Schwartz Principles of Surgery

Chap. 16 Skin and Subcutaneous Tissue

KEY POINTS providing soft-tissue durability

1. EPIDERMIS primarily composed of a dense ECM
consists of five layers provides support for a complex network of
two most superficial layers contain nonviable nerves, vasculature, and adnexal structures
keratinocytes. collection of fibrous proteins and associated
STRATUM CORNEUM glycoproteins embedded in a hydrated ground
STRATUM LUCIDUM substance of glycosaminoglycans and
2. COLLAGEN III proteoglycans
provides tensile strength to the dermis and provides architectural framework that imparts
epidermis. mechanical support and viscoelasticity
3. Adult dermis regulate the neighboring cells, including their
contains a 4:1 ratio of type I:type III collagen. ability to migrate, proliferate, and survive injury
4. congenital skin disorders responsive to surgical
rejuvenation EPIDERMIS
PSEUDOXANTHOMA ELASTICUM Composed primarily of keratinocytes
CUTIS LAXIA dynamic, multilayered composite of maturing cells
5. HEMANGIOMA internal to external-most layer, the epidermis is
most common cutaneous lesion of infancy composed of
large majority spontaneously involute (resolve) past STRATUM GERMINATUM
the first year of patient age. STRATUM SPINOSUM
6. BASAL CELL CARCINOMA (BCC) keratinocytes are linked together by
most common form of skin cancer TONOFIBRILS
NODULAR BCC as they produce keratin, they drift upward,
most frequent form of this tumor. andlose their mitotic ability
7. BRESLOW THICKNESS STRATUM GRANULOSUM
most important prognostic variable predicting cells accumulate keratohyalin granules
survival in those with cutaneous melanoma. STRATUM LUCIDUM
STRATUM CORNEUM.
Background Basal cells are a mitotically active
SKIN single-cell layer of the least-differentiated keratinocytes
largest human organ at the base of epidermal structure
demonstrates profound regional variation due to the As basal cells multiply, they leave the basal lamina to
highly structured organization of many different cell types begin their differentiation and upward migration
and dermal elements In the horny layer, keratinocytes age, lose their
protective barrier allowing interface with our surroundings intercellular connections, and shed.
environmental buffer, the skin protects against a vast From basal layer exit to shedding, keratinocyte transit
array of destructive forces: time approximates 40 to 56 days
structural integrity of the epidermis MELANOCYTES
creates a semipermeable barrier to chemical Initially derived from precursor cells of the neural
absorption crest
prevents fluid loss extend dendritic processes upward into epidermal
protects against penetration of solar radiation tissues from their position beneath the basal cell
rebuffs infectious agents layer
dermal durability resists physical forces number approximately one for every 35
ability to regulate body heat keratinocytes
makes it the body's primary thermoregulatory produce MELANIN from tyrosine and cysteine
organ Once the pigment is packaged into
MELANOSOMES within the melanocyte cell body,
Anatomy and physiology of the skin these pigment molecules are transported into
skin may be divided into three layers the epidermis via dendritic processes
As dendritic processes (apocopation) are
EPIDERMIS
sheared off, melanin is transferred to
very little extracellular matrix (ECM)
keratinocytes via phagocytosis
composed primarily of specialized cells that
Density of melanocytes is constant among
perform vital functions
individuals
BASEMENT MEMBRANE
determine the degree of skin pigmentation
Sandwiched between epidermal and dermal
rate of melanin production
structures dermis
transfer to keratinocytes
anchors these layers together
melanosome degradation
fulfills many biologic functions
North European ancestry have melanocytes
tissue organization
that release relatively low amounts of
growth factor reservoir
melanin
support of cell monolayers during tissue
African descent demonstrate the same
development, semipermeable selective
overall quantity of melanocytes, but with
barrier
much higher melanin production
DERMIS
increase melanin production

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Schwartz Principles of Surgery
Chap. 16 Skin and Subcutaneous Tissue
Genetically activated factors
ultraviolet (UV) radiation
hormones
estrogen
adrenocorticotropic hormone
melanocyte-stimulating hormone
play a critical role in neutralizing the sun's harmful
rays
UV-induced damage affects the function of tumor
suppressor genes
directly causes cell death
facilitates neoplastic transformation
UVA (315 to 400 nm)
majority of solar radiation that reaches the Earth
damage DNA, proteins, and lipids
UVB (240 to 315 nm)
causes majority of skin damage
major factor in sunburn injury
a known risk factor in the development of
melanoma
causes considerable DNA damage in the skin
UV-related damage can either be potentiated by or
contribute to effects of other harmful agents such as
ionizing radiation, viruses, or chemical carcinogens
complex network of filaments to maintain cellular
integrity
durable barrier against external forces a
KERATINS
Intermediate filaments
found within the spindle layer
provide flexible scaffolding that enables the
keratinocyte to resist external stress.
expressed according to keratinocyte maturation
phase
mitotically active keratinocytes mainly express
keratins 5 and 14
EPIDERMOLYSIS BULLOSA
Point mutations affecting these genes that
express keratins
blistering diseases
associated with spontaneous release of
dermal-epidermal attachments
role in resisting radiation, toxin absorption, and deforming
forces immunoreactive barrier
LANGERHANS' CELLS
migrates into epidermal structure from the bone
marrow
act as the skin's macrophages
expresses class II major histocompatibility antigens
has antigen-presenting capabilities
initiates rejection of foreign bodies
play a crucial role in immunosurveillance against
viral infections and neoplasms of the skin
The Dermis
mostly comprised of structural proteins
COLLAGEN
main functional protein within the dermis
constitutes 70% of dermal dry weight
responsible for its remarkable tensile strength
TROPOCOLLAGEN
collagen precursor
consists of three polypeptide chains
HYDROXYPROLINE
HYDROXYLYSINE
By: Rem Alfelor
GLYCINE
wrapped in a helix
long molecules are then cross-linked to one
another to form collagen fibers
skin primarily contains TYPE I
Fetal dermis contains mostly TYPE III (RETICULIN
FIBERS)
Collagen only remains in the basement membrane
zone and perivascular regions during postnatal
development
ELASTIC FIBERS
highly branched proteins capable of stretching to
twice their resting length.
allow a return to baseline form after the skin
responds to deforming stress
GROUND SUBSTANCE
consisting of various polysaccharidepolypeptide
(GLYCOSAMINOGLYCANS) complexes
amorphous material that occupies the remaining
spaces
secreted by fibroblasts
can hold up to 1000 times their own volume in
water
constitute most of dermal volume
blood supply to the dermis is based on an intricate
network of blood vessels provide vascular inflow to
superficial structures
regulate body temperature
vertical vascular channels that interconnect two
horizontal plexuses
one within the papillary dermis
other at the dermalsubcutaneous junction
GLOMUS BODIES
tortuous arteriovenous shunts
allow a substantial increase in superficial blood flow
when stimulated to open
Cutaneous sensation is achieved via activation of a
complicated plexus of dermal autonomic fibers synapsed
sweat glands
erector pili
vasculature control points connect to corpuscular
receptors that relay information from the skin back to the
central nervous system
transmit information on pressure, vibration, and touch
Meissner's
Ruffini's
Pacini's corpuscles
"unspecialized" free nerve endings report temperature,
touch, pain, and itch sensations
Cutaneous Adnexal Structures
three main adnexal structures:
ECCRINE GLANDS
sweat producing
located over the entire body but are
concentrated on the palms, soles, axillae, and
forehead
PILOSEBACEOUS UNITS
Composed:
HAIR FOLLICLES
mitotically active germinal centers
produce HAIR
a cylinder of tightly packed cornified
epithelial cells
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Schwartz Principles of Surgery
Chap. 16 Skin and Subcutaneous Tissue

