59 Unit II Skin and Soft Tissue
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59
Unit II Skin and Soft Tissue
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13. BENIGN SKIN CONDITIONS
14. MALIGNANT SKIN CONDITIONS.
JANUARY 2017
Q2) A 25 year old woman presented with painful relapsing nodules with abscesses in her both axilla and groin since
the last one year.
a) What is your diagnosis (HS) and how will you manage her according to its stages.
b) What is the recent medical therapy for stage III. (TNF α inhibitor and ustekinumab for 06 months)
JANUARY 2017
Q11) A 25 year old patient who had undergone breast augmentation 3 months back, complains of hypertrophic
scarring.
a) What are the different modalities of treatment and their mechanisms.
b) Despite your treatment, her scars extend beyond the surgical incision mark. How will you manage it in the long
term.
JANUARY 2017
Q16) A 75 year old lady presented with a history of an ulcerative lesion for the last 8 years around the outer
canthus of the right eye involving at least 1/3 of both the upper and lower eyelids. On examination, she also has
difficulty in lateral rotation of the right eye.
a) How will you evaluate this patient for diagnosis and treatment.
b) Give the types of basal cell carcinoma.
c) What is the treatment plan for this patient. (see eyelid recon table)
APRIL 2016
Q16) A middle aged diabetic male presents with multiple abscesses and discharging sinuses in both arm pits for the
past 10 years.
a) What is the most likely diagnosis. HS
b) What is the pathogenesis of this condition.
c) How will you manage this case.
APRIL 2015
Q20) A 65 year old fair complexion lady presents with a pigmented nodular lesion of 0.5cm on the right inner
canthus of 8 year duration with some bloody discharge.
a) What is the most likely diagnosis? BCC
b) What will be your treatment plan if the upper and lower eyelids are spared?
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c) How will you follow-up this patient?
OCT 2014
Q5) A 40 year old male developed a black spot with ulcer on the heel since 2 years, with itching and bleeding on
and off.
a) What is the differential diagnosis of this lesion? Melanoma
b) How would you investigate this lesion?
c) What is the principle and surgical technique of sentinel lymph node biopsy in this patient?
OCT 2013
Q8) A 25 year old man presents with 1cm non-healing lesions on his nose for 2 years. He has variegated,
pigmented skin since childhood.
a) What is the likely skin condition, and what is the genetic and molecular basis of this condition? XP
b) What is the management of the underlying skin condition?
c) Give treatment options for the nasal lesions.
MAR 2012
Q.14. A 36 year old lady presented to you with butterfly shaped keloid in pre sterna region with a discharge,
synmastia, itching and great discomfort.
a) Give an outline of management
b) What measures would you take to decrease the incidence of recurrence?
MAR 2012
Q.7 A 26 year old man presents to you with a 2 cm brownish, hard nodular painless swelling on his left cheek. He
noticed this gradually increasing swelling about two years ago. There is no history of injury.
a) What is the differential diagnosis? (morpheaform/sclerosing bcc, DFSP, Scar, parotid tumor)
b) Incisional biopsy has proven the lesion to be dermatofibrosarcoma protuberance. How would you plan to
manage this patient to minimize the local recurrence? (3 cm margin)
c) Enumerate 3 methods of reconstruction of defect (check cheek recon table)
d) What is the role of adjuvant therapy? (reduce risk of local recurrence when residual disease remain after
surgery)
OCT 2012
Q.20. A middle age man of 40 years who had sustained burn injury over his right leg about 10 years ago, he
developed an ulcer in burn scar, distal to knee joint. Size about 5x4 cm with palpable lymph nodes in right groin.
a) What is your diagnosis?
b) How will you investigate and manage this case.
MAR 2011
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Q.11: A young man with extensive bilateral axillary hidradenitis suppurativa for the last 4 years. He also has similar
lesions on both groins.
a) What are the non-surgical aspects of management of this condition?
b) How would you surgically treat this patient?
MAR 17, 2010
Q.20 Describe the difference between hypertrophic scar and keloid as regards to their pathology, clinical features
and management.
SEPT 2010
Q.3: A young male of 22 years presents with a recurrent, painful and discharging tender swelling at the bottom of
the spine (coccyx area).
a) What is the likely diagnosis? Pilonidal sinus
b) What is the pathology of the condition?
c) How will you treat it?
d) How will you treat it’s recurrence?
MAR 2009
Q.1 A 40 Years old female had a keloid excised from right clavicular area 10 years ago. She developed a 7x3 cm
recurrent growth in the scar.
a) what is your differential diagnosis
b) How would you investigate and diagnose the lesion
c) how would you treat the patient surgically
MAR 2009
Q.11 A 26 year old man presents with recurrent purulent infection of the axillae, groins and perineum, on and off
for the last two years.
a) What is the most likely diagnosis?
b) What is the underlying pathology?
c) What are the principles treatments?
JAN 2008
Q.7 A 43 year old female presents with a large fungating tumor over the anterior aspect of right leg.
She sustained a deep burn in this area in childhood and there is a history of repeated skin breakdown.
a) What is the likely diagnosis and what are the characteristics of this condition?
b) How will you manage this patient giving reasons for your actions?
JAN 2008
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Q20
a) How can you differentiate between hypertrophic scars and keloids
b) How can you prevent these?
c) How would you propose to treat a large pre-sternal keloid in a 40 year old male?
MAR 2006; JUNE 2008;
Q.16 Write a short essay on “Dermatofibrosarcoma protuberance" with emphasis on presentation, metastasis and
treatment.
FEB 2007
Q.4: A 40 year old anxious lady presents with a pigmented lesion on the sole, present for many years. Her friend
had a similar lesion which had turned malignant.
a) What important questions in history taking would help you to decide whether to operate or not?
b) Give 2 important histological classifications commonly employed. How will they influence the surgical plan and
prognosis.
c) What is the importance of sentinel lymph node biopsy in high grade tumors and at least 2 methods of
identification of the sentinel lymph node.
AUG 2006
Q.9)
a) Give the differential diagnosis of a pigmented lesion on the face of a 48 year old lady.
b) Briefly describe the surgical management of a basal cell carcinoma of 1 cm diameter near the medial canthus of
a patient
AUG 2006
Q.16. Write a short note on xeroderma pigmentosum.
MAR 2005
Q.14 a) Give one classification for the staging of soft tissue sarcomas.
b) How would you evaluate a suspected soft tissue sarcoma on the extensor aspect of a forearm?
Depending upon the size and spread of the tumor give three surgical options that are in practice
SEP 2005
Q.16
a) How does silicone gel sheeting help in scar maturation?
b) What instructions for use would you give to a patient for its application in a facial hypertrophic scar?
c) What other methods are useful in scar management in conjunction with silicone gel sheeting?
MAR 2004
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Q.11 .Give an account of isolated limb perfusion in patients with malignant melanoma of extremities
a) Enumerate the body contouring procedures are available for the unsightly abdomen,
b) How will you select a procedure for a particular patient?
c) Which patients are at a higher risk for developing post-operative complications?
SEP 2004
Q.20) A 35 year old man presents with a lesion on his nasal tip for 2 years. The lesion is about 1.8 cm diameters. He
is sensitive to light and has thinning of skin since childhood.
a. What is the likely skin condition?
b. What is the differential diagnosis of lesion on the tip of nose?
c. How will you treat the nasal tip lesion?
MAR 2003
Q.5) A 35 year old male present with a three months old history of swelling measuring 5x9cm over the left volar
expect of the left forearm. The overlying skin is adherent, finger flexion is not effected. An FNA report from
elsewhere suggests a malignant soft tissue lesion.
a) What investigations would you order? Explain their rationale.
b) What are your options of treatment?
SEP 2003
Q.1 What do you understand by (ELND) Elective Lymph Node Dissection in patients with Malignant melanoma.
What are its indications, benefits and disadvantages?
SEP 2003
Q.7 Enumerate the destructive treatments of basal cell carcinoma their indications and disadvantages
SEP 2000
Q.8 write short essay on
A) discuss briefly course and management of Rhinophyma
B) briefly discuss the types and management of zygomatic bone fractures.
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Hidradenitis Suppurativa:
• Syn: Acne inversa (AI), Pyoderma fistulans significa, verneuil’s disease or smoker’s boil.
• Is a disabilitating chronic inflammatory disease with major negative impact on quality of life and
significant co-morbidity.
• HS is a potential severe and disabilitating chronic inflammation disorder of apocrine gland-
bearing body areas (i.e. axillary region, anogenital or inframammary regions in female)
• Pathogenesis: o Follicular occlusion of pilosebaceous unit by infundibular hyperkeratosis play a crucial
role. o Pro-inflammatory cytokines such as interleukin (IL-1β), IL-10 and TNF(α) are markedly
increase in lesional and perilesional skin.
• Risk factors:
o Smoking
o Obesity
o Female gender (3:1)
• Clinical features:
o Pain (describe as hot burning, pressure, aching, sharp, splitting, gnawing, throbbing)
o Early: one/several break out that look like pimples/boil
o Late:
▪ Painful breakout
▪ Foul smelling discharge
▪ Scarring
o Pilonidal sinus is seen by some authors as a unilocalized type AI.
