Plastic SurgeryPlastic SurgerySkin Cancer and BurnsSkin Cancer and Burns

Dr Alistair BrownDr Alistair Brown

Basal cell carcinomaBasal cell carcinoma Locally invasive tumour of epidermal keratinocytesLocally invasive tumour of epidermal keratinocytes ““pearly papule” with surface telangectasia and rolled pearly papule” with surface telangectasia and rolled

edges, may have ulcerated centre.edges, may have ulcerated centre. Risk factors Risk factors

Intermittent sun damageIntermittent sun damage Skin type 1 Skin type 1 MaleMale ImmunosuppresionImmunosuppresion Previous hx of skin cancerPrevious hx of skin cancer Genetic predispositionGenetic predisposition

ManagementManagement SurgicalSurgical RadiotherapyRadiotherapy Other: cryotherapy, curretage and cautery, topical photodynamic Other: cryotherapy, curretage and cautery, topical photodynamic

therapy, imiquimod cream.therapy, imiquimod cream.

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Squamous cell carcinomaSquamous cell carcinoma

Invasive malignant tumour of epidermal kertinocytes or Invasive malignant tumour of epidermal kertinocytes or appendages with potential to metastasise. appendages with potential to metastasise.

Risk factors: sun exposure, pre-malignant skin Risk factors: sun exposure, pre-malignant skin condistions eg. Actinic keratoses, chronic inflammation condistions eg. Actinic keratoses, chronic inflammation (leg ulcers), immunosuppression, genetic predisposition, (leg ulcers), immunosuppression, genetic predisposition, smoking.smoking.

Treatment: Treatment: Surgical excision Surgical excision Moh’s micrographic surgeryMoh’s micrographic surgery RadiotherapyRadiotherapy Chemotherapy – metastatic diseaseChemotherapy – metastatic disease

http://www.dermnetnz.org/lesions/melanoma.htmlhttp://www.dermnetnz.org/lesions/melanoma.html

Malignant melanomaMalignant melanoma Invasive malignant tumour of epidermal melanocytes with metastatic Invasive malignant tumour of epidermal melanocytes with metastatic

potential.potential. ABCDE approach ABCDE approach

AsymmetryAsymmetry BorderBorder ColourColour DiameterDiameter EvolutionEvolution Symptoms – bleeding, itchSymptoms – bleeding, itch

Risk factors:Risk factors: Atypical molesAtypical moles Large numbers of molesLarge numbers of moles Skin type 1&2Skin type 1&2 Severe sun burn <14Severe sun burn <14 FhxFhx Sun exposureSun exposure Previous melanomaPrevious melanoma immunosuppressionimmunosuppression

ManagementManagement

Surgical excisionSurgical excision Excision biopsyExcision biopsy WLE +/- sentinel node biopsyWLE +/- sentinel node biopsy If node positive – axillary clearanceIf node positive – axillary clearance If further nodes positive – stagingIf further nodes positive – staging

Intensive follow-upIntensive follow-up Palliative options – aim to reduce macroscopic Palliative options – aim to reduce macroscopic

disease burden.disease burden.

PrognosisPrognosis

BurnsBurns

A burn is an injury caused by thermal, chemical, electrical, or radiation energy.

Common ~250000 primary care attendances, 0.3/1000 hospital admissions, 300 deaths.

Most common in under 5s and over 75

Initial AssessmentInitial Assessment ABCDE approach!ABCDE approach!

Airway – thermal burns in an enclosed space – consider Airway – thermal burns in an enclosed space – consider inhalation injury.inhalation injury.

Clinical indications of inhalation injury include: Face and/or neck burns. Singeing of the eyebrows and around the nose. Carbon deposits and acute inflammatory changes in the oropharynx. Carbon particles seen in sputum. Hoarseness. History of impaired awareness, eg alcohol or head injury, and/or

confinement in a burning environment. Explosion, with burns to head and torso. Carboxyhaemoglobin level greater than 10% if the patient is involved

in a fire.

May require ET intubation and transfer to a burns unitMay require ET intubation and transfer to a burns unit

BreathingBreathing Assume CO poisoning for all burns in an enclosed space. Give Assume CO poisoning for all burns in an enclosed space. Give

high flow oxygen.high flow oxygen.