contains a reservoir of pluripotential initially seem innocuous

stem cells critical in epidermal
reproductivity
capable of near limitless expansion to
replace lost or injured cells
restore epidermal continuity after
wounding
skin graft harvest, residual hair follicles
supply new keratinocytes to regenerate
the epidermis and restore skin integrity
SEBACEOUS GLANDS
oil-secreting
APOCRINE GLANDS
pheromone-producing
play a distinct role in lower mammalian life
have not been shown to demonstrate significant
activity in human populations
primarily found in the human axillae and
anogenital region
predispose both regions to SUPPURATIVE
HYDROADENITIS
INJURIES TO THE SKIN AND SUBCUTANEOUS TISSUE
lapses in continuity provide entry of microorganisms,
allow injury to deeper tissue layers, and prompt local
tissue inflammation
In addition to penetrating trauma, the environment offers
a host of potentially injurious elements, such as
caustic substances
extreme temperatures
prolonged or excessive pressure
radiation
Traumatic Injuries
TRAUMATIC WOUNDS
caused by penetrating, blunt, and shear force, bite,
and degloving injuries.
CLEAN LACERATIONS
closed primarily after irrigation, debridement
careful evaluation
CONTAMINATED OR INFECTED WOUNDS
should be allowed to heal by secondary intention
or delayed primary closure
principles guiding the management of more complex
wounds
Dbridement of nonviable tissue
aggressive irrigation of the wound
TANGENTIAL ABRASIONS
approached similarly to second-degree burns
DEGLOVING INJURIES
considered third-degree or full-thickness burns
degloved skin may be partially salvaged by
placing it back on the wound like a skin graft
replacement of clean, avulsed tissue can
effectively provide wound coverage as a
biologic dressing
necrotic debris is removed
Areas of uncovered wound bed undergo delayed
primary closure
allowed to granulate in, or undergo
definitive reconstruction
BITE WOUNDS
account for 4.5 million injuries each year
prompt 2% of all emergency rooms visit
SMALL PUNCTURE WOUNDS
impregnation of oral bacteria into deep,
contained tissue layers can lead to
significant morbidity if unrecognized
most common infectious organisms found with
human bites are
Viridans streptococci
Staphylococcus aureus
Eikenella corrodens
Haemophilus influenza
beta-lactamase-producing bacteria
DOG BITES
account for the most frequent animal-
related wound
canine jaw can exert over 450 pounds of
pressure per square inch, dog bites often
add a crushing element in addition to
penetrating injury as well as an avulsion
element
may contaminate tissues with both aerobic
and anaerobic organisms
most commonly cultured bacteria include
Pasteurella multocida
Staphylococcus species
alpha-hemolytic streptococci
E. corrodens
Actinomyces
Fusobacterium
whether from human or animal is a
contaminated wound, should not be closed
primarily
Selected facial wounds may be closed primarily
after very thorough cleansing and initiation of
antibiotic therapy
should be approached via
drainage
copious irrigation
dbridement of necrotic material
antibiotic therapy
extremity immobilization
elevation
Exposure to Caustic Substances
Injuries secondary to caustic substance exposure may be
categorized as resulting from
ACIDIC SOLUTION
effect of acid exposure on the skin is determined
by
concentration
duration of contact
amount
penetrability
Deep tissue coagulative injury may result,
damaging nerves, blood vessels, tendons, and
bone
initial treatment should include
copious skin irrigation for at least 30
minutes with either saline or water
dilutes active acid solution
helps return the skin to normal pH
HYDROFLUORIC ACID
present an additional treatment challenge
Fluoride ions continue to injure underlying
tissue until they are neutralized with
calcium

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Schwartz Principles of Surgery
Chap. 16 Skin and Subcutaneous Tissue

absorb the body's calcium supply, PACLITAXEL

which may prompt cardiac arrhythmia Following extravasation, edema, erythema, and
Effectively detoxifies fluoride ions. induration usually are present
Topical quaternary ammonium Injury to underlying nerves, muscles, tendons, and
compounds are widely used blood vessels must be taken into account
Topical calcium carbonate gel successfully managed through a conservative
ALKALI SOLUTIONS approach
Alkaline agents often used as household SEVERE INFUSION INJURY
cleaning agents vigorous liposuction with a small cannula may be
After penetrating the skin cause fat used to introduce saline flush into the injured
saponification that facilitates tissue penetration area
and increases tissue damage flush is then allowed to egress via the small
liquefactive injury produced by alkali burns liposuction wounds
provides a longer, more sustained period of useful in the acute setting
injury Surgery
Immediate irrigation of the affected area limited to patients with necrotic tissue, pain, or
continuous water flow should be maintained damage of underlying structures
for at least 2 hours, or until symptomatic
relief is achieved Hyper- and Hypothermic Injury
INTRAVENOUS FLUID (IVF) EXTRAVASATION Skin exposed to temperature extremes is at significant
leakage of injectable fluids into interstitial space risk of hypo- or hyperthermic injury.
considered a chemical burn Depending upon
occurs from underneath the skin surface Temperature
actually a deep injury Period
produces injury via method of exposure
chemical toxicity HYPERTHERMIC INJURY
osmotic toxicity hyperthermic burns may cause varying degrees of
from pressure effects in a closed environment tissue injury affecting the skin at different levels of
displacement may be the result of IV catheter depth
movement or increased vascular permeability ZONE OF COAGULATION
most common substances associated with these central area of injury
injuries are exposed to the most direct heat transfer
cationic solutions (e.g., potassium ion, calcium Typically becomes necrotic.
ion, bicarbonate) ZONE OF STASIS
osmotically active chemicals (e.g., total Surrounding the zone of coagulation
parenteral nutrition or hypertonic dextrose has marginal tissue perfusion and
solutions) questionable viability
antibiotics or cytotoxic drugs ZONE OF HYPEREMIA
dorsum of the hand is the most common site of outermost area
extravasation in the adult most similar to uninjured tissue
May result in extensor tendon exposure. demonstrates increased blood flow due to
Patients undergoing chemotherapy 4.7% risk for the body's response to injury
developing extravasation children present an HYPOTHERMIC INJURY (frostbite)
incidence as high as 58% results in the acute freezing of tissues
Newborn babies are at particular risk due product of two factors:
fragility and small caliber of their veins duration of exposure
poor ability to verbalize pain temperature gradient at the skin surface
frequent use of pressurized IVF pumps used in SEVERE HYPOTHERMIA
their care exerts its damaging effect by causing
most common IVF extravasations causing direct cellular injury to blood vessel walls
necrosis in the infant are microvascular thrombosis
high-concentration dextrose solutions
skin's tensile strength decreases by 20% in a cold
calcium environment [12C, (53.6F)]
bicarbonate
treatment protocol for frostbite
parenteral nutrition rapid rewarming
adult population, commonly extravasated drugs close observation
chemotherapeutic agents elevation and splinting
DOXORUBICIN (Adriamycin) daily hydrotherapy
direct toxic effects of doxorubicin serial dbridements
causes cellular death
Perpetuated by release of doxorubicin- Pressure Injury
DNA complexes from dead cells. Prolonged, excessive pressure often results in pressure
prevents release of cytokines and ulcer formation
growth factors, which may ultimately As pressure is applied to overlying tissues, cutaneous
result in wound healing failure vascular flow is decreased