• Clinical diagnostic criteria:
o Typical lesion deep seated nodules/and or fibrosis
o Typical location i.e. axillary or anogenital regions
o Typical course relapse and chronicity
• Severity Assesement: Hurley and Sartorius scale
o Hurley: Based on degree of inflammation and fibrosis
▪ Stage I: Abscess (es) without scarring or sinuses
▪ Stage II: recurrent abscess without tract formation and scarring
▪ Stage III: multiple interconnected tracts and abscess throughout an entire area.
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• Differential Diagnosis:
o Crohn’s disease
o Nodular acne
o Tuberculosis
o Leprosy and
o Furunculosis
• Complication:
o Local:
▪ Scarring
▪ Infection
o Systemic:
▪ Anemia
▪ Hypoproteinemia
▪ Nephritic syndrome
▪ Arthopathies
▪ Dactylitis
▪ Secondary lymphedema
▪ Fistulae formation (rectum, vagina, urethra, urinary bladder)
▪ Squamous cell carcinoma- very rarely, in long standing cases.
• Treatment:
o Conservative:
▪ Good hygiene
▪ Lose weight
▪ Quit smoking
▪ Avoid shaving affected region
▪ Wear loose fitting clothes
▪ Keep your skin cool
▪ Avoid using deodorant.
o Medical:
▪ Topical application
• Clindamycin rifampicin or rifampicin-moxifloxacin-metronidazole
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• Tumor necrosis- α inhibitor like infliximab, adalimumab and etanercept,
most recently- ustekinumab – for 6 months
o Laser therapy:
▪ IPL- twice weekly for four weeks
▪ Photodynamic therapy with 20% 5-aminolevulinic acid and was applied weekly
for four weeks
▪ Long-pulsed Nd:YAG (1064nm) twice a month-for grade II
o Surgical options: Excision
▪ Secondary intention healing- gold standard
▪ Primary closure
▪ Skin grafting
▪ Flap Coverage
Comparison of Hypertrophic scarring and Keliod:
Keloid HTS
Grows beyond the borders of the original wound Pruritic and painful Predominant anatomical sites (earlobes, sternum, shoulder, upper back, post neck, cheeks, knees) Post traumatic or spontaneous Not associated with contractures Do not regress spontaneously Do not improve with time; there is continuous growth Develop later Appear at 3 months or later after initial scar, then gradually proliferate indefinitely More common in darker skin types Genetic predisposition Thick collagen fibers Absence of myofibroblast and α-SMA
Remain confined to borders of the original wound Less pruritic and rarely painful No predominant anatomical sites (but commonly occurs on extensor surface of joint, or when skin creases at a right angle) Only post traumatic Associated with contractures Regress spontaneously Improve with time (regress or stabilize) Develop sooner Generally appear within 1 month, grow for 6 months, then regress often within 1 year Less association with skin pigmenation Less genetic predisposition Fine collagen fibers Presence of pyofibroblast and α-SMA
Prevention:
• Surgical excision scar should be positioned along relaxed skin tension lines
• Appropriate strength, depth and number of suture should applied
• Minimize inflammatory response.
Different treatment modalities and their mechanism:
1. Intralesional corticosteroids injection:
• Dose: 3-4 injection (TAC) 10-40 mg/dl every 3-4 weeks for 6 months
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• MOA: suppressive effect on inflammatory process in wound and Secondarily from
reduced collagen and glycosaminoglycan, inhibition of fibroblast growth, as well as
enhanced collagen and fibroblast degeneration
• Response rate: 50-100%
• Recurrence rate: 9-50%
• Adverse effect: dermal atrophy, telangiectasia, and pain at injection site.
2. Pressure therapy:
• MOA: dec. collagen synthesis by limiting capillary perfusion and dec. O2 supply of scar
tissue as well as inc. apoptosis.
• Dose: 15-40mmgh for atleast 23 hours for 6 months
• Adverse effect: maceration, eczema, and odor emanating from garment
3. Radiotherapy: superficial xray, electron beam and low or high does rate brachytherapy
• MOA: inhibits neovascular buds and proliferating fibroblasts resulting in dec collagen
production. Started 24-48hours after excision
• Dose: total 12 Gy divided into 6-10 fractons applied daily or every 2nd day
• Adverse effect: hypo or hyperpigmentation, erythema, telangectesia and atrophy and
some risk of carcinoma
4. Laser therapy: PDL (585nm)
• MOA: induce capillary destruction, which generates hypoxemia and atrophy and in turn
alter collagen production
• Dose: 2-6 treatment session are necessary to improve scar color, height, pliability and
texture.
• Adverse effect: mild and include predominantly purpura, usually persisting for 7-14 days
• Recently, the 1064nm Nd:YAG has been suggested for therapy 5-10 session (at 1-2 week
interval)
5. Silicon based products:
• MOA: normalization of transepidermal water loss is likely the underlying mechanisms
• Dose: 12-24 hrs/day for 12-24 weeks.
Emerging option for the treatment of keloid and HTS:
6. 5-Fu:
• MOA: inhibits proliferation of fibroblast as a pyrimidine analog
• Dose: 40-50mg/ml, 2-4 session
• Adverse effect: pain at injection site, hyperpigmentation, skin irritation
• Contraindication: anemia, leukopenia, thrombocytopenia, ulceration and pregnancy
7. Onion extract (extractum cepae): anti-inflammatory manner and bactericidal
8. Intralesional cryotherapy:
• intralesional cryo needle—connected to liquid nitrogen, which cause the cryoneedle to
freeze thereby freezing scar tissue from inside out.
• 51% volume reduction—ist year
• Scar vol for ear-70% reduction
• 60% reduction on upper back, shoulder and chest
9. Imiquimod: topical -5% cream
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• MOA: stimulate interferon, a pro-inflammatory cytokines which increase collagen
breakdown
• Dose: starting at night of surgery with daily treatment or 2 weeks after the operation
every alternative night for 8 weeks
10. Bleomycin:
• MOA: inhibit collagen synthesis via dec stimulation by TGF-β,
• Dose: 1.5 IU/ml
• Route: intralesional
11. Interferon (IFN):
• MOA: markedly dec collagen synthesis
• Route: intralesional
12. Botulinum toxin A (BTA):
• MOA: paralyses local muscle, reduce skin tension, caused by muscle pull, and dec
microtrauma and inflammation
• Route: intralsesional
13. Photodynamic therapy:
14. Recombinant TGF-β3
Basal cell carcinoma:
o For most common cutaneous malignancy
o 80% of all skin cancers
o Risk factors:
▪ Intense sunlight
▪ Fitzpatrick skin types I-II
▪ Family hx
▪ Male sex
▪ Smoking
▪ Human papilloma virus
▪ Exposure to arsenic and hydrocarbons
▪ Immunodeficiency
▪ Previous radiaton
o Associated clinical syndromes:
▪ Bazex syndrome
▪ Gorlin syndrome (basal cell nevus syndrome)
▪ Xeroderma pigmentosum
o Types:
▪ Nodular Bcc: most common
• rodent ulcer appearance (cystic and pigmented)
▪ Superficial Bcc: 2nd most common
• Trunk and extremities
• Radial growth pattern
▪ Morpheaform or sclerosing Bcc: most aggressive tumor
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• Usually found in head and neck
• Resemble scar without hx of trauma
o Diagnosis:
▪ Tissue biopsy
▪ Overall cure rate can exceed 90%
▪ Staging rarely performed
o Management:
▪ Destructive therapy:
• Electrosurgery
• Cryosurgery
• Topical 5-flurouracil
• Topical imiquimod
• Intralesional interferon
• Radiation and
• Photodynamic therapy
▪ Surgical excision: (safe margin)
• Tumor less than 1 cm- 4-5mm margin
• Tumor more than 1 cm- 5-10mm margin
▪ Moh’s micrographic surgery:
• 98% cure rate in primary tumor
• 95% cure rate in recurrent tumor
o Follow up:
▪ Every 4 month- ist year than
▪ 6 monthly- 2nd year and then
▪ Yearly- for rest of life
o Recurrence rate:
▪ 1/3rd in first year
▪ Half in 2nd year
▪ 2/3rd in 3rd year
Features of high-risk basal cell carcinoma and cSCC:
o Anatomic site
▪ Central face, periorbital region, ears/postauricular region,hands, feet
o Tumor site
▪ >5 mm. on high-risk sites of central face, ears, hands, feet
▪ > 10 mm. on scalp, forehead, cheek, neck
▪ >20 mm. on trunk, extremities
o Histologic characteristics
▪ Morpheaform/sclerosing, infiltrative, or micronodular subtypes (BCC)
▪ Basosquamous differentiation
▪ Perineural invasion
o Clinical features
• Recurrent tumors
• Previously irradiated site
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• Poorly defined clinical borders
• Immunosuppression
• Site of chronic inflammation
Squamous cell carcinoma: (15-20% of all malignant skin tumors)
o Risk factors:
• Environmental:
▪ Skin exposure
▪ Hx. Of radiation
▪ Chronic inflammation (i.e. marjolin ulcers)
▪ Exposure to arsenic and hydrocarbons
▪ Chronic immunosuppression
• Host factors:
▪ Fitzpatrick skin type I-II
▪ Fair hair
▪ Previous hx. Of non-melanoma skin cancer
▪ Infection with HPV
• Disorders in which chances of cSCC is high:
▪ Xeroderma pigmentosum
▪ Epidermolysis bullosa and
▪ Albinism
o Diagnosis/Staging:
• 80% arises from
actinic keratosis
• Features of actinic
keratosis malignant
transformation:
▪ Inflammation
▪ Diameter
>1cm
▪ Rapid growth
▪ Ulceration
▪ Bleeding and
erythema
• 15% cutaneous horn contain cSCC
• Erythtoplasia of Queyrat: cSCC in situ recur on mucocutaenous epithelium of glans of
penis or labia majora
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o Premalignant lesion:
• Actinic keratosis
• Leukoplakia
• Cutaneous horn
• Bowen’s disease
• Keratocanthoma- low variant of cSCC
o Treatment:
• Non-surgical- destructive
• Surgical
▪ Low risk- 4mm margin
▪ High risk- 6-10mm margin
o High- risk features:
• Location: lip, ear, within chronic
wounds or scar
• Size:
▪ Horizontal size > 2cm
▪ Thickness of 2-6mm (low risk) or >6mm (high risk)
• Poorly differentiated cell type
• Perineural invasion and
• Rapidly growing or recurrent lesion and
• Immunosupresent patient.
