plastic

• Not favored by patients due to:
  • Intensive regime
  • Compliance issues

** Diuretics are relatively contraindicated

• Laceration
• Subcutaneous haematoma

• Lacrimal gland (produces tears)
• Puncta
• Canaliculi
• Lacrimal sac
• Nasolacrimal duct

Injuries to the medial aspects of the eye may result in permanent tearing if not repaired appropriately. It is important to consult OVS if damage is suspected.

Use silicon tubes to maintain patency of the drainage while the laceration heals.

Pitanguy's Line is located 0.5 cm below the tragus to 1.5 cm above the lateral eyebrow and is used for delineating the frontotemporal branch (temporal branch) of CN7.

A Tripod (Tetrapod) fracture involves the following combining fractures:

1. Zygomatic arch
2. Lateral orbital rim
3. Inferior orbital rim
4. Anterior & Posterior maxillary sinus walls

A Nasal bone fracture is a common type of fracture that is often detailed in ENT (Ear, Nose, and Throat) contexts.

Understanding the components of a Tripod fracture is crucial for:

• Diagnosis: Identifying the specific areas affected helps in accurate diagnosis.
• Treatment planning: Knowing the involved structures aids in determining the appropriate surgical or non-surgical interventions.
• Predicting complications: Awareness of potential complications related to the fractures can improve patient outcomes.

The components of the Primary Survey in the ATLS Protocol are Airway, Breathing, and Circulation.

The three main causes of airway obstruction in facial trauma are:

1. Bleeding from fracture sites or torn mucosa leading to blood clots.
2. Mandibular fracture causing a free floating segment to be pulled backwards by the tongue.
3. Foreign body such as loose teeth.

Key findings in the physical examination of the upper face include:

• Forehead laceration
• Crepitus
• CSF otorrhoea

Signs that might indicate an orbital injury include:

• Racoon eyes
• Subconjunctival haemorrhage
• Proptosis / Enophthalmos
• Pupil size changes
• Visual Acuity issues
• Diplopia

The gold standard investigation for facial fractures is a Plain CT Facial Bone plus Coronal Reconstruction.

The management steps for facial fractures include:

1. Gain access to the fracture site.
2. Use plates and screws to fix the fractures.

Associated injuries to look for in facial trauma include:

• Battle's sign
• Haemotympanium in the ear
• Globe injuries in case of orbital fractures (occurring in 25% of cases)
• Cervical injuries in case of facial fractures.

A skin graft is detached tissue without its own blood supply, requiring re-vascularization, while a skin flap is tissue that retains its own blood supply.

Consider the following factors for donor site selection:

1. Size
2. Colour
3. Hair pattern
4. Texture
5. Skin thickness

Additionally, avoid infected/necrotic tissues, irradiated tissues, exposed bone without periosteum, tendon without peritendon, and cartilage without perichondrium.

The stages of skin survival are:

1. Plastic imbibition - Passive absorption of nutrients via diffusion.

2. Inoculation ("To Kiss") ~ Day 3 - Cut ends of vessels on the underside of dermis form connections with the sound bed.

3. Revascularization ~ Day 5 - New vessels grow into the graft.

Reasons for graft failure can be categorized as follows:

1. Local flap: Local tissue rearrangement by rotation, advancement, or transposition.
2. Regional flap: Supplied by a sourced vessel.
3. Free flap: New blood supply by micro-anastomosis of vessels.

• Parallel to natural skin wrinkles.
• Tend to be perpendicular to the underlying muscles.

• Perpendicular to RSTLs.
• Parallel to the fibres of underlying muscles.

• Purplish turgid flap with brisk capillary return.
• Bleeding on pin prick.

• Stitches too tight.
• Blocked drain.
• Expanding haematoma.

1. Urgent assessment: General perfusion of the patient.
2. Management:
   • Remove stitches at bedside.
   • Book EOT for exploration.

Thigh (ALT Flap).

Multiple skin components, vastus lateralis muscle, sensory & motor nerves, and vein.

A 2D flap folded into a 3D flap.

Transfer bone to reconstruct the mandible.

Thigh used (rolled into a tube).

TRAM Flap / DIEP Flap.

The two main types are implant-based reconstruction and autologous flap reconstruction.

Texture-surfaced implants are associated with BIA-ALCL (Breast Implant-Associated Anaplastic Large Cell Lymphoma).

The TRAM flap procedure transfers lower abdominal skin, fat, and one of the rectus muscles to reconstruct the breast, while the DIEP flap uses skin and fat from the lower abdomen but spares the rectus muscle, preserving abdominal strength.

The TRAM flap procedure involves the superior epigastric pedicle, lower abdominal skin, fat, and one of the rectus muscles.

The DIEP flap procedure involves the skin and fat from the lower abdomen, with the DIEA, DIEV, and perforators dissected from the muscle, while sparing the rectus muscle.

The illustration indicates several flap procedures including DIEP, SIEA, Free TRAM, Pedicled TRAM, T-Dap (Latissimus dorsi muscle), LSGAP/SGAP, and TUG.

1. Expander placed under skin
2. Saline is slowly injected into expander
3. Inflate slowly over weeks
4. Stretches skin → Skin grows & reliable vascular network forms around expander

• Colour and texture good match
• No donor site morbidity
• Sensation

• Immature scar
• Irradiation
• Infection
• Skin graft
• Complications:
  • Haematoma
  • Infection
  • Exposure / extrusion of the expander
  • Pain
  • Neurapraxia
  • Pressure effects on surrounding tissue
  • Accidental perforation by missing an integrated filling port
  • Flipping of a remote filling port, making filling impossible

The purpose of fat injection is for breast augmentation.

