Plastic surgery and skin

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CHAPTER 19 Plastic surgery and skin

Plastic surgery has evolved from the innovation of techniques concerning the movement and reconstruction of soft tissue defects by the movement of autologous, distant and allogeneic tissue. Knowledge of anatomy, vascularity, wound healing and vessel, nerve and tendon reconstructive techniques are applied. Excision of benign and malignant tumours of the skin and soft tissue (sarcoma) with subsequent reconstruction of resulting defects forms a large part of the workload. Breast reconstruction following partial or total mastectomy defects, soft tissue defects due to trauma and burns and congenital hand, urogenital and craniofacial abnormalities such as cleft lip and palate are also addressed using these techniques. Elective and traumatic hand surgery and reconstruction forms a large subspecialty. Plastic surgeons often work with other specialties to reconstruct defects that cannot close directly, e.g. orthopaedics (open lower limb fractures), general surgeons and gynaecologists (perineal defects), cardiothoracic surgeons (sternal dehiscence and chest wall defects), neurosurgeons (craniofacial defects), and head and neck surgeons (facial reconstruction following tumour excision and trauma, facial palsy correction). The importance of aesthetics in these reconstructions has led to the refinement of cosmetic surgery which forms the minority of the workload. However the recent increased numbers of obese patients undergoing bariatric surgery has increased the volume of referrals for body contouring procedures (abdominoplasty, belt lipectomy, thigh lift, breast reduction/mastopexy, brachioplasty).

Providing skin cover

Direct closure

Following excision of simple skin lesions or debridement of necrotic tissue in small wounds, the edges may approximate without tension and without deforming neighbouring structures such as the eyebrow, nose, lip or eyelid. Direct closure with simple interrupted or continuous suturing techniques is usually the best approach in such circumstances. Eversion of skin edges is essential with the choice of suture and timing of removal related to the anatomical site. Planned excisions are best performed along relaxed skin tension lines to orientate scars into natural skin creases.

Healing by secondary intention

Where wounds will not close without tension, small defects with a vascularized bed, rather than exposed bone, tendon or prosthesis can be allowed to heal by secondary intention using appropriate dressings. It is remembered, however, that such wounds will heal slowly with contraction which may distort local structures and limit motion if sited over a joint. Such scars can become hypertrophic and therefore problematic. Good results from secondary intention can be seen after excision of small skin cancers in the inner canthal region and may be the most appropriate choice in lower limb ulcers compromised by venous insufficiency where skin grafts are less likely to survive or a patient is not fit for a surgical procedure.

Skin graft

A graft tissue is removed completely from one part of the body and inset onto another site. It is separated from its blood supply and therefore depends on being placed on a healthy vascular bed for its revascularization.

Flaps

A flap is a section of tissue transferred, carrying its own blood supply. They can be defined by their composition, e.g. skin (cutaneous), fasciocutaneous, adipofascial, or muscle with or without skin or bone. They can be local (raised from an area sharing a border with the defect) and move by advancement, rotation or transposition. These can be geometrically designed to rely on the unnamed vasculature from the base of the flap (random pattern → Fig. 19.1) or based on a named or identified vessel – the pedicle, e.g. groin flap, deltopectoral flap or on a vessel perforating from the deeper tissues. These pedicled flaps do not necessarily share a border with the defect (regional), and can be moved into the defect around a pivot point, related to the axis around the pedicle. General indications for flap cover include: avascular areas, e.g. exposed bone or joint surfaces, exposed major blood vessels, irradiated areas or areas to undergo radiotherapy. (For a selection of pedicled flaps, see Figure 19.2.)

Figure 19.1 (A) Some random pattern flap designs used for facial defects and (B) their resultant scars. (a) Bilateral V-Y advancement flaps, move together to complete the primary (excised) defect, without raising eyebrow. The secondary (flap) defects can be closed directly. (b) Rhomboid flap recruits adjacent mobile skin as a transposition flap to cover the primary defect, yet allows direct closure of the secondary defect. (c) Bilobed flap utilizes two transposition flaps recruiting mobile tissue from dorsum of bridge of nose to cover the secondary defect of the transposition flap used to cover the primary defect. (d) Cheek rotation flap utilizes skin laterally via a cheek-lid margin incision extending in the pre-auricular line. (e) Glabellar ‘hatchet’ flap rotates and advances mobile skin between the brows to cover the primary defect. The secondary defect is closed in a V-Y fashion.

