SURGERY OF THE SKIN

Malen M. Gellido, M.D.

LPU – St. Cabrini College of Medicine
May 2, 2022
 Common skin conditions
requiring surgery

OUTLINE Surgical preparation

Specific surgical
procedures
 ANATOMY
OF THE SKIN
 COMMON SKIN CONDITIONS

BENIGN MALIGNANT
• Hemangioma • Basal Cell Carcinoma
• Nevi • Squamous Cell Carcinoma
• Cysts • Melanoma
• Keratosis
• Acrochordons
• Dermatofibroma
• Neurofibromas
TRAUMA
 HEMANGIOMA

• Benign vascular tumors that arise from the

proliferation of endothelial cells that
surround bloodfilled cavities.

• They occur in about 4% of children by 1

year of age.

• Their natural history is typically

presentation shortly after birth, a period
of rapid growth during the first year, and
then gradual involution over childhood in
more than 90% of cases.
 NEVI

• Nevi (singular, nevus) are areas of melanocytic

hyperplasia or neoplasia.
• These collections can be found in the epidermis
(junctional), partially in the dermis (compound), or
completely within the dermis (dermal).
• They commonly develop in childhood and young
adulthood, and will sometimes spontaneously
regress
• The management of epidermal nevi is difficult.
• Full-thickness excision provides definitive
treatment for small lesions, but may not be an
option for large or extensive lesions, due to the
risk of disfiguring scarring
 EPIDERMOID CYSTS

• The most common cutaneous cyst and are histologically

characterized by mature epidermis complete with granular
layer.
• Classically results from keratin-plugged pilosebaceous
units.
• They commonly affect adult men and women, and present
as a dermal or subcutaneous cyst with a single, keratin--
plugged punctum at the skin surface, often at or above the
upper chest and back.
 DERMOID
CYSTS

• Dermoid cysts are congenital

lesions that present as
subcutaneous nodules seen
along embryonic fusion lines on
the face, scalp, and spine and
contain epidermal and dermal
tissues.
• The most common locations
include the anterior fontanelle,
the upper lateral region of the
forehead near the eyebrow
 TRICHILEMMAL
CYSTS

• Also known as Pilar cysts. They

resemble epidermoid cysts as they
are firm, slow-growing subcutaneous
nodules. However, these cysts are
derived from the root sheath of the
hair follicle and are most commonly
located on the scalp
 ACTINIC KERATOSIS

• Neoplasms of epidermal keratinocytes that represent a range in a

spectrum of disease from sun damage to squamous cell carcinoma.
• They typically occur in fair-skinned, elderly individuals in primarily
sunexposed areas, and UV radiation exposure is the greatest risk
factor.
• There are multiple variants, and they can present as erythematous
and scaly to hypertrophic, keratinized lesions. They can become
symptomatic, causing bleeding, pruritis and pain.
• They can regress spontaneously, persist without change, and
transform into invasive squamous cell carcinoma.
• It is estimated that approximately 10% of actinic keratoses will
transform into invasive squamous cell carcinoma, and that
progression takes about 2 years on average.
• About 60% to 65% of squamous cell carcinomas are believed to
originate from actinic keratoses.
 SEBORRHEIC KERATOSIS

• Seborrheic keratoses are benign lesions of the epidermis

that typically present as well demarcated, “stuck on”
appearing papules or plaques over elderly individuals.
• Clonal expansion of keratinocytes and melanocytes make
up the substance of these lesions.
• They carry no malignant potential and treatment is
primarily for cosmetic purposes.
 ACROCHORDONS

• Acrochordons, also known as skin tags, are benign,

pedunculated lesions on the skin made up of epidermal
keratinocytes surrounding a collagenous core.
• Although they can become irritated or necrotic, their
removal is generally cosmetic.
 DERMATOFIBROMA

• Benign cutaneous proliferations that appear

most commonly on the lower extremities
of women.
• They appear as pink to brown papules that
pucker or dimple in the center when the
lesion is pinched. are the result of minor
trauma or infection.
• These lesions are typically asymptomatic,
and treatment is only indicated for
cosmetic concerns or when a histologic
diagnosis is required
 NEUROFIBROMA

• Benign proliferations that are made up of all nerve

elements, and arise as fleshy and nontender, sessile or
pedunculated masses on the skin.
• They can arise sporadically or in association with type 1
neurofibromatosis, and in these cases, are associated with
café-́au-lait spots and Lisch nodules.
 BASAL CELL C ARCINOMA

• Basal cell carcinoma (BCC) is the most common

tumor diagnosed in the United States, with an
estimated one million new cases occurring each year.
• It represents 75% of nonmelanoma skin cancers and
25% of all cancers diagnosed each year.
• BCC tends to occur on sunexposed areas of the skin,
most commonly the nose and other parts of the face.
• A malignant lesion on the upper lip is almost always
BCC, and BCC is the most common malignant eyelid
tumor
 SQUAMOUS CELL
CARCINOMA

