CHIXILOGZ☺☺☺1 SKIN AND SUBCUTANEOUS TISSUE

SKIN and SUBCUTANEOUS TISSUE

GERARDO R. WENCESLAO, M.D.,FPCS
DIPLOMATE PHILIPPINE BOARD OF SURGERY
FELLOW, PHILIPPINE COLLEGE OF SURGEONS

Functions of the Skin

Mechanical barrier
Barrier against radiation
Immunologic barrier
Sensory
Thermoregulation
 Sweat glands
 Blood vessels
Melanocytes
Anatomy of Normal Skin
 Neuroectodermal in origin
 Melanin-pigment produced by
Stratum Corneum
melanocytes
 Barrier against radiation
Epidermis
 Dendritic process-transfer melanin
pigment to neighboring keratinocytes
Dermis
via melanosomes
Variation in skin color
depends on:
 Melanin production
Epidermis
 Transfer to
FUNCTIONS
keratinocyte
Selective absorption-stratum corneum
 Degradation of
 Water-is absorbed in vapor or liquid
melanosomes
form
 Lipid soluble substances-rapidly
absorbed
 Lipid soluble vitamins-are rapidly
absorbed
 Substances in gaseous form except
carbon monoxide easily penetrate the
skin
 Phenol and steroid hormones-can
penetrate the skin
Anatomy
1. Epidermis
- composed mainly of cells
Langerhans cells
a) Keratinocytes
 Originate from the bone marrow
- the main cell type
 They function as skin macrophages
- they originate from the less well
 Immunologic surveillance against viral
differentiated basal cells in the basaL
infection, skin neoplasm, allograft
LayeR
rejection
- they provide a protective mechanical
barrier
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 ¼ of the total blood volume is sent to

the skin surface for cooling
Heat regulation after strenuous physical
activity
 6-8 liters of blood flow to the skin
surface for cooling

Vasoconstriction

Papillary dermis
o Thin arrangement of collagen fiber
o Functions
o Supplies nutrient to selective layer is
the epidermis
o Regulates temperature
 Both functions are
accomplished by extensive
vascular network

Reticular dermis
 Composed of densely packed mainly
type 1 collagen and elastic fibers
 Functions
Gives strength and elasticity
Houses important structures
such as glands , nerves and
hair follicles
A) Collagen
 70% dry weight of the dermis
 Responsible for the tensile strength of
the skin
 Tension-property of the skin that
Thermoregulation resist stretching
Circulatory and Vascular Reaction  Types of collagen
Blood Supply: Type 1-predominant type in
- composed of two horizontal plexuses adults
a) in dermal subcutaneous junction Type 111-predominant type
b) papillary dermis in fetal dermis
Glomus bodies
- they are arterio-venous shunt
- allows tremendous increase in blood flow
when open
- they contribute to thermo regulation
Normal heat regulation
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Ruffini Corpuscle

B) Elastic Fibers c) Krause's and Bulb

they are branching protein that can be - they are involve in the sensation of cold
stretched twice their resting length temp
allow skin to regain its original shape after d) Meisner's Corpuscles
distortion - found in the hands, feet, skin of lips
lines of Langer - they are involved in tactile sensation
- described by Langer 1861 e) Autonomic Fibers
- they synapse to sweat glands and
C) Fibroblast receptors in the vascular system
- responsible for production & maintenance
of protein matrix

Cutaneous Receptors
Sensory Function
a) Pacinian Corpuscles
 found in the palm of the hands and
soles of the feet
 they are involve in the sensation of
pressure
b) Ruffini's Endings
 found in the subcutaneous tissue of
fingers
 they modulate sensitivity to warm
temperature

Pacinian Corpuscle
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Adnexal structure
Sweat Secretion and Insensible Water Loss
a) Eccrine Glands
- secretes aqueous secretion
- highest concentration on the palm
and soles, axilla and forehead

Sweat –produced by sympathetic stimulation

mediated by acetylcholine
It is hypotonic but becomes isotonic with
increased sweat production
Sodium- less that in the plasma
K-same as the plasma
Folliculitis-inflammation of the hair follicle,
Functions of the Skin usually secondary to Staphylococcus
Furuncle- a folliculitis that progresses to form
Thermoregulation a nodule that eventually becomes fluctuant
 For every ml of water evaporated Carbuncles- deep seated infections with
from the surface of the skin, 0.58 Kcal multiple cutaneous draining sinuses
are removed from the body.
 Insensible (evaporation) - skin, Hidradenitis Suppurutiva
respiratory - chronic acne form infection of the cutaneous
apocrine gland, subcutaneous tissue and fascia
approximately 500-700ml/day - found commonly in the axilla, areola of nipple,
No electrolytes are lost groin, perineum
Insensitive to atropine
 Sensible – up to 3 liters/hr Treatment:
Inhibited by atropine - I & D and proper hygiene
b) Apocrine Glands - Mild cases may response well with tetracycline
- they secrete milk like substance found Chronic cases – complete excision of the involve area
mainly in the axilla and anogenital region is necessary with closure using advancement flap or
skin grafting