Figure 19.2 Some of the more commonly used pedicled flaps (a–i):

Free flaps

The blood supply to the flap is completely divided and the flap transferred to another area of the body where revascularization is affected by microvascular anastomosis. Free flaps may be composed of muscle, fasciocutaneous tissue, bone (e.g. fibula, scapula, iliac crest, radius) or a combination of these. Advantages include single-stage reconstruction, a wide choice of donor sites allowing better tailoring and choice of a flap to suit the defect without the constraint of a fixed pedicle and a good success rate (up to 95%). Disadvantages include long operating time and the need for specialized equipment and expertise. (For a selection of free flaps, see Figure 19.3.)

Figure 19.3 Some of the more commonly used free flaps (a–h):

‘Surgical’ skin lesions: principles of management (→ Table 19.1)

• Simple excision for straightforward clinically diagnosed lesions, e.g. skin tags, sebaceous cysts

• Excision biopsy if risk of malignancy, e.g. small pigmented lesions where change may have occurred recently

• Incisional biopsy, e.g. for ulcers which have failed to heal and there is need to exclude malignancy or vasculitis

• Wide excision of adequate margin and depth, e.g. for confirmed malignant lesions

• Radiotherapy for basal cell carcinoma may be an alternative to surgery, especially in sites where skin preservation is important

• Remember that skin lesions may be a manifestation of systemic disease.

TABLE 19.1 ‘Surgical’ skin lesions

Benign
Epidermis	Pedunculated papilloma, wart, seborrhoeic keratosis, keratoacanthoma
Dermis	Pyogenic granuloma, fibrous histiocytoma, keloid
Appendages	Furuncle, carbuncle, hidradenitis suppurativa, sebaceous cyst, dermoid cyst, pilonidal sinus
Subcutaneous	Lipoma, neurofibroma
Melanotic	Intradermal naevus, blue naevus, compound naevus, spitz naevus, congenital naevus
Vascular	Campbell de Morgan spots, haemangiomas, capillary/venous/arteriovenous/lymphatic malformations, spider naevi, glomus tumours
Premalignant
Epidermis	Actinic (solar) keratosis, Bowen’s disease, erythroplasia of Queyrat (penis)
Malignant
Epidermis	Basal cell carcinoma, squamous cell carcinoma
Dermis	Kaposi’s sarcoma, secondary deposits
Appendages	Sebaceous carcinoma (rare), sweat gland carcinoma (rare)
Subcutaneous	Liposarcoma, neurofibrosarcoma
Melanotic	Malignant melanoma
Vascular	Angiosarcoma (rare)

Common benign lesions

Epidermis

Pedunculated papillomas (skin tags)

These small polypoid lesions occur in adults, most frequently on the trunk, neck, axilla and groin. They may catch on clothes and bleed, and are often cosmetically unacceptable. They are removed by excision under local anaesthetic. Small skin tags may be treated by tying a fine ligature around the base, which leads to necrosis.

Warts (verrucae vulgaris)

These are caused by papovavirus, and usually occur in the second decade of life. They are common on fingers, hands and soles of feet (verrucae plantaris). Plantar warts may be very painful. Resolution of warts may occur spontaneously. Treatment may be by curettage, freezing with liquid nitrogen or application of keratolytic agents, e.g. podophyllin.

Seborrhoeic keratoses

These are found in elderly patients, and are often multiple, well-demarcated raised ‘stuck on’ lesions with varying degrees of pigmentation. It may be difficult to differentiate from malignant melanoma if deeply pigmented. Treatment is to leave alone or treat by surgical excision or curettage.

Keratoacanthoma

This is a nodular lesion with a central crater containing a keratin ‘plug’. They progress rapidly in 2 weeks to 2 months. Probably of viral aetiology, they often show spontaneous regression. Occasionally, they are difficult to distinguish from squamous cell carcinomas. Treatment is by excision biopsy or close observation, if the lesion is obviously regressing.