1. Liposuction
2. Centrifugation / usage of sieve to separate layers

3. Re-inject harvested fat into tissues
   • Injected in droplets to ensure enough vascular tissue surrounding.

• The ear is too thick to be used as a graft.
• There is a concern that tissue may die before blood supply is re-established.

• A thin suture is placed within the vessel in an attempt to stent it.
• Capillary refill is used to confirm viable tissue.

Microtia is a congenital anomaly of the ear characterized by malformed and small ears.

• Use the patient's own rib cartilage to carve and produce a similar ear to the contralateral normal side.

1. Harvesting of costal cartilage
2. Fabrication of framework
3. Insertion of framework
4. Bolster dressing to improve appearance

Cosmetic ears can be attached by glue or osteointegrated buttons for the best cosmetic result.

Prominent ears are characterized by an ill-defined or loss of the anti-helical fold.

The goal of treatment is the reconstruction of the anti-helical fold to bring the ear closer to the head.

A burn is a wound caused by externally induced pathological change in energy levels within a tissue, leading to damage.

The main sources of energy that cause burns include:

1. Thermal (most common)

   • Scald injury
   • Flame injury
   • Flash injury
   • Contact injury
   • Cold injury

2. Special Burns

   • Electrical Burn (high voltage can have thermal effects)
   • Chemical Burns
   • Ionizing radiation (can cause thermal burns)
   • Combination of Thermal + Chemical (e.g., frostbite from liquid nitrogen)

The immediate priorities of treatment for burns include:

• Age of the patient
• Severity of the burn
• Presence of inhalational injury

The long-term outcomes to consider in burn treatment are:

• Cosmesis (appearance of scars)
• Functional outcome (limiting joint range of motion)

The three zones in Jackson's Burn Model are:

1. Zone of Coagulation

   • Innermost area with maximal tissue damage and irreversible tissue loss due to thrombosed vessels.

2. Zone of Stasis

   • Middle area with decreased blood flow; can either progress or recover. Viability will declare itself in 3-5 days after injury.

3. Zone of Hyperaemia

   • Peripheral area with vasodilation and increased blood flow, leading to spontaneous healing. In major burns affecting >25%, this zone can involve the whole body.

The Zone of Stasis is significant in burn management because:

• It has decreased blood flow and can either progress to further damage or recover.
• Proper management can maximize survival of this area, which includes:
  • Proper first aid (e.g., tap water irrigation, avoiding ice)
  • Limb elevation to reduce edema
  • Proper wound care to prevent infection

Complications that can arise from the Zone of Hyperaemia in burns include:

• Intravascular fluid depletion leading to shock
• Extravascular fluid accumulation resulting in tissue edema, which can cause:
  • Airway obstruction
  • Compartment syndrome in limbs and abdomen

• External compression from neck tissue oedema & eschar

• Mucosal oedema & secretion
• Narrowing of airway

• Potentially life-threatening
• Can deteriorate rapidly

• Less common, delayed presentation, caused by irritant gases
• Lung parenchymal injury by inhaled products of combustion
• Increased mortality

• Carbon monoxide poisoning

• Burns in enclosed space
• Explosions
• Unconscious patient

• Facial burn
• Singed nasal hair
• Change of voice

• Sooty sputum
• Laboured breathing
• Drooling
• Cough (productive and brassy/barking)
• Stridor

Secure airway BEFORE fluid resuscitation

• Intubation via tracheostomy

• After intubation; otherwise, resultant oedema may lead to airway compromise

CO is a product of incomplete combustion of hydrocarbons, such as indoor burning of charcoal and inefficient indoor heaters.

CO has a 240 times greater affinity for hemoglobin compared to oxygen, which significantly reduces the oxygen-carrying capacity of hemoglobin (Hb).

Pulse oximeter readings are inaccurate in CO poisoning because they cannot detect CO-Hb, leading to potentially misleading results.

A blood gas reading is required to accurately assess CO-Hb levels, as pulse oximeters are not reliable in this context.

The half-life of CO-Hb is 3-4 hours in room air, but it can be reduced to 30-90 minutes when given 100% oxygen.

The acute management steps include:

1. ABC Resuscitation: 100% O2
2. Acute investigations (Ix)
3. Measure CO-Hb level
4. Perform arterial blood gas (ABG)
5. Conduct an ECG

ICU care should be considered if there are features of tissue hypoxia, such as:

• CNS symptoms: Syncope, coma, seizure
• Cardiac issues: Cardiac ischaemia, ventricular arrhythmia
• Metabolic acidosis
• CO-Hb levels of ≥25% or >15% in pregnant women or children

HBO treatment should be considered if there is:

• Evidence of tissue hypoxia
• Symptoms such as headache or nausea
• Abnormal mental or neuropsychiatric status

Stable patients can be discharged when CO-Hb levels are <10% and they are asymptomatic.

• Acid burn: Causes coagulation necrosis, which limits penetration due to the formation of a coagulum.
• Alkaline burn: Causes liquefaction necrosis, leading to protein denaturation and saponification of fats, which does NOT limit tissue penetration.

The severity of a burn depends on:

1. Chemical factors:
   • pH
   • Concentration
2. Injury factors:
   • Duration of contact time
   • Total Body Surface Area (TBSA) percentage involved

1. Document the offending agent.
2. Test skin with litmus paper if the agent is unknown.
3. Stop damage:
   • Remove contaminated clothes.
   • Shave hair if the scalp is involved.
4. Continuous irrigation with Normal Saline until neutral pH, ensuring contaminated irrigation does not run onto unaffected skin.

