PART II ■ SKIN AND SOFT TISSUE

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Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.
Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.
CHAPTER 13 ■ DERMATOLOGY FOR
PLASTIC SURGEONS
ALFRED CULLIFORD IV AND ALEXES HAZEN
The skin, the largest “organ” in the body, performs numer-
ous functions. It provides a barrier from the external world,
protecting the body from temperature extremes, evaporative
losses, minor trauma, and invasion by micro-organisms. The
skin also provides sensibility.
The skin is derived from two embryologic layers—the ec-
toderm and the mesoderm. The epidermis, pilosebaceous and
apocrine units, eccrine sweat glands, and nails are derived
from the ectoderm. The neuroectoderm provides melanocytes,
nerves, and specialized sensory receptors. The mesoderm gives
rise to Langerhans cells, macrophages, mast cells, Merkel cells,
fibroblasts, blood vessels, lymph vessels, and fat cells.
ANATOMY
The skin is comprised of two basic layers—the epidermis and
the dermis. The epidermis is the outer layer containing four
major cell types: keratinocytes, melanocytes, Langerhans cells,
and Merkel cells. The stratified squamous, in turn, consists of
five layers or strata: squamous corneum, s. lucidum, s. gran-
ulosum, s. spinosum, and s. basale (Fig. 13.1). The dermis is
much thicker than the epidermis and is comparatively rich in
noncellular connective tissue elements—collagen, elastin, and
ground substance. The nerves, blood vessels, lymphatics, mus-
cle fibers, pilosebaceous, and apocrine and eccrine units are
within the dermis. The papillary dermis, so named because it
abuts the epidermal papillae, contains fibroblasts, mast cells,
histiocytes, Langerhans cells, and lymphocytes. The reticular
dermis is deeper than the papillary dermis, is thicker than pap-
illary dermis, and extends to the underlying fat. The reticu-
lar dermis contains loosely arranged elastin fibers interspersed
with large collagen fibers.
BENIGN VERSUS MALIGNANT
LESIONS
The plastic surgeon is often faced with distinguishing be-
tween benign and malignant lesions, and thus deciding when
to biopsy, when to “observe,” and when to reassure. Signs
that should lead the physician to biopsy include crusting and
bleeding, scaling, pain, increasing size, change in color, and
surrounding inflammation. The most common malignant skin
lesions are basal cell and squamous cell carcinomas, with basal
cell carcinomas being the most common. Of particular chal-
lenge are pigmented skin lesions. Although new techniques for
diagnosis of melanoma (Fig. 13.2) are being developed, includ-
ing computerized assessment of color variability and irregular-
ity, the ABCDs (asymmetry, border irregularity, color variabil-
ity, and diameter >8 mm) remain the most generally accepted
criteria to indicate biopsy (Chapter 16).
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Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.
PIGMENTED LESIONS
Nevi
Nevi are categorized as intradermal, junctional, or compound,
depending on where the nevus cells are in the dermis, at the
dermoepidermal junction or both, respectively. Junctional nevi
appear smooth and flat and have irregular pigment. They can
occur anywhere on the body and occur most commonly in
early adulthood, although they can arise at any age. Junctional
nevi generally transform to compound nevi in adulthood. In-
tradermal nevi are more commonly known as “moles.” They
can appear anywhere on the body and are characteristically
smooth, raised, flat, tan or pink, round or oval, and less than
6 mm in size.
Atypical Moles
Atypical moles (formerly known as dysplastic nevi) are ac-
quired lesions that are often mistaken for melanoma (Fig. 13.3).
Histologically, they are formed from a cluster of melanocytes.
The lesions vary in color from brown to black to pink, typi-
cally are smooth, may have irregular borders, and may be scaly.
Lesions are usually between 5 and 10 mm. Atypical moles are
most often sporadic, although they can be familial. Lesions
tend to occur in sun-exposed areas. The risk of melanoma is
higher in patients who have atypical moles, and the risk in-
creases as the number of atypical moles increases. Most pa-
tients have a few atypical moles, although some patients may
have more than 100 atypical lesions. These patients present
a clinical challenge because atypical moles, by definition, are
moles that have the appearance of melanomas. They require
close follow-up with baseline total-body photography. It is im-
practical and infeasible to biopsy all lesions in such patients.
Removal of lesions is reserved for those that exhibit changes,
emphasizing the importance of close follow-up. When surgery
is warranted, excisional biopsies should be performed, with
histologic confirmation of clear margins.
Other related pigmented lesions include blue nevus (Fig.
13.4), ephelis (Fig. 13.5), solar lentigo (Fig. 13.6), congenital
nevi (Fig. 13.7), and nevus of Ota. Although there is a recog-
nized malignant potential for a congenital nevus to transform
to malignant melanoma, the true incidence varies widely in the
literature (Chapter 16). Malignant degeneration of a blue ne-
vus is rare and close observation is necessary. The nevus of
Ota is totally benign, occurs in the distribution of the first
and second branches of the trigeminal nerve, and management
can use the Q-switched ruby, neodymium:yttrium-aluminum-
garnet (Nd:YAG), or alexandrite lasers (Chapter 20). The other
lesions are benign and may be excised (with a minimal area of
surrounding tissue) for cosmetic purposes.
105
106 Part II: Skin and Soft Tissue
FIGURE 13.1. Cross-section view of skin.
There are many different categorizations of benign, prema-
lignant, and malignant skin tumors. A particularly useful cat-
egorization is to classify tumors according to their primary
origin. Thus the tumors that originate from the epidermis are
categorized together.