Dermis

Pyogenic granuloma

This is a dark red nodule of exuberant granulation tissue and polymorphs. There is rapid initial growth, often at the site of trauma. Occasionally, the surface may ulcerate and then must be distinguished from amelanotic melanoma. Treatment is by excision.

Fibrous histiocytoma

This is a well-circumscribed deep reddish-brown tumour. On inspection, it may be mistaken for a malignant melanoma. However, palpation reveals a hard consistency due to the dense fibrous stroma. Treatment is by excision.

Keloid

This involves excessive deposition of collagen beyond and above the wound itself and is covered by normal epithelium. It must be distinguished from a hypertrophic scar in which the wound becomes broad and raised – the latter usually settles within 6 months. Keloid may increase after 6 months. Black Africans and the young are particularly affected. It may follow burns. Treatment is by intralesional injection of steroid, pressure garment therapy, applying silicon-impregnated dressings; or for refractive, problematic lesions, radiotherapy after excision is an option.

Skin appendages

Boil (furuncle)

This is an infection in a hair follicle usually caused by Staphylococcus aureus. It can occur in any part of the body but is more common in the head, neck, axilla and groins. Diabetes, immunosuppression and general debility are predisposing conditions. Multiple boils (furunculosis) are common in diabetics. Any patient presenting with boils should have the urine tested for sugar.

Usually, they are self-limiting and heal when pus has discharged. Antibiotics should be avoided except in the following situations:

• ‘Dangerous’ areas of the face, i.e. between the orbit and angle of the mouth where venous drainage is into the cavernous sinus – cavernous sinus thrombosis may occur

• Multiple boils with surrounding cellulitis in diabetics and immunosuppressed patients where septicaemia is a risk.

Carbuncle

An infection which dissects through the dermis and subcutaneous tissues to form connecting channels, some of which open to the surface. There is considerable induration and pus discharges through the sinuses. The back of the neck is a common site. Treatment is with antistaphylococcal antibiotics, e.g. flucloxacillin, with desloughing and adequate drainage of the abscesses if necessary.

Hidradenitis suppurativa

A chronic disease of skin and subcutaneous tissue in apocrine gland-bearing areas, e.g. axilla, groin, perineum and perianal areas. The involved area is indurated, fibrotic and inflamed with sinuses draining pus. Staph. aureus is the usual organism grown but occasionally coliforms may be cultured. Treatment is initially by antibiotics. Abscesses are incised and drained. Advanced cases may need wide excision with or without skin grafting. Severe perianal disease may require a diverting colostomy prior to skin grafting.

Sebaceous cysts

These are common on the scalp, face, neck, and back and are soft or firm and spherical. They contain cheesy sebaceous material, which may become infected and discharge. They are attached to the skin and a punctum is usually seen at the point of attachment. Treatment is by excision under local anaesthetic.

Dermoid cysts

These may be congenital or acquired.

Congenital

They are formed in intrauterine life when skin dermatomes fuse and present at birth or a few years after. They are most common in head and neck, e.g. outer end of eyebrow (external angular dermoid). Treatment is by excision. Midline dermoid cysts should be radiologically assessed to exclude intracranial extension.

Acquired

These are implantation dermoids. A piece of skin is forcibly implanted into the dermis as a result of trauma. They are common on fingers. Treatment is by excision.

Pilonidal sinus

This chronic infection in the sinus is caused by penetration of hairs into skin and subcutaneous tissues. Infection leads to pilonidal abscesses. The sinus leads to a cavity filled with hair and granulation tissue. Common sites include posteriorly in the midline over the sacrococcygeal area and natal cleft (usually hirsute males with sedentary occupations); between the fingers in hairdressers; occasionally umbilicus, axilla and nipple. Differential diagnosis includes perianal fistulae, hidradenitis suppurativa, simple boils. Treatment includes:

• Deroofing the track, removing the hairs and packing; the surrounding skin should be shaved until the sinuses have healed

• Injection of the sinuses with methylene blue, followed by wide excision of all tracts until no dye is seen and either packing, primary suture or reconstruction of large defects using local flaps can be carried out under GA

• For pilonidal abscesses, incising, curetting and packing.