Clinical features:

• Pain out of proportion.
• Can be fatal if 5% TBSA burn with >50% concentration.

Management:

• General management includes a first aid kit and possible ICU support.
• Nail plate removal may be necessary.
• Close monitoring for cardiac arrhythmias and blood electrolytes (Ca, Mg).
• Use Calcium Gluconate gel (75mL KY jelly + 25mL of 10% calcium gluconate) and SC Calcium Gluconate injection (10% calcium gluconate 0.5mL/cm² of burn BSA).

Major complications of electrical burns include:

• Cardiac injury
• Rhabdomyolysis
• Compartment syndrome

Close monitoring is essential, including continuous cardiac monitoring and checking urine color for myoglobinuria.

Urgent investigations for a patient with an electrical burn include:

• ECG
• Cardiac enzymes
• Creatine Kinase (CK)
• Lactate Dehydrogenase (LDH)

• Thermal (most common):
  ◦ Scald injury
  ◦ Flame injury
  ◦ Flash injury
  ◦ Contact injury
  ◦ Cold injury
• Special Burns:
  ◦ Electrical Burn
  ◦ Chemical Burn
  ◦ Ionizing radiation

• Enclosed area: Higher chance of inhalation injury.
• Open area: Lower risk.
• It is important to explore signs and symptoms of inhalation injuries if the burn occurred in an enclosed space.

• Longer contact time with the source of energy results in a greater depth of burn.

• Water from cold tap is the most effective immediate management.
• Do not use ice as it can cause further tissue damage.

• The Rule of Palm estimates the burn surface area by using the size of the patient's closed palm (including fingers), which equals 1% TBSA.
• Note: This method is not accurate for obese patients.

• The Rule of Nines estimates burn surface area as follows:
  • Head & Neck: 9%
  • Each Upper Limb: 9% (total 18% for both)
  • Front trunk: 18%
  • Back trunk: 18%
  • Each Lower Limb: 18% (total 36% for both)
  • Perineum: 1%

• The Lund Browder chart is used in burn units for the most accurate assessment of burns.
• It includes components such as:
  ◦ Location of burn
  ◦ Partial vs full thickness
  ◦ Diagrammatic representation
• It is reliable in children and can also be used in teenagers and adults.

The Lund and Browder Chart is used to estimate the percentage of total body surface area (TBSA) affected by burns, providing a more accurate assessment than simpler methods.

The Lund and Browder Chart provides a more detailed assessment by accounting for different body regions and age variations, while the Rule of Nines uses a simpler method with fixed percentages for body sections.

In adults, the head accounts for 3.5% of the total body surface area according to the Lund and Browder Chart.

Each arm accounts for 4.5% of the total body surface area on each side according to the Rule of Nines.

The anterior trunk accounts for 18% of the total body surface area in the Rule of Nines.

In a 15-year-old, one thigh accounts for 4.5% of the total body surface area according to the Lund and Browder Chart.

The genitalia area accounts for 1% of the total body surface area in the Rule of Nines, which is important for assessing burn severity and treatment needs.

The Lund and Browder Chart provides specific percentages for burn areas that vary by age, reflecting the differences in body proportions as a person grows.

• Erythematous skin
• No blistering
• Painful

Heals without surgery in 14 days.

• Blistering+
• Impaired neurovascular function
  • Capillary refill >2s
  • Reduced pain sensation

• Complete loss of dermis & epidermis
• No capillary refill
• Fixed red staining
• All blood coagulated to skin
• Painless/insensate

Impaired distal limb perfusion and difficult ventilation if over the chest.

30 mmHg, measured by Stryker needle.

1. Escharotomy (LA)

   • From normal unburnt skin to normal unburnt skin
   • Full thickness skin incision with diathermy

2. Fasciotomy (GA)

   • Fascia incision of involved muscle compartment

Destruction of RBC in skin vessels leads to increased hydrostatic pressure, reduced oncotic sequestration, and increased capillary permeability.

• Paediatric patients not in a dedicated paediatric facility
• Special requirements including social, emotional, and rehabilitation needs

• Face
• Hands and feet
• Genitalia and perineum
• Major joints

• Full thickness burns
• Partial thickness burns covering more than 10% of body surface area (BSA)

• Complicated burns such as inhalation injuries, chemical burns, and electrical burns
• Presence of complex comorbidities

• Resuscitation (ABC)
• Irrigation of the burn area
• Addressing concomitant injuries

• If healing is expected within 2-3 weeks, a conservative approach is taken.

• Surgery for superficial and superficial partial thickness burns, including debridement and skin grafting.

• Treatment of complications such as cosmetic concerns related to scars and limitations of joint movement due to contractures.

1. Airway: Intubation for inhalation injury
2. Breathing: Oxygen supplementation
3. Circulation: Establish IV access
4. Disability: Assess GCS and pupils
5. Exposure: Control environmental factors

• Administer fluids according to the modified Parkland Formula to ensure adequate hydration.

• IV Morphine at a dose of 0.1 mg/kg, titrated to effect.

• A head-to-toe examination, obtaining SAMPLE history, checking for tetanus status, documentation, and supportive treatment.