EPIDERMAL LESIONS
Seborrheic Keratosis
Seborrheic keratoses (SKs), also known as verruca senilis or
pigmented papilloma, are extremely common and arise from
the basal layer of the epidermis. They are composed of well-
differentiated basal cells, and contain cystic “inclusions” of ker-
atinous material called “horn cysts.” Typically lesions exhibit
hyperkeratosis, acanthosis, and papillomatosis. The growth
and depth of pigmentation vary directly with exposure to sun-
light. Microscopically, a benign epithelial proliferative process
is seen. If left untreated, they will gradually enlarge and in-
crease in thickness; there is no spontaneous involution. SKs
are most commonly seen on the head, neck, and trunk after the
fifth decade of life. They are often distinctly marked and have a
waxy, stuck-on appearance. The surface is soft, verrucoid, often
pedunculated and oily to the touch. They can vary in color from
light tan to yellow, dark brown, and black. They range in size
from 1 mm to 5 cm. No treatment is necessary but these lesions
FIGURE 13.2. Melanoma of the lower extremity.
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Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.
are unsightly and patients frequently request removal for cos-
metic purposes. Cutaneous malignancies (including small cell
carcinoma [SCC], basal cell carcinoma [BCC], and melanoma)
can develop within seborrheic keratoses. For typical SKs, shave
techniques tend to be efficient and effective. Dermabrasion and
cryotherapy can also be used. For larger lesions and pigmented
lesions where the diagnosis is unclear, excisional biopsy may
be performed.
Verruca Vulgaris
The common wart is an infection caused by the human papil-
loma virus; it is not a true neoplasm. It can be solitary or occur
in clusters. Verruca most often occurs on the upper extremity,
occasionally on the face, and is most common in children and
young adults. The lesion has a characteristic scaly and rough
appearance with variegations and a cap of friable keratotic
material. A lesion can persist for months to years, although
most often is self-limited and resolves spontaneously. Histology
shows hyperkeratosis and parakeratosis. Lesions arise from
FIGURE 13.3. Atypical mole.

FIGURE 13.4. Blue nevus.
the stratum granulosum of the epidermis. Various treatments
are possible, including cryotherapy and chemical ablation, but
multiple treatments may be necessary. Excision is reserved for
a lesion that is painful or resists other treatment options.
Actinic Keratosis
Otherwise known as solar keratoses, actinic keratoses (AKs)
occur on sun-exposed skin (Fig. 13.8). An aggressive form of
AK called actinic cheilitis occurs on the lips. Fair-skinned indi-
viduals with blue or green eyes are at highest risk, and patients
with immune compromise are also at risk. AKs represent the
most common premalignant skin lesion. Despite the similarity
of the name, AKs are totally distinct from seborrheic keratoses.
Lesions are most often multiple and small (<1 mm) and appear
as scaly patches. They are usually flat or slightly raised erythe-
matous lesions with adherent epidermal scales. Histologically,
AKs are characterized by dyskeratosis and atypia in the basal
layer of the epidermis. Inflammation, hyperkeratosis, hyper-
chromasia, and nuclear pleomorphism are often seen. AKs may
progress to squamous carcinoma, and therefore require treat-
FIGURE 13.5. Ephelis.
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Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.
Chapter 13: Dermatology for Plastic Surgeons 107
FIGURE 13.6. Solar lentigo.
ment. An estimated 5% to 20% of patients with these lesions
will develop SCC.
Treatment involves monitoring closely and removal. Pa-
tients with multiple lesions and lesions with significant ery-
thema should be biopsied. Multiple treatment modalities are
effective in the treatment of AKs, including cryosurgery, typ-
ically with liquid nitrogen, electrodesiccation and curettage,
topical treatments, and laser and surgical excision.
Many topical treatments are effective, including
5-fluorouracil (5-FU) cream, imiquimod 5% (Aldara),
chemical peels using trichloroacetic acid (TCA) or phenol, and
combination gel treatments using diclofenac and hyaluronic
acid. Aldara is popular for the treatment of AKs and viral
infections. It can be administered three times a week for 8
to 12 weeks and works by stimulating an immune response.
5-FU can be used in 5% (Efudex), 1% (Fluoroplex), and 0.5%
(Carac) concentrations. Some patients experience sensitivity
with 5-FU, resulting in significant erythema, scaling, and crust-
ing; however, lower concentrations seem to be well tolerated by
most patients. Laser resurfacing with a carbon dioxide laser or
the YAG laser directed at the lesion can result in removing the
epidermis, which can be effective in small areas, particularly on
the lips. Loss of pigment is a sometimes unwelcome side effect
FIGURE 13.7. Congenital nevus.
108 Part II: Skin and Soft Tissue
FIGURE 13.8. Actinic keratosis.
of laser treatment. Photodynamic therapy (PDT) is a relatively
new treatment that involves the application of a topical agent,
such as 5-aminolevulinic acid, followed by exposure to strong
light 24 hours later, which results in activating the acid and
selective destruction of the actinic keratosis. PDT is quite
effective for lesions on the face or scalp, although it has
the unwanted and common side effect of localized swelling.
Topical treatment may be preferred over surgical treatment
in patients with multiple lesions in cosmetically sensitive
areas.
Cutaneous Horn
The typical lesion appears as a well-circumscribed cone with
hyperkeratotic features. Horns consist of a buildup of cornified
material; thus their height comes to exceed their radius. His-
tologically, they resemble actinic keratoses and must be distin-
guished from squamous cell carcinoma. The treatment usually
calls for excisional biopsy with careful pathologic evaluation
of the base of the lesion.
Leukoplakia
This is a mucosal lesion that consists of a white plaque that
exists on the stratified squamous epithelium and cannot be
removed. The oral mucosa is the most common site of these
lesions, although they also can occur on the mucosal surface
of genitalia. Leukoplakia is often associated with chronic in-
flammation and irritation often associated with alcohol and
tobacco consumption. Treatment of leukoplakia involves elim-
inating the irritant. These lesions can degenerate into SCC. In
cases where the lesions remain after the irritant has been re-
moved, biopsy is indicated.