Disorders of the nails

Ingrowing toenail (IGTN)

A common condition, it usually appears on the great toe, particularly the lateral side. Caused by a combination of tight shoes and paring the nail downwards into the nail fold rather than cutting it transversely. The sharp edge of nail then grows into the nail fold producing ulceration, infection, and granulation tissue.

Treatment

Non-infected

Give advice on correct cutting of nails, i.e. transversely. Avoid tight, pointed shoes. Tuck a pledget of cotton wool soaked in mild antiseptic under the corner of the nail to lift it out of the soft tissue. Soak feet in warm water regularly.

Infected

With mild infection, it may be possible to adopt the above regimen in addition to the administration of antistaphylococcal antibiotics. If this fails carry out the following:

• Simple nail avulsion with curettage of infected granulation tissue under local anaesthetic. Antistaphylococcal antibiotics should be administered.

• Wedge excision. Lateral or medial nail and nail bed are removed together with granulation tissue and germinal matrix. Liquefied phenol may be applied to the germinal matrix to ensure complete removal.

• Zadik’s procedure. This is reserved for recurrent IGTN. The nail is avulsed and the germinal matrix completely excised after raising a skin flap to expose it. To ensure complete removal of the germinal matrix liquefied phenol is applied after protecting the skin. The nails should not re-grow after this procedure.

Complications

Recurrence may occur. This is common after simple avulsion. Spikes of nail may occasionally re-grow after a Zadik’s procedure. Infection may occur and it is appropriate to give a course of antistaphylococcal antibiotics prophylactically. Osteomyelitis and septic arthritis may occur after Zadik’s procedure.

Onychogryphosis

This is a ‘ram’s horn’ deformity of the toenail. The nail thickens and curls over the end of the toe as it grows. Common in the elderly, it may follow trauma to the nail in the younger patient. It can be treated by either cutting the nail with bone forceps or grinding the nail down. Avulsion is always followed by recurrence. Zadik’s operation is curative.

Nail bed lesions

Haematoma

There is a history of trauma, e.g. trapping, or dropping a heavy object on the nail. Very painful. A haematoma is evacuated by piercing the nail with a red-hot paper clip. Small haematomas following trivial injury may closely simulate subungual melanoma. Haematomas grow out with growth of the nail. If there is any doubt, biopsy should be carried out.

Melanoma

Subungual malignant melanoma is not uncommon. The lesion does not grow out with the nail. Biopsy is necessary. If the diagnosis is confirmed, amputation of the digit is required.

Subungual exostosis

This nearly always affects the great toe. It occurs in adolescents and young adults. It lifts the overlying nail and causes deformity. Diagnosis is confirmed by radiograph. Treatment is to remove the nail and excise the underlying bony nodule.

Subcutaneous tissues

Lipoma

This is a common, benign tumour of fatty tissue. It is soft, lobulated and pseudofluctuant and the overlying skin appears normal. It is slow growing. Treatment is by excision. Multiple lipomas may occur. These need to be distinguished from neurofibromata by biopsy of at least one lesion. Occasionally, there may be multiple tender lipomas on the trunk (Dercum’s disease). Treatment of lipoma is by excision, which is curative. Liposarcomatous change may rarely occur in a benign lipoma.

Neurofibroma

These are benign tumours arising from the connective tissue element of peripheral nerves. They are often multiple and may be asymptomatic, but if closely related to the nerve the patient may get paraesthesia in the distribution of the nerve. Biopsy of one lesion may confirm the diagnosis. If neurofibromata are multiple, congenital and familial, the condition is known as von Recklinghausen’s disease. Occasionally malignant change to neurofibrosarcoma occurs.

Premalignant lesions

Actinic (solar) keratoses

These are rough, scaly epidermal lesions on sites of exposure to the sun; 10–20% undergo malignant change. The diagnosis is confirmed by biopsy and then the lesion is excised. Topical chemotherapy with 5-fluorouracil cream has been used in patients with multiple lesions.