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Melanoma:
o Risk factors:
• Host factors:
▪ Congenital nevi
▪ Fitzpatrick I-II skin types
▪ Blue/ green eyes
▪ Atypical nevi
▪ Personal hx of melanoma
• Environmental factors:
▪ Sun exposure
▪ One or more blistering sunburn early in life or
▪ Greater than five sun burn at any age increase the lifetime risk of developing
melanoma two fold
o Diagnosis:
• American ABCDE system:
▪ A- asymmetry
▪ B- border irregularity
▪ C- color variegation
▪ D- diameter >6mm and
▪ E- evolution or changing in
appearance of lesion over time
• Glassgow system:
▪ Major:
o Change in size
o Irregular pigment
o Irregular outline
▪ Minor:
o Diameter > 6mm
o Inflammation
o Oozing/ bleeding
o Itch/ altered sensation
o Types:
• Superficial spreading melanoma:
▪ Most common
▪ Flat or slightly elevated
▪ Commonly on trunk in men and leg in women
▪ Patient of age 30-50 years
• Nodular melanoma:
▪ 2nd most common
▪ Smooth single colored (black or brown)
▪ Elevated nodule or ulcerated mass on exam
▪ Commonly involve legs or trunk
▪ Delay diagnosis due to lack of radial growth phase
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• Lentigo maligna melanoma:
▪ Slow growing
▪ Arise in long standing pigmented lesion
▪ Chronically sun damage anatomic sites (i.e. hand and arm)
▪ Fair skin individual > 60 years of age
• Acral lentiginous melanoma:
▪ Commonly occurs on palm of hand,sole of feet or beneath nail plate (subungual)
▪ Hutchinson sign
▪ Diagnosed is an old age
• Dermoplastic melanoma:
▪ Present as an unremarkable plaque or nodule and can easily be misdiagnosed at
an early stage
▪ Affects older patient (man:women 2:1)
▪ Most commonly occur in head and neck region
▪ Frequently involve nerve invasion
▪ Closely resemble a soft tissue sarcoma
o Work up:
• Full thickness excisional biopsy with a 1-2mm margin (no shave biosy)
• Further screening
▪ xray, cbc, lfts, serum LDH, CT scan, PET scan, Serum ALP, body ct imaging, bone
scan and MRI brain
• tumor thickness, mitotic rate and ulceration are the most significant prognostic factors
o Surgical management:
• Wide and deep excision: 3-5cm margin is recommended for local excision
• Sentinel Lymph node biopsy:
▪ Sentinel lymph node is the first lymph node in the drainage basin to receive
afferent lymphatic communication from primary tumor site, prior to spread to
other nodes in the region
▪ Technical limitation to sentinel lymph node biopsy:
o Previous wide and deep excision with recon and tissue rearrangement
o Anatomic site where there are more than one drainage basin (i.e. scalp)
o Anatomic site where primary tumor is very close to sentinel l.n (i.e.
overlying the parotid) and Ɣ-detection is difficult
▪ Two complementary technique:
o Pre-operative lymphoscintigraphy:
• Technetium 99m is injected around tumor site at the morning of
surgery then followed by serial image of Ɣ emission pattern.
o Direct intraoperative visualization:
• Blue dye (isosulfan blue or methylene blue) is injected
intradermally around the primary melanoma and massaged for
5 min to augment dye in lymphatic channel.
o s-100 is most sensitive marker in detecting melanoma
o HMB-45 and MART-1 are specific cellular marker, detected in melanoma but each lacks
sensitivity.
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o Recently, reverse transcriptase polymerase chain reaction has been used as a molecular staging
tool, and ongoing trial as evaluating its utility.
o Lymphadenectomy:
o Advanced melanoma:
▪ Stage iv melanoma
▪ Poor prognosis 10-15 % --- 5% survival
▪ Immunotherapy (high dose interleukin 2, interferon α, combination therapy, adoptive
immunotherapy and vaccines)
▪ Systemic chemotherapy (dacarbazine and fotemustine)
▪ Isolated limb perfusion and
▪ Radiotherapy
▪ However, there are no provocative data indicating that any of these treatments reliably
prolongs survival in stage IV melanoma.
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Isolated Limb perfusion:
o Patient with poor prognosis receive great benefit from this procedure
o Developed in 1950, as an alternative to amputation
o ILP with cytotoxic medication is intended to get rid of mets.
o In this procedure:
▪ Femoral a. and vein (if treating leg) or axillary a. and vein (If treating arm) are
clamped. Subclavian or iliac approaches in
this procedure are also possible but less
common. A tourniquet is applied to
produce pressure on small veins thus
isolating limb form rest of the body.
▪ Tube are inserted into affected limb and
attached to a machine to circulate healed
chemotherapy medication (cytotoxic
drugs). A combination of phenylalanine
mustard and actinomycin D is often used.
▪ The cytotoxic durgs are allowed to
circulate for 60-90min, the limb is then
allowed to cool and then is flushed to
remove any residual medication.
▪ The tubes are removed and vessels reattached before closure of incision.
o When should it be confirmed:
▪ Indication- may include following criteria
• Melanoma metastases that are confirmed to single limb
• Primary lesion with poor prognosis
• Thick or ulcerated tumors
• Palpable regional nodal mets.
o Adverse effects/complication of ILP:
▪ Redness-will settle within 6 months
▪ Blistered or peeling of skin
▪ Swelling and lymphedema
▪ Change in nails
o Outcome:
▪ 75% response rate to procedure
▪ Achievement of local disease control
▪ An enhanced patient survival rate compared to no treatment
▪ The death rate from procedure is 0.6% and limb loss rate is 0.8%.
Pros Cons
Its efficacy It avoid systemic treatment
It is invasive and carries risk of infection It is highly specialized, expensive, require a perfusionist, surgeon and extensive supportive staff Unpleasant side effects
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Xeroderma pigmentosum:
o Description:
• Literally dry pigment skin, is defined by extreme sensitivity to sun light, resulting in
sunburn, pigment change in the skin and a greatly elevated incidence of skin cancer
• Disorder was originally classified as “classical XP” (skin abnormalities only) and De-
sancti-cacchione syndrome with skin abnormalities and extreme neurological
degeneration.
o Epidemiology:
• Found in all continents and across all racial groups
• Consistent with autosomal recessive inheritance
• Male and female equally affected
o Clinical description:
• Extreme sensitivity to sunlight
• Inc no. of lentigines (freckle-like pigmentation)
• Photophobia, keratitis
• Pigmented seborrheic warts
• Telangiectasia
• The signs of xeroderma pigmentosum usually
appear in infancy or early childhood. Many affected children develop a severe
sunburn after spending just a few minutes in the sun. The sunburn causes redness
and blistering that can last for weeks. Other affected children do not get
sunburned with minimal sun exposure, but instead tan normally. By age 2, almost
all children with xeroderma pigmentosum develop freckling of the skin in sun-
exposed areas (such as the face, arms, and lips); this type of freckling rarely
occurs in young children without the disorder. In affected individuals, exposure to
sunlight often causes dry skin (xeroderma) and changes in skin coloring
(pigmentation). This combination of features gives the condition its name,
xeroderma pigmentosum.
• People with xeroderma pigmentosum have a greatly increased risk of developing
skin cancer. Without sun protection, about half of children with this condition
develop their first skin cancer by age 10. Most people with xeroderma
pigmentosum develop multiple skin cancers during their lifetime. These cancers
occur most often on the face, lips, and eyelids. Cancer (like bcc,scc ) can also
develop on the scalp, in the eyes, and on the tip of the tongue. Studies suggest that
people with xeroderma pigmentosum may also have an increased risk of other
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types of cancer, including brain tumors. Additionally, affected individuals who
smoke cigarettes have a significantly increased risk of lung cancer.