• Adults: >20% TBSA involved
• Children: >10% TBSA involved

Fluid resuscitation is calculated as: 2 to 4 mL × Weight (kg) × TBSA%

• 4mL: Tolerated by younger individuals
• 2mL: For elderly patients (risk of fluid overload)
• Administered in the first 24 hours from the moment of burn:
  • 50% of fluid given in the first 8 hours
  • Remaining 50% in the next 16 hours

Hartmann's solution is used for fluid resuscitation.

• Adults: 0.5 mL/kg/h (30-50 mL/h)
• Children: 1 mL/kg/h

1. Aggressive rehydration (NS & D5)

   • Aim for urine output of 200-300 mL/h

2. Urine alkalinization

   • Use NaHCO3 (50mmol/L) in every 2nd/3rd bottle of D5
   • Aim for urine pH >6.5
   • Monitor arterial pH, HCO3, Ca
   • Stop if arterial pH >7.5, HCO3 >30mmol/L, or symptomatic HypoCa

3. Osmotic diuresis

   • Administer 20% mannitol at 1-2g/kg over 4h
   • Keep plasma osmolar gap below 55mOsm/kg

1. Remove clothing
2. Irrigation
   • Under cold water (e.g., tap water) for 10-15 minutes
   • Effective within 3 hours to reduce ongoing damage
   • Do NOT use ice (causes vasoconstriction and reduced blood flow)
3. Elevate affected limbs above heart level
   • Reduces edema and improves tissue perfusion
   • Remove watches and jewelry

The procedure involves expanding the skin by creating holes through a mesher, allowing for an expansion ratio of 1:1.5/1.6.

• Increases surface area
• Holes allow for drainage of seroma and haematoma

• Concerns regarding cosmesis
• Large holes can lead to poor healing due to more areas not being covered

Integra consists of two layers:

1. Collagen layer: Placed on the debrided burn wound.
2. Silicone layer: At the surface of the substitute epidermis, providing waterproofing and protection.

Blood vessels grow into the collagen layer, creating a neodermis that turns pink. The silicone layer can then be removed for the placement of a skin graft in a second stage operation.

Meek Micrografting is a grafting technique preferred in total body surface area (TBSA) greater than 30%.

• Requires a small donor site
• Allows for a large expansion ratio
• Graft is easy to manipulate
• Promotes fast and uniform epithelization due to close graft islands

It is time and manpower consuming.

Formation of bands that can affect activities of daily living (ADL).

Free flap is a management option for burn scars.

The Fitzpatrick Scale is a numerical classification schema for human skin color, categorizing skin types based on their reaction to sun exposure.

The six skin types are:

1. Type I: Light, Pale White - Always burns, never tans
2. Type II: White, Fair - Usually burns, tans with difficulty
3. Type III: Medium White to Olive - Sometimes mild burn, gradually tans to olive
4. Type IV: Olive Tone - Rarely burns, tans with ease to moderate brown
5. Type V: Light Brown - Very rarely burns, tans very easily
6. Type VI: Dark Brown - Never burns, tans very easily, deeply pigmented

The key components include:

• Inspection: Site, Size, Shape, Surface, Skin, Scars, Edges/Borders
• Palpation: Temperature, Tenderness, Consistency, Mobility, Pulsation, Reducibility, Regional LNs

The 'Surface' category refers to the Size, Shape, and Site of the skin lesion.

A darkly pigmented ulcerated lesion may indicate a malignant skin lesion, requiring further evaluation.

Special comments to consider include:

• Consistency/Compressibility
• Transillumination
• Tethering
• Fluctuance

Seborrheic Keratoses are benign overgrowths of the basal cell layer of the epidermis, characterized histologically by:

• Hyperkeratosis: Thickening of the keratin layer
• Acanthosis: Thickening of the prickle cell layer
• Hyperplasia: Of pigmented basaloid cells

Seborrheic Keratoses present as benign, pigmented lesions, commonly found in individuals aged 40-50 years and older. They may itch with age and are most commonly located on the head and trunk, particularly in sun-exposed areas. They can appear as single or multiple lesions with a 'stuck-on' appearance, varying in pigmentation from light brown to black, and have a velvety or warty surface.

Management options for Seborrheic Keratoses include:

• Non-surgical: Conservative observation
• Surgical: Superficial shaving or cautery

Actinic Keratosis is a pre-malignant lesion characterized by atypia of the epidermis that does not involve full thickness. It results from UV radiation damage to keratinocytes due to repeated sun exposure, particularly UV-B, leading to thickening and scaling of the keratin layer, resulting in hard scaly plaques.

Actinic Keratosis is a pre-malignant lesion with a 25% risk of transforming into squamous cell carcinoma (SCC) if untreated. It is more common in older individuals with chronic sun exposure and light skin.

Physical examination findings for Actinic Keratosis include:

• Site: Most commonly found in sun-exposed areas such as the face, ears, neck, limbs, and dorsum of hands.
• Appearance: Typically presents as multiple yellow-grey or brown scaly plaques with ill-defined borders, often in the background of sun-damaged skin.

Management options for Actinic Keratosis include:

• Investigation: Biopsy required for diagnosis
• Non-surgical: Cryotherapy, Photodynamic therapy (PDT), Topical therapies such as 5-FU, Imiquimod, and Retinoic acid
• Surgical: Shaving of affected skin

Bowen's Disease is a pre-malignant lesion, also known as SCC in-situ, primarily affecting females. It is associated with HPV types 16 and 18 and has a risk of evolving into squamous cell carcinoma (SCC) in 10-20% of cutaneous lesions and over 20% of mucosal lesions. It is characterized by an erythematous plaque-like lesion with sharply demarcated red and scaly borders, typically measuring 1-3 cm in diameter, found on skin and mucous membranes.