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Schwartz Principles of Surgery
Chap. 16 Skin and Subcutaneous Tissue
rendering local tissues functionally ischemic
As little as 1 hour of 60 mmHg pressure produces
histologically identifiable
venous thrombosis
muscle degeneration
tissue necrosis
Healthy individuals regularly shift their body weight, even
while asleep. However,
Patients unable to sense pain or shift their body weight,
such as paraplegics or bedridden individuals, may
develop prolonged elevated tissue pressures and local
necrosis
muscle tissue is more sensitive to ischemia than skin,
necrosis usually extends to a deeper area than that
apparent on superficial inspection
elements of pressure sore treatment include
relief of pressure
wound care
systemic enhancement, such as optimization of
nutrition
Air flotation mattresses and gel seat cushions
redistribute pressure
decrease the incidence of pressure ulcers
cost-effective in the care of patients at high risk
nutritional support services to facilitate proper dietary
intake
Surgical management
dbridement of all necrotic tissue followed by
irrigation
Shallow ulcers are allowed to close by secondary
intention
Deeper wounds with involvement of the underlying
bone require surgical dbridement and coverage
Radiation Exposure
frequently produced by a wide range of environmental
elements
solar (UV) exposure
iatrogenic management
industrial/occupational applications
SOLAR OR UV RADIATION
most common form of radiation exposure
UV spectrum is divided into
UVA (400 to 315 nm)
UVB (315 to 290 nm)
UVC (290 to 200 nm)
ozone layer absorbs UVC wavelengths below 290 nm,
allowing only UVA and UVB to reach the earth
UVB
responsible for acute sunburns and chronic skin
damage leading to malignant degeneration
IONIZING RADIATION
effectively blocks mitosis in rapidly dividing cell types
mainstay in the treatment of various malignancies
extent of cellular damage is dependent on
radiation dose
exposure period
cell type being treated
Acute radiation changes include
Erythema
basal epithelial cellular death in the area of
direct application
With cellular repair, permanent
hyperpigmentation is observed in healing areas
chronic radiation changes
By: Rem Alfelor
Four to 6 months following radiation application
characterized by a
loss of capillaries via thrombosis
fibrinoid necrosis of vessel walls
Progressive fibrosis and hypovascularity may
eventually lead to ulceration
when poor vascular inflow results in poor
tissue perfusion that progresses as the skin
ages
INFECTIONS OF THE SKIN AND SUBCUTANEOUS TISSUE
CELLULITIS
Heralded by erythema, warmth, tenderness, and edema
superficial, spreading infection of the skin and
subcutaneous tissue most common organisms associated
with cellulitis
group A streptococci
S. aureus
uncomplicated cellulitis usually can be managed with oral
antibiotics on an outpatient basis.
Folliculitis, Furuncles, and Carbuncles
FOLLICULITIS
infection of the hair follicle
causative organism is usually Staphylococcus, but
gram-negative organisms may cause follicular
inflammation as well
folliculitis usually resolves with adequate hygiene
FURUNCLE (boil)
begins as folliculitis, but may eventually progress to
form a fluctuant nodule
soaking the furuncle in warm water hastens
liquefaction and hastens spontaneous rupture
CARBUNCLES
deep-seated infections that result in multiple draining
cutaneous sinuses
Along with furuncles, these lesions often require incision
and drainage before healing can be initiated
Necrotizing Soft-Tissue Infections
remain localized, some result in rapid, necrotizing spread
and septic shock
most common sites are
external genitalia
perineum
abdominal wall (Fournier gangrene)
classification of these infections is based on
a) tissue plane affected and extent of invasion
b) anatomic site
c) causative pathogen
Deep soft-tissue infections are classified as either
NECROTIZING FASCIITIS
rapid, extensive infection of the fascia deep to
the adipose tissue
NECROTIZING MYOSITIS
primarily involves the muscles
typically spreads to adjacent soft tissues
most common organisms isolated
gram-positive organisms:
group A streptococci
enterococci
coagulase-negative staphylococci,
S. aureus
S. epidermidis
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Schwartz Principles of Surgery
Chap. 16 Skin and Subcutaneous Tissue

Clostridium species presence of sulfur granules within purulent

Gram-negative species specimen is pathognomonic
Escherichia coli Penicillin and sulfonamides are typically effective
Enterobacter against these infections
Pseudomonas species areas of deep-seated infection, abscess, or chronic
Proteus species scarring
Serratia species require surgical therapy
Bacteroides
Polymicrobial infections tend to be more common VIRAL INFECTIONS OF THE SKIN AND SUBCUTANEOUS TISSUE
than single organism disease in these cases
Clinical risk factors Human Papillomavirus
WARTS
diabetes mellitus
epidermal growths resulting from human
malnutrition
papillomavirus (HPV) infection
obesity
Different morphologic types have a tendency to occur at
chronic alcoholism
different areas of the body
peripheral vascular disease COMMON WART (VERRUCA VULGARIS)
chronic lymphocytic leukemia found on the fingers and toes
steroid use rough and bulbous
renal failure PLANTAR WARTS (VERRUCA PLANTARIS)
cirrhosis occur on the soles and palms
autoimmune deficiency syndrome may resemble a common callus
Appropriate management FLAT WARTS (VERRUCA PLANA)
1. starts with prompt recognition slightly raised and flat
2. broad-spectrum IV antibiotics tends to appear on the face, legs, and hands
3. aggressive surgical dbridement VENEREAL WARTS (CONDYLOMATA ACUMINATA)
Dbridement must be extensive, including all
grow in the moist areas around the vulva, anus,
skin, subcutaneous tissue, and muscle, until
and scrotum.
there is no further evidence of infected tissue.
Histologic examination demonstrates
intensive care unit support
Hyperkeratosis
Initial resection is followed by frequent returns to the
hypertrophy of the horny layer
operating room for additional dbridement as
required acanthosis
aggressive fluid replacement is typically needed to hypertrophy of the spinous layer
offset acute renal failure from ongoing sepsis papillomatosis
HIDRADENITIS SUPPURATIVA Treatment
defect of the terminal follicular epithelium Warts may be removed via application of chemicals,
results in apocrine gland blockage, obstructed such as
infection leads to abscess formation throughout Formalin
affected axillary, inguinal, and perianal regions. podophyllum,
Following spontaneous rupture of these localized phenol-nitric acid
collections, foul smelling sinuses form and repeated Curettage with electrodesiccation
infections create a wide area of inflamed, painful used for scattered lesions
tissue surgical excision under general anesthesia
Treatment of acute infections involves extensive areas of skin
application of warm compresses recurrences are common
antibiotics repeated excisions are often necessary
open drainage Some warts (especially HPV types 5, 8, and 10)
CHRONIC HIDRADENITIS associated with squamous cell cancers
wide excision is required lesions that grow rapidly, atypically, or ulcerate
closure may be achieved via skin graft or should be biopsied
local flap placement CONDYLOMATA ACUMINATA
ACTINOMYCOSIS one of the most common sexually transmitted
granulomatous suppurative bacterial disease diseases
caused by Actinomyces largely results from HPV types 6 and 11
Nocardia Extensive growths, facilitated by concomitant HIV
Actinomadura infection
Streptomyces often multiple and can grow large in size (BUSCHKE-
produce deep cutaneous infections that present LWENSTEIN tumor)
as nodules spread to form draining tracts within treatment:
surrounding soft tissue. local destruction or excision
Forty to 60% = within the face or head adjuvant therapy with INTERFERON,
usually results following tooth extraction, ISOTRETINOIN, or AUTOLOGOUS TUMOR
odontogenic infection, or facial trauma VACCINE
Accurate diagnosis depends on decreases recurrence rates
careful histologic analysis