3. Basement Membrane
- anchors the epidermis to the dermis

SKIN INFECTIONS
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Treatment:
- For Acute Pilonidal Abscess - I & D
- For Chronic Sinus Tract
> Local excision and closure
> Fistulotomy and marsupialization
> Cleft shaving, personal hygiene

Viral Infection

Verruca Vulgaris
 epidermal growth associated with human
papilloma virus
 characterized by:
a) hyperkeratosis
b) acanthosis
c) papillomatosis

 recurrences are common

 some warts (caused by human papilloma type
5, 8,10) are associated with squamous cell
carcinoma

Pilonidal cyst and Sinus Types:

Formed as a result of penetration of 1. Common warts (Verruca vulgaris)
congenital coccygeal sinus by in grown hair - found in fingers and toes
Common among males - rough gray brown surface
Also called Jeep Drivers Disease- 2. Plantar warts
 sweating and friction brought about - sole and palm
by seating in extended period of time- - look like callous
set stage for infection and cyst 3. Flat warts
formation - flat slightly raised
Post operative Pilonidal wound exhibiting a - found in face, legs, hands
number of adverse features including: 4. Venereal warts
a. superficial bridging - found in moist areas lik vulva, anus, scrotum
b. bleeding
c. insufficient
depilation Treatment:
i. Chemical – formalin, podophyllin, phenol,
nitric acid
ii. Curettage and electro dessication
iii. Surgical excision – for extensive warts and for
those lesions with ulceration and exhibit rapid
growth
iv. Adjuvant treatment – interferon, isotritenoin
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- nevus resting completely in the dermis

- most of them would undergo spontaneous
involution

II. Congenital
- comprises only 1 %
- 5 % of which degenerate to malignant
melanoma
Trauma

1. Pressure Ulcer
- caused by excessive unrelieved pressure
- 60 to 70 mmHg amount of pressure
normally exerted on the sacrum, occiput
and heel
- muscle tissue is affected most

Treatment
- relief of pressure
- nutritional support
- debridement

2. Keloids and Hypertrophic Scars

Hypertrophic scars
- thick red raised scar that do not outgrow
their original border

Keloids
- they are much bulkier, their nodularity and
firmness extend beyond the wounds could be
secondary to cytokine called TGF ----  collagen
synthesis
- common among dark skinned individual

Treatment
1. intradermal injection of
triamcinolone
2. Mechanical pressure
3. Excision of keloids and hypertropic scar
- most effective treatment

BENIGN TUMORS

Nevus
I. Acquired
- more common
Types 1.Epidermal cyst
a) Junctional - most common
- nevus found in the epidermis - they have mature epidermis with granular
b) Compound layer
- nevus that migrate partially in the dermis
c) Dermal
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2.Trichilemmal cyst
- next most common
- occur more often in females and usually
on the scalp
- does not have a granular layer

3. Dermoid Cyst
 may result from epithelium trapped during
midline closure in fetal development
 commonly found on body fusion planes
such as midline abdomen and sacrum over
the occiput as well as eyebrow
 they all contain white creamy substance
with strong odor

Epidermal,Dermoid Trichilemmal

Epidermal cyst-basal layer located

superficially. Horny layer-located deep

Dermoid cyst- have squamous

epithelium,eccrine glands, pilosebaceous unit,
bone tooth or nerve tissue

Trichilemmal cyst-doesn’t have granular layer

but a layer resembling the outer root sheath
of a hair follicle BENIGN SOFT TISSUE TUMORS