• About 30 percent of people with xeroderma pigmentosum develop progressive
neurological abnormalities in addition to problems involving the skin and eyes
o Frequency:
• Xeroderma pigmentosum is a rare disorder; it is estimated to affect about 1 in 1 million
people in the United States and Europe. The condition is more common in Japan, North
Africa, and the Middle East.
o Aetiology:
• Xeroderma pigmentosum is caused by mutations in
genes that are involved in repairing damaged
DNA.DNA can be damaged by UV rays from the sun
and by toxic chemicals such as those found in
cigarette smoke. Normal cells are usually able to fix
DNA damage before it causes problems. However, in
people with xeroderma pigmentosum, DNA damage
is not repaired normally. As more abnormalities
form in DNA, cells malfunction and eventually
become cancerous or die.
o Inheritance pattern:
• This condition is inherited in an autosomal recessive pattern, which means both copies
of the gene in each cell have mutations. The parents of an individual with an autosomal
recessive condition each carry one copy of
the mutated gene, but they typically do not
show signs and symptoms of the condition.
o Diagnosis:
• Genetic testing
• Clinical examination
• Cultured skin fibroblast
• Complementation test (in some countries)
o Differential diagnosis:
• Solar urticaria
• Erythropoietic protoporphyria
• Cockayne syndrome
• Rothmund-thompson syndrome
• Carney complex and leopard syndrome
• Peutz-jeghar syndrome
o Genetic Counselling:
• As with all genetic disorders, genetic counselling and psychological support is
appropriate for the families, to disease etiology, probably of occurrence in future
pregnancies, increased likelihood of occurrence in which consanguineous marriage are
common, feeling of isolation and concern about career prospects.
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o Antenatal diagnosis:
• DNA repair test- can be carried out on chorinic villus-derived cells or on amniocytes in
affected families
o Management and treatment:
• No cure is available for XP
• Protective measure include the following
▪ All windows in home, car or school should be covered with UV resistant films
▪ When outside during daylight
• Sunscreen
• Long trouser
• Long sleeve and gloves with UV resistant face mask
▪ Regular visits --- dermatologist
▪ Frequent eye examination by ophthalmologist
▪ Rigorous sun protection result in vit. D deficiency
▪ Patient should avoid cigarrete smoking and other environmental carcinogens
▪ Psychological issue need to be addressed
▪ Routine audiometry, measurement of head circumference, aberrant of gait and
delay tendon reflex testing
o Prognosis: is good.
Soft tissue sarcoma:
o Is rare cancer that affects the soft tissue that support, surround and connect organ and
body structures
o Tissue affected by sarcoma include muscles, blood, vessels, fats, tendons and ligaments
o Risk factors:
• Having following certain inherited disorders
▪ Retinoblastoma
▪ Neurofibromatosis type 1
▪ Tuberous sclerosis
▪ Familial adenomatous polyposis
▪ Li-Fraumeni syndrome
▪ Werner syndrome (adult progeria)
▪ Nevoid basal cell ca syndrome (Gorlin syndrome)
• Other risk factors:
▪ Hx. Of radiation therapy
▪ Exposure to certain chemicals (i.e. thorotrast (thorium dioxide vinyly
chloride or arsenic)
▪ Lymphedema
o Clinical features:
• Non tender mass (produce compression effect to underlying structure)
• Entire body system: pain, swelling, fatigue, anemia, fever
• Respiratory system: dyspnea
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• G.I system: vomiting, constipation, abd. Pain- retroperitoneal sarcoma
• Neurologic: radiculopathy
o Work up:
• Hx. And physical examination
• MRI (lesion)
• CT scan
• Biopsy
• CXR
• PET scan
o Metastatic way:
• Tissue
• Lymph system
• Blood
o Prognosis factor:
• The type of soft tissue sarcoma
• The size, grade and stage of tumor
• How fast cancer cells are growing and dividing
• Tumor site
• Any residual tumor
• Patient age and general health
• Recurrent tumor
Chemosensitive tumor Radiosensitive tumor
Synovial sarcoma Leiomyosarcoma Angiosarcoma
Ewings sarcoma Rhabdomyosarcoma
o Staging and grading:
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Table 5. AJCC Prognostic Stage Groups for Soft
Tissue Sarcoma of the Trunk and Extremities: and
Retroperitoneum
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15. THERMAL, CHEMICAL & ELECTRICAL INJURY.
16. PRINCIPLES OF BURN RECONSTRUCTION.
17. RADIATION & RADIATION INJURY.
JULY 2017
Q4) A 25 year old lady, who is visiting from abroad, sustained 20% deep thickness burn to her chest, face and arms.
She is transferred to the burn center after 2 days. She is very anxious to go home early after recovery.
a) What is your operative plan?
b) What are the different types of excisions and their drawbacks?
c) What are the different types of coverage options?
JULY 2017
Q5) A 25 year old lady from showbiz has consulted you for a 10o burn contracture on her right cubital fossa.
a) How would you counsel this patient?
b) How would you prevent a possible bad outcome? (early grafting, movment and appropriate splinting)
JANUARY 2017
Q12) A young man was rescued from the 7th floor after a fire accident, with hoarse voice, face and body burns.
a) What are the signs you will look for in inhalational injury and enumerate the indications for ventilation.
b) Give an outline of your management plan.
JANUARY 2017
Q19) A 7 year old child has sustained flame burns involving 17% of BSA, mostly deep dermal, but with no element
of inhalational injury. After initial resuscitation and stabilization, you plan to do tangential excision of the burnt
tissue under general anesthesia.
a) What operative strategies can be utilized to minimize blood loss.
b) During surgery, what steps will you take to minimize mortality from this procedure.
c) How much percentage burn can be tangentially excised safely in a single setting.
OCTOBER 2016
Q3) A young mane of 25 years, worker in an electric company, is brought to the casualty department with history
of fall from a main line pole while at work. On examination, both upper limbs are affected, with some other areas
involved.
a) What is the criteria for admission after electrical injury.
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b) What are the important points in management of high voltage injury.
c) In a high voltage injury, how would you council the family.
OCTOBER 2016
Q13) A young woman in a fertilizer factory using alkalis sustained a burn injury while at work.
a) What is the pathology of this chemical burn and its prognosis.
b) Give broad principle of management in chemical burns.
c) Enumerate the different chemical burn wounds which should not be irrigated with saline.
OCTOBER 2016
Q14) A 25 year old coal miner with 50% BSA burn to head, neck, chest, abdomen and arms is brought to the
casualty within 30 minutes of the accident.
a) Enumerate the initial steps in the management of this patient.
b) What are the wound management plans in the early period.
c) What are the current trends in management.
APRIL 2016
Q7) A 25 year old lady having 35% burns is admitted in your ward.
a) How will you monitor her nutritional status?
b) List common formulae to calculate the caloric requirement
c) Please formulate a 24 hour feeding regimen for this patient.
APRIL 2016
Q8) A 38 year old lineman got electrocuted while disentangling high voltage electrical lines 3 days ago. He
underwent a right mid-forearm amputation and is now referred to you for a 10x6 cm wound over the right ankle,
with exposed bone and tendons.
a) How would you assess the extent of damage.
b) What are the reconstructive options for this defect.
c) Enumerate possible systemic complications of high voltage electrical injury in this case.
APRIL 2016
Q12) A 25 year old college lecturer was assaulted, with a corrosive thrown on her face half an hour back. On
examination, she had ash grey discoloration of the forehead, upper and lower eyelids, nose, cheeks and front of
the neck.
a) How will you try to reduce the extent of her injury?
b) How will you prevent ophthalmic complications in this case?
c) What are the principles of corrosive burn wound management to prevent disfigurement in such cases?
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APRIL 2015
Q13) A 35 year old woman comes to the emergency with chemical burns of the face and neck.
a) What is the initial management plan?
b) What determines the severity of the chemical burns?
c) Almost complete loss of both lips has occurred, what would be your plan of reconstruction with brief reasoning
for each?
APRIL 2015
Q4) A WAPDA lineman was working on a 11000 kVa pole. He had an electric shock and was brought to the
emergency in an unconscious state.
a) How will you do the primary survey?
b) How will you manage this patient in the emergency?
c) How will you protect the renal function in the initial phase?
OCT 2014
Q13) A young man sustained 40% deep 2nd degree burns of the trunk and limbs. He underwent tangential excision
and biological dressing on day 3. Patient developed high grade fever >39oC on day 5.
a) What are the causes of his high temperature?
b) How would you manage this patient?
c) Write briefly on enzymatic debridement as an early strategy for burn wound management.
OCT 2014
Q16) A 13 year old girl, who sustained burns during her childhood, was brought to your clinic. Her parents have
concerns about the burn scars over her chest, regarding future breast development.
a) How will you evaluate this patient?
b) How will you counsel the parents regarding their main concern?
c) Give your treatment plan. (u-shaped 5/8 circular incision—release—mound (contour) creation—maintaince of
inframmary crease—skin graft—NAC tattooing (later on)
OCT 2014
Q20)
a) What are the characteristics of the burned claw hand deformity?
b) What is the underlying mechanism for this deformity? (MP—shortening of collateral ligament with edema and
scar formation, PIP—flexion—due to strong flexor tendons)
c) What are the principles of treatment?
