Cutaneous Cysts

Epidermoid cyst (50,51) is a common cutaneous tumor derived from squamous epithelium. It is skin-colored or yellowish, dome-shaped, smooth, mobile, and ranges in size from 0.5 to 5 cm in diameter. Many lesions have a characteristic central punc-tum from which a cheeselike material can be expressed. They usually appear on the face or trunk. Epidermoid cysts develop in patients with acne conglobata or by implantation of squamous epithelium into the dermis secondary to sharp injury or trauma....

Pilosebaceous Unit

Langer Lines Borges Lines

Pilosebaceous units contain sebaceous glands, sensory end organs, arrector pili muscle, hair, and the hair follicle. Thick hair, such as on the scalp, is terminal hair fine, nearly imperceptible hair, is vellus hair. Depending on the part of the body, the sebaceous unit may be predominant (e.g., nose). The hair follicle has three named portions (from the skin to the base) the infundibulum (to the sebaceous gland duct), the isthmus (from the duct to the arrector pili muscle insertion), and the...

Sarcomas of Fibrous Tissue

Fibrosarcoma is a rare malignant tumor from deep tissues such as fascia or tendons. Well-established causative factors include ionizing radiation (204), chronic scars, and certain chromosomal aberrations. Fibrosarcoma affects all ages but is more common during the fourth to sixth decade of life. Tumors present clinically as subcutaneous masses with intact overlying skin. Ulceration indicates aggressive growth. Pain is present in 50 of cases. Approximately 50 of lesions occur on the lower...

Vessel Selection in the Difficult Neck

The lack of a suitable recipient vessel may jeopardize successful free tissue transfer. Common problems include inadequate pedicle length, a lack of suitable veins, arterial mismatch, poor-quality vessels, or a total lack of a suitable artery or vein. Inadequate pedicle length can be remedied through the use of reversed vein grafts. Vein grafts are most commonly obtained from the cephalic vein, external jugular veins, or from various leg veins. Vein grafts are reversed so that the valves are...

Management of Primary BCC

Overall, 90 of tumors can be completely eradicated with simple techniques, but recurrences are likely if therapy is not optimal (75). Recurrent lesions are larger, more aggressive and difficult to treat, and may appear only after several years have elapsed, therefore, the first treatment session is the most important and must be definitive. To ensure an adequate therapeutic plan, the pathologist's report should include not only the histological diagnosis of BCC and the adequacy of surgical...

Soft Palate Resection

The speech and swallow disability experienced after resection of the soft palate is generally proportional to the amount of palate excised. Although important in the production of intelligible speech, the soft palate's main function is to close off the nasopharynx during the pharyngeal phase of swallowing. This obviously prevents the food bolus from entering the nasopharynx but also provides a pumping mechanism to propel the bolus over the epiglottis to enter the piriforms. The ability of the...

Management of Primary SCC

Treatment of SCC varies depending on its cause, anatomical site, growth rate, previous treatment, size, depth of invasion, differentiation, patient's immune status, and perineural invasion. It is important to encourage microstaging as in melanoma using depth and Clark's level. Surgical excision is the preferred modality for treatment of SCC. Approximately 95 of tumors less than 2 cm in diameter can be excised with 4 mm margins, whereas those larger than 2 cm require 6 mm margins (111). Surgical...

Malnutrition

The negative impact of malnutrition on healing is well known. The degree of protein deficiency required to affect wound repair is usually quite severe and typically only seen in cases of chronic alcohol abuse or patients with advanced malignancies. Clinical studies have shown that the levels of albumin, prealbumin, transferrin, and total lymphocyte counts are sensitive indicators of malnutrition. Albumin is an excellent predictor of chronic malnutrition. Because its half-life is 20 days, it is...

OTAT plasty

The T-plasty consists of bilateral random-pattern sliding skin advancements transforming an O-shaped defect O-T plasty or an A-shaped defect A-T plasty into a final T-shaped scar. A circular defect is converted to an A shape by excising a superior wedge of tissue creating a partial ellipse with a blunt base. The base is closed Figure 6 Sequence of a typical nasolabial V-Y advancement flap. Figure 6 Sequence of a typical nasolabial V-Y advancement flap. through bilateral tissue advancement with...

Breast Carcinoma

Approximately 6.3 of patients with breast carcinoma experience cutaneous involvement, but in only 3.5 of cases is this the initial presentation. More than 50 of metastatic lesions occur as direct extension from the tumor mass in the form of Paget's disease or as nodular-ulcerative lesions. Other common presentations are inflammatory carcinoma and carcinoma en cuirass. IHC stains may aid in the diagnosis of highly undifferentiated tumors adenocarcinomas GCDFP-15 antigen is highly specific for...

Facial Platysma Flap

Submental Myocutaneous Flap

The facial platysma flap is a skin-muscle flap based on the pars modiolaris portion of the platysma 41 . The pars modiolaris represents the muscle fibers that extend over the mandible to insert on the ipsilateral modiolus, and are located just lateral c to the lateral border of the depressor anguli oris muscle. Motor innervation is via the marginal branch of the facial nerve and sensory innervation is from the mental nerve trigeminal . Vascular supply is via the facial artery as it crosses the...

Skin Typing

Skin typing is helpful in predicting the response of different types of skin to chemical peeling or laser resurfacing. Grading the skin content of melanin is important to assess the risk of postinflammatory hyperpigmentation. The Fitzpatric classification 30 of skin types defines them as I white skin always burns first summer exposure , never tans II white skin, usually burns III white skin, sometimes burns IV moderate brown skin, rarely burns V dark brown, very rarely burns VI black, never...