Keratoacanthoma is a pseudo-benign or pseudo-malignant lesion characterized by a benign overgrowth of hair follicle cells that produces a central keratin plug. It is an epithelial neoplasm with atypical keratinocytes in the epidermis, often associated with HPV, UV radiation, and chemical carcinogens. It typically presents as a rapidly growing lesion that forms within 6 weeks and may regress if left untreated, leaving a depressed scar.

Keratoacanthoma presents as a rapidly growing lesion, often found in males over 50 years old. Important differential diagnoses include:

1. Squamous Cell Carcinoma (SCC) - Difficult to differentiate clinically; treat as SCC until proven otherwise.
2. Hypertrophic Solar Keratosis - Similar appearance but different management.

Physical examination findings for Keratoacanthoma include:

Management options for Keratoacanthoma include:

1. Investigation: Biopsy is required.
2. Non-surgical: Observation and monitoring for regression, especially in younger patients.
3. Surgical: Complete excision of the lesion with histology, particularly in elderly patients due to a high index of suspicion for SCC.

• Patient factor: Caucasian
• Naevus factors:
  • Multiple Naevus
  • Giant melanocytic naevi (>20cm or >2% TBSA)
  • Congenital melanocytic naevi (100x more likely)

• Limited to papillary and upper reticular dermis
• Does NOT involve skin appendages

• Melanocytic proliferation at the dermo-epidermal junction
• Can be found at any site
• Tendency to progress to compound/intradermal naevi

• Maculopapular pigmented lesions appearing in adolescence
• Due to junctional proliferation of melanocytes

• Cessation of junctional proliferation
• Proliferation of dermal melanocytes

• Histologically similar to compound naevi
• Features: Large, hairy, pigmented, and verrucous
• Giant lesions: >20cm or >2% TBSA
• Risk of malignancy: 5% of malignant transformation, most common within the first 5 years of life

• 10-15% risk of transformation, classically to BCC, but also to SCC, sebaceous, and apocrine carcinomas

• Hamartomatous lesion present at birth in 0.3% of neonates

• Accumulation of mature sebaceous glands with overlying epidermal hyperplasia

A lipoma is a benign tumor arising from adipose tissue and can occur anywhere there is fat in the body.

The differential diagnosis for lipomas, particularly when they are larger than 5 cm, is liposarcoma.

Dercum's Disease is associated with multiple painful lipomas.

The clinical features of a lipoma include:

1. Slippage sign
2. Pseudo-fluctuant consistency
3. Soft and rubbery texture
4. Normal overlying skin

Imaging techniques used for investigating lipomas include Ultrasound (USG) and MRI.

The management of lipomas includes:

1. Observation
2. Surgical excision to rule out liposarcoma
3. Liposuction for smaller scars

Sebaceous cysts are also known as epidermal cysts.

A sebaceous cyst is an inclusion cyst due to the implantation of epidermis into the dermis, originating from the proliferation of epidermal cells from the infundibulum of hair follicles.

The histological features of sebaceous cysts include:

• Cyst lined by stratified squamous epithelium
• Filled with keratin

The clinical features of sebaceous cysts include:

1. Attached to skin
2. Rounded or hemispherical shape
3. Smooth surface
4. Cystic nature
5. Indentation sign positive
6. Slipping sign negative
7. May have a punctum

Complications from sebaceous cysts can include trauma and infection.

Gardner Syndrome (Familial Adenomatous Polyposis - FAP) is associated with sebaceous cysts.

The management of sebaceous cysts includes:

1. Elliptical excision with inclusion of the punctum (if present)
   • If excised without the punctum, they may recur.
2. If infected, perform incision and drainage (I&D) and administer antibiotics.

Skin tags are small flesh-colored growths that hang off the skin, often with stalks. They are most commonly found on the neck, armpits, and groins, particularly in older individuals and in areas where skin rubs against skin or clothing.

Skin tags are most common in older people and typically occur in areas where skin rubs against skin or clothing.

Warts are viral in origin, caused by the Human Papillomavirus (HPV), and are contagious.

Warts often have a 'cauliflower' appearance, characterized by a rough, raised growth.

Treatment options for warts include:

1. Salicylic acid
2. Silver nitrate
3. Cryotherapy
4. Electrocautery
5. Laser (not recommended)
6. Excision

Basal Cell Carcinoma (BCC) most commonly occurs between 40-90 years old.

Basal Cell Carcinoma (BCC) is the most common skin cancer regardless of ethnicity.

A large proportion of BCC cases in Hong Kong occur in non-sun exposed areas.

The primary site for Basal Cell Carcinoma (BCC) is the head and neck, accounting for 85% of cases.

Basal Cell Carcinoma is locally destructive but rarely metastasizes.

Pre-malignant lesions associated with BCC include Actinic Keratosis and Bowen's Disease (SCC in-situ).

Histologically, BCC is characterized by sheets/nests of small round basophilic cells and peripheral palisading.

Congenital predisposing factors for BCC include Xeroderma pigmentosum and Gorlin Syndrome.

Gorlin Syndrome is inherited in an autosomal dominant pattern.

The main features of Gorlin Syndrome include multiple BCC, palmar pits, odontogenic cysts, bifid ribs, calcification of falx cerebri, and learning difficulties.

The most common clinical subtype of BCC is Nodular/Nodulo-ulcerative, which is characterized by a well-defined rolled, pearly edge and central ulceration (Rodent ulcer).

Pigmented Basal Cell Carcinoma contains melanin and can be confused with malignant melanoma, but it is typically found in Hong Kong.

