyst originates
from hair follicles, but neither type of cyst is strictly a sebaceous cyst
• The fatty, white, semi-solid material in both cysts is not sebum, but
keratin,
and under the microscope neither entity contains sebaceous glands.
• "True" sebaceous cysts are known as steatocystomas or, if multiple, as
steatocystoma multiplex.
Steatocystoma multiplex Epidermoid cyst

17. Pathogenesis: formation of acne
1 Increased activity of sebaceous glands with production of
excess sebum plays an important role
2 Occlusion of the pilo sebaceous orifices plays an
important
role
1 Hormones : Increased activity of sebaceous glands and
occlusion of the cornfied hypertrophic pilosebaceous
follicles lead to retention of sebum into the follicles, which
dilate and rupture by time.
2 Anaerobes such as Corynebacterium (Propionibacterium)
acne, Pityrosporon ovale and Staphylococci cause split of
the sebum into fatty acids and triglycerides which act as
an important irritating factors & → to the formation of the
different clinical types of acne which varies from
papules, pustules ,cysts and comedones

18. RX : SURGICAL
EXCISION OF THE CYST

19. SEBACEOUS CYST

20. DERMOID CYST

21.  Cyst lined by squamous epithelium
containing desquamated cells
 CONTENTS
mixture of sweat, sebum,
desquamated epithelial cells, hair

22. CLINICAL
TYPES
 CONGENITAL / SEQUESTRATION
DERMOID
SITE: along lines of embryonic fusion
(midline of body or face)
FORMATION: dermal cells sequestrated in
subcutaneous plane > proliferate & liquify
> cyst > grows & indents
mesoderm(future bone) > bony defects

23.  MEDIAL NASAL DERMOID CYST
(root of nose at fusion lines of frontal
process)
 EXTERNAL AND INTERNAL
ANGULAR DERMOID ( fusion line of
frontonasal and maxillary processes)
 SUBLINGUAL DERMOID
 PRE –AURICULAR DERMOID
 POST AURICULAR DERMOID

25. CLINICAL
FEATURES Manifests in childhood or adolescence
 Typically a painless slow growing
swelling
 Soft, cystic, fluctuant, yield to pressure of
finger and will not slip away
 Transillumination negative
 Putty in consistency
 No impulse on coughing
 Underlying bony defect – clue to
diagnosis

27. OTHER
TYPES
 IMPLANTATION DERMOID
> in women, tailors, agriculturists who
sustain repeated minor injuries
> sharp injury- epidermal cells implanted
in subcutaneous plane- dermoid cyst
> fingers, palm, sole of foot
> hard in consistency ( skin is thick)

28.  TERATOMATOUS DERMOID
> arise from totipotent cells
> ectodermal, mesodermal, endodermal
elements
> ovary, testis,retroperitoneum, mediastinum

30.  TUBULO-EMBRYONIC DERMOID
> from ectodermal tubes
> thyroglossal cyst, post- anal
dermoid

31. INVESTIGATIO
NS
 BLOOD – TC, DC,Hb,ESR
 URINE Examination
 FNAC-
 X ray- subjacent bone eroded by
dermoid
 Ultrasonography- mass cystic/ solid
 CT scan- size , shape , local spread

32. TREATME
NT Excision of the
cyst
Mass shown ( implantation
dermoid)
Incision
marked

33. Incision started ( cyst contents
leaking)
cyst being
removed

35. KELOID

36. History
A 23 year old female was referred by
plastic surgeons for radiotherapy to th
posterior ear lobe, following the
development of a Keloid Scar, three
years after an ear piercing
No family history of keloids
e

37. Pathology
Keloid is a unique huma
fibroproliferative disorde
inflammation, surgery,a
Commonly causes of kel
folliculitis, chicken pox,
(such as, earlobe piercin
wounds).
It is a benign growth, we
fibrous tissue overgrowt
original defect
n dermal
r that occurs after injury,
nd burn.
oids include acne,
accinations and trauma
g, lacerations, or surgical
ll-demarcated area of
h that extends beyond
the
v