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Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.
FIGURE 13.9. Keratoacanthoma.
Keratoacanthoma
Keratoacanthomas (KAs) are common lesions encountered by
plastic surgeons. Most often they occur as solitary lesions on
the head, neck, and sun-exposed regions of elderly patients.
The lesion has a characteristic growth pattern that consists of
a rapid growth phase followed, in some cases, by a spontaneous
regression (Fig. 13.9). The lesion begins as a firm, dome-shaped
nodule and grows to approximately 1 to 3 cm within a period of
6 to 8 weeks. Mature lesions become raised and have a promi-
nent horn-filled central depression. Typically, these resolve over
6 months, but leave a small scar. Histologically, the mature le-
sion demonstrates a central crater filled with keratin and sur-
rounded by thickened epidermis. Because KAs are difficult to
distinguish from SCCs, most clinicians excise lesions when the
diagnosis is made. Topical agents, such as 5-fluorouracil, are
effective and are practical for use in patients with multiple
lesions.
Bowen Disease
Bowen disease is cutaneous squamous cell carcinoma in situ
and is characterized by a thickened, scaly, rough, red, patchlike,
crusting, slow-growing lesion. Lesions can occur anywhere on
the body, but are most often found on the trunk and extremities.
Histologic examination demonstrates a thickened epidermis
with an intact dermal–epidermal junction. Chronic exposure to
arsenic has been implicated as a possible etiologic agent. If left
untreated, Bowen disease may progress to invasive squamous
cell carcinoma. Treatment by surgical excision is preferred over
other techniques (such as dermabrasion). If a patient has mul-
tiple areas of Bowen disease, a visceral work-up is indicated.
Adnexal Tumors
The term adnexal tumor is a catch-all phrase that describes
lesions in which the normal relationship between epithelial
and stromal components of skin is altered. There may be pref-
erential differentiation of sebaceous glands, hair follicles, or
apocrine or eccrine sweat glands. Descriptive terms such as ap-
pendageal, organoid, and hamartomas are used interchange-
ably with the term adnexal tumor. They may be classified as

nevus, adenoma, or epithelioma; they are excised for aesthetic
concerns only.
Hair Follicular Tumors
Trichofolliculoma (hair follicle nevus) typically is a solitary le-
sion on the face that has a characteristic group of thin, pale
hairs emanating from a central pore. The lesion itself is gener-
ally small (<1 cm), skin colored, and requires no more than an
excisional biopsy for complete management.
Pilomatricoma (calcifying epithelioma of Malherbe) is most
often seen in the younger (<20 years old) patient and typi-
cally in the face and upper extremities. It is a single, solid,
subdermal nodule whose firmness makes it difficult to distin-
guish from other calcified lesions or a carcinoma. Patholog-
ically, the typical pilomatricoma consists of an encapsulated
mass of epidermoid cells that are interspersed with basophilic
and eosinophilic cells. Extracellular calcifications are also char-
acteristic. Simple excision is sufficient treatment, although re-
currence rates can be as high as 10%.
Tricholemmoma is a benign lesion found on the scalp or,
less commonly, other hair-bearing areas. Lesions appear as a
smooth asymptomatic papule. They may be single or multi-
ple. When on the scalp there is an association with nevus se-
baceous of Jadassohn (Fig. 13.10); consequently, these lesions
should be biopsied. In patients with multiple lesions, Cow-
den disease (multiple hamartoma syndrome) should be sus-
pected. Histologic examination shows glycogen-rich epithelial
cells surrounded by sheaths of cells that resemble hair follicles.
Treatment involves surgical removal, as this lesion appears sim-
ilar to a BCC and a trichilemmal carcinoma.
Multiple trichoepitheliomas are often seen in a symmet-
ric distribution around the face and eyes. They appear as
smooth, translucent, pale papules that generally have an in-
creased growth phase during early childhood and puberty.
Women are affected more frequently than men; these lesions
are most effectively treated with electrodesiccation for purely
aesthetic concerns.
Eccrine Tumors
Syringomas are usually multiple and seen on the lower eyelids
and cheeks of women, although they may be solitary and found
anywhere on the trunk, neck, or extremities. They are small (1
to 3 mm in diameter) papules that range in color from yel-
low to pink. On appearance alone they may be confused with
other benign lesions, including xanthelasma or trichoepithe-
FIGURE 13.10. Nevus sebaceous of Jadassohn.
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Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.
Chapter 13: Dermatology for Plastic Surgeons 109
lioma. The best aesthetic removal is through laser treatment or
electrodesiccation.
Eccrine hidrocystoma share a similar distribution as sy-
ringomas, but they appear as translucent vesicles with a slightly
blue tint. Histologically, they represent dilated and obstructed
sweat ducts. The lesions tend to swell in environments of in-
tense heat and humidity and regress in cooler and dryer cli-
mates. Release of the buildup of pressure through simple punc-
ture may be adequate treatment; refractory lesions rarely re-
quire excision.
Eccrine poromas are common benign tumors of the eccrine
sweat glands found on the palms and soles of feet. They ap-
pear as firm, papular, or nodular lesions that are typically sur-
rounded by a rim of hyperkeratotic tissue. Athough benign in
nature, poromas are often excised for diagnosis when there
is doubt regarding the pathology as they frequently resemble
amelanotic melanomas and pyogenic granulomas.
Eccrine spiradenoma is a very rare tumor that manifests as
a solitary pink, purple, blue, or gray nodule on the upper half
of the ventral surface of the body. Lesions are generally seen
in younger adults. There is frequently exquisite tenderness or
intense pain on manipulation; thus, these may be mistaken for
glomus tumors. Simple excision is indicated for symptomatic
lesions.