OCT 2013
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Q 4) A 26 year old laborer, while working for an outdoor advertiser, got electrocuted from high voltage
transmission lines and fell down the hoarding.
a) What will be the initial management on receiving this patient?
b) He has a 10x8cm full thickness scalp loss over the left temporo-parietal area. How would you plan to treat this
area?
c) Please enlist the long term sequelae of this type of electric injury that you would like to explain to the patient.
OCT 2013
Q5) A 14 year old girl, who sustained a burn on her trunk as a child, is brought to your clinic by her mother. On
examination, there is scarring over the right breast area and abdomen.
a) What would be your main area of emphasis during your assessment?
b) Give management plan for the patient and enlist treatment options.
OCT 2013
Q9) A middle aged woman was referred to you by an oncologist. She had received radiotherapy of 6000Gy over
the right neck by CHART regimen. About 2 years ago she developed a small ulcer of 2x1.5cm with surrounding skin
changes, incisional biopsy is inconclusive.
a) Briefly write the long term changes that radiotherapy has brought about in this patient.
b) What are the implications for reconstructive surgeons treating these patients?
c) Do you know about any recently described treatment modality that would reverse radiotherapy damage to the
skin and soft tissue?
OCT 2013
Q12) A 22 year old girl was criminally assaulted by her estranged husband with industrial strength bleaching agent.
She was brought to the emergency room. On examination, her head, neck and upper chest were involved.
a) What would be your immediate management?
b) What is the mechanism of injury and how would you counsel her regarding the prognosis?
MAR 2004
Q.2
a) Briefly describe the initial management of an acute deep dermal hand burn.
b) Enumerate the advantages and disadvantages of early excision and grafting.
APRIL 2015
Q1) A 24 year old lady presents with post burn contracture of the neck.
a) What are your options for coverage after release of the contracture?
b) What are the specific difficulties with neck contractures during induction of anesthesia and how do you plan to
address them?
c) How will you follow up this patient?
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MAR 2011
Q16 Write an overview of importance of nutrition in early burn care, in the context of:
a) Energy requirements
b) Protein requirements
c) Immunity
d) Nutrition monitoring
SEP 2005
Q.15
a) What clinical features on history and clinical examination would make you suspect the presence of an
inhalational injury?
b) What tests can be performed to confirm the diagnosis?
c) What are the three components of an inhalational injury?
(SUPRAGLOTTIC, SUBGLOTTIC AND SYSTEMIC)
SEP 2000
Q.6 A 5 years old child fell into hot oil and sustained 21% mixed thickness burns involving hands and lower limbs.
Discuss its management with special reference to:
A) Fluid and electrolyte balance.
B) Place of tangential excision and skin grafting in hands.
SEP 2010
Q.5: Patients of major burns are prone to local & systemic infections.
a) Explain the factors which render these patients more susceptible to infection?
b) What specific steps in the management can help to prevent sepsis?
MAR 2011
Q.1. A 48 years old male has presented to emergency department with chemical burns to face, arms and legs. You
are being called by the casualty officer to assess this patient and help in management. The patient is a non-insulin
dependent diabetic.
a) How will you communicate with the casualty officer if this patient is being referred to you from another hospital
which is 150 km away from your Burns center?
b) How do you classify chemical burns?
c) Give a brief outline of management plan for this patient?
d) What do you understand by secondary cell damage by chemical burns?
MAR 2011
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Q.3 A 17 years old male has presented to you with post burn deformity of right hand. He has adduction
contracture of the 1st web and flexion contractures of index and middle fingers.
a) How will you assess this patient?
b) Classify adduction contractures of 1st web.
c) How would you treat this contracture according to its severity?
OCT 2011
Q.4 A 40 years old lady is brought to the burns department with 25% flame burn in the kitchen to her face, neck
front of chest and both hands. Her weight is 68 kg and is known hypertensive.
a) How will you assess the depth and surface extent of the burn?
b) How would you recognize inhalational injury? Describe its management. c) Write down intravenous fluid
resuscitation schedule for 1st 36 hours for this lady.
d) How would you monitor your fluid resuscitation in this patient?
JAN 2008
Q.16 A 27 year old industrial worker is brought to you in casualty after accident when some chemical was spilled
over his face and chest.
What is the mechanism of injury of chemicals?
What will be the management in first 24 hours?
Mention briefly about management of chemical burn injury to Upper eye lid
JAN 2008
Q.4 A ten years old child while flying a kite with a wire has an electric injury from WAPDA street wires. He comes
with deep burns of fingers. His hand is stiff and swollen.
What are the likely injures he has sustained?
Discuss the short term and long term management?
MARCH 2004
Q.4: Write a short essay on the measures employed in the therapy of acute frostbite.
AUG 2007
Q.8 An aid worker in Kashmir after the earthquake fell into a crevice in the snow. He was evacuated 4 hours later.
Initially both his feet were numb but later became swollen and very painful with blister formation. After 4 days the
tips of the toes became black.
a) What is the physiology of the disease?
b) How do you classify it?
c) What measures if taken early can reduce the extent of damage?
OCT 2011
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Q.6 A 3 years old toddler sustained scalds to his left forearm and hand.
A) How would you manage his burn wound?
b) What are the possible early and late complications in this child? c) How would you prevent these complications?
JUNE 2008
Q.20 A young female presents with post burn mentosternal Contracture of 5 years duration.
a) What potential problem do you anticipate during anesthesia and how will you overcome it?
b) What are the options of reconstruction in this case?
c) What will be the post-operative management in her case?
JUNE 2008
Q.11
a) How does early excision and coverage of a burn benefit the patient?
b) What are the difficulties associated with this form of management?
c) What skin substitutes can be used in this situation?
MAR 2009
Q.14 A 28 years old lady presented with left axillary contracture after sustaining flame burn
a) How do you grade axillary contractures?
b) She has grade III axillary contracture on the affected side, how will you treat it?
c) How will you prevent recurrence after surgery in her case?
MARCH 2000
Q.8: Write a short essay on Musculoskeletal abnormalities as a complication of burns.
MAR 2004
Q.18 A 25 years old housewife sustains 70% TBSA deep burns while cooking.
a) How will you explain the prognosis of this patient to the relatives?
b) What is the usual sequence of events leading to tile mortality in such patients?
MAR 2005
Q.13
a) What are the characteristics of the burned hand claw deformity?
b) What is the underlying mechanism for the deformity?
c) What are the principles of treatment?
AUG 2007
Q.19 A 15 years old girl presents with severe post burn deformity of the hand of 5 years duration.
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The MP joints are hyperextended and the PIP Joints are flexed with their atrophic skin over the dorsum.
A) What are the factors which can contribute to 'the development of this deformity?
b) Give your plan of treatment
MAR 2009
Q-6 A 23 year old housewife sustains a flame burn (25% BSA) to the anterior torso and face while cooking in her
tiny kitchen.
What potentially fatal injury could she have sustained?
How can you suspect such injury on history?
What are signs and symptoms?
What are the three components of such an injury?
March 2012
Q.16. AN obese young lady with one week old 15% deep flame burn, treated at home, comes to burns unit with
septicemia shock. Her Na is 120, Bicarbonate 20, chloride 90 and potassium is 3.8meq/liter. Her wound swab
shows large numbers of staphylococci. In her management
a) What is your assessment of electrolytes?
b) How will you manage fluid and electrolyte imbalance?
c) Name five antibiotics from different groups of antibiotics which are usually effective against staphylococci?
d) What is the other measure that would help in this patient?
SEPT 2010
Q.16: An 18 month old girl fell on a gas heater, sustaining deep dermal burns to the face.
a) How would you manage this girl?
b) After 3 weeks, the burns have all healed. Give your long-term management plan.
AUG 2006
Q.17. With regards to skin substitutes for burn wound coverage
Give two advantages and two disadvantages of cultured keratinocytes
Write briefly on tissue engineered dermal substitutes.
AUG 2006
Q.20 A 30 years old man was trapped inside a room on fair, he has been brought to the hospital with some
breathing difficulty apart from presenting complaints.
a) How would you confirm the diagnosis of inhalational injury?
b) Manage the inhalational injury?
SEP 2004
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Q.11
Write an essay on principles of diathermy use.
How can you prevent diathermy Burns and treat them.
SEP 2004
Q.13 A 15 year old boy sustains fire burns affecting mainly his face and chest.
a. What are indications for admission of burn patient to hospital?
b. What factors suggest inhalational injury?
c. What diagnostic tests are done to confirm inhalational injury?
d. What are indications for ventilation?
MAR 2005
Q.20 A 30 years old man weighing 75 kg presents with burns affecting trunk, and upper extremities, approximately
40 % TBSA.
a) Calculate his energy requirement using the Curreri formula.
b) How would you assess the adequacy of nutritional support?
c) What is the prophylaxis against stress ulcers?