Bowen’s disease

Intraepidermal squamous cell carcinoma (carcinoma-in-situ). A well-defined erythematous plaque with occasional crusting, it occurs in the fourth to sixth decade and may be associated with the presence of internal malignancy. Diagnosis is confirmed by a biopsy. Treatment is by excision, cryotherapy, curettage, topical 5-fluorouracil or photodynamic therapy. Intraepidermal carcinoma may occur on the glans penis and is then called erythroplasia of Queyrat and appears as a reddish-brown velvety plaque.

Leucoplakia

Leucoplakia consists of a thickened white patch on a mucous membrane. It can occur on the vermillion border, oral mucosa and the vulva. It occurs due to chronic irritation. In the mouth, this is usually due to sunlight but can occur due to dentures. Approximately 20% will show dysplasia and may progress to carcinoma. Erythroplasia is a red patch and always represents in situ carcinoma.

Lentigo maligna

Also known as Hutchinson’s freckle. It occurs on sun-damaged skin in the elderly. It is an irregular flat brown-black lesion. It may increase in size over many years and it consists of an abnormal proliferation of atypical melanocytes in the dermo-epidermal junction. It is essentially malignant melanoma in situ. Development of invasion and therefore malignancy is usually heralded by the development of a pigmented nodule within the lesion. Confirmed by incision biopsy, treatment is by excision.

Malignant lesions

Epidermis

Basal cell carcinoma (rodent ulcer)

Basal cell carcinoma arises from epithelial cells. It is common in the middle-aged and elderly. Locally invasive; it very rarely metastasizes. Frequently found on skin exposed to sunlight, the commonest area is the face above a line drawn from the angle of the mouth to the lobe of the ear. Other predisposing factors include immunosuppression, radiotherapy, xeroderma pigmentosum and naevus sebaceous.

There are several different types:

• Nodular – most common, starts as a nodule that ulcerates and develops a rolled edge with a pearly appearance and local telangiectasia

• Superficial – presents as red scaly patches

• Morphoeic or sclerosing – forms a flat spreading plaque; it has a fibrous stroma and may cause distortion, i.e. around the eyelids

• Gorlin’s syndrome – autosomal dominant condition associated with multiple basal cell carcinomas, dental cysts and a splayed 12th rib; radiotherapy will convert the basal cell carcinoma to a much more aggressive form and is thus contraindicated.

Differential diagnosis includes seborrhoeic keratoses and malignant melanoma. Treatment options include surgical excision (with a 3–5 mm margin) or radiotherapy. Cure rate is high when treated early and adequately. Larger defects may require reconstruction using the principles of the reconstructive ladder.

Squamous cell carcinoma

Squamous cell carcinoma arises from keratinocytes in the epidermis. This may grow rapidly. It metastasizes via lymphatics and rarely via the bloodstream. Exposure to sunlight may be a causative factor. It can also develop in areas of Bowen’s disease and erythroplasia of Queyrat. Other causative factors include chemical burns, chronic ulcers (e.g. Marjolin’s ulcer, i.e. malignant change in a chronic venous ulcer), irradiation dermatitis.

It starts as a lump, which ulcerates with bleeding and discharge. The edge of the ulcer is characteristically raised and everted. Local lymph nodes may be involved. Differential diagnosis includes keratoacanthoma, basal cell carcinoma, amelanotic malignant melanoma, pyogenic granuloma, traumatized seborrhoeic wart. Diagnosis is confirmed by biopsy. Treatment is by wide excision (with a 4?10 mm margin) or radiotherapy. Block dissection of regional lymph nodes is required if these are affected. Large defects may require reconstruction with skin grafts, local or free flaps as described above.

Dermis

Kaposi’s sarcoma

These are raised purplish nodules. Initially, they are usually single, but gradually multiple nodules occur and may ulcerate. It is the commonest tumour to develop in patients with AIDS; 90% are in male subjects. The solitary nodule should be excised. Local radiotherapy or cytotoxic therapy is useful for multiple lesions.

Metastatic carcinoma

Small, hard, painless, skin nodules may occur. Skin secondaries are commonest with cancer of the breast, lung and bowel. In most patients, the primary will be obvious or will already have been treated. Ulceration of the secondaries may occur. Biopsy confirms the diagnosis. Treatment is given that is appropriate for metastatic disease for that particular tumour, e.g. tamoxifen in carcinoma of the breast.