Cylindroma (turban tumor) appear early in adulthood and
are slow-growing tumors that persist throughout life. They
may be solitary or occur in groups, appearing as firm, smooth,
pink nodules that may be up to several centimeters in diameter.
Cylindromas are often said to resemble a turban, forming a
heaped up cluster of tissue that may cover substantial portions
of tissue. Simple surgical excision is appropriate.
Apocrine Tumors
Apocrine cystadenoma is a benign, solitary translucent nodule
that generally appears on the face. On routine physical exami-
nation, it may be difficult to differentiate this lesion from pig-
mented nevi, pigmented basal cell epithelioma, or melanoma.
This is because the lesions often have brown- or blue-tinged
fluid inside of them.
Chondroid syringoma is a firm, benign lesion that is com-
posed of both sweat gland elements and cartilaginous elements.
Most often they are not tethered to the overlying normal epi-
dermis and can easily be shelled out during excisional biopsy.
As with other mixed tumors, there are both epithelial (sweat
gland) and mesenchymal (cartilage) elements present in these
lesions on pathologic evaluation.
Syringocystadenoma papilliferum is a hamartomatous le-
sion that is most often found on the scalp. Frequently, they
develop during childhood and may have an associated seba-
ceous nevus surrounding them. After excision (including the
surrounding sebaceous nevus), nearly 1 in 10 lesions will be
found to harbor a focus of basal cell epithelioma.
Sebaceous Tumors
Sebaceus nevus of Jadassohn has a distinct appearance that
is often described as cerebriform, nodular, or verrucous. It is
hairless and generally appears on the scalp, but also may be
seen on the face and neck. Frequently present at birth, it per-
sists throughout life and tends to become more verrucous and
nodular during the growth phase associated with puberty. Over
time, there is a risk of basal cell carcinoma developing in these
lesions, which occurs in approximately 15% to 20% of these
lesions. Keratoacanthoma and squamous cell carcinoma may
also develop within these lesions, although with less frequency
than basal cell carcinoma.
Sebaceous epithelioma displays a strong similarity to basal
cell carcinoma, with the distinguishing difference being a more
yellow color resulting from the presence of sebaceous cellular
110 Part II: Skin and Soft Tissue
elements. Lesions are most often found on the face and scalp,
and removal is generally performed for cosmetic reasons only.
The lesions are radiosensitive and may also be treated using ra-
diation, with electrocoagulation and curettage, as well as with
carbon dioxide laser. Simple excision is often the best option, as
there is a small chance that the lesion may harbor a sebaceous
carcinoma.
Senile sebaceous hyperplasia is typically found in older
(>60 years old) males with “seborrheic” complexions. Char-
acteristically, they are numerous, soft papules with central de-
pressions and edges that are discreet and may be covered with
fine telangiectatic vessels. Excision is frequently performed as
the lesions may be misdiagnosed as basal cell epitheliomas.
Treatment is indicated for aesthetic purposes only, and simple
electrodesiccation is all that is required.
SMOOTH MUSCLE TUMORS
Leiomyomas are benign cutaneous lesions that represent an ab-
normal proliferation of smooth muscle. They most often occur
on multiple sites, but can be concentrated on a single part of
the body. Over time, lesions increase in size and number and
may become symptomatic, becoming painful with exposure to
cold or to pressure. Leiomyomas appear as a firm and pale in-
tradermal nodule with a faint brown hue. They may exceed
1 cm in diameter. Leiomyomas may require excisional biopsy
for diagnosis, especially when symptomatic. Lesions that grow
larger should be excised to rule out malignant degeneration
into leiomyosarcoma, which, although rare, can occur. Local
recurrence is not uncommon after excision.
FIBROUS TUMORS
Dermatofibrosarcoma protuberans is a slow-growing “be-
nign” lesion that may be found anywhere on the body, although
usually on the trunk. It is a nodular, hard mass found in the der-
mis, covered by a shiny epithelium, and can appear “thinned
out” on gross examination. Often lesions appear like a keloid.
On pathologic evaluation, there is a characteristic “cartwheel”
appearance of hypercellular fibrous tissue that extends radially
into the adjacent soft tissue. Wide excision with a margin of
deep fascia is necessary to prevent recurrence. When possible,
margins in excess of 3 cm should be taken. Although metastatic
disease is unusual, it is possible when lesions are not appropri-
ately and expediently treated after initial presentation.
Angiofibroma is generally found on the lower third of
the face and appears as a pale and firm papule, usually less
than 2 mm in size. Some lesions may display telangiectatic or
erythematous changes. Solitary lesions are removed for cos-
metic concerns only. When the lesions are multiple, however,
there may be an association with a tuberous sclerosis complex
(Bourneville disease). In these patients, the fibrous papules that
are seen in the face can be a source of significant anxiety for
the patient.
Pseudosarcomatous lesions potentially may be confused
with a true fibrosarcoma based on the localized proliferative
changes and numerous mitoses that are seen. Disorders that
require a pathologic diagnosis to exclude a true malignancy in-
clude nodular pseudosarcomatous fasciitis, atypical fibroxan-
thoma, and infantile digital fibromatosis. Nodular pseudosar-
comatous fasciitis generally occurs on the upper extremities
and develops as a rapidly progressing, painful nodule that is
adherent to the deep fascia. Atypical fibroxanthoma is seen on
the sun-exposed areas of the elderly, especially the head and
neck. On gross examination, the lesion can resemble a basal
cell epithelioma. Treatment is by simple excision. Pathologic
evaluation reveals spindle cells and giant cells with high mitotic
Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.
rates that are separated from the epidermis by a thin, collage-
nous layer. If the lesion extends to deeper tissue layers, then
it is termed a malignant fibrous histiocytoma. Infantile digi-
tal fibromatosis is a condition where there may be numerous
firm, red, painless, smooth nodules on the dorsal and lateral
aspects on the digits on both upper and lower extremities that
appear during the first decade of life. Lesions do not regress
and excision is recommended.