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Schwartz Principles of Surgery
Chap. 16 Skin and Subcutaneous Tissue

Immune response modifiers, such as immune response to certain drugs such as

IMIQUIMOD sulfonamides, phenytoin, barbiturates, and
optimize long-term eradication of HPV- tetracycline
induced anogenital lesions Diagnosis is made via skin biopsy
Because larger lesions have a significant risk of Histologic analysis
malignant transformation SSSS
close observation of lesion return or atypical cleavage plane in the granular layer of the
presentation should be advised. epidermis
TEN
HUMAN IMMUNODEFICIENCY VIRUS structural defects at the dermoepidermal
As a result of intrinsic wound-healing deficiencies and junction
much lower resilience, these patients frequently develop similar to a second-degree burn
chronic wounds Treatment
risk of postoperative soft tissue complications directly fluid and electrolyte replacement
increases with disease progression wound care similar to burn therapy
cause for delayed wound healing is secondary to:
TEN
decreasing T-cell CD4+ count
those with more than 30% of total body surface
opportunistic infection area involvement
low serum albumin STEVENS-JOHNSON SYNDROME
poor nutrition less than 10% of epidermal detachment are
Overall, these effects are thought to result in poor categorized as
collagen cross -linking and deposition producing a respiratory and alimentary tract epithelial
profound compromise in wound healing sloughing may result in intestinal malabsorption
and pulmonary failure
INFLAMMATORY DISEASES OF THE SKIN AND SUBCUTANEOUS Management
SOFT Patients with significant soft-tissue loss should
TISSUE
be treated in burn units with specially trained
staff and critical equipment
PYODERMA GANGRENOSUM
temporary coverage via cadaveric, porcine skin,
uncommon destructive cutaneous lesion or semisynthetic biologic dressings (Biobrane)
rapidly enlarging, necrotic lesion allows the underlying epidermis to
undermined border regenerate spontaneously
surrounding erythema STAPHYLOCOCCAL SCALDED SKIN SYNDROME
Linked to underlying systemic disease in 50% of associated with retained foreign objects colonized
cases with toxin-secreting staphylococcus strains.
commonly associated with
inflammatory bowel disease BENIGN TUMORS OF THE SKIN AND SUBCUTANEOUS TISSUE
rheumatoid arthritis
hematologic malignancy CYSTS (EPIDERMAL, DERMOID, TRICHILEMMAL)
monoclonal immunoglobulin A gammapathy Cutaneous cysts are categorized as either
Management EPIDERMAL
Recognition of the underlying disease is of DERMOID
paramount importance TRICHILEMMAL
Management without correction of underlying surgeons often refer to cutaneous cysts as sebaceous
systemic disorders is fraught with complication cyst
systemic steroids or cyclosporine appear to contain sebum
medical management alone may slowly misnomer and the substance is actually keratin
result in wound healing EPIDERMAL CYSTS
chemotherapy with aggressive wound care and most common type of cutaneous cyst
skin graft coverage present as a single, firm nodule anywhere on the
STAPHYLOCOCCAL SCALDED SKIN SYNDROME body
TOXIC EPIDERMAL NECROLYSIS DERMOID CYSTS
STAPHYLOCOCCAL SCALDED SKIN SYNDROME congenital lesions
(SSSS)
result when epithelium is trapped during fetal midline
TOXIC EPIDERMAL NECROLYSIS (TEN)
closure
create a similar clinical picture including
eyebrow is the most frequent site of presentation
skin erythema
bullae formation common anywhere from the nasal tip to the forehead
TRICHILEMMAL (PILAR) CYSTS
wide areas of tissue loss
second most common cutaneous cyst
SSSS
caused by an exotoxin produced during occur more often on the scalp of females
staphylococcal infection of the nasopharynx or When ruptured, these cysts have an intense,
middle ear characteristic odor.
TEN On clinical examination, it is difficult to distinguish one
type of cyst from another:
Each cyst presents as

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Schwartz Principles of Surgery
Chap. 16 Skin and Subcutaneous Tissue
Subcutaneous
thin-walled nodule containing a white, creamy
material
Histologic examination
Cyst walls consist of an epidermal layer oriented with
the basal layer superficial
more mature layers deep
desquamated cells (keratin) collect in the center to
form the cyst
EPIDERMAL CYSTS
have a mature epidermis complete with granular
layer
DERMOID CYSTS
demonstrate squamous epithelium, eccrine
glands, and pilosebaceous units
particular cysts may develop bone, tooth, or
nerve tissue on occasion
TRICHILEMMAL CYST
walls do not contain a granular layer
cysts contain a distinctive outer layer resembling
the root sheath of a hair follicle (trichilemmoma)
cysts typically remain unnoticed and asymptomatic until
they rupture
cause local inflammation, or become infected
Once infected, these cysts behave similar to abscesses
incision and drainage is recommended
After resolution of inflammation, cyst wall must be
removed in its entirety or the cyst will recur
KERATOSES (SEBORRHEIC, SOLAR)
SEBORRHEIC KERATOSES
arise in sun-exposed areas of the body such as the face,
forearms, and back of the hands
Most notable in the older age groups
lesions appear light brown or yellow
have a velvety, greasy texture
considered premalignant lesions
squamous cell carcinoma (SCC) may develop over time
sudden eruptions of multiple lesions may be associated
with internal malignancies
rarely mistaken for other lesions, so biopsy and treatment
are seldom required
Histologically
lesions contain atypical-appearing keratinocytes
evidence of dermal solar damage
malignancies that do develop rarely metastasize, lesion
destruction is the treatment of choice
other treatment modalities
application of topical 5- fluorouracil
surgical excision
electrodesiccation
dermabrasion
NEVI (ACQUIRED AND CONGENITAL)
Depending on the location of nevus cells, acquired
melanocytic nevi are classified as
JUNCTIONAL
COMPOUND
DERMAL
does not represent different types of nevi, but rather
different stages in nevus maturation
JUNCTIONAL
Initially, nevus cells accumulate in the epidermis
COMPOUND
By: Rem Alfelor
As they mature, nevus cells migrate partially into the
dermis
DERMAL
finally rest completely within dermal tissues
most lesions undergo involution
CONGENITAL NEVI
relatively rare
found in less than 1% of neonates
lesions are larger
often contain hair.
Histologically, congenital and acquired nevi appear
similar.
GIANT CONGENITAL LESIONS (GIANT HAIRY
NEVI)
most often occur in a swim trunk distribution,
chest, or back lesions cosmetically unpleasant
may develop into malignant melanoma in 1 to 5% of
cases
Total excision of the nevus is the treatment of choice
lesion is often so large that inadequate tissue for
wound closure precludes complete resection
serial excisions with local tissue expansion/
advancement are frequently required over
several years
Vascular Tumors of the Skin and Subcutaneous Tissue
HEMANGIOMAS
benign vascular neoplasms
present soon after birth
initially undergo rapid cellular proliferation over the
first year of life, then undergo slow involution
throughout childhood
Histologically
mitotically active endothelial cells
surroundings several, confluent blood-filled
spaces
lesions may enlarge significantly in the first year of
life
approximately 90% involute over time
Acute treatment
limited to hemangiomata
interfere with function, such as airway,
vision, and feeding
lesions resulting in systemic problems, such as
thrombocytopenia or high-output cardiac failure,
should prompt resection
growth of rapidly enlarging lesions also can be
halted with
systemic PREDNISONE
INTERFERON ALPHA-2
absence of acute surgical indications or
significant patient/parent concern
lesions are allowed to spontaneously
involute
hemangiomata that remain into
adolescence or involute to leave an
unsightly telangiectasia typically
require surgical excision for optimal
resolution
VASCULAR MALFORMATIONS
result of structural abnormalities formed during fetal
development
grow in proportion to the body and never involute
Histologically
Page 8 of 16
Schwartz Principles of Surgery
Chap. 16 Skin and Subcutaneous Tissue