38. Baron Jean-Louis Alibert
(1768-1837)
Described appearance
Crab-claw-like  Cheloid  Keloid

39. Effects of keloids
Compromise aesthetic Impairment of function

40. Itchy
Pain
Pruruti
c

41. How best can they be treated?

42. Treatment Options
Surgery
Intralesional Steroids
Radiation
Laser
Cryotherapy
Pressure
Multimodality
Therapy

43. Still Trying

44. Surgery Drawbac
ks
Painful
Difficult reconstruction with large keloids
Utilizes normal surrounding tissue – limiting later
reconstructive options
Low long term success as monotherapy

45. Steroids
 Triamcinolone
 Hydrocortisone
 Dexamethasone
 Methylprednisone

47. Laser
1980s in vogue
Proposed Mechanism
No knife  Less tissue
trauma

48. Cryotherapy- cold treatment

49. Di
us
 <10
minishes size and induration (HTS >Keloid) when
ed as monotherapy
% Recurrence when combined with surgery
Photos Courtesy of Dr.
Pressure Therapy

50. Radiation

52. Basal cell carcinoma (BCC) is a slow
progressing nonmelanocytic skin cancer
that arises from basal cells (ie, small,
round cells found in the lower layer of
the epidermis).

53. It is the most common skin cancer (80%)
Estimated 3.3 million cases are diagnosed per
year(US) and incidence doubles every 25 years
The incidence high in areas of ↑UV radiation
(Australia,South africa)
estimated lifetime risk of 33-39% for men
and 23-28% for women
Men >Women
It increases with age (50-80 yrs )
 Rare in <40 yrs (5-15%)

55. Sun damage
Repeated prior episodes of
sunburn
Fair skin, blue eyes and blond or
red hair ( also affect darker skin
types)
Previous cutaneous injury,
thermal burn, disease
(eg cutaneous lupus, sebaceous
naevus)

56. Inherited syndromes: BCC is a particular problem
for families with basal cell naevus syndrome
(Gorlin syndrome), Bazex syndrome, Rombo
syndrome and xeroderma pigmentosum
,albinism
Other risk factors include ionising radiation,
exposure to arsenic, coal tar, smoking tanning
bed and immune suppression due
to disease or medicines

57. The cause of BCC is multifactorial.
DNA mutations in the patched
(PTCH) tumour suppressor gene, part of hedgehog
signalling pathway (SHH)
triggered by exposure to ultraviolet radiation
Various spontaneous and inherited gene defects
predispose to BCC

58. BCC is a locally invasive skin tumour and
rarely
metastatize(< 0.01%)
The main characteristics are:
Slow growing: 0.5 cm in 1-2 years
Varies in size from a few millimetres to several
centimetres in diameter
Skin coloured, pink or pigmented
Spontaneous bleeding or ulceration
Waxy papules with central depression
Pearly appearance

59. Oozing or crusted areas: In large
BCCs
Rolled (raised) border
Translucency
Telangiectases over the surface
Black-blue or brown areas

60. BCC distrubution
:
Head and neck
60%
Nose 14%
Trunk 30%
Extremities 10%

61. There are several distinct clinical types
of BCC, and over 20 histological growth
patterns of BCC
Nodular
Superficial
Morphoeic
Basisquamous
Fibroepithelial tumour of Pinkus

62. Most common type of facial BCC
Shiny or pearly nodule with a smooth
surface with telangiectases
May have central depression or ulceration,
so its edges appear rolled
Cystic variant is soft, with jelly-like
contents
Micronodular, microcystic and infiltrative
types are potentially aggressive subtypes

64. Most common type in younger adults
Most common type on upper trunk
and shoulders
Slightly scaly, irregular plaque
Thin, translucent rolled border
Multiple microerosions

66. Also known as morphoeiform or
sclerosing
BCC
Usually found in mid-facial sites
Waxy, scar-like plaque with indistinct
borders
Flat or slightly depressed, fibrotic, and
firm
Wide and deep subclinical extension

