15 Skin And Soft Tissue 1


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15 Skin And Soft Tissue 1

  1. 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
  3. 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
  4. 8. Skin
  5. 9. Skin <ul><li>Prevent fluid loss </li></ul><ul><li>Temperature control </li></ul><ul><li>Elasticity and support </li></ul>
  7. 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
  8. 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
  9. 14. Dermoid
  10. 15. Dermoid
  11. 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
  12. 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
  13. 19. Avulsion
  14. 20. Incised Wounds
  15. 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.
  16. 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
  17. 24. LESIONS OF SKIN AND SOFT TISSUE TRAUMATIC C. Burns  Thermal  Open flame  Boiling water  Smoke inhalation injuries  Chemical  Electrical
  18. 25. Partial Thickness Burns
  19. 26. Occlusive Dressing w/ Duoderm
  20. 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 .
  21. 28. OTHER LESIONS KELOIDS Accepted form of treatment  Surgery with post –op radiation  Surgery with intra –op steroid injection  Triamcinolone>> promising steroid
  22. 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
  23. 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
  24. 31. Cellulitis
  25. 32. Cellulitis
  26. 33. Cellulitis
  27. 34. Cellulitis
  28. 35. Furuncle
  29. 36. Furuncle
  30. 37. Carbuncle
  31. 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
  32. 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
  33. 40. Verruca Vulgaris
  34. 41. Verruca Vulgaris
  35. 42. Verruca Vulgaris
  36. 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
  37. 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
  38. 45. Sebaceous Cysts
  39. 46. Application of Anesthesia
  40. 47. Start of Excision
  41. 48. The final outcome
  42. 49. Sebaceous cyst in eyelids
  43. 50. Stellate Suturing of Ganglion Cyst
  44. 51. Stellate Suturing of Ganglion Cyst
  45. 52. Lines of Langers
  46. 53. NEOPLASTIC CONDITIONS Benign conditions C. Vascular Tumors 1. Capillary Hemangiomas (Port wine- Stain)  found in the face, chest, extremities 
  47. 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
  48. 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
  49. 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
  50. 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
  51. 58. Lipoma
  52. 59. Axillary Mass
  53. 60. Mass Nape
  54. 61. Another View
  55. 62. Ready for Surgery
  56. 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
  57. 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)
  58. 65. Neuro Fibroma
  59. 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
  60. 67. Actinic Keratosis
  61. 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
  62. 69. Bowen’s Disease
  63. 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
  64. 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
  65. 74. Epidermal Nevus
  66. 75. Halo Nevus
  67. 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
  68. 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 -
  69. 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
  70. 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
  71. 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
  72. 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
  73. 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
  74. 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
  75. 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
  76. 85. Superficial Spreading Melanoma
  77. 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
  78. 87. Nodular Melanoma
  79. 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
  80. 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
  81. 91. Lentigo Maligna
  82. 92. Lentigo Maligna
  83. 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 )
  84. 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
  85. 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 )
  86. 96. MALIGNANT LESIONS Malignant Melanoma Treatment : A. Excision B. Resection C. Adjuvant Therapy  Regional hyperthermic perfusion  Chemotherapy  Immunotherapy  Radiotherapy
  87. 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
  88. 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
  89. 99. Basal Cell Carcinoma
  90. 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
  91. 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
  92. 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
  93. 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
  94. 104. Squamous Cell Carcinoma
  95. 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
  96. 106. SQUAMOUS CELL CARCINOMA Treatment Methods 1. Electrodessication For lesions less than 1cm in diameter For older individuals In patients with recurrence of tumors
  97. 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
  98. 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
  99. 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%
  100. 123. Thank You