enlarged vascular spaces lined by appear as blue, subungual discolorations of 1 to

nonproliferating endothelium Arteriovenous 2 mm
malformations Tumor excision is the treatment of choice
high-flow lesions that often present as subcutaneous
masses associated with locally elevated temperature, SOFT-TISSUE TUMORS (ACROCHORDONS,
dermal stain, thrill, and bruit DERMATOFIBROMAS, LIPOMAS)
overlying ischemic ulcers LIPOMAS
adjacent bone destruction most common subcutaneous neoplasm
local hypertrophy found most frequently on the trunk but may appear
Very large malformations may cause anywhere
cardiac enlargement soft and fleshy on palpation
congestive heart failure may grow to a large size and become substantially
Complications of arteriovenous malformations, such deforming Histologic
as lobulated tumor composed of normal fat cells
Pain benign with essentially no risk of malignant
Hemorrhage devolvement
Ulceration observation is an option
cardiac effects surgical excision is required for tumor removal
local tissue destruction ACROCHORDONS (SKIN TAGS)
should prompt attempts at lesion destruction fleshy, pedunculated masses
Therapy: surgical resection located on the preauricular areas, axillae, trunk, and
Even when complete lesion resection is not eyelids
possible, significant composed of hyperplastic epidermis over a fibrous
debulking may greatly diminish symptomatology connective tissue stalk
angiography with selective embolization just usually small
before surgery frequently treated via "tying off" or with resection in
facilitates operative removal the clinic
CAPILLARY MALFORMATION (PORT-WINE STAIN) DERMATOFIBROMAS
flat, dull-red lesion often located on the trigeminal solitary, soft-tissue nodules
(cranial nerve V) usually approximating 1 to 2 cm in diameter
distribution on the face, trunk, or extremities found primarily on the legs and flanks
Presentation within the V1 or V2 facial regions should Histologically
prompt composed of unencapsulated connective tissue
concern of a possible link to more systemic whorls containing fibroblasts
syndromes such majority can be diagnosed clinically
Sturge-Weber syndrome atypical presentation or course should prompt
Leptomeningeal excisional biopsy to assess for malignancy
angiomatosis may be managed conservatively, operative
epilepsy removal is the treatment of choice
glaucoma
Histologically NEURAL TUMORS (NEUROFIBROMAS, NEURILEMOMAS,
composed of ectatic capillaries lined by mature GRANULAR CELL TUMORS)
endothelium Benign, cutaneous neural tumors
lesions may be treated with pulsed dye laser, primarily arise from the nerve sheath
covered with cosmetics, or surgically excised NEUROFIBROMAS
GLOMUS TUMOR sporadic and solitary
Uncommon majority are associated with
benign neoplasm of the extremity caf au lait spots
Representing less than 1.5% of all benign, soft-tissue Lisch nodules
extremity tumors autosomal dominant inheritance (VON
arise from dermal neuromyoarterial apparatus RECKLINGHAUSEN'S DISEASE)
(glomus bodies) lesions are firm, discrete nodules attached to a nerve
more commonly affects the hand Histologically
presentation within the subungual region of the toe is proliferation of perineurial and endoneurial
rare fibroblasts with Schwann cells embedded in
Diagnosis collagen
traditionally delayed NEUROFIBROMAS
atypical presentation on the foot or toes often leads direct nerve attachment
to even greater diagnostic challenges NEURILEMOMAS
severe pain solitary tumors arising from cells of the peripheral
point tenderness nerve sheath discrete nodules that may induce local
cold sensitivity or radiating pain along the distribution of the nerve
SUBUNGUAL GLOMUS Microscopically
tumor contains Schwann cells with nuclei packed
in palisading rows
By: Rem Alfelor Page 9 of 16
Schwartz Principles of Surgery
Chap. 16 Skin and Subcutaneous Tissue

Surgical resection is the management option of tan to black in color

choice. MORPHEAFORM BCC
GRANULAR CELL TUMORS often appears as a flat, plaque-like lesion
usually solitary lesions of the skin or, more considered relatively aggressive
commonly, the tongue consist of granular cells should prompt early excision
derived from Schwann cells BASOSQUAMOUS type
often infiltrate the surrounding striated muscle rare form of BCC
Based on the severity of symptomatology, operative contains elements of both basal cell and squamous
resection is the primary therapy of choice cell cancer
metastasize similar to SCC
MALIGNANT TUMORS OF THE SKIN
should be treated aggressively
malignancies arising from cells of the dermis or adnexal
slow growing
structures are relatively uncommon
metastasis is extremely rare
skin is frequently subject to epidermal tumors
Due to this slow developmental progression, patients
BASAL CELL CARCINOMA (BCC)
often neglect these lesions for years and presentation
SCC with extensive local tissue destruction is common
MELANOMA majority of small (less than 2 mm), nodular lesions may
increased exposure to UV radiation is associated with an be treated via curettage
increased development of all skin cancer electrodesiccation
at greater risk
laser vaporization
persons with outdoor occupations effective
fair complexions destroy any potential tissue sample for confirmatory
people living in regions receiving higher per capita pathology diagnosis and tumor margin analysis.
sunlight Surgical excision
albino individuals of dark-skinned races are prone to used to both effect complete tumor removal as
develop cutaneous neoplasms well as allow proper laboratory evaluation
melanin, and its ability to limit UV radiation tissue located at areas of great aesthetic value, such as the
penetration, plays a large role in carcinogenesis cheek, nose, or lip
protection may be best approached with MOHS' SURGERY
development has been linked to chemical carcinogens
completed by specialized dermatology surgeons
such as tar, arsenic, and nitrogen mustard.
uses minimal tissue resection and immediate
Radiation therapy directed at skin lesions increases the
microscopic analysis to confirm appropriate
risk for local BCC and SCC
resection
certain subtypes of HPV have been linked to SCC.
Large tumors
chronically irritated or nonhealing areas such as burn
Invade surrounding structures
scars, sites of repeated bullous skin sloughing, and
decubitus ulcers present an elevated risk of developing aggressive histologic types
SCC MORPHEAFORM
Systemic immunologic dysfunction is also related to an INFILTRATIVE
increase in cutaneous malignancies. BASOSQUAMOUS
increased incidence of BCC, SCC, and melanoma best treated by surgical excision with 0.5-cm to 1-cm
Immunosuppressed patients receiving chemotherapy margins
advanced HIV/AIDS
SQUAMOUS CELL CARCINOMA
immunosuppressed transplant recipients
arise from epidermal keratinocytes
less common than BCC
BASAL CELL CARCINOMA
Arising from the basal layer of the epidermis more devastating due to an increased invasiveness and
most common type of skin cancer tendency to metastasize
Before local invasion, in situ SCC lesions are termed
Based on gross and histologic morphology, divided into
BOWEN'S DISEASE
several subtypes:
ERYTHROPLASIA OF QUEYRAT
NODULAR
In situ SCC tumors specific to the penis
SUPERFICIAL SPREADING
Following tissue invasion, tumor thickness correlates well
MICRONODULAR
with malignant behavior
INFILTRATIVE Tumor recurrence is more prevalent once SCC tumors
PIGMENTED grow more than 4 mm in thickness
MORPHEAFORM lesions that metastasize are typically at least 10 mm in
NODULOCYSTIC OR NODULOULCERATIVE type diameter
accounts for 70% of BCC tumors Tumor location
Waxy and frequently cream colored great prognostic importance
Lesions present with rolled, pearly borders tumors in areas with cumulative solar damage are less
surrounding a central ulcer aggressive
SUPERFICIAL BASAL CELL TUMORS respond well to local excision
commonly occur on the trunk metastasize early
form a red, scaling lesion MARJOLIN'S ULCER
PIGMENTED BCC LESIONS lesions arising in burn scars areas