68. Mixed basal cell carcinoma (BCC)
and squamous cell carcinoma (SCC)
Infiltrative growth pattern
Potentially more aggressive than other forms of
BCC

69. Warty plaque
Usually on
trunk

70. Characteristics of recurrent BCC
often
include:
Incomplete excision or narrow margins
at
primary excision
Morphoeic, micronodular, and
infiltrative subtypes
Location on head and neck

71. Advanced BCC
Advanced BCCs are large, often neglected tumours.
They may be several centimetres in diameter
They may be deeply infiltrating into tissues below
the
skin
They are difficult or impossible to treat surgically

72. Nevi malignant
melanoma
Keratoacanthoma
Seborrheic keratosis
Bowen disease
Actinic keratosis
Squamous cell carcinoma

73.  Skin biopsy
 To confirm and diagnose bcc and
its subtype Shave biopsy
Punch biospy
 Cytology
 Histologic findings
 Laser doppler (eyelids tumor
margins)

75. Treatment depends on size ,location and type
of
BCC
Curretage and electrosessication
Mohs micrographic surgery
Excisional surgery
Radiation
Cryosurgery
Photodynamic theray
Laser surgery
Topical medications

76. Curretage and electricdesiccation : The growth is
scraped off with a curette, an instrument with a
sharp, ring-shaped tip), then the tumor site is
desiccated (burned) with an electrocautery needle.
Small lesions
Leaves round whiitish scar
Not suitable for advanced bcc, in high risk sites.

77. Excision means the lesion is cut out and the skin
stitched up.
Most appropriate treatment for nodular,
infiltrative and morphoeic BCCs
Should include 3 to 5 mm margin of normal skin
around the tumour
Very large lesions may require flap or skin graft to
repair the defect
Further surgery is recommended for lesions that
are
incompletely excised

79. Cryotherapy is the treatment of a superficial
skin lesion by freezing it, usually with liquid nitrogen.
Suitable for small superficial BCCs on covered areas
of trunk and limbs
Results in a blister that crusts over and heals within
several weeks.
Leaves permanent white mark

80. Photodynamic therapy (PDT) refers to a technique in
which BCC is treated with a photosensitising
chemical, and exposed to light several hours later.
Topical photosensitisers include aminolevulinic acid
lotion and methyl aminolevulinate cream
Suitable for low-risk small, superficial BCCs
Results in inflammatory reaction, maximal 3–4 days
after procedure
Treatment repeated 7 days after initial treatment
Excellent cosmetic results

82. Radiotherapy or X-ray treatment can be used to treat
primary BCCs or as adjunctive treatment if margins are
incomplete.
Mainly used if surgery is not suitable
Best avoided in young patients and in genetic conditions
predisposing to skin cancer
Best cosmetic results achieved using multiple fractions
Typically, patient attends once-weekly for several weeks
Causes inflammatory reaction followed by scar
Risk of radiodermatitis, late recurrence, and new
tumours

83. Imiquimod cream
Imiquimod is an immune response modifier.
Best used for superficial BCCs less than 2 cm diameter
Applied three to five times each week, for 6–16 weeks
Fluorouracil cream
5-Fluorouracil cream is a topical cytotoxic agent.
Used to treat small superficial basal cell carcinomas
Requires prolonged course, eg twice daily for 6–12
weeks
Causes inflammatory reaction
Has high recurrence rates

85. SURGERY
TARGET THERAPY (SHH PATHWAY
INHIBITORS)
Vismodegib Erivedge™ȋ Ȍ
Sonidegib (Odomzo®)

86. Protect skin from sun exposure daily, year-round
and
lifelong.
Stay indoors or under the shade in the middle of the
day
Wear covering clothing
Apply high protection factor SPF50+ broad-
spectrum sunscreens generously to exposed skin if
outdoors
Avoid indoor tanning (sun beds, solaria)