Others

Malignant change may take place in neurofibromas and lipomas, giving rise to neurofibrosarcoma and liposarcoma. Other soft tissue sarcomas may also arise in this area and are treated by wide excision.

Melanocytic lesions

Benign lesions

Freckle (ephelis)

Solar lentigo

Occur in areas of sun-damaged skin, especially on the hands and face. They consist of an increase in the number of melanocytes producing normal amounts of pigment. There is no atypia.

Naevi

(→ Fig. 19.4)

Figure 19.4 Pathological varieties of naevus (mole): (A) normal skin, (B) junctional naevus, (C) compound naevus and (D) intradermal naevus.

A naevus is defined as an increased number of melanocytes in an abnormal position producing normal or increased amounts of melanin. Melanocytes are present throughout the dermis and epidermis with similar numbers in all races, which differ in melanin production. At birth, most melanocytes are situated in the basal layer of the epidermis. Over the next few decades, some will migrate to the dermis. Melanocytes within the dermis have no malignant potential as they have lost their ability to divide.

The position of melanocytes can give rise to a number of pigmented lesions:

• Melanocytes in the basal layer form a simple lentigo or mole.

• Melanocytes at the dermo-epidermal junction form a junctional naevus. These appear as either a macule or papule and are brown, smooth and hairless. They develop at or around puberty and can occur anywhere, including the hands and the soles of the feet. A small percentage may turn malignant but this comprises the vast majority of malignant melanomas.

• Fibroblast migration may draw some melanocytes into the dermis, leaving some at the dermo-epidermal junction. This forms a compound naevus. It is clinically indistinguishable from an intradermal naevus. It does, however, have malignant potential.

• As a naevus matures in the late 30s, an intradermal naevus is formed, all the melanocytes lying in the dermis. Clinically they appear as a well-defined papule. They are brown or flesh-coloured and often hairy. They have no malignant potential.

Spitz naevus

Benign lesions, usually seen in children and young adults. Clinically they appear as pink, dome-shaped nodules. Histologically, they can be difficult to differentiate from malignant melanomas.

Halo naevus

Benign lesion. Clinically it appears as a lesion surrounded by an area of depigmentation secondary to invasion of lymphocytes. This phenomenon can occur in malignant melanomas and is thus an important differential diagnosis.

Blue naevus

Consists of melanocytes in the dermis. They form lesions with a slate-blue colour. There are two types:

Common

Benign lesion often seen in the head or hands. More common in women and usually seen in women in their 40s.

Cellular

More common in women. More than 50% occur in the sacrococcygeal/buttock area. They are benign but malignant transformation may occur.

Congenital naevi

May be single or multiple. One important variant is the giant pigmented naevus. These lesions are >20 cm in diameter and are flat, pale brown and hairless or lumpy, black and hairy in appearance. Malignant melanoma may develop, usually in the teenage years. Management is usually by excision. This may require extensive plastic surgical reconstruction due to tissue loss.

Malignant melanoma

More than 9500 cases of malignant melanoma are diagnosed annually in the UK. They may occur anywhere on the skin or on the retina, oesophageal mucosa or anus. Malignant melanomas can arise in pre-existing naevi or de novo.

Signs of malignant change in a mole include:

• Change in size, shape or deepening of colour

• Irregular border

• Bleeding or ulceration

• Itching.

Classification

Superficial spreading melanoma

This is the commonest type of melanoma. In males it occurs most commonly on the back; in females most commonly the legs. Prognosis tends to be good, as growth is predominantly radial rather than vertical (this correlates to a reduction in the level of invasion).

Nodular melanoma

Found on the trunk they appear as raised nodules often with ulceration. The growth is almost entirely vertical, thus these tumours have a poor prognosis.

Lentigo maligna melanoma

Arises from lentigo maligna. Occurs in the elderly, i.e. 60–70 years. Tends to have a good prognosis and has low metastatic potential.

Acral lentiginous melanoma

Rare. Occurs on the soles, palms and under nails (subungual).