By: Rem Alfelor Page 10 of 16

Schwartz Principles of Surgery
Chap. 16 Skin and Subcutaneous Tissue
chronic osteomyelitis
areas of previous injury
treatment
small lesions
curettage
electrodesiccation
most surgeons recommend surgical excision.
Lesions should be excised with a 1-cm margin
histologic confirmation of tumor-free borders is
mandatory
tumors within areas of great aesthetic value, such as
the cheek, nose, or lip
best approached with MOHS' SURGERY
uses minimal tissue resection and
immediate microscopic analysis to confirm
appropriate resection yet limit removal of
valuable anatomy.
Regional LN excision
indicated for clinically palpable nodes
SCC lesions arising in chronic wounds are more
aggressive and regional lymph node metastases are
observed more frequently
PROPHYLACTIC LN DISSECTION
lymphadenectomy before development of
palpable nodes
Metastatic disease is a poor prognostic sign, and only
13% of patients typically survive 10 years
MOHS' SURGERY for Squamous and Basal Cell Carcinomas
uses serial excision in small increments
coupled with immediate microscopic analysis to ensure
tumor removal, yet limit resection of aesthetically
valuable tissue
advantage: all specimen margins are evaluated.
ability to remove a tumor with minimal sacrifice of
uninvolved tissue
of particular value when managing tumors of the eyelid,
nose, or cheek
one major drawback is procedure length
Total lesion excision may require multiple attempts at
resection procedures may be carried out over several
days.
Recurrence and metastases rates are comparable to
those of wide local excision
MALIGNANT MELANOMA
arise from transformed melanocytes anywhere that these
cells have migrated during normal embryogenesis
NEVI (FRECKLES)
benign melanocytic neoplasms found on the skin
DYSPLASTIC NEVI
contain a histologically identifiable focus of atypical
melanocytes.
represent an intermediate stage between benign
nevus and true malignant melanoma
increased relative risk of melanoma development based
on increasing numbers of dysplastic nevi found on the
patient
strong genetic component
Up to 14% of malignant melanomas occur in a
familial pattern
family members of those with either dysplastic nevi
or melanoma are at increased risk for tumor
development
By: Rem Alfelor
Following malignant transformation, invasive melanoma
cells replicate, penetrate surrounding epidermal layers,
and migrate to more distant tissues.
Once the melanocyte has transformed into the malignant
phenotype, tumor growth occurs radially in the epidermal
plane
Even though microinvasion of the dermis may have
occurred, metastases do not occur until these
melanocytes form dermal nests. During the subsequent
vertical growth phase, cells develop different cell-surface
antigens and their malignant behavior becomes much
more aggressive
lengthened cellular life span and increased malignant
growth despite significantly poor nutrient medium
eye and anus are notable sites, over 90% of melanomas
are found on the skin
4% of tumors are discovered as metastases without any
identifiable primary site.
Suspicious features suggestive of melanoma
pigmented lesion with an irregular border
darkening coloration
ulceration
raised surface
note recent changes in nevus appearance that denote
malignant transformation
approximately 5 to 10% of melanomas are nonpigmented
In order of decreasing frequency, the four types of
melanoma
SUPERFICIAL SPREADING
NODULAR
LENTIGO MALIGNA
ACRAL LENTIGINOUS
SUPERFICIAL SPREADING
most common type
accounts for up to 70% of melanomas
occur anywhere on the skin except the hands and
feet
typically flat
measure 1 to 2 cm in diameter at diagnosis
Before vertical extension, a prolonged radial growth
phase is characteristic of these lesions
NODULAR TYPE
Typically of darker coloration
often raised
accounts for 15 to 30% of melanomas
lack of radial growth
all are in the vertical growth phase at diagnosis
considered a more aggressive lesion
prognosis is similar to that for a patient with a
superficial spreading lesion of the same depth
LENTIGO MALIGNA
accounts for 4 to 15% of melanomas
occurs most frequently on the neck, face, and hands
of the elderly
tend to be quite large at diagnosis
have the best prognosis because invasive growth
occurs late
Less than 5% are estimated to evolve into melanoma
ACRAL LENTIGINOUS MELANOMA
least common subtype
constitutes only 2 to 8% of melanomas in white
populations.
among dark-skinned people is relatively rare
Page 11 of 16
Schwartz Principles of Surgery
Chap. 16 Skin and Subcutaneous Tissue
accounts for 29 to 72% of all melanomas in dark-
skinned people (African Americans, Asians, and
Hispanics)
most frequently is encountered on the palms, soles,
and subungual regions
Most common on the great toe or thumb
SUBUNGUAL MELANOMA
appear as blue-black discolorations of the posterior
nail fold
HUTCHINSON'S SIGN
additional presence of pigmentation in the
proximal or lateral nail folds
diagnostic
clinical features of melanoma have been identified as
significant prognostic indicators.
Independent of histologic type and depth of invasion
lesions of the extremities have a better
prognosis than patients with melanomas of the
head, neck, or trunk
10-year survival rate of 82% for localized
disease of the extremity compared to a 68%
survival rate with a lesion of the face)
Lesion ulceration carries a worse prognosis
incidence of ulceration increases with
increasing thickness
tumors ulcerate as the result of increased
angiogenesis
Gender is also a substantial prognostic indicator
females have an improved survival
compared to males
females continue to have a higher survival
rate than men
In general, there is no significant difference between
different histologic tumor types in terms of prognosis,
when matched for tumor thickness, gender, age, or
other
Lentigo maligna types have a better prognosis
acral lentiginous lesions have a worse prognosis
acral lentiginous melanoma has a shorter interval to
recurrence
most current staging system, from the American Joint
Committee on Cancer (AJCC), contains the best method of
interpreting clinical information in regard to prognosis of
this disease
represented the dominant factors in the T classification
BRESLOW THICKNESS
vertical thickness of the primary tumor
CLARK LEVEL
anatomic depth of invasion
T classification of lesions comes from the original
observation by Clark prognosis is directly related to the
level of invasion of the skin by the melanoma
used the histologic level
I = superficial to basement membrane (in
situ)
II = papillary dermis
III = papillary/reticular dermal junction
IV = reticular dermis
V = subcutaneous fat
Breslow modified the approach to obtain a more
reproducible measure of invasion by the use of an ocular
micrometer
lesions were measured from the granular layer of the
epidermis or the base of the ulcer to the greatest
depth of the tumor
I = 0.75 mm or less
By: Rem Alfelor
II = 0.76 to 1.5 mm
III = 1.51 to 4.0 mm
IV = 4.0 mm or more
levels of invasion have been subsequently modified
and incorporated in the AJCC staging system
new staging system has largely replaced the Clark level
with another histologic feature, ulceration, based on
analysis of large databases available to the AJCC
Melanoma Committee.
Evidence of tumor in regional LNs is a poor prognostic
sign associated with a precipitous drop in survival at 15-
year followup.
Identification of distant metastasis is the worst prognostic
sign and classified as stage IV disease.
median survival ranges from 2 to 7 months
depending on the number and site of metastases
Diagnosis of melanoma typically requires EXCISIONAL
BIOPSY
1-mm margin of normal skin is taken if the wound
can be closed primarily
If removal of the entire lesion creates too large a
defect, then an INCISIONAL BIOPSY of a
representative part is recommended
should be made with the expectation that a
subsequent wide excision of the biopsy site may be
done.
Treatment
simple excision
regardless of tumor depth or extension it is the
management of choice
lymphadenectomy or immunotherapy
Lesions 1 mm or less in thickness = 1-cm margin
lesions 1 mm to 4 mm thick = 2-cm margin is
recommended
Lesions of greater than 4 mm = 3-cm margins
surrounding tissue should be removed down to the
fascia to remove all lymphatic channels
If the deep fascia is not involved by the tumor,
removing it does not affect recurrence or survival
rates, so the fascia is left intact
thin lesions (less than 1 mm), the tumor cells are still
localized in the surrounding tissue, and the cure rate
is excellent with wide excision of the primary lesion;
therefore treatment of regional LNs is not beneficial
lesions deeper than 4 mm, it is highly likely that the
tumor cells already have spread to the regional LNs
and distant sites
Removal of the melanomatous LNs has no effect on
survival
Most of these patients die of metastatic disease
before developing problems in regional nodes.
intermediate-thickness tumors (T2 and T3, 1 to 4.0
mm)
no clinical evidence of nodal or metastatic
disease
prophylactic dissection (elective LN dissection on
clinically negative nodes)
recurrence may be decreased with LN dissection
Sentinel lymphadenectomy
sentinel node may be preoperatively located
with the use of a gamma camera, which
identifies the radioisotope injected into the
primary lesion
provide the surgeon greater reliability in
localizing the LN
Page 12 of 16
Schwartz Principles of Surgery
Chap. 16 Skin and Subcutaneous Tissue