There are numerous types and names for cutaneous tags and
papillomas including fibroepithelial polyp, fibroma pendulum,
fibroma molluscum, fibroma molle, acrochordon, and cuta-
neous papilloma They generally have a papillomatous, fibrillar
dermal core and may resemble seborrheic keratoses. Simple
excision or stalk electrodesiccation is appropriate.
GENERALIZED DISORDERS
Xeroderma pigmentosum is a rare, autosomal recessive disor-
der in which the repair mechanisms for DNA repair are defec-
tive. Affected patients have a frequency of skin cancer more
than 1,000 times that seen in the general population. Patients
cannot protect themselves from actinic rays. Tumors that are
seen most often include squamous cell carcinoma, basal cell
carcinoma, and melanoma. Historically, patients would not
survive beyond their teenage years. However, recent aware-
ness of preventative strategies (including strict ultraviolet [UV]
light avoidance as well as isotretinoin [in several studies]) has
led to a decrease in the frequency of new cutaneous malig-
nancy detection. Once lesions are detected, however, treatment
approaches include use of topical chemotherapeutic agents (5-
fluorouracil), excision of malignant and suspicious lesions, ag-
gressive dermabrasion, and coverage with skin grafts. Long-
term prognosis remains poor in this patient group.
Dystrophic epidermolysis bullosa is a hereditary disease of
the skin and mucosa whereby bullae form after minor trauma;
excessive scarring results that can be functionally limiting. Al-
though any mucosal surface in the body may be affected, it is
most noticeable in the hands, where progressive encasement of
the digits in a circumferential scar eventually constricts move-
ment and may render the digits useless. Surgical intervention
with scar releases and Z-plasties can improve the patients’ qual-
ity of life, although only temporarily. Topical steroids offer
some benefit in some patients. The most effective treatment
approach focuses on prevention, with patients and family mem-
bers going to great lengths to avoid the minor traumatic events
that fill an otherwise normal day for a nonaffected patient.
Cutis laxa represents a defect in elastic fibers that results in
the skin hanging in loose folds from the body. It may be inher-
ited as an autosomal dominant (type I) or recessive (type II)
trait. The primary complaint of affected patients is the ap-
pearance of premature aging, as the skin is loose and inelastic.
Repeated blepharoplasty and rhytidectomy may be beneficial.
Wound healing is normal in affected patients.
Pseudoxanthoma elasticum can be inherited as a dominant
or recessive disorder affecting elastic fibers and collagen forma-
tion. When mechanically stressed, the skin thickens and takes
on a cobblestone appearance. Significant vascular arterioscle-
rosis develops early in life, but wound healing is normal.
Ehlers-Danlos syndrome (cutis hyperelastica) is an autoso-
mal recessive or X-linked disorder that is characterized by hy-
perextensible skin and severe laxity in joints. Skin is loose and
friable. Affected patients are particularly susceptible to minor
trauma, as the skin and blood vessels are delicate. Wound heal-
ing is abnormal, skin tensile strength is markedly diminished,
and any surgery should be approached with extreme caution
in these patients.
Acne vulgaris is a disease seen in young patients that
has a wide spectrum of presentations and symptoms. Milder
 Chapter 13: Dermatology for Plastic Surgeons 111

forms include comedones, inflammatory cysts, and seborrheic

plaques. More severe forms can affect deeper tissue planes with
subsequent inflammatory fluid collections that may ultimately
become infected (cystic acne). Visible non–hair-bearing areas
of the face are the most commonly affected sites. Drainage of
infected pustules can treat lesions that exceed the local con-
trol measures previously instituted. In the past two decades
there have been remarkable advances in the care of affected
patients. Retinoic acid (applied topically) can have dramatic
results when used appropriately. Retin-A and oral antibiotics
(typically clindamycin) are effective treatments for both pre-
vention and treatment of flare-ups. Antibiotic pads (benzoyl
peroxide) and washes also have good results for acne. Perma-
nent remission is frequently seen after cessation of the drug.
Once the disease process has been controlled, attention can be
focused on skin resurfacing. The most commonly used modal-
ities are dermabrasion and laser resurfacing.
Acne rosacea is a spectrum of disorders affecting the fore-
head, glabella, malar region, nose, and chin, and has been de-
scribed as having four stages by Rebora. The earliest stage is FIGURE 13.12. Radiation dermatitis of the breast.
characterized by facial flushing, which represents increased vas-
cularity. This, consequently, contributes to the second stage,
where thickened skin erythema, and telangiectasias are seen.
Formal acne rosacea follows, which is characterized by erythe- come thick and fibrotic, have a “wooden” appearance, and fre-
matous papules and pustules. Rhinophyma (Fig. 13.11) is the quently have chronic draining sinus tracts and deeper abscesses
fourth and final stage and most frequently affects the nose, al- (Fig. 13.12). Oral and intravenous antibiotics are required for
though involvement of other facial structures may occur. The local control of infection, which are usually Staphylococcus
nasal skin becomes erythematous with telangiectatic changes; aureus or S. epidermidis. Excision of all involved soft tissue is
over time, pits and scarring develop. Acne rosacea can be required. There are generally numerous microabscesses in these
treated with oral antibiotics and retinoids (much like acne). excisions, and the wound is frequently kept open and treated
Ideally, treatment will prevent the progression of acne rosacea with dressing changes prior to definitive closure or coverage
to rhinophyma; however, some patients will require surgical with a graft. Once the wound is clean, skin grafting can be
treatment for rhinophyma. The basic principles of the surgi- performed. Healing by secondary intention is also a potential
cal treatment of rhinophyma include skin excision followed by approach that yields good results.
