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7.3 High-Yield Dermatopathology Differential Diagnoses
Fig. 7.67 Cutaneous polyarteritis nodosa. The affected small arteries in the upper subcutis show marked brin extravasation into their walls. Only a tiny amount
of inammation tends to spill into fat lobules that are in immediate proximity to
the affected vessels n
vasculopathic reaction pattern. In: Weedon’s Skin Pathology. 5th ed. Elsevier.
2021:241–304.)
very mild lobular panniculitis. (From Patterson JW. The
Table 7.32 High-Yield Vascular Tumors
Masson’s/IPEH Papillary projections of bland
Angiosarcoma Poorly-formed vessels filled with RBCs
Glomeruloid hemangioma Round nodules comprised of capillaries
Angiolymphoid hyperplasia
with eosinophilia/epithelioid
hemangioma
Kaposi sarcoma Bloody “busy dermis ” spindled
IPEH, intravascular papillary endothelial hyperplasia
endothelial cells around hyaline
cores; well-circumscribed (not a
feature seen in malignant vascular
neoplasms); arises within large
thrombosed vessel (weird
papillary-like appearance is due
to re-canalizing of vessel)
(Fig. 7.69)
and lined by large, dark, atypical
endothelial cells that protrude into
the lumen in a “piled-on” fashion;
NOT well-circumscribed
(Fig. 7.70)
contained within a large dilated
vascular space in the dermis →
resembles renal glomerulus; part of
POEMS syndrome
Lymphoid nodules 1 TONS of
eosinophils around thick-walled
vessels with large “epithelioid”
endothelial cells often w/
intracytoplasmic vacuoles
(Fig. 7.71)
cells with adjacent slit-like vessels,
“promontory sign” (vessels forming
around vessels), ↑ plasma cells,
↑ hemosiderin and siderophages (See
Fig. 7.22)
Fig. 7.68 Pancreatic panniculitis. Characteristic “ghost” cells, neutrophils, and
basophilic calcication are seen.
Table 7.31 High-Yield Neural Tumors
Neurofibroma (NF) “Seagull”-shaped wavy nuclei in bubble
Plexiform neurofibroma Wavy fascicles of NF embedded in myxoid
Schwannoma Encapsulated SQ nodule, Antoni A/B areas,
Palisaded encapsulated
neuroma (solitary
circumscribed neuroma)
Traumatic neuroma Small nerve fascicles surrounded by scar
Nerve sheath myxoma
(“Neurothekeoma”)
gum pink stroma; scattered mast cells
background of diffuse NF
hyalinized ectatic vessels within tumor
Well-circumscribed, pesudoencapsulated
superficial dermal nodule comprised of
nerve fascicles separated by clefts
tissue
Myxoid lobules of spindled cells in dermis
surrounded by fibrous septa
Fig. 7.69 Intravascular papillary endothelial hyperplasia. “Pseudoangiosarcoma”
appearance is due to re-canalization of a thrombus within a large vessel (helpful
clue = look for the old vessel wall surrounding the well-circumscribed lesion).
435
CHAPTER 7 • Dermatopathology
Fig. 7.70 Angiosarcoma. Observe the “dissecting vascular spaces” that appear
to be cutting the dermis into multiple pieces. Vascular spaces are poorly-formed
and leaky (results in hemorrhagic/bruise-like clinical appearance), and lined by
atypical, hyperchromatic endothelial cells with a “piled-on” appearance. Some of
the tumor cells appear to be free-oating in the vascular spaces.
Fig. 7.71 Angiolymphoid hyperplasia with eosinophilia (epithelioid hemangioma).
Nodular proliferation of vessels lined by plump epithelioid endothelial cells. A
orid inammatory inltrate of lymphocytes and eosinophils is present. (From
Buehler D, Billings SD. Soft tissue tumors and tumor-like reactions. In: Busam
KJ, ed. Dermatopathology: A Volume in the Series: Foundations in Diagnostic
Pathology, 2nd ed. Philadelphia: Elsevier; 2016, pp 513-594.)