Keratoacanthoma

Keratoacanthoma KA is a tumor derived from hair follicle epithelium and associated with HPV 9, 16, 19, 25, and 37. It is a rapidly growing neoplasm that resembles SCC. Whites are more commonly affected than other racial groups and the tumors present in sun-exposed areas of the extremities, head, and neck. KA affects all age groups occurring most often in the middle-aged and elderly and it has a 3 1 predominance in men. Sun exposure is the main predisposing factor, but immuno-suppression and...

Deltopectoral Flap

Deltopectoral Flap

The vascular supply to the rib via the periosteum is tenuous and its use for mandibular segmental defects is associated with a high rate of failure. Marginal necrosis of the skin paddle is relatively common, especially if the distal part of the skin paddle extends beyond the underlying muscle 18 . The subcutaneous tissue can be bulky, especially in women in whom the incisional scars may be less acceptable. The weight of the flap and the tendency for regional flaps to return to their site of...

Leiomyoma

Leiomyoma 70 is derived from the arrector pili muscle of hair follicles or from muscle fibers present in the wall of blood vessels. In the multiple familial type, lesions are distributed over neck and limbs. Onset is in childhood and tumors are red, pink, or brown. A characteristic feature is that pain can be elicited by pressure or low temperature. Also, lesions may shrink when the skin is chilled. The solitary leiomyoma occurs anywhere in the body including the nipple and areola. It is also...

Estlander Flap

Estlander Flap

Estlander 35 described a single-stage full-thickness cross-lip flap based on the labial artery for closure of lower lip defects near the commissure of the mouth. As with the Abbe flap, the width of the flap should be one-half the width of the defect, and the height should equal the height of the defect. The Estlander flap transfers the lateral portions of the opposite lip around the existing commissure to replace the missing lip tissue. Blunting of the commissure is expected and secondary...

Sweat Gland Differentiation

Microcystic adnexal carcinoma MAC shows dual differentiation into sebaceous gland and sweat gland structures. There are no known causative factors, although in some cases there is history of ionizing radiation exposure. The incidence in men and women is approximately equal and the median age at presentation is 65 years range, 11-82 . MAC presents clinically as a nodule, plaque, or cyst that grows slowly over years 173 . The lesion is markedly indurated and has surface telangiec-tasias. It...

Mustarde Cheek Rotation Flap for Lower Eyelid Repair

Mustarde Flap

A Mustarde cheek flap is a large rotation flap with its leading edge at the lateral canthus extending laterally and arching like a Tenzel flap 12 . The incision is then continued laterally to the preauricular crease toward the level of the earlobe. A wide subcutaneous undermining proceeds, the extent of which is determined by the laxity of the skin and the extent of the defect. The posterior lamella must be reconstituted and Mustarde recommends a composite graft of nasal septal cartilage and...

Melolabial Nasolabial

Nasal Interpolation Flap

The melolabial nasolabial flap is a random-pattern local flap based either superiorly or inferiorly along the melolabial sulcus and cheek-nasal sidewall. The type of tissue movement is lifting either by transposition into the defect or by interpolation. If the intervening skin between the melolabial sulcus and the defect remains intact, then a staged interpolation flap may be necessary. The flap is harvested preserving the subdermal plexus distally and is based on a skin-subcutaneous pedicle...

Flap Classification and Local Facial Flaps

Classification Fasciocutaneous Flaps

Lahey Clinic Medical Center, Burlington, Massachusetts, U.S.A. Flap classification is based on an evolving paradigm as new uses and new flaps are discovered. The earliest report of a facial flap the midline forehead flap is found in the Sushruta Samhita, a Hindu holy book, in 600 bce 1 . Flap development was largely ignored or relegated to the unholy in the period between the emergence of Buddhism in India to the 16th century 2 . In the 1500s, Tagliacozzi perfected the arm-pedicled technique of...

Rhombic

Limberg Flap

The nomenclature surrounding this flap is inconsistent. Flaps called rhombic rhomboid rhombus all share a common origin with Limberg's original flap described in 1963 16 . These designations do not reflect the shape of the flap but more literally the shape of the defect. A rhombic defect has the shape of a rhombus an equilateral parallelogram . Limberg's flap is rhombic i.e., a rhombic flap with opposing angles of 60 and 120 degrees that is random-pattern and lifting. A rhombic flap is similar...

Distraction Osteogenesis

Distraction Osteogenesis Mandible

Distraction osteogenesis is a process that results in the creation of new bone in an enlarging gap between two bone fragments caused by their gradual separation 59 . Originally described by Codivilla 1904 for lengthening lower extremity bones, the process gained wider acceptance after Gavril Ilizarov, a Russian surgeon, studied the mechanics and physiology of limb lengthening in 1954. Dr. Ilizarov continued his work and has contributed much of the current clinical knowledge of the method and...

References

Wound healing for dematologic surgeons. J Dermatol Surg Oncol 1988 14 4 959-972. 2. Kanzler MH, Gorsulowsky DE, Swanson NA. Basic mechanisms in the healing cutaneous wound. J Dermatol Surg Oncol 1986 12 1156-1164. 3. Kirsner RS, Eaglstein WH. The wound healing process. Dermatol Clin 1993 11 4 629-640. 4. Pollack SV. Wound healing, a review, the biology of wound healing. J Dermatol Surg Oncol 1979 5 389-393. 5. Schaffer CJ, Narrey LB. Cell biology of wound healing. Int Rev Cytol...

Skin Surface Analysis

Microanatomy The Epidermis

Skin surface analysis is often tailored to the goals of restorative surgery or nonsur-gical treatments. Patients undergoing scar revisions require analyses to include the resting skin tension lines. In the patient undergoing nasal reconstructive surgery after Mohs' resection, an analysis of the topographical units of the face is important. If cutaneous resurfacing is planned, an analysis of skin type and reaction to solar damage are also needed. Koebner's phenomenon is also an important...