resurfacing. There are numerous techniques for removing the Pyoderma gangrenosum is a pathologic term to describe the
involved layers of skin. Simple sharp excision, dermabrasion, multiple superficial abscesses with significant ulceration and
cryosurgery, and carbon dioxide laser are all reasonable options skin necrosis. Although lesions may become superinfected, the
and can yield excellent results. Currently, the most common primary etiology is believed to be a necrotizing vasculitis with
methods of treatment are scalpel excision and dermabrasion. subsequent liquefaction necrosis of the skin. Any anatomic site
Care must be taken not to remove the entire dermis, which will can be affected, although it is frequently seen in the intertrigi-
result in scarring. Following excision, contraction of the freshly nous folds of the body, especially in overweight patients. When
epithelialized surface with further contribute to reduction in an lesions become infected, the patient may become septic and
often bulbous nose. Should full dermal excision be necessary, fatalities have occurred. Broad-spectrum antibiotics, hemody-
skin grafting is required. namic support, and surgical debridement might be necessary in
Hydradenitis suppurativa is a chronic infection of the apoc- these cases. In nearly half of affected patients there is associated
rine sweat glands, most frequently affecting the axilla, per- ulcerative colitis. Judicious debridement and carefully tailored
ineum, breast, and buttocks. It is most often seen in younger antibiotic therapy may facilitate the use of local or systemic
patients, particularly darker-skinned individuals. This is an un- steroids to control the vasculitis.
fortunate affliction that causes significant pain and suffering,
conferring tremendous disability as a result. Affected tissues be-

BASAL CELL CARCINOMA

Basal cell carcinoma is the most common human malignancy
worldwide. It accounts for more than 75% of skin cancers
in the United States, affecting nearly 800,000 people yearly.
Although the incidence has risen sharply over the last several
decades, the average age of diagnosis has steadily decreased
because of improved awareness and surveillance. The disease
predominantly affects people with white skin, and the male-to-
female ratio is 3:2.
Chronic exposure to sunlight is the principal cause of basal
cell carcinomas, and thus lesions characteristically occur on ex-
posed parts of the body—the face, ears, neck, scalp, shoulders,
and back (Fig. 13.13). Other known etiologic factors include
exposure to ultraviolet (both short and long rays) light, cer-
tain chemical carcinogens (arsenic and hydrocarbons), ionizing
radiation, xeroderma pigmentosum, Bazex syndrome, Gorlin
FIGURE 13.11. Rhinophyma. syndrome (basal cell nevus syndrome), chronic irritation or

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Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.
112 Part II: Skin and Soft Tissue

surgical complications. Topical chemotherapy (5-fluorouracil)

may be used to treat nodular and superficial (least aggressive
variants) subtypes; it is employed more often in treatment of
premalignant lesions. Other less-traditional treatments include
chemotherapeutic injection to tumor site and PDT.
Surgical excision of basal cell carcinoma results in a cure rate
greater than 90%. As with other forms of treatment, the size,
location, and histologic subtype contribute to overall progno-
sis. There is no uniform recommendation regarding the size
of surgical margins; most surgeons will choose a margin of
at least 3 to 5 mm for small, well-circumscribed lesions, and
1 cm or greater for larger, more aggressive variants of basal
cell carcinoma. The margin simply has to be sufficient to be
confirmed “negative” by histologic examination. Mohs micro-
graphic surgery (Chapter 14) is the treatment of choice for
lesions in difficult areas and recurrent lesions.
Gorlin syndrome, or basal cell nevus syndrome, is an auto-
somal dominant condition in which the patient develops mul-
tiple BCCs, along with odontogenic keratocysts, palmoplan-
FIGURE 13.13. Basal cell carcinoma of the cheek. tar pitting, intracranial calcification, and rib anomalies. Treat-
ment is close observation and judicious excision of suspicious
lesions.
ulceration, and human papillomavirus. Patients who are im-
munocompromised have an increased risk of developing this
skin cancer.
Histologically, basal cell carcinomas arise from the basal
SQUAMOUS CELL CARCINOMA
layer of the epidermis. They classically have raised borders and Squamous cell carcinomas account for 20% of skin cancers
a pearly central area with associated telangiectasias. They may in the United States. It affects approximately 200,000 people
appear scaly with areas of atrophy or scarring from chronic every year. Risk factors are similar to those of basal cell carci-
inflammation. BCC is classified by subtypes that exhibit more noma, with exposure to sunlight the principal cause. Other
or less aggressive behavior. The subtypes are nodular, micron- known etiologic risk factors include ultraviolet light expo-
odular, superficial, pigmented, cystic, infiltrating, and mor- sure, chemical carcinogens, chronic irritation, cigarette smok-
pheaform. The term rodent ulcer has been used to describe ing, and infection with human papillomavirus.
the ulcerative lesion, often the nodular subtype. The infiltrat- Squamous cell carcinomas arise from basal keratinocytes of
ing and morpheaform subtypes are the most aggressive and of- the skin. They migrate from the proliferating basal layer, and
ten exhibit focal areas of tumor penetrating into local tissues. acquire the ability to undergo uncontrolled growth. Lesions are
This pathologic finding makes these two subtypes the most typically on exposed areas of skin and typically present with
locally aggressive, resulting in the highest rates of recurrence a firm nodular plaque on an erythematous base with raised
and positive margins among the various subtypes. The least borders (Fig. 13.14). An area of central ulceration may be
aggressive are the nodular and superficial. The micronodular
variant displays an intermediate level of aggressive biologic
behavior.
Obtaining a histologic diagnosis may be achieved through
a biopsy or after definitive surgical excision. Smaller lesions
may be excised completely with no biopsy necessary, but larger
ones often require tissue biopsy prior to final therapy. Different
methods for obtaining tissue include a shave, punch, incisional,
and excisional biopsies.
Treatment of basal cell cancers involves complete removal
of the lesion, which may be accomplished by several methods.