Table 7.33 High-Yield Adipocytic Tumors
Disease Key Features
Lipoma Solely mature lipocytes with small eccentric nuclei
Mobile encapsulated lipoma Lobules of necrotic fat enclosed within fibrous capsule
Angiolipoma Lipoma with capillary proliferation; capillaries filled w/ fibrin thrombi
Pleomorphic lipoma Mature lipocytes among myxoid matrix with interspersed ropey collagen, bland spindle cells, and floret giant cells
Spindle cell lipoma
Hibernoma Multivacuolated tumor cells, not as pink or grainy-appearing as granular cell tumor. Lipocytes look like small berries
Nevus lipomatosus superficialis Mature lipocytes infiltrating the superficial dermis; similar, but more extreme features seen in Goltz syndrome
Table 7.34 High-Yield Smooth Muscle DDx
Accessory nipple Central pore-like structure, deep mammary (modified apocrine) glands and scattered smooth muscle bundles
Becker’s nevus
Piloleiomyoma Haphazardly arrayed smooth muscle fascicles in superficial-mid dermis
Angioleiomyoma Round, well-circumscribed pink nodule with compressed vascular lumen in deep dermis/subcutis
Leiomyosarcoma Hypercellular proliferation of spindled smooth muscle cells w/ atypical, hyperchromatic nuclei and mitoses. Deep tumors are more
Table 7.35 DF Versus DFSP Versus Fibromatosis
DF Dermal-based spindle cell neoplasm with “ curlicue” pattern, collagen trapping (most obvious at periphery), overlying epidermal/
DFSP Densely cellular dermal and SQ tumor w/ storiform pattern, infiltrates deep into SQ fat enveloping lipocytes in a “honeycomb”
Fibromatosis Long “sweeping” fascicles of myobroblasts with wavy corkscrew nuclei and wavy collagen
Looks like epidermal nevus 1 smooth muscle hamartoma together with terminal hairs
aggressive than tumors located entirely within the dermis.
follicular induction, and hemosiderin-laden GCs and histiocytes ; 1/– significant hemorrhage (aneurysmal DF); Never infiltrates
deeply into fat!; factor XIIIa
pattern; CD341, factor XIIIa , stromelysin-3 , and t(17;22) translocation (detectable by FISH) (Fig. 7.72)
Inclusion body bromatosis (infantile digital broma) has characteristic perinuclear eosinophilic inclusions
(main distinguishing feature from spindle cell lipoma!); CD341, S100 negative, loss of RB1 in ~100% of cases ("RB1deleted soft tissue tumor family" = spindle cell lipoma/pleomorphic lipoma, pleomorphic fibroma, atypical spindle cell/
pleomorphic lipomatous tumor, and other less common entities; loss of RB1 distinguishes from liposarcoma )
Mature lipocytes among myxoid matrix containing spindle cells and interspersed ropey collagen, CD341 S100–,
loss of RB1 in ~100% of cases ("RB1-deleted soft tissue tumor family" = spindle cell lipoma/pleomorphic lipoma,
pleomorphic fibroma, atypical spindle cell/pleomorphic lipomatous tumor, and other less common entities; loss of RB1
distinguishes from liposarcoma)
1
, stromelysin-31, and CD34
436
7.3 High-Yield Dermatopathology Differential Diagnoses
A B
Fig. 7.72 Dermatobrosarcoma protuberans (DFSP). (A) Low power shows a spindle-cell neoplasm in the dermis. (B) High power shows so-called honeycombing in
the fat.
Table 7.36 Amorphous “Pink Stuff in Dermis” DDx
Amyloid (macular/lichen) Sparse pink deposits of amyloid ( AK type) in superficial dermis, melanophages, no inflammation (Fig. 7.73)
Amyloid (nodular) Fissured, pale pink amyloid (AL type) material in superficial to mid dermis, and abundant plasma cells (distinguishes
Colloid milium Fissured, pale pink deposits completely filling/expanding superficial-mid dermis (deeper than macular/lichen
Erythropoietic protoporphyria Dermal deposits of pink material; hyaline cuff around superficial vessels, no solar elastosis (because patients diligently
Lipoid proteinosis
AL, light chain-derived amyloid; BMZ, basement membrane zone; PAS-D, periodic acid-Schiff with diastase; EPP, erythropoietic protoporphyria
from colloid milium) (Fig. 7.74)
amyloid); extensive solar elastosis (adult form only); no inflammation (vs. nodular amyloid) (Fig. 7.75)
avoid sun) (Fig. 7.76)
Pink hyaline BMZ material (type IV collagen; PAS-D1) predominantly centered around superficial and deep (deeper than
EPP) vessels and adnexae, with “onion skin” pattern (Fig. 7.77)
Fig. 7.73 Macular amyloid. (From Brinster NK, Liu V, Diwan AH, McKee PH.