Spread of melanoma occurs by local growth and infiltration. Lymphatic spread occurs early. Bloodstream spread occurs in almost any organ, particularly the liver, brain and lung.

Staging

A number of different classifications may be used to stage the level of invasion – this links directly with prognosis. Classifications are as follows:

• Breslow thickness – <1 mm, 1–2 mm, 2–4 mm and >4 mm

• Clarke’s level

I Epidermis

II Papillary dermis

III Junction of papillary and reticular dermis

IV Extends to reticular dermis

V Subcutaneous tissue

• AJCC (American Joint Committee on Cancer)

M1 Metastatic disease.

Treatment

1. Confirm the diagnosis and depth of invasion. Occasionally a malignant melanoma is clinically obvious but lesions may need to be confirmed by excisional or incisional biopsy.

2. The mainstay of treatment is surgical. Initial excision should be performed with an adequate clearance margin. Following removal of the lesion histology will confirm the diagnosis and allow the measurement of Breslow thickness.

3. After measuring the Breslow thickness, further surgery may be needed. A tumour of <1 mm in thickness requires a 1 cm excision margin. Tumours of greater depth may need a wider margin but margins over 3 cm confer no survival benefit.

4. In patients with involved nodes, a regional lymph node dissection should accompany the removal of the lesion. In patients with no clinical involvement, the management is controversial. As many as 20% of T2/T3 patients may have metastases. Accurate staging is assisted by radiolabelled probe/dye-directed sentinel node biopsy.

5. Chemotherapy is of little value in primary disease. Isolated limb perfusion may be used in local recurrence.

6. Radiotherapy and immunotherapy have been used but are strictly palliative.

Prognosis

Favourable factors include early diagnosis, a depth of penetration of <1 mm, and melanoma in a radial growth phase. Unfavourable factors include lymph node and distant metastases at presentation, increasing depth of penetration, ulceration and presence of vertical growth phase. If the disease is confined to the primary site and has a penetration of <1 mm, then a 5-year survival of 90% may be expected. With lymph node metastases, this is reduced to 30% and with distant metastases, patients rarely survive for 1 year.

Lesions of vascular origin

Campbell de Morgan spots

These are small bright red spots containing capillaries and connective tissue. They are rare before the age of 40 and increase with age. They are of no serious significance. Patients should be reassured and the lesions left alone.

Haemangiomas (strawberry naevi)

Grow rapidly in the first few months of life; are red, soft, compressible fleshy lesions that commonly involute; 50% of haemangiomas have resolved by 5 years of age. Haemangiomas that ulcerate and bleed, obscure vision or hearing or interfere with speech development may require treatment with steroids or excision, otherwise they are treated expectantly during involution.

Capillary malformations (port-wine stains)

These are flush with the skin and occur on the face, lips and buccal mucosa. They can become more thickened during life and are reddish-blue in colour. If the lesion is small, surgical excision may be attempted. Larger lesions are cosmetically distressing. Sclerosing agents and lasers have been used. Advice on the use of cosmetic preparations may be the most appropriate. Lesions in the 5th cranial nerve dermatome (ophthalmic division – VI) may be seen in association with meningeal involvement (Sturge–Weber syndrome), which may cause focal epilepsy. Similar lesions may be seen in the Klippel–Trenaunay syndrome.

Venous malformations, arteriovenous malformations (AVM)

Grow in proportion with the child’s growth. High flow lesions (AVM) can progress to high output cardiac failure – treatment is by a combination of radiologically guided sclerotherapy and excision if symptomatic.

Lymphatic malformations

Can be macrocystic (cystic hygroma) or microcystic and localized or involve whole limbs, leading to lymphoedema and limb hypertrophy. Associations with AVM (Parkes–Weber syndrome) and capillary malformations (Klippel–Trenaunay) are recognized. Treatment is usually conservative as lesions often recur after excision.

Glomus tumour

Glomus bodies occur in the subcutaneous tissues of the limbs – especially the fingers, toes and nail bed. They are small arteriovenous communications associated with muscle and nerve (angioneuromyoma). Clinically, they are small, raised, bluish-red lesions. They are painful and exquisitely tender if pressed. Treatment is by surgical excision.