Sclerosing Basal Cell Carcinoma is flat/depressed with an ill-defined edge and may be ulcerated, occurring later in the disease progression.

Superficial Basal Cell Carcinoma presents as erythematous scaly patches and can be confused with Bowen's Disease.

• Hair-bearing skin of sun-exposed areas
• Most common on the face, especially around the eyes
• More prevalent in elderly individuals

• Well-defined rolled, pearly edge
• Central ulceration
• Telangiectasia

• Fixation of BCC deep to the skin indicates deep local invasion

• Wide excision under local anesthesia with 3mm margins is recommended, achieving a 95% clearance rate.

• 4-6mm margins are recommended for lesions greater than 2cm or morpheic lesions.

• Mohs micrographic surgery involves removing one layer of tissue at a time and checking under microscopy for the presence of cancer.

• Radiotherapy (less effective, used for elderly or non-surgical candidates)
• Cryotherapy
• Curettage
• Intra-lesional interferon (buys time but not curative)

• Radiotherapy is typically administered for 5 days in a row with cycles until all cancer is removed.

SCC has a 1/3 incidence compared to BCC.

SCC arises from epidermal cells that normally migrate to the skin surface to form the superficial keratinizing squamous layer.

The degrees of differentiation in SCC are:

1. Well differentiated (keratin production+)
2. Moderately differentiated
3. Poorly differentiated

Congenital factors:

• Xeroderma Pigmentosum (100% Risk)

Acquired factors:

• Accumulative sun exposure
• Ionizing radiation
• Industrial carcinogens (e.g., arsenic)
• Pre-existing skin lesions (e.g., Actinic Keratosis, Bowen's Disease, Leukoplakia)
• Viral infections (e.g., HPV 5 & 8)
• Immunosuppression (e.g., post-transplant therapy, HIV infection)
• Chronic cutaneous ulceration (e.g., Marjolin Ulcer)

Individuals with Xeroderma Pigmentosum have a 100% risk of developing Squamous Cell Carcinoma, as well as risks for Basal Cell Carcinoma and Malignant Melanoma.

Poor prognostic indicators for SCC include:

1. ↑ Depth of invasion
2. Vascular invasion
3. Perineural invasion
4. Lymphocytic infiltration
5. Poorly differentiated tumors have a higher recurrence rate (28%) compared to well-differentiated tumors (7%).

Children with Xeroderma Pigmentosum typically have a limited lifespan and may die before the age of 20 due to the disease.

The recurrence rate of SCC is:

• Poorly differentiated: 28%
• Well-differentiated: 7%
• There is a 2-3% risk of occult lymph node metastasis at presentation.

Early disease: Red scaly patches

Late disease: Nodular lesions with vascular (red-brown) appearance, raised and everted edges, possible erosion of facial architecture, and central ulceration.

• Low risk: Complete excision with a margin of ≥4-6mm
• High risk: Complete excision with a margin of ≥1cm
• Wider margins may be required if the lesion is on the trunk.

The risk for lymph node metastasis is small (<1%) but increases with:

1. Size of the lesion (>2m)
2. Thickness of the lesion (>4mm)
3. Poorly differentiated tumors
4. Recurrent disease

Radiotherapy is indicated for:

• Primary therapy for patients over 60 years
• Adjuvant therapy for cases with perineural involvement or positive margins
• Palliative therapy for large inoperable or recurrent SCC

Mohs's Micrographic Surgery is used for skin lesions located in special areas such as eyelids, ears, or nasolabial folds, particularly when there is a risk of lymph node metastasis or when the lesion is recurrent.

• Uncommon but highly fatal
• Accounts for 5% of all skin cancers
• Responsible for 64% of all skin cancer deaths
• Rare in Orientals, most common in Australia

• Malignant transformation of melanocytes
• Consists of loose nests of melanocytes in the basal cell layer
• Derived from neural crest cells
• Invades the epidermis leading to destruction and ulceration
• Penetrates deeper into the dermis and subcutaneous fat

• Xeroderma Pigmentosum
• Dysplastic nevus syndrome
• Giant congenital melanocytic naevus
• Patient demographics: Female, Fitzpatrick I & II, higher socioeconomic group

• Family history positive in first-degree relatives
• Environmental factors: Accumulative sun exposure, especially in fair-skinned people with red hair
• Pre-existing skin lesions: More than 20 benign pigmented naevi (prone to lentigo maligna)
• Infection: Viral warts (HPV 5 & 8)
• Immunosuppression: Post-transplant anti-rejection therapy, HIV infection

• Avoidance of causative factors:
  1. Reduce sun exposure
  2. Wear sunscreen (SPF 15+)

• Pigmented lesions (red / white / blue)
• Irregular edges
• Intra-lesional colour differences
• Most commonly palpable but thin

The most common site for Superficial Spreading melanoma in women is the leg.

Acral Lentiginous melanoma is most common in Asians, accounting for 5-10% of cases, and represents 50% of all melanoma cases in Asians.

Common sites for Acral Lentiginous melanoma include the subungual area, palm, and sole.

The Glasgow 7-Point Checklist is recommended for primary care professionals to evaluate pigmented skin lesions for possible melanoma.

A score of ≥3 on the Glasgow 7-Point Checklist is suggestive of possible melanoma, warranting urgent referral.

The major features (2 points each) are:

1. Change in Size
2. Change in Shape
3. Change in Colour

The minor features (1 point each) are:

1. Diameter ≥7mm
2. Inflammation
3. Crusting / Bleeding
4. Mild itch / Altered sensation

Nodular melanoma is characterized by being protruding with well circumscribed margins.