Cryotherapy is a technique that can be used when primary le-
sions are smaller than 2 cm. Although excellent results have
been reported with this technique (>95% cure rate), there are
potential shortcomings. Hypopigmentation, scarring, and in-
advertent injury to local nerves are associated with this form
of treatment. The technique is limited to the less aggressive
subtypes, and is contraindicated in patients with cryoglobu-
linemia or in areas in which scar contracture may lead to an
unacceptable functional or cosmetic result.
Electrodesiccation and curettage is a commonly employed
treatment option for lesions that are less-well circumscribed.
It may be used as a primary treatment modality with nodu-
lar subtypes of less than 2 cm and superficial variants of any
size. Although cure rates in excess of 90% are reported, local
recurrence is reported in 30% of lesions greater than 3 cm in
diameter.
Radiotherapy may be used to treat patients with basal cell
carcinoma, although overall cure rates may be low. It is gener-
ally reserved for patients who are deemed to be at high risk for FIGURE 13.14. Squamous cell carcinoma.

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.

Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.

present. Larger lesions may present with infection. Histolog-
ically, there are irregular nests of epidermal cells invading the
dermal layer. As with other tumors, histologic grading relies
on the degree of cellular differentiation. The better differenti-
ated the lesion, the less invasive a growth pattern it displays,
leading to an improved prognosis. Although uncommon, squa-
mous cell carcinomas can metastasize to regional lymph nodes.
Overall, this occurs in approximately 2% to 5% of cases. If
lymph node spread has occurred, further metastatic sites in-
clude bone, brain, and lungs. A Marjolin ulcer is a squamous
cell carcinoma that has developed in an area of chronic inflam-
mation and scarring, which carries a risk of metastasis of nearly
50%.
Squamous cell carcinomas are generally treated with curet-
tage and electrodesiccation, radiotherapy, or surgical excision.
The same limitations of radiotherapy in treatment of basal cell
carcinoma are applicable. Curettage may be used in treatment
of lesions less than 2 cm in diameter with clear, well-defined
borders. It should not be used for larger lesions. Mohs micro-
surgery technique may be used in challenging anatomic loca-
tions.
Surgical excision yields excellent results for small, well-
differentiated lesions. As in BCC, there is no standard mar-
gin of resection. Larger lesions require larger margins. There
is no way to know if a margin is adequate until histologic
confirmation is made. This group of higher-risk tumors has
an increased tendency to metastasize to regional lymph nodes.
Lymphadenectomy is indicated for clinically palpable nodes or
if biopsy of a lymph node is positive for malignancy. Radiother-
apy is indicated in situations where disease is present in more
than one lymph node, there are microscopic margins, there is
perineural tumor involvement, or there are larger lesions. Close
surveillance and clinical follow-up is mandatory, as the major-
ity of patients who develop recurrence do so within 2 years of
initial treatment.
SKIN PRODUCTS
Alpha-Hydroxy Acids
Alpha-hydroxy acids (AHAs) are organic carboxylic acids and
the mildest peeling agents used. They improve fine lines and
wrinkles, areas of sun damage, dry and scaly patches, acne
scars, and acne rosacea. AHA peels are also sometimes used as
pretreatment for stronger chemical peels such as TCA. AHAs
are often combined in skin products such as creams and cleans-
ing agents at lower concentrations than in peels, as part of a
daily regimen. Glycolic, lactic, malic, citric, pyruvic, salicylic,
and fruit acids chemically exfoliate the skin. Their action is
thought to be at the layer of the stratum corneum resulting
in increased cell turnover, although the precise mechanism is
not well understood. The overall effect is increased thickness
of the skin with greater collagen and mucopolysaccharide con-
tent, which makes skin look fresher, healthier, and smoother.
Salicylic acid has been long used for the treatment of come-
dones. Except in rare cases, AHAs have virtually no long-term
side effects, although the greater the dermal penetration, the
greater the irritancy of the product. The benefits of AHAs are
also limited.
Retinoids
Topical retinoids such as retinol are derivatives of vitamin A.
Tretinoin (or Retin-A) and Retin-A Micro are also retinoids
that are the most commonly used products for treatment and
prevention of photoaged skin. They improve skin quality and
Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.
Chapter 13: Dermatology for Plastic Surgeons 113
texture by increasing cell turnover in the dermal layer of the
skin. These improvements are likely a result of mediation of
binding to retinoic acid receptors (RARs), which then can bind
to specific genes. Retin-A is available in many formulations
and strengths. Higher concentrations induce greater irritation.
Renova is a combination of tretinoin 0.05% in a water-in-oil
emulsion. This is thought to moisturize and thus reduce the
incidence of dermatitis. Retin-A Micro is a gel formulation
of tretinoin encapsulated in microspheres, which may result
in slower delivery of the medication and thus decreased red-
ness. Retin-A Micro (in 0.1% and 0.04% concentrations) was
specifically designed for the treatment of acne, but also can be
used for aging skin. Third-generation retinoids such as Differin
and Galderma are made of adapalene gel and are approved for
the treatment of acne; they have a smaller side-effect profile,
with fewer reports of sensitivity. Tazarotene gel is a retinoid
used for psoriasis and acne and thought to bind selectively to
RARs. In aging, the process of cell turnover slows, the skin
appears dull and thickened, pores can appear larger, and wrin-
kles develop. Increasing the cell turnover results in a smoother,
healthier-looking skin, smaller pores, finer wrinkles, and de-
creased pigmentation, roughness, and sallowness. Although
retinols are very effective, they have the common side effects of
increased sun sensitivity and redness, called retinal dermatitis,
which typically develop at 2 to 4 weeks of treatment and sub-
sequently subside. Patients need to avoid sun exposure when
being treated with retinoids. Clinicians use retinols in combina-
tion with bleaching agents (hydroquinones) for the treatment
of hyperpigmentation.