• The second most common skin cancer and accounts for

approximately 100,000 cases each year.
• The primary risk factor for the development of SCC is UV
radiation exposure
• SCC classically appears as a scaly or ulcerated papule or
plaque, and bleeding of the lesion with minimal trauma is
not uncommon, but pain is rare.
 MELANOMA

• Arises from melanocytes at the epidermal-dermal junction but

may also originate from mucosal surfaces of the oropharynx,
nasopharynx, eyes, proximal esophagus, anorectum, and female
genitalia.
• The most important risk factor for the development of
melanoma is exposure to UV radiation
• Approximately 30% of melanoma lesions arise from a preexisting
melanocytic nevus.
• The most common subtype of melanoma is superficial spreading.
This accounts for 50% to 70% of melanomas and typically arises
from a precursor melanocytic nevus.
• Nodular subtype accounts for 15% to 30% of melanomas
TRAUMA
 ANATOMY
OF THE SKIN
TRAUMA
WOUND
HEALING
 WOUND EVALUATION

• Mechanism of injury
• Wound age
• Degree of contamination
• Presence of a foreign body
• Wound size and depth
• Presence of neurovascular compromise
• Injury to adjacent structures (eg, ligaments, tendons, muscles, bone, or joints)
• Need for tetanus prophylaxis
 INDICATIONS FOR
SUTURING

• Sutures are appropriate to use for primary closure of

skin lacerations when the wound extends through the
dermis and is likely to cause excess scarring if the
wound edges are not properly opposed.
• Sutures are preferred when the wound requires
careful approximation (eg, lacerations that cross skin
tension (Langer’s) lines or that span important
structures such as the eyebrow or vermillion border).
 Primary
TYPES OF
WOUND
CLOSURE
Secondary

Delayed Primary
 • Wounds caused by clean, sharp objects that may
undergo primary closure at any time up to 12 to 18
hours from the time of injury
PRIMARY • Location on the trunk or proximal extremity and the
WOUND patient's lack of other risk factors favor success in
later closure.
CLOSURE
• Wounds of the head and neck may be closed up to
24 hours after injury because of the rich vascular
supply of the face and scalp.
 Indications for secondary closure include:

• Deep stab or puncture wounds that cannot be

adequately irrigated
HEALING BY
SECONDARY • Contaminated wounds
INTENTION • Abscess cavities
• Presentation after a significant delay (eg, >24
hours)
• Noncosmetic animal bites
 • Delayed primary closure consists of initial cleaning
and debridement of the wound followed by at least a
four- to five-day waiting period prior to wound
closure.
• The waiting period permits the host defense system
DELAYED to decrease bacterial load.
PRIMARY • At the time of closure, additional debridement may be
CLOSURE needed and excessive accumulated granulation tissue
trimmed back to the wound margins.
• For this reason, unless the provider has extensive
experience with delayed primary closure, referral to a
cosmetic surgeon or other wound expert is advised.
 Delayed primary closure should be considered
for uncomplicated wounds that present after the
safe period for primary closure.
• Examples of such wounds include:
DELAYED • Animal and human bites, which likely harbor high
PRIMARY bacterial loads coupled with complex injuries to the soft
CLOSURE tissue (ie, crushing, avulsions, and multiple perforations)
• Wounds older than 24 hours that were insufficiently
cleansed, debrided, or decontaminated
• Wounds older than 24 hours that present in the setting
of advanced age, diabetes mellitus, renal impairment,
impaired nutrition, smoking, obesity, and chronic steroid
use
 Antisepsis
PREPARATION
FOR WOUND
CLOSURE
Anesthesia

Aseptic Technique
VIDEO FOR WOUND
PREPARATION
 CONTRADIC ATIONS TO PRIMARY CLOSURE
IN THE AMBULATORY SETTING:
WHEN TO DO SURGIC AL CONSULT?

• Lacerations for which suturing will significantly increase the risk of wound
infection:
• Lacerations through infected skin
• Deep puncture wounds
• Lacerations that have been grossly contaminated with foreign debris that cannot
be completely removed by irrigation and debridement at the bedside
• Superficial wounds that would be expected to heal without significant scarring,
such as lacerations or abrasions that only involve the epidermis. Suturing in these
wounds will potentially cause increased scar formation and risk for infection.
 CONTRADIC ATIONS TO PRIMARY CLOSURE
IN THE AMBULATORY SETTING:
WHEN TO DO SURGIC AL CONSULT?

Relative contraindications to primary closure of skin lacerations in the ambulatory setting include:
• Dog and cat bites (exception facial and other potentially cosmetic wounds
• Most human bites (exception facial and other potentially cosmetic wounds
• Wounds, other than facial wounds, that are older than 24 hours in patients with risk factors for
infection or poor wound healing (eg, immunocompromise, peripheral arterial disease, or diabetes
mellitus), especially when presentation from the time of injury is delayed (eg, >18 hours old) or
the wound site is more prone to infection (eg, hands or feet).
• Lacerations with significant tissue loss in which suturing will cause too much tension across the
suture line. In this instance, surgical consultation for consideration of grafting versus healing by
secondary intention with later scar revision may be a better approach.
•
SUTURING
 SUTURING