Lentigo Maligna is a type of melanoma that is pre-existing and can develop into intra-lesional ulcer or colour changes.

• A: Asymmetry
• B: Border Irregularity
• C: Colour variation (intra-lesional)
• D: Diameter (large)
• E: Evolution (changing with time)

• E: Elevated
• F: Firm
• G: Growing

• Loss of skin creases around lesion
• Presence of ulceration
• Evidence of bleeding from lesion
• Presence of halo of brown pigment in skin around lesion
• Presence of satellite nodules of tumour around lesion

Breslow's thickness is a key prognostic indicator for melanoma, with worse prognosis associated with thicker lesions. For example:

• Perform a biopsy with 2mm of normal skin and a cuff of fat.
• Send the biopsy for histopathology to evaluate:
  1. Breslow thickness
  2. Histologic ulceration
  3. Peripheral & deep margin status of biopsy
  4. Microsatelltosis

• PET-CT
• CXR (Chest X-Ray)
• CT/MRI

Clark's levels of invasion are less useful because:

• The reticular dermis varies in thickness in different regions.
• There is too much variation in the levels.
• It is primarily descriptive rather than prognostic.

The procedure involves:

1. Primary excision with margins.
   • For subungual cases:
     • Remove the nail plate, then remove the nail bed.
     • Avoid merely performing an incision biopsy.
2. Secondary excision may be necessary after histo-pathological results of the excisional biopsy.

The procedure for Sentinel Lymph Node Biopsy involves:

1. Injecting dye and radioisotope into the lesion.
2. Sampling the lymph node and sending it for pathology.
3. Proceeding to lymph node dissection if SLNB is positive.

Note: The frozen section for melanoma is not reliable and is not used.

Targeted therapy for BRAF V600E mutation includes:

• BRAF inhibitors such as Vemurafenib.

Extramammary Paget's Disease (EMPD) is characterized by:

• Intraepithelial adenocarcinoma with a predilection for apocrine gland-bearing skin (e.g., penoscrotal, vulval, groin, axilla).
• Approximately 20% can become invasive.
• 7-40% are associated with internal malignancies (e.g., bladder, colon, kidney cancer).
• Symptoms include pruritus and it is commonly misdiagnosed as eczema or psoriasis.

Treatment involves:

• Wide excision with a 2cm margin.
• Frozen section of the margin.
• Extending beyond the visible border diffusely/multifocally.
• There is a high rate of recurrence.

1. Vascular malformation (apparent at birth)
2. Haemangioma (apparent after birth)

• Errors of vascular development occur around the 8th week of gestation.
• High flow types include arterial and arteriovenous malformations (AVM, AVF), which can lead to tissue overgrowth and cardiac failure.
• Low flow types include capillary, venous, and lymphatic malformations, which are most commonly seen and are mostly benign.

Vascular malformations tend to remain static but grow in proportion with the patient.

Klippel-Trenaunay Syndrome is associated with tissue and bone hypertrophy.

• Skin capillary malformation
• 1/4 associated with Sturge-Weber Syndrome
• Early presentation: flat and pink lesion
• Late presentation: deepens to purplish color, may have nodules

• Intellectual disability
• Leptomeningeal vascular malformations
• Seizures
• Hemiparesis

• Glaucoma
• Homonymous hemianopia

Growth hormone (GH) deficiency is associated with Sturge-Weber Syndrome.

The treatment involves Pulse Dye Laser (PDL) therapy, which works by:

1. Energy absorbed by erythrocytes
2. Heat transferred to vessel walls
3. Vessels contract down
4. Lesion improves with reduced flow

• 70% of patients experience reasonable improvement
• 10% have a good response
• 10% have a poor response

A haemangioma is a benign vascular neoplasm of unknown cause, often appearing as a raised, erythematous lesion with an irregular border.

Capillary haemangioma is associated with AW/PHACE syndrome and typically presents as a raised, erythematous but non-blanchable lesion with an irregular border.

Haemangiomas commonly appear in the first few weeks after birth, with 30% presenting at birth. They grow rapidly, often faster than the child, and typically undergo involution, with 50% resolving by 5 years and 90% by 9 years.

Complications of haemangiomas include:

1. Bleeding and ulceration
2. Critical site involvement leading to:
   • Airway issues: Stridor, hoarseness of voice
   • Peri-orbital issues: Visual defects, squint
   • Peri-auricular issues: Hearing defects
   • Abdominal issues: Haemangiomas on liver and spleen
   • Flexor region issues: Bleeding leading to secondary bacterial infection
3. Kasabach-Merritt Phenomenon: A triad of giant haemangioma, thrombocytopenia, and consumptive coagulopathy
4. Heart failure: High output cardiac failure

The Kasabach-Merritt Phenomenon is characterized by a triad of giant haemangioma, thrombocytopenia, and consumptive coagulopathy, resulting from platelet trapping in the vascular tumor, leading to thrombocytopenia.

Investigations for haemangiomas include:

Treatment options for asymptomatic haemangiomas include:

1. Antibacterial medication

2. Splinting and casting

   • Immobilization promotes healing.