Cutaneous amyloidosis. In: Dermatopathology: A Volume in the High Yield Pa-
thology Series. Philadelphia: Elsevier, 2011, pp 278-280.)
Fig. 7.74 Nodular amyloid. (From Ferringer T. Metabolic disorders. In: Elston DM,
Ferringer T, eds. Dermatopathology, 3rd ed. Philadelphia: Elsevier, 2019; pp 251-263.)
437
CHAPTER 7 • Dermatopathology
Fig. 7.75 Colloid milium. Fissured pale-pink deposits ll and expand the supercial
and mid dermis. Lacks lymphoplasmacytic inammation (vs nodular amyloid).
Fig. 7.76 Erythropoietic protoporphyria. (From Ferringer T. Metabolic disorders.
In: Elston DM, Ferringer T, eds. Dermatopathology. 3rd ed. Philadelphia: Elsevier;
2019:251–263.)
Fig. 7.77 Lipoid proteinosis. Pink, hyaline BMZ material (Type IV collagen) forms
“onion skin” deposits around vessels in supercial and deep dermis (deeper than
EPP).
438
7.3 High-Yield Dermatopathology Differential Diagnoses
Table 7.37 Immediate Pattern Recognition Diagnoses
Chondrodermatitis
nodularis chronicus
helicis
Coma blister
Cutaneous endometriosis Well-formed glands of varying sizes, lined by pseudostratified columnar epithelium and surrounded by endometrial stroma
Elastosis perforans
serpiginosa
Giant cell tumor
of tendon sheath
Granular cell tumor
Myofibroma/
myopericytoma
Nevus sebaceus Papillomatosis overlying increased number of sebaceous glands directly opening onto epidermis; terminal hairs replaced
Nodular fasciitis Circumscribed nodule located in deep dermis/SQ; stellate myofibroblasts w/ “ tissue culture” appearance set in loose
Ochronosis Yellow-brown “bananas” in superficial dermis
Pseudoxanthoma elasticum
Sweet syndrome Dense neutrophilic infiltrate with karyorrhexis in dermis and marked papillary dermal edema; tissue cultures and bug stains
Verruciform xanthoma Verrucous hyperplasia with xanthoma cells stuffed in dermal papillae and superficial dermis ( Fig. 7.82)
PEH, pseudoendothelial hyperplasia; HPC, hemangiopericytoma
Ulcer w/ adjacent epidermal acanthosis, underlying reparative change, fibrin, vascular ectasia, and eosinophilic degenerated
cartilage
Paucicellular/noninflammatory subepidermal bulla, diffuse epidermal necrosis n subepidermal bulla, and sweat gland necrosis
(differentiates from SJS/TEN) (Fig. 7.78)
(basaloid cells in fibromyxoid background); RBCs and hemosiderin within and surrounding glands. No atypia (unlike cutaneous
mets of endometrial cancer) (Fig. 7.79)
Elastic fibers (stains black with VVG) spiraling through narrow serpiginous channel in epidermis
Deep tumor arising from tendon, containing innumerable multinucleate osteoclast-like giant cells, and fibrotic pink stroma
(Fig. 7.80)
PEH 1 pink cells in dermis w/ granular cytoplasm and round pustulo-ovoid bodies of Milian
Dermal-SQ tumor w/ multiple blue-gray (cartilage-colored) hypocellular nodules surrounded by hypercellular areas
containing “HPC-like” “staghorn” vessels (Fig. 7.81)
by apocrine glands
myxoid stroma with foci of hemorrhage and inflammation
Fragmented purple elastic fibers in dermis (VVG1 , von Kossa1)
MUST be negative!
A B
Fig. 7.78 Coma blister. (A) Pauci-inammatory subepidermal separation. (B) Basophilic necrosis of eccrine glands.
439
CHAPTER 7 • Dermatopathology
Fig. 7.79 Endometriosis of the umbilicus. Glands and stroma are set in brous
tissue. The glands are functional with some luminal hemorrhage.
Fig. 7.81 Myobroma. Biphasic tumor composed of hypocellular, blue-grey
myoid nodules surrounded by immature mesenchymal cells and hemangiopericytoma-like vascular spaces.