FEB 2007
Q.2: Regarding mass burn casualties:
a) What is triage and how is it applicable in mass burn casualties?
b) How can you predict mortality?
c) How can you decide which facility is optional for treating a particular burn patient?
MAR 2010
Q.9
a) What skin substitutes are available for resurfacing a wound?
b) What is their importance in the management of extensive burns.
April 2014
Q.10: A young male of 25 years while igniting a match in an underground water tank had blast and was brought to
the hospital in a state of altered consciousness due to inhalational injury.
a) What clinical findings will support your diagnosis?
b) What are the pathological changes at the alveolar level?
c) What precautions are required if ventilator support is provided due to ARDS?
April 2014
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Q.17: A 24 year old worker in a glass factory is brought to ER by his supervisor stating that while working, he
accidentally spilled hydrofluoric acid on his right hand.
a) What is the mechanism of injury by this chemical?
b) How will you manage this patient?
April 2014
Q.20: A patient with 30% surface burn comes to Emergency.
a) What fluids and electrolytes disturbances will occur in this patient in next 72 hours and what agents bring these
changes?
b) Why Ringer’s lactate is a better crystalloid for burn resuscitation then isotonic normal saline?
MAR 2013
Q.10 In you ward pantry one of the following attendant caught flames.
A) What would you do immediately?
b) What would be your management for the 1st 24 hours if he has got burn on face and chest?
Oct 2012
Q.12. A young boy aged 16 year was caught in a fire in his room due to short circuiting. He was evaluated in about
twenty minutes and brought to the hospital with severe facial burns, lacrimation and hoarseness. He has 20% BSA
mixed thickness burns.
a) How will you evaluate the patient?
b) Enumerate the investigations which will help you with the diagnosis
c) Give an outline of initial management
OCT 2012
Q.15) Large major deep burns >60% of TBSA present as thermal wound management challenge in our health care
delivery system. Early closure can significantly reduce the mortality and morbidity.
a) What are the surgical modalities, if made available, that can significantly improve the outcome in such patients?
b) Write a short note on skin bank.
OCT, 2012PII
Q.19. A young lady with homicidal acid burn to her face is brought to the hospital. On examination her right side is
involved including her right upper and lower ribs.
a) What are the consequences of eyelid damage?
b) How will you manage if her eyelids are unable to cover the globe?
c) What are the principles of eyelid reconstruction?
JUNE 2008
Q.6 A 28 years old male with 60% flame burns is admitted to the burns unit.
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a) What systemic pathophysiological changes you expect in this patient?
b) What are the likely complications in the first three days and their management?
MAR 2003
Q.2 A toddler accidentally bites on a live electric wire. Due to which he sustains a deep burn to the left oral
commissural area.
a) What are the potential early and long term complications?
b) Briefly describe three methods of commissural reconstruction of this case.
c) What should be the timing of reconstruction give reasons?
MAR 2006
Q.5 A Young man of 30 years sustained 40% BSA thermal burns (mostly partial Thickness). Enumerate the local and
systemic effects of bums on his body?
MAR 2006
Q.6 Write a short essay on tangential versus facial excision of partial thickness burns?
MAR 2010
Q.5 After a suicidal attempt a 34 yr. old lady is brought to the burn unit with 55% TBSA deep burns including the
face and chest.
a) How will you manage her?
b) Give method of assessment of inhalation injury?
c) How will you calculate her nutritional requirements?
MAR 2004PI
Q.6 A hospital is planning to add a ten-bedded burns unit.
a) Give an outline of the ideal plan to help the architect.
b) What factors in the plan can help reduce cross infection?
MAR28, 2013PII
Q.18 A 35 years old patient presented to you with 10% deep wound on anterior trunk sustained 1 week back.
a) What factors you will consider with managing the burn wound?
b) What topical antibiotics can be used on this wound to the advantages and disadvantages
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Burn management:
o Evaluation of burn pt:
• Determination of burn extent
▪ Rule of 9
▪ Lund and Browder
o Initial management:
• Standard ATLS protocol (ABCDE)
• Assessment of burn
• IV fluids
• Debridement
• Escharatomy
• Wound coverage
• Rehabilitation
o Burn depth assesement:
• Clinical exam
• High frequency ultrasound
• Laser Doppler flowmetry for blood flow assessment
• Punch biopsy for histologic confirmation
• Fluorescence
• Recent advances- Fiber optic confocal imaging
o Current novel and future therapies for management of burn scarring:
• Current techniques:
▪ Massage therapy
▪ Silicon therapy
▪ Intralesional corticosteroid therapy
▪ Pressure therapy
• Novel therapies and future therapies:
▪ Flurouracil, mitomycetric and bleomycin
▪ Autologous fat grafting
▪ Laser therapy
▪ Stem cells (future)
Technique of Excision:
Excision Tangential Fascial
Definition Is the sequential removal of layers of eschar and necrotic tissue until a layer of viable, bleeding tissue that can support a skin graft is revealed.
Involve excision of burned tissue and subcutaneous tissue down to layer of muscle fascia
Disadvantages Excising large surface area, substantial blood loss Difficult to accurately assess the viability of excised wound bed
Cosmetically unacceptable contour deformity Lymphedema of excised extremities
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Coverage option:
→ Secondary intention healing
→ Skin graft
→ Skin substitute
→ Flap coverage
o Local
o Regional
o Distant
→ Free tissue transfer
→ Tissue expansion
Wound care in burn patient:
1. Topical antibiotic in burn Mx:
o Mafenide acetate
o Bacitracin
o Mupirocin
o Neosporin
o Ploymyxin B
o Nitrofurazone
o Nystatin (antifungal)
2. Topical silver preparation:
o Silver nitrate
o Silver sulfadiazine
o Serous nitrate-SSD
o Sustained silver releasing system
o Silver impregnated biological material
3. Iodine preparation:
o Povidone-iodine
o Liposomal iodine (repithel)
o Cadexomer iodine (iodosorb)
o Other iodine preparation
4. Skin subsitutues:
o Synthetic skin substitute:
• Duoderm (polyurethane and hydrochloride)
• Opsite (polyurethane film)
• Omiderm (acrlamide film and hydroxymenthyl-methacrylate with fibroblast)
o Biosynthetic skin subsitute:
• Biobrane (silicon film, nylon, collagen-derived peptide) and
• TransCyte (polymer with fibroblast)
o Biological skin substitute:
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• Homologus skin
• Porcine skin
• Collagen derivative
• Human amniotic membrane and
• Cultural allograft
5. Photodynamic therapy
6. Antimicrobial peptide
7. Miscellaneous
Elbow contracture: Stern et al (anatomic) and Baux et al (functional)
1. Scar band :
a. Simple: involve only one joint- local flap
b. Complex: more than one joint- local flap + skin graft
2. Moderate: involve up to 50% of antecubital surface- local flap + skin graft
3. Major: more than 50% of antecubital surface- release + skin graft
4. Heterotopic ossification and deep contracture: joint capsule release, myotendon lengthening
and excision of ectopic bone.
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Axillary contracture: Kurtzman and stern classification
S .no Class Description
1.
2.
3.
4.
Type 1a
Type 1b
Type 2
Type 3
Involving anterior axillary fold
Involving posterior axillary fold
Involving both ant. And post. Axillary fold
Type plus axillary dome
Operative technique with indication:
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Neck contracture: o Prevention: early excision and grafting, early therapy and splinting
o Classification: by BM Achauer in 1991
Difficulties with neck contracture during intubation
and induction of anesthesia:
o Restricted mouth opening
o Decreased oropharyngeal space
o Limited atlanto occipital joint extension
o Reduced submandibular space compliance
and
o Heavily fibrosed neck
Plan to address it:
o Fibreoptic intubation
o First plan is awake oral fibreoptic
bronchoscopy (FOB) and intubation
thorough berman’s airway and alternative
plan was release of contracture and
microstomia correction under ketamine
anesthesia, followed by direct laryngoscopy intubation or laryngeal mask aiwary (LMA)
insertion, if FOB intubation failed.
Grade Description Treatment
Mild
Moderate
Severe
Extensive
Scar band involving less than 1/3rd of ant. Surface
Neck extension 95-1100
Greater than 1/3rd but less than 2/3rd of ant.neck
Neck extension 85-950
Greater than 2/3rd of ant neck surface
Neck extension < 850
Mentosternal adhesion in neglected cases
No extension at all.
Local flap or z-plasty
Tissue expansion (if more than
20% of ant. Surface involved)
Tissue expansion
Local flaps and skin graft
Flap or skin graft
(mutter flap, jabaley or bilobed)
Release with skin grafting
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Ist web space adductor contracture:
S.no Type (anatomical) Features Management
1. 2. 3.
Edge (dorsal/palmer) Medial Total
Comprising 80% of all ist web space contracure Often develop in patient sustaining either dorsal or palmer hand burn Along the dorsal or palmer side of web Scar sheet length deficiency is trapezoid shape Develop in patient sustaining total ist web space burn As a result cresent shaped fold is found Surface deficiency is trapezoid shape and spread from top of fold to ist metacarpal. Always severe and develop in case of total deep hand burn Scaring brings the thumb and 2nd metacarpal together Scar replace the web space
Skin grafting, Z-plasty variations (4-flap, 5-flap), V-Y plasty, first dorsal metacarpal artery flap, posterior interosseous flap, radial forearm flap, lateral arm flap, anterolateral thigh flap, and skeletal traction
Stern classification flexion contracture of digits:
S.no Type Features
1. 2. 3.