3. Negative pressure wound therapy

   • Reduces exudate and encourages wound healing

1. Healing by Secondary Intention

2. Direct Closure (primary intention) + delayed direct closure

3. Skin Graft

4. Local or Regional Flap

5. Distant Pedicled Rotate Flap

6. Free Flap (with microsurgery)

The pros of autologous flap reconstruction include:

1. Better cosmesis
2. Permanent results
3. No foreign body involved.

The cons of autologous flap reconstruction include:

1. More difficult to perform
2. Specific complications associated with each choice.

In the pedicled flap TRAM procedure:

1. A section of skin and fat attached to the rectus abdominis is cut from the abdomen.
2. The flap remains attached to the body by a piece of muscle.
3. The flap is rotated and passed under the skin to the new location on the chest.
4. There is a rare chance of complete flap failure, but a higher chance of hernia without abdominal muscles, which can be prevented by placing abdominal mesh.

The DIEP flap (Deep Inferior Epigastric Perforator Flap) is considered the current gold standard because:

• It spares muscle, preserving abdominal strength.
• Blood vessels are anastomosed to the vessels in the breast using micro-surgery.
• The abdominal wall is not weakened after surgery, but there is a risk of complete flap failure if the anastomosis fails, requiring microvascular surgical techniques.

Other options for autologous flap reconstruction include:

• SIEA (Superficial Inferior Epigastric Artery)
• LSGAP (Lower Saphenous Graft Artery Perforator)
• SGAP (Superior Gluteal Artery Perforator)
• TUG (Transverse Upper Gracilis)

Pros of implant-based reconstruction:

• No donor site morbidity.

Cons of implant-based reconstruction:

• Less ideal cosmesis.
• Risk of rejection and infection due to foreign body.
• Prone to fibrosis/capsular contracture, especially after radiation therapy.
• Migration of the implant, with a maximum lifespan of 10 years and a revision needed at 5 years.
• Textured-surface implants carry a risk of BIA-ALCL.

• Cover with cling film (transparent) to reduce pain
• Avoid using adherent tulle or wet gauze

Most wounds heal by themselves in 7-15 days.

Keep the burn clean to promote healing.

Biological dressings require no change of dressing, are only for partial thickness burns expected to heal spontaneously, and are made from processed amniotic membrane which accelerates burn healing.

Patients and donors are screened for viral diseases and other risk factors before using biological dressings.

The biological dressing adheres to the wound when applied and is performed only once to twice, flaking off when the burn has healed.

Surgery for full thickness burns uses autografts or alternatives.

Tangential excision involves removing eschar and excising up to the bleeding tissue (viable dermal layer).

The procedure involves using a skin graft knife to take a thin layer of skin at the mid dermis level, leaving behind bleeding skin that will heal by itself.

Wound debridement, including tangential and fascial excision, is performed to remove non-viable tissue and promote healing of the wound.

• Tissue trauma (must be minimized)
• Haematoma
• Blood supply
• Temperature
• Infection

• Nutrition
• Chronic illness
• Other treatments such as:
  • Steroid use
  • Chemotherapy use

• Protect the wound from trauma
• Provide an environment for healing

Hypertrophic scars and Keloid scars are the two main types.

Non-surgical management options

• massage and moisture

• compression pressure garments

• silicone sheets or gels

• intralesional corticosteroid injections

• laser

• cryotherapy

Surgical management options

• scar excision + adjuvant therapies (radiation therapy and pressure therapy)

The primary functions of the lymphatic system include:

1. Clearance of interstitial space protein and lipid
2. Transport of these substances to the vasculature based on differential pressures
3. Maintenance of fluid homeostasis
4. Regulation of immunity

Lymphoedema is defined as the accumulation of proteinaceous fluid within the interstitial compartment, which occurs secondary to abnormalities in the lymphatic transport system.

Stewart-Treves Syndrome is associated with lymphangiosarcoma that can occur more than 10 years after the onset of lymphoedema and is characterized by a poor prognosis.

Secondary causes of lymphoedema include:

1. Infection: Such as filariasis caused by Wucheria Bancrofti, rare in developed countries.

2. Post-cancer: Resulting from post-lymph node dissection

3. Radiotherapy

4. ??? Inflammation: Associated with chronic venous ulcers or DVT/trauma.

The stages of Lymphoedema are as follows:

• Conal measurement: Limb circumference at set intervals
• Water displacement
• Bioimpedence spectroscopy: Uses electrical current to measure tissue fluid retention, useful in detecting early-stage lymphoedema.

Common clinical features of lymphoedema include:

• Pitting or non-pitting oedema

• Skin ulceration

• Pain

** defined by age of onset

1. Lymphoedema Congenita: Onset within 2 years of birth due to VEGFR3 gene mutation, often showing severe hypoplasia or aplasia.

2. Lymphoedema Praecox (Meige's Disease): Onset between 2-35 years, most common type of primary lymphoedema, typically unilateral, and may show hypoplasia on lymphangiography.

3. Lymphoedema Tarda: Onset after 35 years, typically shows hyperplasia on lymphangiography.

1. Lymphoscintigraphy (gold standard): A radioactive tracer is injected intradermally or subfascially. Delayed or absent radiotracer suggests lymphatic abnormality.

2. MRI lymphangiogram: visualize diffuse and subcutaneous oedema and may replace lymphoscintigraphy in the future, though it is limited by availability.

3. ICG lymphography: A dye is injected intradermally and taken up by lymphatic capillaries, allowing for real-time imaging of superficial lymphatic flow, which is staged based on lymphatic flow patterns.

** direct/ indirect lymphangiography is NO LONGER USED: involves direct cannulation or lymphatic vessels with injection of oil/ water soluble contrast —> potentially further damaging the lymphatics

1. Conservative management: complete decongestive therapy

2. Surgical management

** details see notes!!!