For proper healing, the edges of

the wound must be everted. To
accomplish this, the needle should
penetrate the skin at a 90 degree
angle to its surface.
 PROPER
TECHNIQUE FOR
WOUND EDGE
EVERSION

• The needle has been inserted at a 90

degree angle.
• The suture loop is as wide at the base as
it is at the skin surface. The width and
depth of the suture loop are the same on
both sides of the wound. In the panels on
the right, improper technique has
resulted in inversion of the wound edges,
which will interfere with wound healing.
• The needle has entered the skin at an
angle.
• The base of the wound is narrower than
the skin surface.
SURGICAL
KNOTS
 SUTURE PLACEMENT

• To ensure proper apposition of the wound

without excess tissue on one side (also called a
"dog ear"), the clinician places the first stitch at
the midline of the wound.
• The next two stitches go on each side of the first
stitch, midway between the center stitch and the
wound corners.
• Additional bisecting stitches are placed until the
wound is properly aligned.
• The number of sutures needed to close a wound
varies depending upon the length, shape, and
location of the laceration.
• In general, sutures are placed just far enough
from each other so that no gap appears in the
wound edges.
 TECHNIQUE FOR
PLACING A
DERMAL SUTURE

• Absorbable suture material should be used

for dermal sutures.
• The knot is buried by placing the suture
using an inverted technique in which the
suture loop begins in the dermis.
• The needle is directed toward the skin
surface, exiting near the dermal-epidermal
junction.
• It is then inserted into the opposite side of
the wound directly across from the point
of exit.
• The loop is completed in the dermis at the
level where the needle was initially placed.
INSTRUMENT
SUTURE
TYING
 VERTICAL MATTRESS
STITCH (SHORTHAND
METHOD)
• To place a vertical mattress suture using the
shorthand method, the needle is initially inserted
at the epidermal/dermal (near-near) edges as if
performing a simple interrupted suture. This near-
near portion of the suture loop everts the edges
of the wound.
• The needle is then rotated 180° in the needle
holder, and the direction of the suture loop is
reversed (backhanded).
• The needle entrance is at a distance from the
wound edge, crossing through the dermal tissue
and exiting through the skin on the opposite side
at an equal distance from the wound edge. This is
the far-far portion. This stitch approximates the
dermal structures.
 T E CH N I Q UE FO R P LA CI N G A
H O R I ZO N T A L M A T T R E SS
ST I T CH

• A horizontal mattress suture can be used

to achieve wound eversion in areas of high
skin tension.
• The needle is introduced into the skin in
the usual manner and brought out on the
opposite side of the wound.
• A second bite is taken along the opposite
side, approximately 0.5 cm from the first
exit site, and is brought back to the original
starting side, also 0.5 cm from the initial
entry point.
 RUN N I N G SUT UR E

• (A) The closure is started with the standard

technique of a percutaneous simple
interrupted suture, but the suture is not cut
after the initial knot is tied.

• (B and C) The needle is then used to make

repeated bites, starting at the original knot by
making each new bite through the skin at an
angle of 45 degrees to the wound
orientation.

• (D) The cross stays on the surface of the skin

will be at an angle of 90 degrees to the
wound.

• (E and F) The final bite is made at an angle of

90 degrees to the wound orientation to bring
the suture out next to the previous bite. The
final bite is left in a loose loop, which acts as a
free end for tying the knot.
 SUBCUTICULAR CLOSURE WITH
ABSORB ABLE SUTURE

• The suture is anchored at one end of the laceration (A).

• The plane chosen is either the dermis or just deep to the
dermis in the superficial subcutaneous fascia. While
maintaining this plane, "mirror image" bites are taken
horizontally the full length of the wound (B).
• The final bite leaves a trailing loop of suture, as shown, so
that the knot can be fashioned for final closure (C).
• This technique is commonly supplemented with wound
tapes, particularly if there remains some degree of gapping
of the edges.
VIDEO FOR WOUND CLOSURE
VIDEO FOR EXCISION
RECONSTRUCTIVE
TECHNIQUES FOR
WOUND CLOSURE
SKIN GRAFT

Skin grafts categorized based on thickness.

SKIN GRAFT
PHASES OF SKIN GRAFT HEALING
EXCISION OF MELANOMA AND SKIN GRAFTING
 A surgical flap is a unit of tissue harvested from a donor site and
transferred to another location for reconstructive purposes.

The term “flap” is derived from techniques of adjacent skin tissue

transfers fashioned as flaps of skin that were elevated and folded
into the defect.

The distinguishing feature of a surgical flap is having a blood supply

independent of the injured area.
SURGICAL FLAP
A graft must go through the phases of healing described previously
as it derives a new blood supply from the wound bed.

A flap is brought to the wound with its own blood supply.

This allows restoring tissue in areas of poor blood supply or with

tissue requirements greater than what can be supported through a
period of diffusion only.
LOCAL FLAP
MOVEMENT
M U S C U L O C U TA N E O U S
FLAP
LATISSIMUS DORSI FLAP
 Common skin conditions
requiring surgery

SUMMARY Surgical preparation

Specific surgical
procedures