Type 1 Type 2 Type 3
With the MP joint flexion a PIP joint extension occurs With MPj flexion a full pip joint extension improve but not fully extended Fixed pip joint, regardless of MPj position
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Web space deformities (Burn syndactyly):
• Alexander et al propose a grading of web space deformities based on distance the scar band
extends along the length of involved digit.
S.No Grading Feature
1. 2. 3. 4.
Grade 1 Grade 2 Grade 3 Grade 4
Extends upto 1/4th of distance from MP to PIPj Extends upto 1/2nd of distance from MP to PIPj Extends upto 3/4th of distance from MP to PIPj Greater upto 3/4th of distance from MP to PIPj
• Treatment option: Two common methods, V-M and Tanzer Flap, Y-V plasty, an hourglass flap,
double z-plasty.
General principles in management of post burn hand deformity:
➢ While reconstructing a burnt hand, burn surgeon must concentrate on restoring function than
just an increasing the range of movement of individual joint, must restore pinch, ability to grasp
large object and power grip
➢ When a hand is severely involved, choose the first set of procedures that will bring maximum
benefit to patients
➢ Function is very important, but a burn surgeon must also constantly think of the aesthetic aspect
of reconstruction of burn hand
➢ Assess the deformity in each tissue component to make treatment plan
➢ Correction of deformity depends on excision of scar tissue and correcting deformity than on
type of skin cover provided
➢ Timing of surgery is crucial to get a good outcome in deformity correction
➢ Physiotherapy, splinting and scar control measurement are important to achieve good outcome
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Classification of Burn Scar contracture: by McCauley’s
Inhalational injury:
o Diagnosis is best made by consideration of circumstances surrounding the burn injury and
finding on physical examination
o Gold standard is Bronchoscopy (both therapeutic and diagnostic)
o ABG’s- carboxyhemoglobin level
o Physical findings includes:
• Facial injury
• Singed nasal hairs
• Sooth particles in proximal airway
• Carbonaceous sputum production and
• Hoarseness of voice
o Pathological level at alveolar level:
• Mucociliary transport is destroyed
• Alveolar collapse and atelectasis occur due to surfactant loss
• Alveolar macrophages are stressed leading to inflammatory response with chemotaxis
• Early inflammatory changes—diffuse exudate formation
o Management:
• History
• Physical exam
• Investigation (ABG’s, Bronchoscopy, Radiography)
• Management/Treatment: is supportive
▪ Standard ATLS protocol
▪ ICU Care
▪ Bronchoscopy
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▪ ABGs
▪ Hyperbaric oxygen- CO toxicity
▪ Aggressive pulmonary toilet
▪ Mechanical ventilation
▪ Medical adjuncts for treatment of smoke inhalation
• β –agonist
• pulmonary blood flow
• anticoagulant
• anti-inflammatory agents
▪ Rehabilitation
• Precautions to prevent ARDS in ventilator supported patient :
▪ Routine prevention strategies include:
• Elevation of head of the bed
• Frequent position changes and
• Oral care
• No use of antibiotic—may increase infection rate
• Extracorporeal membrane oxygenation is perhaps the most dramatic
rescue therapy
• Simple strategies such as prone positioning are more practical in the
hypoxic patient.
Electrical injury: (first documented case—french carpenter in 1879—250v)
o Low voltage: less than 1000v
o High voltage: greater than 1000v
o Management:
• Standard ATLS protocol
• Once stabilized it is important to ascertain the circumstances surrounding the injury,
voltage of injuring current, whether there was loss of consciousness at scene, whether
there was cardiac or respiratory arrest.
• Pt with low voltage- no loss of consciousness and no dysrhythmia—can be discharged
home
• Except, children with oral burn—monitor for labial artery bleed
• High voltage injuries:
▪ Extent of injury
▪ Presence of cutaneous burn
▪ Presence of myoglobinuria
▪ Parkland formula is applied and fluid administered to achieve a urine output of
30cc/h
▪ If myoglobinuria present—iv fluid—so that 100cc/h urine output is achieved
▪ Alkalinzation of urine
▪ Cardiac monitoring for 24 hours at least
▪ Fasciotomy or compartment release
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▪ Debridement after 3-5 days, in presence of myonecrosis
o High risk patient:
• Initial loss of consciousness
• Dysrhythmia
• Soft tissue damage and burn
• Elevated troponin level
• Chances of compartment syndrome
• Children with oral burn
• Inhalational injury
• Concomitant fracture or head injury
Complication of high voltage electrical injury: (Survive or Dies)
Psychological symptoms Neurologic symptoms Physical symptoms
Depression Post-traumatic stress disorder Insomnia Nightmares Anxiety Flashbacks Fear of electricity Frustration Hyperarousal Panic attacks Low self esteem Guilt Moodiness Memory loss/impairment Increased temper Poor verbal learning
Memory loss Numbness Headache Chronic pain Weakness Poor concentration Paresthesia Syncope Loss of balance Gait/ataxia Sciatica Carpal tunnel Seizures Dizziness Tinnitus Poor coordination
Generalized pain Fatigue/exhaustion Reduced range of motion Contracture Pruritus Musculospasm , fits ,twitch Headache Migraine Night sweats Fever Joint stiffness
Chemical Burn:
• Acid burn and base (alkali) burn
• Severity assessment: Depend on composition of agent, concentration and duration of contact
with agent. Alkali burn are more severe than acid burn.
• Alkali causes liquification necrosis and acid causes coagulative necrosis.
• Classification: According to their mechanism of destruction.
o Reduction
o Oxidation
o Corrosive agent
o Protoplasmic poison
o Vesicants and desicants
• Management:
o Remove the inciting agent (i.e. including clothes, shoes)
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o Copious irrigation with water (verified by checking pH of skin) except burn with chemical
powder, in this case it should be first dusted off than irrigation.
o Neutralization should never be attempted, it causes exothermic reaction
o If ocular injury has occurred, the eyes should be copiously irrigated (eye wash station
should be located in most workplaces where chemicals are used)
o It is important that the eye be forced open to allow for adequate irrigation
o Ophthalmologist should be consulted
• Hydrofluoric acid:
o Commonly used in glass and silicon chip industries
o Penetrates skin, reach to calcium i.e. bone—hypocalcemia
▪ Management:
• Irrigation
• Use of calcium
• If ineffective—than an intra-arterial calcium gluconate
• Decrease in pain is hallmark of effective treatment.
Principles of emergency treatment for chemical burn:
S.No Principle Action/Comment
1. 2. 3. 4. 5. 6.
Removal of chemical Irrigation (Dilution) Antidotes Extent of burn Systemic toxicity Ocular contact
Remove particulate debris, brush off dry chemical, water lavage Copious high-density shower with tap water, Do not immense Notable exceptions:
o Phenol: wipe off with 50% polyethylene glycerol,sponges before lavage
o Sulfuric acid and muriatic acid: soda lime or soap wash , avoid irrigation
o Chlorox: milk, egg white or 1 % sodium thiosulphate wash, then irrigation
Generally to be advoided: DILUTION NOT NEUTRALIZATION Notable exception:
o Hydrofluoric acid—subeschar injection of 10% calcium gluconate until pain is relieved (up to 0.5 ml/cm2 ), monitor Ca+ and Mg+
o White phosphorus—lavage with 1% or 2% copper sulfate. Immerse in water (note toxicity of copper sulfate)
Deceptive, be aware of tendency to underestimate extent of burn Consult nearest poison control center for information on toxicity of chemical agent Water lavage at scene Irriagate eyes with conitnous stream of 1-2 liter of normal saline via intravenous tubing and 18G angiocatheter
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7.
Inhalational injury
Ophthalmology consultation Be suspicious if chemicals is in aerosol form, consider intubation, supplemental oxygen, bronchoscopy for diagnosis
Radiation and radiation injury:
o Roentgen’s discovery of x-rays in 1895 was closely followed by the introduction of radiation
therapy for the treatment of variety of cancers and other disease process
o Radiation refers to the high-energy particles (α particles, β particles and neutrons) and
electromagnetic waves (x-ray and Ɣ rays) that are emitted by radioactive substances (uranium,
radon etc)
o Unit of radiation is Gray (Gy)
o Def: The absorption of 1J of ionizing radiation of 1 kg of tissue
o Atypical curative treatment could be in range of 60-80Gy
o The two main form of radiation exposure are irridation and contamination
o Advantage over surgery: is local treatment of disease with preservation of surrounding
uninvolved structure
o Disadvantages: include
• length of treatment need
• need for access to appropriate facilities and equipment
• potential additive and chronic effects of radiation therapy
o Delivery of radiaton: (for diagnostic and therapeutic purposes)
• Diagnostic: x-rays—amount of radiation 20-150kv.