CirculationCirculation IV access and fluid replacement – all adults >15% BSA or IV access and fluid replacement – all adults >15% BSA or

children >10% BSA, catheter to monitor outputchildren >10% BSA, catheter to monitor output Parkland formulaParkland formula

3-4mls/kg/%BSA burnt (adults)3-4mls/kg/%BSA burnt (adults) Children – as above +maintenance (100;50;20)Children – as above +maintenance (100;50;20) Half volume over first 8 hours then second half over 16 hoursHalf volume over first 8 hours then second half over 16 hours

DisabilityDisability Neurological statusNeurological status Tetanus prophylaxisTetanus prophylaxis

Exposure – prevention of hypothermiaExposure – prevention of hypothermia

Estimating BSAEstimating BSA

Rule of 9sRule of 9s Palmar surface Palmar surface

(incl.fingers) ~ 1%(incl.fingers) ~ 1% Children – Lund Browder chartChildren – Lund Browder chart

Burn SeverityBurn Severity

• Burn wounds are dynamic and need reassessment in the first 24-72 hours because depth can increase as a result of inadequate treatment or superadded infection. 

Burn managementBurn management

Stop the burning process: Dry chemical powders should be carefully brushed from

the wound. Cool the burn with tepid water for up to 20 mins, alkali

burns require prolonged irrigation.

Full-thickness circumferential burns, escharotomy may be required to avoid respiratory distress or reduced circulation to the limbs as a result of constriction.

Ensure adequate analgesia. Abx reserved for tx of infection.

Referral to Burns UnitReferral to Burns Unit All complex injuries should be referred - particularly:

Age under 5 years or over 60 years. Site of injury: face, hands, perineum, any flexure (including neck

or axilla) and circumferential dermal burns or a full-thickness burn of the limb, torso, or neck.

Inhalation injury. Mechanism of injury:

Chemical burns affecting over 5% total body surface area (over 1% for hydrofluoric acid burns).

Exposure to ionising radiation. High-pressure steam injury. High-tension electrical injury.

Suspected non-accidental injury in a child. Large affected area

Which of these is a skin cancer?Which of these is a skin cancer?

MCQ2MCQ2

If you left this lesion alone what would happen?If you left this lesion alone what would happen? A) Rapidly metastasize with resultant poor A) Rapidly metastasize with resultant poor

prognsosis.prognsosis. B) Rapidly increase in size, with local invasion – may B) Rapidly increase in size, with local invasion – may

metastasize later.metastasize later. C) Slowly increase in size with local invasion only.C) Slowly increase in size with local invasion only. D) Rapidly increase in size then spontaneously D) Rapidly increase in size then spontaneously

regress and disappear.regress and disappear.

MCQ 3MCQ 3

True or False which of the following are known True or False which of the following are known risk factors for melanoma?risk factors for melanoma?

Sun burn as a childSun burn as a child Xeroderma pigmentosumXeroderma pigmentosum CiclosporinCiclosporin Living in the South WestLiving in the South West Fhx of MelanomaFhx of Melanoma

MCQ4MCQ4 How would you manage this 35yo How would you manage this 35yo

patient, with a new mole?patient, with a new mole? Imiquimod creamImiquimod cream Watch and waitWatch and wait Punch biopsy of the lesion for Punch biopsy of the lesion for

histologyhistology Take a picture and review in Take a picture and review in

3months to see if it has grown3months to see if it has grown Surgically remove with a 2mm Surgically remove with a 2mm

margin for histologymargin for histology WLE with a 2-3cm marginWLE with a 2-3cm margin

MCQ 5MCQ 5

Whats the most important prognostic factor for Whats the most important prognostic factor for this patient?this patient? A) AgeA) Age B) Performance statusB) Performance status C) Breslow thicknessC) Breslow thickness D) Size of lesionD) Size of lesion C) Site of lesionC) Site of lesion

MCQ 6MCQ 6 A 45yo farmer presents with a 3week hx of a rapidly A 45yo farmer presents with a 3week hx of a rapidly

enlarging keratotic lesion. By the time he gets an enlarging keratotic lesion. By the time he gets an appointment with the dermatologist the lesion has appointment with the dermatologist the lesion has begun to regress. What is it likely to be?begun to regress. What is it likely to be? SCCSCC BCCBCC MelanomaMelanoma Seb KSeb K Actinic keratosisActinic keratosis KeratoacathomaKeratoacathoma

MCQ 7MCQ 7

A 50 year old man has partial thickness burns to A 50 year old man has partial thickness burns to both of his legs front and back and his both of his legs front and back and his perineum, what is the total BSA affected?perineum, what is the total BSA affected? A) 36%A) 36% B) 18%B) 18% C) 19%C) 19% D) 45%D) 45% E) 37%E) 37%

MCQ 8MCQ 8

True or FalseTrue or False Burn depth remains constant after the initial injuryBurn depth remains constant after the initial injury Alkali burns are normally less deep than acid burnsAlkali burns are normally less deep than acid burns A patient with stridor following a fire should be A patient with stridor following a fire should be

considered for emergency ET intubation.considered for emergency ET intubation. Full thickness burns are the most painful.Full thickness burns are the most painful. If blisters are present it is likely to be an epidermal If blisters are present it is likely to be an epidermal

burn.burn.