Systemic Retinoids
Isotretinoin as a systemic formulation has primarily been used
to treat acne and psoriasis, but has some usefulness in the
treatment of photoaged skin. Women of child-bearing years
need to be counseled carefully before embarking on the use of
isotretinoin because of the birth defects associated with their
use.
Vitamin A
Vitamin A, also known as retinol, is a precursor to retinoic
acid. Although it can be effective in the treatment of photoaged
skin, patients frequently do not tolerate the side effect of skin
irritation, causing them to abandon treatment.
Furfuryladenine
This is a newer, less-prescribed agent, also known as kinetin
(active ingredient in Kinerase). It acts on photoaged skin by
slowing the aging process at the cellular level by altering the cell
shape, changing the cytoskeleton structure, changing growth
rates, and altering the synthesis and quantity of lipofuscin.
Vitamin C
Topical vitamin C, or ascorbic acid, is an antioxidant. It helps
to regenerate vitamin E and inhibits lipid peroxidation. After
UV exposure vitamin C stores become deleted, yet when vi-
tamin C is used topically, it seems to have a protective effect
against UVB rays. It is thought to improve skin quality and
texture by increasing collagen turnover. Some studies suggest
an impact on dermal fibroblasts proliferation and improved
wound healing and scar formation. Many forms of vitamin C
are unstable and thus easily degraded. l-Ascorbic acid is well
114 Part II: Skin and Soft Tissue
absorbed by the skin and relatively stable, thus is an excellent
topical formulation. The formulation and percentage of vita-
min in the cream or gel is critical to its effectiveness, with the
best results seen in 10% to 20% formulations. Vitamin C seems
to have an effect on fine lines and wrinkles and to improve
wound healing. It may also have an anti-inflammatory effect.
Because some studies have shown that vitamin C improves the
efficacy of bleaching agents on the skin, many clinicians use it
in combination with bleaching agents.
Vitamin E
Vitamin E is widely thought to improve scars. Many people use
it topically on healing scars with the belief that it will improve
the color and texture of the scar. Vitamin E is a lipid-soluble
antioxidant that can serve to reduce free radical production.
Alpha-tocopherol is the biologically active form of vitamin E.
It inhibits protein kinase C, which, in turn, inhibits collagenase
production and collagen degradation. In theory, this leads to
increased collagen and decreased aging in the skin; however,
few studies exist that support this clinically. There may be a
selective photoprotective effect with topical application of the
active form of vitamin E and UVB exposure, but it is not clearly
beneficial.
Bleaching Agents
Many formulations exist for the treatment of solar lentigos,
melasma, and dyschromia. Hydroquinone is the most com-
monly used agent and produces a reversible depigmentation of
the skin. The 4% formulation is frequently used with the best
effect; however, combination products exist with lower con-
centrations. It can also be combined with hydrocortisone to
reduce irritation seen with hydroquinone use. It often is also
combined with sunscreen, an essential treatment in the effec-
tive improvement of pigmented areas of skin, and with vitamin
C and lipid-soluble vitamin E, which are thought to improve
the efficacy of the bleaching agents. Hydroquinone has the fre-
quent side effect of local skin irritation and the uncommon,
but devastating, side effect of exogenous ochronosis, the ir-
reversible blue-black pigmentation of treated areas. Patients
should always patch test prior to treatment. Patients can also
have severe allergic reaction (hives, wheezing, and even ana-
phylaxis) to the product.
Kojic acid is an alternative to hydroquinone and can be
used alone or in combination with hydroquinone or AHAs. It
is derived from a Japanese mushroom and, like hydroquinone,
is a tyrosinase inhibitor.
Sunscreen
If a physician could prescribe a single agent to treat photoag-
ing, it should be sunscreen. Not only can sunscreen help prevent
skin cancers, but the judicious use of sunscreen and limited ex-
posure to the sun will reduce the development of unwanted
pigmented areas of the skin, reduce the development of fine
lines and wrinkles, and help slow the aging process of the skin.
Sunscreens are typically either selective in their absorption of
particular rays, or physical blocks that serve as a barrier that re-
flects or scatters radiation. The first sunscreens were developed
in 1920s and were selective for UVB protection (the part that
causes sunburn); they contained benzyl salicylate and benzyl
cinnamate. UVB sunscreens tend to absorb the entire spectrum
of UVB rays, whereas UVA sunscreens absorb selective shorter
Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.
wavelengths. The main active ingredients in sunscreens that are
selective for UVB rays are p-aminobenzoic acid (PABA) and
derivatives thereof. UVA sunscreens contain benzophenones,
dibenzoylmethanes, and anthranilates. The physical barrier
creams contain titanium dioxide, micronized zinc oxide, mi-
cronized metallic oxide reflecting powders, and avobenzone
(Parsol 1789). PABA and its derivatives were very common
sunscreen ingredients in the 1950s and 1960s, but have recently
fallen out of favor because they do not effectively absorb all
wavelengths of UV light, are not water soluble, some people
are allergic to the compounds, and they can cause yellow dis-
coloration of fabric. Cinnamates are effective UVB blockers
but have poor waterproofness, thus are used in combination
with other agents. The FDA rates sunscreens for their effective-
ness and their waterproofness. Agents available in Canada and
Europe that seem to be quite effective are Mexoryl, which is
a camphor-based lotion that produces a total physical block.
A sun protection factor (SPF) of 20 means that it would take
you 20 times longer to sunburn with the sunscreen than if you
stayed in the sun with untreated skin. New FDA categories will
soon be implemented that will describe sunscreen as 1 (mini-
mal protection), 2 (moderate protection), and 3 (high sunburn
protection; SPF of 30 or greater). A sunscreen or block should
protect against both UVB and UVA rays.
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