intraoperative mapping with 1% isosulfan

blue dye injection may be equally effectively
Both techniques identify the lymphatic
drainage from the primary lesion, and
determine the first (sentinel) LN draining the
tumor area
If micrometastasis is identified in the removed
node by frozen-section examination, a complete
LN dissection is performed
used to identify patients who would benefit
from LN dissection, while sparing others an
unnecessary operation.
All microscopically or clinically positive LNs should be
removed by regional nodal dissection
When groin LNs are removed, the deep (iliac) nodes
must be removed along with the superficial (inguinal)
nodes, or disease will recur in that region Although Breslow's thickness has traditionally been used to
anticipate clinical outcomes based on the depth of melanoma
For axillary dissections, the nodes medial to the
invasion, more recent staging criteria advanced by the
pectoralis minor muscle also must be resected
American Joint Committee on Cancer (AJCC) are today's
For lesions on the face, anterior scalp, and ear
standard of
superficial parotidectomy to remove parotid care.
nodes
modified neck dissection is recommended
Once melanoma has spread to a distant site, median
survival is 7 to 8 months and the 5-year survival rate is
less than 5%
Solitary lesions in the brain, GI tract, or skin that are
symptomatic should be excised when possible
In-transit disease (local disease in lymphatics) develops in
5 to 8% of melanoma patients with a high-risk primary
melanoma (>1.5 mm)
Hyperthermic regional perfusion + chemotherapeutic
agent (e.g., melphalan) is the treatment of choice
goal of regional perfusion therapy is to increase the
dosage of the chemotherapeutic agent to maximize
tumor response while limiting systemic toxic effects
Melphalan generally is heated to an elevated
temperature [up to 41.5C, (106.7F)] and perfused The diagnosis of melanoma should be made via excisional
for 60 to 90 minutes. associated with complications biopsy. Based on tumor depth, appropriate margins may be
(neutropenia, amputation, death) planned. Indications for lymph node evaluation continue to
produce a high response rate (greater than 50%) advance as our understanding of tumor behavior improves
introduction of tumor necrosis factor alpha or and outcome data become available. LAD =
lymphadenopathy.
interferon- with melphalan results in the regression of
more than 90% of cutaneous in-transit metastases
ADDITIONAL MALIGNANCIES OF THE SKIN
High-dose-per-fraction radiation produces a better
response rate than low-dose large-fraction therapy
MERKEL CELL CARCINOMA (PRIMARY
radiation therapy
NEUROENDOCRINE CARCINOMA OF THE SKIN)
treatment of choice for patients with symptomatic neuroepithelial differentiation
multiple brain metastases associated with a synchronous or metasynchronous SCC
produced measurable improvement in tumor size, 25% of the time
symptomatology, or performance status in 70% of Due to their aggressive nature, wide local resection with
treated patients 3-cm margins is recommended
use of immunologic manipulation Local recurrence rates are high
Interferon alfa-2b distant metastases occur in one third of patients
adjuvant treatment for AJCC stages IIB/III Prophylactic regional LN dissection and adjuvant radiation
melanoma therapy are Overall, the prognosis is worse than for
Side effects were common and frequently severe malignant melanoma

KAPOSI'S SARCOMA
rubbery bluish nodules
occur primarily on the extremities but may appear
anywhere
on the skin and viscera
multifocal rather than metastatic
Histologically