Fig. 7.80 Giant cell tumor of tendon sheath. (From Elston DM, Ko CJ, Ferringer
T. Fibrous tumors. In: Elston DM, Ferringer T, eds. Dermatopathology, 3rd ed.
Philadelphia: Elsevier, 2019; pp 350-392.)
440
A
B
Fig. 7.82 (A) and (B) Verruciform xanthoma. Mnemonic 5 “wart with foam cells
in dermal papillae.”
Table 7.38 High-Yield Infectious Diseases
HPV-induced lesions
Verruca Vulgaris
Myrmecia (Fig. 7.83)
Verruca plana (Fig. 7.84)
Verruca plana with EDV changes (Fig. 7.85)
Verrucous carcinoma (Fig. 7.86)
Histiocytic inclusions
“His GIRL Penelope”: Histoplasmosis, Granuloma Inguinale, Rhinoscleroma, Leishmaniasis/Leprosy, Penicillium
Infections with endospores
Rhinosporidiosis (“spores as big as a rhino!”) (Fig. 7.87)
Coccidioidomycosis (Fig. 7.88)
7.3 High-Yield Dermatopathology Differential Diagnoses
Fig. 7.83 Verruca with myrmecial changes (“myrmecial wart”). Compared with
verruca vulgaris, this entity has more extreme hyperkeratosis, epidermal
hyperplasia, and bright pink-purple inclusion bodies.
Fig. 7.84 Verruca plana. Minimal papillomatosis (vs VV), mild hypergranulosis,
supercial clear-colored koilocytes.
Fig. 7.85 Verruca plana with changes characteristic of epidermodysplasia verruciformis. Distinguished from normal verruca plana by presence of blue-gray
color of upper portion of epidermis.
Fig. 7.86 Verrucous carcinoma. (From Elston DM. Malignant tumors of the epidermis. In: Elston D, Ferringer T, eds. Dermatopathology. 3rd ed. Philadelphia:
Elsevier; 2019:54–67.)
441
CHAPTER 7 • Dermatopathology
Fig. 7.87 Rhinosporidiosis: individual spores mature to form small trophic cysts.
(From Grayson W, Calonje E. Infectious diseases of the skin. In: Calonje E, Brenn
T, Lazar AJ, Billings SD, eds. McKee’s Pathology of the Skin with Clinical Cor-
relations. 5th Ed. Philadelphia: Elsevier; 2020:826–975.)
Fig. 7.88 Coccidioidomycosis. Multiple spherules are present with surrounding
chronic inammation.
442
8
Dermatologic Surgery
Phillip C. Hochwalt and Thomas L.H. Hocker
CONTENTS LIST
8.1 SURGICAL ANATOMY
8.2 LOCAL ANESTHETICS AND PERIOPERATIVE PAIN CONTROL
8.3 SURGICAL INSTRUMENTS AND NEEDLES
8.4 SUTURE TECHNIQUES
8.5 WOUND CLOSURE MATERIALS
8.6 ANTISEPSIS AND STERILIZATION
8.7 ELECTROSURGERY
8.8 CRYOSURGERY
8.9 EXCISIONS
8.10 MOHS SURGERY
8.11 FLAPS
8.12 GRAFTS
8.13 SURGICAL COMPLICATIONS AND MEASURES TO AVOID THEM
8.14 SCAR IMPROVEMENT
8.15 NAIL SURGERY
8.16 WOUND DRESSINGS
8.1 SURGICAL ANATOMY
• Skin lines
■
Langer’s lines: skin lines that orient in the direction of
the natural gape of a wound after puncture with a
circular spike; lines run parallel to underlying muscles
Different than relaxed skin tension lines (RSTLs);
frequently perpendicular to them, in fact
■
RSTLs (Kraissl and Borges lines): lines that run
perpendicular to underlying muscles; most elective
incisions should be made parallel to these lines
• Head and neck anatomy
■
Arterial supply (Fig. 8.1)
Face supplied by external AND internal carotid:
♦ External carotid: supplies lateral, mid, and lower
face; most important branches include:
Supercial temporal artery: anterior and
parietal branches; supplies temple, scalp, and
lateral forehead
Maxillary artery: gives rise to:
Infraorbital artery: exits infraorbital
foramen; supplies mid face; anastomoses
with the internal carotid-derived arteries
(supratrochlear and supraorbital arteries)
Mental artery: exits mental foramen;
supplies chin and lower lip
Facial artery: gives rise to:
Labial arteries (inferior and superior):
supplies lips, columella, and ala
Angular artery: extension of facial artery
starting near base of ala (susceptible to
intraarterial ller injection); eventually
ends in anastomoses with branches of the
internal carotid (dorsal nasal artery
specically) near medial canthus
♦ Internal carotid: supplies mid forehead and
nasal root; anastomoses with branches of the
external carotid in the area of the medial canthus
and dorsal nose
Ophthalmic artery: responsible for most of
the facial arteries supplied by the internal
carotid. It travels through the optic canal into
the orbit where it supplies the retinal,
supraorbital and supratrochlear (axial artery
required for paramedian forehead ap),
infratrochlear, dorsal nasal (anastomoses with
angular artery), external nasal, anterior and
posterior ethmoidal, and lacrimal branches.