Burns

A burn is the destruction of tissue due to external stress. Burns may be caused by heat, cold, ultraviolet light, irradiation, electricity, chemicals and friction. In the UK there are about 300 hospital deaths annually from burns, there being approximately 450 000 injuries each year. Domestic burns and scalds, especially in children and the elderly, form a large proportion of the 175 000 patients presenting to A&E units.

Classification of depth

Superficial

This involves the superficial epidermis only. The underlying germinal layer is intact. It presents with a blanching erythema and pain which resolves over the first 24 h. Analgesia is usually all that is required.

Superficial partial thickness

Damage penetrates to the depth of the superficial dermis. They present with blanching erythema, with blistering and pain. Healing occurs from epithelial elements within the skin appendages (hair follicles, sweat glands, sebaceous glands), taking approximately 3 weeks using appropriate dressings.

Deep dermal

Tissue damage may extend into the remaining dermis, damaging sources of epithelial growth, such as sweat glands and hair follicles. Blistering occurs. The underlying dermis may be non-blanching and white or pink with fixed-staining. There may be some surviving skin appendages, and a second look at 48 h and subsequently, will demonstrate any progression of the depth of the burn and potential for healing without the need for skin grafting. Those that are not anticipated to heal by 3 weeks proceed to skin grafting to prevent wound contracture and hypertrophic scarring.

Full thickness

All layers of the skin are destroyed, presenting with a white, insensate, non-blanching, or brown and leathery appearance or eschar. If left, the wound heals by separation of the eschar and healing by secondary intention with subsequent contraction of fibrous tissue and centripetal growth of the peripheral epithelium. In all but the smallest full thickness burns, skin grafting is required to prevent dense scarring, contractures, and deformity.

Management of burns

First aid

1. Stop the burning process. Dousing with tepid water has both a quenching and analgesic affect. Beware copious cold water irrigation in the young scalded infant, as this may induce hypothermia, and may increase the depth of the burn.

2. If scalding, remove clothes.

3. If a chemical burn, perform copious irrigation with cool water.

4. Remove from smoke. Ensure clear airway.

5. Cover the burn in a clean sheet soaked in cold water, or cling film. Avoid tight circumferential cover, as the wound will swell.

6. Get the patient to hospital.

Assessment of the patient

1. Initial assessment is made using ATLS principles: airway, breathing, circulation, disability and exposure. Do not forget to assess for associated injuries that may be a greater threat to life than the burn itself.

2. Airway – Apply 100% oxygen. Look for signs of inhalation injury, hoarse voice, brassy cough, soot around mouth or nostrils, singed nasal hair, oromucosal oedema and ulceration. Supraglottic thermal burns can swell and obstruct the airway at a frightening pace, and therefore any evidence of airway injury is assessed by a senior anaesthetist for consideration of early endotracheal intubation to protect against later obstruction.

3. Breathing – Inhalation of smoke causes injury to the subglottic airway and systemic toxicity of carbon monoxide, hydrogen cyanide and other toxins may present with an unconscious, confused patient.

4. Ensure an adequate circulation. Obtain i.v. access with two large-bore cannula in burns >15% body surface area (BSA) in adults or 10% in children and resuscitate according to the Parkland formula (see below). If resuscitating, pass a urinary catheter.

5. Obtain a history: source of burning, e.g. fire or scald; duration of contact, indoors or outdoors; contact with any toxic gases; first aid given.

6. Assess the site, depth and BSA of the burns. Use the ‘rule of nines’ to calculate BSA (→ Fig. 19.5) or a Lund and Browder chart. Alternatively, the palm and finger surface of the patient’s hand may be used as representing 1% of the BSA. It may be difficult to determine the depth of a burn clinically. Frequently there are areas of partial and full thickness burns. Partial thickness burns may show erythema. Pain is characteristic with normal pin-prick sensation. Full thickness burns are charred, or may be white, grey or leathery. They are usually dry. The surface is pain-free and pin-prick sensation is absent. However, final differentiation between partial and full thickness burns may be dependent on the degree of healing that occurs with time.