Vascular Tumors SOFT TISSUE TUMORS

Hemangiomas- benign vascular neoplasm that
arise soon after birth.
 Can enlarge during the first year of
life. 90% regress spontaneously with
time
 Those that persist after early
adolescence will most likely not
involute further
Capilllary-soft compressible
papular lesions w/ sharp
borders .
Cavernous-bright red or
purple w/ spongy consistency
Vascular Malformations-they are vascular
structural abnormalities formed during fetal
development
 They don’t involute spontaneously
but grow in proportion to the body
Lipoma-most common benign soft tissue
tumor;mostly on the trunks
Acrochordons(skin tags)-pedunculated mass
located on the axilla, trunks and eyelids
Ganglion cyst-most common soft tissue
tumor of the hands.
They are painful mucinous
pseudocyst from the irritated synovial
linings of the joints, ligaments and
tendons
Commonly seen on the dorsal wrist
then on the volar wrist
MALIGNANT TUMORS
I. Basal Cell CA
- most common, they originate
pleuripotential cells of the basal
epithelium
- they are slow growing, rarely metastasize
- locally invasive, death is rare
- they often contain central ulcer
(Rodent Ulcer)
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 they are commonly found at the vermillon

border of the lips, paranasal and maxillary
skin
they tend to occur in persons with blonde hair
and those with light, thin dry irritated skin

Types
1) Nodulo ulcerative
- most common type 70 % Bowen's Disease
- they are cream colored lesions with rolled - in situ CA
pearly borders - 10 % progress to invasive squamous cell CA

2) Pigmented Basal Cell Erythroplasia of Queyrat

- Squamous cell CA of the penis
3) Superficial Basal Cell
- occur commonly in the trunk Marjolin Ulcer
- Squamous cell CA arising from burn scar
4) Baso Squamous
- rarest BIOLOGIC BEHAVIOR
- contain basal and squamous cells
- they metastasize like the 1. Tumor thickness
squamous cell CA - > 4 mm tends to recur locally
- > 10 mm they tend to metastasize
5) Morphea Form 2. Location
- most aggressive  those arising from burn scar areas of chronic
- has the ability to produce Type IV osteomyelitis and previous injuries - tend to
collagenase which facilitate local spread metastasize earlier
 lesion on the ear – frequently recur
Treatment spread to regional lymph nodes
1. curettage and electrodessication - usually  solar damage-less aggressive
done for small lesions (< 2mm)
2. Surgical Excision Treatment
 the preferred treatment 1. surgical excision
 large lesions and those with - the preferred treatment
aggressive histologic type a 2 - 4 mm - lesion shall be excise with 1 cm
of normal tissue should be excised Margin

II. Squamous Cell CA Lymph node dissection:

 they arise from the keratinocytes of the  Regional LN excision-for clinically
epidermis palpable nodes
 they grow more rapidly, invade surrounding  Prophylactic LN excision- indicated
tissues, they metastasize rapidly only for those arising from chronic
wounds
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Alternative tx basal and squamous ca 3. Lentigo Maligna Type

1. Topical 5 FU - account for 5 - 10 %
2. Radiotherapy - occur most commonly on the neck, face
3. Intralesional injection with Interferon and back of the hands of the elderly people
4. MOH’s micrographic surgery - have the best prognosis because growth
occur late

4. Acral lentiginous
 Least common but most common on
dark skinned people (Asians,
Hispanics ,African American-29-72%)
 Common on the palm ,soles and
subungual region.
 Hutchinson’s sign-pigmentation on
the proximal or lateral nail folds
 Worst prognosis

MALIGNANT MELANOMA

- can arise anywhere that melanocytes

migrated during embryogenesis
- 90 % are found in the skin
-other notable sites are the eyes and anus
- 2/3 arise from the pre-existing mole Treatment:
with junctional activity a. Surgical-primary treatment of choice
In-situ lesions-
Types  0.5-1cm margin
T1 –invasion of papillary dermis ( Clark’s
1. Superficial spreading level 2) or 0.75mm thickness or
- most common type, representing 70 % less(Breslow level1)
- they occur anywhere except on the hands  1cm margin
and feet T2 or >(Clark’s level3 or>, Breslow level 2
- they are flat commonly contain areas of or>)
regression
- there is long radial growth before vertical b. Prophylactic lymph node dissection-
growth begin -indicated only for those w/ high risk
of metastasis.
2. Nodular type • Ulcerated lesions
- accounts for 15 - 20 % • Lesions on the trunk, head and
- they are darker and raised neck
- they lack radial growth and usually in the
vertical growth at the time of diagnosis
- poorer prognosis
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Hyperthermic Regional Perfusion with

Chemotherapy (Melphalan)
- treatment of choice for patient with locally
recurrent, lypmphatic invading melenoma and
those not amenable to excision
-
 High dose per fraction radiation- tx of choice
for with multiple symptomatic brain
metastasis

Malignant Melanoma
Prognostic Factors
Anatomic location-extremities do better than
those on the face and trunks
Ulceration- worst prognosis
Sex-females higher survival rate than men
Histologic type- acral lentiginous: worse
prognosis.
Clark level-histologic level
Breslow- the base of the ulcer- greatest depth
of the tumor