• Therapeutic: is from 200kv- 25MV
• Brachytherapy: delivery of radiation from within patients body
▪ Pelvic cancer i.e: cervix or prostate or adjunctive for soft tissue tumors
o Radiation damage:
• Early effects: (within few weeks)- usually self-limited
▪ Tissue: skin and mucosa
▪ Sign and symptoms: erythema and skin hyperpigmentation
▪ Treatment: moisturizes, local wound care and observation
• Inhibit fibroblast proliferation –permanent damage to fibroblast—irreversible injury
• Late injuries: not limited to tissue fibrosis, telangiectasia, delayed wound healing,
lymphedema, ulceration, infection, alopecia, malignant transformation, xerostomia,
osteoradionecrosis and endarteritis.
• Long term effects: include constriction, microangiopathic change to small and medium
size vessels, which are significant when performing reconstruction procedure.
o General principles of treating irradiated wounds:
• The plastic surgeon will generally be called upon to care for three diifernet population of
irradiated patients.
1. First population: who have not yet received irradiation but will be receiving
radiation therapy intra or post-op.
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2. Second population: those who have already received radiation therapy and now
have a recurrent or new tumor
3. Third group: includes those who require reconstruction of intra-operative radiation
therapy
o Basic tenets for treating irradiated wound are:
1. Establish a diagnosis (rule out malignancy) and determine the extent of tissue
damage
2. If tumor is present, perform the appropriate workup and treatment
3. Thoroughly debride the radiated wound of all nonviable tissue and foreign bodies
and transfer as much tissue as possible to permit resection of even more of
periphery is questionable wounds
4. After adequate debridement has been obtained, usually in stages, reconstruct
osseous defects with vascularized bone grafts and soft tissue defect with well
vascularized non-irradiated soft tissue. All neurovascular bundles, bones, tendons,
and prosthetic material must be covered with healthy soft tissue.
5. In the case of pedicled flap, it is better to base of flap on a non-irradiated pedicle,
and in the case of free tissue transfer, it is best to use non-irradiated recipient
vessels. Consider preoperative evaluation of vessels and anticipate the need of vein
graft.
6. Reconstruction of these defects is challenging and fraught with high complication
rates, so always have a “plan B” in mind and anticipate complication.
o Recent advances/treatment modality: Autologous fat grafting
Frostbite injury:
o Frostbite is an injury caused by freezing of the skin and underlying tissues.
o Physiology:
• Cellular injury from ice crystals formation occurs during the period of cold exposure,
whereas microvascular thrombosis is thought to occur during reperfusion when the
affected limb is rewarmed. (Extreme cold—ice crystals formation—microvascular thrombosis—cell death and tissue necrosis)
o Classification:
Degree Features
First degree Second degree Third degree Fourth degree
Numbness, erythema, swelling, desquation, dysesthesia. Blisters of skin Tissue loss involving the entire thickness of the skin Tissue loss involving the entire thickness of the part, in deep structures, resulting in the loss of the part
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o Management:
• Removal of all wet clothes, gloves, shoes and socks
• Patient should then be wrapped in warm blanket
• Use of warm intravenous fluid,
• Bladder irrigation with warm saline,
• Placement of peritoneal catheter and
• Chest tube through which warm fluids can be administered and even
• Cardiopulmonary bypass (if available)
• Frostbite extremities should be rapidly rewarmed in water that is 400C.
• Typically, rewarming can be completed in 20-30min
• Adjunctive use of NSAIDS and calcium channel blockers.
o “Frostbite in January, amputate in July”.
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18. LASERS. (Light Apmlification by Stimulated Emission of Radiation)
APRIL 2016
Q6)
a) What are the basic principles underlying laser treatment of vascular and pigmented lesions.
b) What is the role of lasers in treating scars?
c) What are the complications of CO2 lasers?
OCT19, 2011PII
Q.12 Write an account of laser skin resurfacing with reference to principles, indications,
contraindications and complications.
SEP 2005, PI
Q.17 A 26 years old unmarried lady consults you for facial hirsutism. She is moderately obese. and gives
history of irregular menstrual cycles
a) How would you investigate the cause of her hirsutism?
b) Enlist important factors which will determine her suitability for LASER ablation. .
c)Enlist complications of laser hair removal
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Lasers with plastic surgery application:
Clinically useful lasers and other phototherapy devices:
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Specific laser treatment:
Vascular lesion Skin lesion
Haemangioma Capillary vascular malformation Venous malformation Lymphatic malformation Venolymphatic malformation Telangictesias / Rosacea Pyogenic granuloma Spider angioma Chery angioma Spider vein/ varicose vein Adenoma sebaceous/ tuberous sclerosis Pigmented lesion
Neurofibromatosis Syringomas/cylinderomas Actinic keratosis Verruca vulgaris Sebaceous nevi (nevus sebaceous of jadassohn) and rhinophyma Epidermal nevi Lentigines Hair removal Tattoo removal Cosmetic indication: Photoaging Wrinkles Dyspigmentation Elastosis Increased vascularity Precancerous lesion (actinic keratosis)
Basic principle of laser:
1. An, appropriate wavelength should be employed that can be absorbed preferentially by the
targeted tissue chromophore
2. The pulse duration of laser must be shorter than the chromophores thermal relaxation time,
which is the time required for the target to lose half of its peak temperature following
irradiation
3. The fluence (or energy) must be sufficient to achieve destruction of the target with in the
appropriate time interval.
Role of laser in scar:
• Atrophic scar:
o All patients with box scar (superficial or deep) or rolling scars are candidates for laser
treatment
o Different type of laser including non-ablative and ablative lasers are very useful in
treating acne scars
▪ Ablative scar:
• Achieve removal of damaged scar tissue through melting, evaporation
or vaporization
• Abrade surface and also tighten collagen fiber beneath
o i.e. CO2 laser and Erbium YAG laser
▪ Non-ablative laser:
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• Do not remove the tissue, but stimulate new collagen formation and
cause tightening of skin resulting in scar being raise to surface
o i.e. Nd:YAG and diode laser
o Hypertrophic Scar:
▪ PDL: pulsed dyed laser
• PDL decrease number and proliferation of fibroblast and collagen fibres
appear to looser and less coarse
• Also produce increase in MMP-13 (collagenase-3) actively and decrease
in collagen type 3 deposition—as a result scar get flatten and decreases
• Pruritus and pain get improved within the scar
Laser skin resurfacing (i.e. CO2)
• Principle: o The target must contain chromophores that absorb a specific laser wavelength o These chromophores should not be found in the surrounding tissue and o Minimization of damage of surrounding tissue is achieved through the high peak
pressure and short pulse width of laser energy in milisecon, nansecond or microsecond
domains.
• Indication: o Late prof. Isaac Kaplan “CO2 laser could (and should) be used for almost anything
surgical”. ▪ Skin lesions (nevis, seborrheic keratitis, syringoma, xanthalasmia) ▪ Warts ▪ Toenail disease ▪ Antiaging ▪ Hypertrophic scar ▪ Keloid and ▪ Atrophic scar
Complication:
• Short term:
o Infection
▪ Bacterial
▪ Herpatic or
▪ Fungal
• Long term
o Persistent erythema
o Hyperpigmentation
o Scarring
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Wavelength is sown on the x-axis (200–400 nm, UV; 400 - 7 - nm, visible light; 700 – 2000 nm, nearinfrared; > 2000 nm, mid-infrared) with an arithmetic scale from 200 – 1000 nm (1.0 µm) and a logarithmic scale from 1.0 µm and longer. The y-axis denotes the coefficient of molar extinction in logarithmic units. This can be thought of as denoting the degree of penetration into tissue: the lower the value on the y-axis, the better the penetration of light at the given wavelength. The absorption spectra are for the laser tissue chromophores comprising the major biological pigments (oxy- and deoxyhemoglobin and melanin) and water. Note the high absorption in water at 10,600 nm, the wavelength of the CO2 laser.
Manipulation of the biological effect of the laser beam through moving the handpiece towards or away from the
focal point of the beam, shown in 2a. (2b): Linear motion of the handpiece can give laser incision. Note the zone of
RTD adjacent to the ablated tissue. The focused beam can also be used to excise tissue en bloc, with traction being
applied to the lesion as indicated. Note the use of a wet cotton bud as a backstop to prevent damage to the
normal tissue behind the lesion. (2c): By slightly defocusing the beam, and reducing the irradiance, bulk
vaporization of tissue is achieved, again leaving a zone of RTD around the ablated tissue. (2d): By moving the
handpiece further away from the tissue, a dramatic drop in irradiance is achieved which will result in nonablative
coagulation of tissue. This is useful for swift hemostasis of small bleeding or oozing vessels.
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Complication and treatment of laser hair removal:
Complication Treatment
Burning Scarring Pigmentary changes Posttraumatic erythema and edema Reticulate erythema Ocular complication Pain Purpura
Topical steroid plus antibiotic, preventive (epidermal-cooling device) Preventive only (adjust laser’s parameter and epidermal cooling device) Topical steroid, preventive (adjust laser’s parameter, avoid sun exposure) Topical steroid Topical steroid Specific to each complication Epidermal cooling devices, topical anesthetic Preventive only (adjust laser’s parameter)
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