By: Rem Alfelor Page 13 of 16

Schwartz Principles of Surgery
Chap. 16 Skin and Subcutaneous Tissue
composed of capillaries lined by atypical endothelial
cells
Early lesions may resemble hemangiomas
older lesions contain more spindle cells and resemble
sarcomas
seen in people of Eastern Europe or sub-Saharan Africa
lesions are locally aggressive but undergo periods of
remission different variety of KS has been described for
people with AIDS or with immunosuppression from
chemotherapy
AIDS-RELATED KS
occurs primarily in male homosexuals and not in
IV drug abusers or hemophiliacs
lesions spread rapidly to the nodes
GI and respiratory tract often are involved
Development of is associated with concurrent
infection with a herpes-like virus
Treatment: radiation to the lesions
Combination chemotherapy
effective in controlling the disease
most patients develop an opportunistic infection
during or shortly after treatment
Surgical treatment
reserved for lesions that interfere with vital
functions, such as bowel obstruction or airway
compromise
EXTRAMAMMARY PAGET'S DISEASE
histologically similar to the mammary type.
cutaneous lesion that appears as a pruritic red patch that
does not resolve
Biopsy demonstrates classic Paget's cells
cutaneous extension of an
underlying adenocarcinoma, although an associated tumor
cannot always be demonstrated.85
ANGIOSARCOMA
arise spontaneously, mostly on the scalp, face, and neck
usually appear as a bruise that spontaneously bleeds or
enlarges without trauma
also may arise in areas of prior radiation therapy or in the
setting of chronic lymphedema of the arm, such as after
mastectomy (STEWART-TREVES SYNDROME)
arise in these areas of chronic change occur decades
later
tumors: anaplastic endothelial cells surrounding vascular
channels
total excision of early lesions can provide occasional cure
prognosis usually is poor, with 5- year survival rates of
less than 20%
Chemotherapy and radiation therapy are used for
palliation
DERMATOFIBROSARCOMA PROTUBERANS
1 to 2% of all soft-tissue sarcomas
occurs most frequently in persons aged 20 to 50 years
more common in males
most common presenting location is on the trunk (50 to
60%)
proximal extremities (20 to 30% of cases)
head and neck affected (10 to15%)
often appears as a pink, nodular lesion that may ulcerate
and become infected
Histologically:
By: Rem Alfelor
lesions contain atypical spindle cells, probably of
fibroblast origin, located around a core of collagen
tissue
treatment:
complete lesion excision, local recurrence remains
frequent
mortality associated with metastasis relatively high
Local recurrence rates of up to 50% have been
reported after simple excision
wide local excision with 3-cm margins is linked to a
20% recurrence rate
three-dimensional margin of 2 to 3 cm with resection
of skin, subcutaneous tissue, and the underlying
investing fascia
periosteum and a portion of the bone may also need
to be resected to achieve negative deep surgical
margins
achieving wide macroscopic resection
conformation of negative microscopic margins is
especially critical radiosensitive tumor
radiotherapy following wide local excision has
reached local control rates approximating 95% at 10
years
chemotherapy efficacy
IMATINIB
selective inhibitor of platelet-derived growth
factor (PDGF) -chain alpha
PDGF receptor beta protein-tyrosine kinase
activity
alters the biologic effects of deregulated
PDGF receptor signaling
activity against localized and metastatic
DFSP containing the t(17:22) translocation
targeting the PDGF receptors may become a
new therapeutic option for DFSP
FIBROSARCOMA
hard, irregular masses found in the subcutaneous fat
fibroblasts appear markedly anaplastic with disorganized
growth
if they are not excised completely, metastases usually
develop
5-year survival rate after excision is approximately 60%
LIPOSARCOMA
arise in the deep muscle planes
rarely, from the subcutaneous tissue
occur most commonly on the thigh
enlarging lipoma should be excised and inspected to
distinguish it from a liposarcoma
treatment:
Wide excision is the treatment of choice
radiation therapy reserved for metastatic disease
SYNDROMIC SKIN MALIGNANCIES
genetic syndromes are associated with an increased
incidence of skin malignancy
related to development of a specific lesion, others appear
to produce a more generic prevalence for neoplastic
formation
Diseases linked with BCC include
BASAL CELL NEVUS (GORLIN'S) SYNDROME
autosomal dominant disorder
characterized by the growth of hundreds of BCCs
during young adulthood
Page 14 of 16
Schwartz Principles of Surgery
Chap. 16 Skin and Subcutaneous Tissue

Palmar and plantar pits are a common physical not rejected by the recipient patient
finding HUMAN DERMAL MATRIX is commercially-available
represent foci of neoplasms (AlloDerm)
Treatment is limited to excision of only functions much like Integra
aggressive and symptomatic lesions. similar limitations of engraftment and high cost.
NEVUS SEBACEUS OF JADASSOHN Both forms of dermal replacements are more
lesion containing several cutaneous tissue frequently used in delayed reconstruction of burn
elements that develops during childhood. patients than in the acute setting
lesion is associated with a variety of neoplasms lack of means to quickly provide numerous autologous
of the epidermis, but most commonly BCC. skin cells for permanent skin replacement
Diseases associated with SCC may have a causative role expansion of epidermis by the growth and maturation of
in the development of carcinoma keratinocytes in culture is readily performed
Skin diseases that cause chronic wounds small skin biopsy specimen can produce enough
EPIDERMOLYSIS BULLOSUS autologous epithelium to cover the entire body surface.
LUPUS ERYTHEMATOSUS on the body, the cultured epidermis often blisters and
associated with a high incidence of SCC sloughs as a consequence of slow restoration of the
EPIDERMODYSPLASIA VERRUCIFORMIS basement membrane
rare autosomal recessive disease Improving the durability of these cells may one day
associated with infection with HPV negate autologous skin grafting technique or the
requirement for cadaveric soft tissues.
Large verrucous lesions develop early in life
Characterization of these growth factors on a structural
often progress to invasive SCC in middle age
and functional level is progressing rapidly
XERODERMA PIGMENTOSUM
autosomal recessive disease CONCLUSION
associated with a defect in cellular repair of DNA play a vital role in maintaining dermal/epidermal integrity
damage EPIDERMAL
inability of the skin to correct DNA damage from
BASEMENT MEMBRANE
UV radiation leaves these patients prone to
DERMAL LAYERS
cutaneous malignancies
environment offers a host of potentially injurious
SCCs are most frequent, but BCCs, melanomas,
elements
and even acute leukemias are seen
DYSPLASTIC NEVI are considered precursors to caustic substances
melanoma extreme temperatures
FAMILIAL DYSPLASTIC NEVUS SYNDROME prolonged or excessive pressure
autosomal dominant disorder radiation
develop multiple dysplastic nevi Infections ranging from simple bacterial to necrotizing,
almost 100% incidence of melanoma life-threatening disease may also affect the skin and
subcutaneous tissues
treated
greatest public concern, a multitude of benign and
close surveillance
malignant tumors threaten to disrupt, disfigure, and
frequent biopsy of all suspicious lesions invade normal skin structure.
FUTURE DEVELOPMENTS IN SKIN SURGERY
Autologous skin grafts
best method to cover skin defects
Donor-site problems and limited availability of
autologous skin remain problematic
Tissue expansion with subcutaneous balloon implants
produces new epidermis
mobilization achieved via expansion remains a highly
effective approach to wound coverage
Several dermal replacements based on synthetic
materials or cadaveric sources are in clinical use
has been used primarily in burn patients
BOVINECOLLAGEN
shark-proteoglycanbased dermis (Integra)
prosthetic dermis
available in ready-to-use form
can cover large surface areas
Vascularization of this dermis takes 2 to 3 weeks
final epidermal coverage of the wound requires a
thin skin graft
final result is functionally and aesthetically good,
but the high cost has been problematic
CADAVERIC DERMIS
with all of the cellular elements removed, is not
antigenic

By: Rem Alfelor Page 15 of 16

Schwartz Principles of Surgery
Chap. 16 Skin and Subcutaneous Tissue

By: Rem Alfelor Page 16 of 16