These branches supply the retina, forehead,
upper dorsal nose, and eyelids
Branches of the ophthalmic artery
anastomose heavily with those supplied by
the external carotid system
443
CHAPTER 8 • Dermatologic Surgery
Superficial temporal artery
Anterior branch
Parietal branch
Supratrochlear artery
Supraorbital artery
Zygomatico-orbital artery
Angular artery
Transverse facial artery
Superior labial artery
Facial artery
Inferior labial artery
Fig. 8.1 Arterial blood supply of the face. (From Salasche SJ. Anatomy. In: Rohrer TE, Cook JL, Nguyen TH, eds. Flaps and Grafts in Dermatologic Surgery. Philadel-
phia: Elsevier; 2007:1–14.)
These anastomoses are important when
inadvertent intraarterial injection of
steroids or llers occurs. Inadvertent
intraarterial injection of ller (glabellar
area most commonly) carries risk of
blindness due to retrograde movement of
ller to ophthalmic artery and
Sensory nerves are located supercial to SMAS
→ often transected during facial surgery →
numbness
■
Sensory nerves (Tables 8.1–8.2 and Figs. 8.2–8.4)
Cranial nerve (CN) V (trigeminal nerve): almost
wholly responsible for sensory innervation of face
♦ Boards factoids: Damage to CN V may result in
embolization into retinal artery
■
Venous system
Veins typically follow their associated arteries
Facial vein can communicate w/ cavernous sinus of
♦ Clinical pearl: injection of anesthetic into the
brain via pterygoid plexus or ophthalmic vein
♦ Danger triangle: area extending from corners of
the mouth to nasal root; infections in this area
can cause septic cavernous sinus thrombosis,
meningitis, and brain abscesses
■
Lymphatic system
Important for skin cancer mets; drainage can be
variable
♦ Upper and lateral face → parotid, preauricular,
and infraauricular nodes
♦ Lower and medial face → submandibular nodes
♦ Central lower lip and chin → submental nodes
♦ Lateral cervical nodes collect from the above areas
■
Supercial musculoaponeurotic system (SMAS)
Cervical plexus: supplies sensory innervation to
neck and occipital scalp
Sensory innervation of ear is complex
■
Motor innervation (Tables 8.3 and 8.4; Fig. 8.5)
Muscles of facial expression are innervated by
CN VII (facial nerve); facial muscles receive motor
innervation from their undersurface
♦ Boards factoid: as a minor function, CN VII
Composed of muscles and fascia of the face and neck;
allows for coordinated facial movement and helps
contain infection and cancer; contiguous w/ galea
Motor nerves all run deep to SMAS (penetrate
muscles from undersurface) → staying above SMAS
during facial surgery prevents motor nerve damage
Facial nerve emerges from stylomastoid foramen,
travels within the parotid gland and then splits into
ve branches: temporal, zygomatic, buccal,
mandibular, and cervical branches (“To Zanzibar By
Motor Car”)
Dorsal nasal artery
Anterior ethmoidal artery
Infraorbital artery
Buccal artery
Mental artery
trigeminal trophic syndrome and Frey’s
syndrome; CN V also supplies motor innervation
to muscles of mastication
supraorbital, supratrochlear, infraorbital, and
mental foramens will result in prolonged
anesthesia for vast majority of face (exceptions 5
parts of nose and angles of mouth)
also provides sensory input for anterior tongue
(via chorda tympani branch) and a small amount
of external auditory meatus
444