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Skin Cancer (Squamous Cell Cancer)
JohnathanSadeh
138
How It May BeAsked?
A new patient presents to your ofce with concerns of a new
skin lesion on his arm. The patient states that they just
recently noticed it but they are unsure how long it has been
there. The lesion is noted to be on the right forearm and
appears to be 0.8cm, ulcerated with telangiectasias.
Or
A patient presents to you after being recommended to see
a surgeon for a new skin lesion. The patient had previously
seen their PCP/dermatologist where the lesion was biopsied.
The patient comes to you today with the pathologist report
stating that it is squamous cell cancer.
How toAnswer?
Brief H+P
Risk Factors
• (Excessive) sun exposure
• Use of sunscreen
• Radiation
• Immunosuppression
• Inherited skin disorders
• Family history of cancer
• Previous skin cancers
• Previous genetic testing
Physical Exam:
• Comprehensive full skin exam (including the axillae,
groin, scalp)
• Characteristics of lesion (size, shape, color)
• Examination of lymph node basins
J. Sadeh (*)
Department of Surgery, Jefferson Einstein Hospital,
Philadelphia, PA, USA
e-mail: Johnathan.Sadeh@jefferson.edu
Others:
• Biopsy
• Imaging of lymph node basins (if applicable)
• Pathology report noting grade, depth, and any high-risk
features (i.e., acantholytic (adenoid), adenosquamous
(mucinous), or metaplastic (carcinosarcomatous)
subtypes)
Risk Stratication forRecurrence
Treatment of squamous cell carcinoma is based on risk of
recurrence, features of the lesion, lymph node status, recurrence, and surgical candidacy.
High Risk:
• Lesions on the trunk or extremities between 2 and 4cm
• Lesion on the head, neck, hands, feet, pretibial, and anogenital area of any size
• Poorly dened margins
• Recurrent lesions
• Immunosuppression
• Prior radiation therapy or chronic inammatory process
(Marjolin’s ulcer)
• Rapidly growing tumor
• Neurologic symptoms
• High-risk histologic features
• 2–6mm depth of invasion
• Perineural involvement
Very High Risk:
• Anywhere >4cm
• Poor differentiation
• Desmoplastic histology
• >6mm depth or invasion beyond subcutaneous fat
• Perineal invasion of tumor cells within nerve sheath lying
beyond the dermis
• Lymphatic or vascular involvement
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_138
479
480
J. Sadeh
Treatment
Actinic keratosis (conuent epidermal dysplasia): should be
treated when discovered
• Topical 5-FU±calcipotriol
• Ablation
• Cryotherapy
• Curettage and electrodessication
• Retinoids which reduce the development
• Capecitabine
Low-Risk Lesions:
• Curettage and electrodessication (C&E) or shave removal
– This is limited only for tumor not extending beyond
the dermis.
– C&E is very limited for well-selected low-risk patient
and confers a higher risk of recurrence regardless.
• Standard surgical excision with
– 4mm margins if <2cm
– 6mm margins if low risk >2cm
– If + margins □ Mohs or surgical re-excision if possi-
ble. If not, RT
• Radiation therapy for those declining surgery
High-/Very-High-Risk Lesions Where Surgery Has a
High Chance of Curing:
• Sentinel lymph node biopsy for lesions that are recurrent
or with several high- risk features
• Mohs for lesions in cosmetically sensitive areas (i.e., face,
periauricular, hands)
– Preferred for very-high-risk patients
• Standard surgical excision with wide margins
– No denitive NCCN Guidelines recommended;
however, European guidelines recommend
6–10mm margins
– If + margins □ re-resect if possible or RT
– If − margins but with signicant perineural or named
nerve involvement □ adjuvant radiation
• Denitive radiation therapy for nonsurgical candidates
Very High Risk with Signicant Local Recurrence Risk
or Nodal Involvement:
• Imaging studies
• SLNB
• Neoadjuvant therapy prior to Mohs vs surgical excision
vs RT
Clinically palpable lymph nodes or abnormal lymph
nodes on imaging:
• FNA or core needle biopsy
– If − re-evaluate with imaging/possibly more biopsies
– If + perform re-imaging to determine extent and FDG-
PET/CT to rule out distant metastasis
– If on the trunk and extremities, perform mapping and
lymph node dissection ± adjuvant RT
If on the head or neck, perform regional lymph
node dissections
Head and Neck Lesions:
• Lesion with ipsilateral nodes: excision of the primary +
ipsilateral neck dissection
• Lesion with bilateral nodes: excision of primary + bilateral neck dissection
• Parotid nodes involved: excision of primary and parotidectomy + ipsilateral neck dissection
• Any + node requires adjuvant radiation therapy ± systemic chemotherapy.
Follow-Up
Follow-up is dependent on the stage of the lesion and generally follows:
• Low risk: q3–12 months for 2 years, then 6–12 months for
3 years, q year for life
• High risk: q3–6 months for 2 years, then 6–12 months
for 3 years, q year for life
• Very high risk: q3–6 months for 2 years, then 6–12 months
for 3 years, q6–12 months for life
Bonus
For wounds facing difcult closure or signicant tension,
assistance from plastic surgery colleagues may be used.
Some options for closure depending on the wound bed
include:
• Local ap (i.e., rotational, advancement, transposition,
bilobed)
• Full thickness skin grafts
• Free aps
Common Curveballs
• Pathology will come back melanoma (change scenario).
• There will be palpable nodes.
• Excised lesion will recur.
• Lesion will be on the face and will need local ap vs full
thickness skin graft.
• Tumor will be large and ulcerating.
138 Skin Cancer (Squamous Cell Cancer)
481
• Tumor will be preauricular invading parotid gland.
• Treatment of lesion (cancer) that develops in chronic
wound (Marjolin’s ulcer).
Clean Kills
• Discussing electrodessication and curettage
• Discussing Mohs surgery when not indicated
• Discussing simply treating with radiation/chemotherapy
when not indicated
• Reconstructing/closing wound prior to margins conrmed
negative
Bibliography
NCCN Clinical Practice Guidelines in Oncology. Squamous cell skin
cancer. Version 1.2024—November 9, 2023. NCCN.org.
Basal Cell Carcinoma
AliaAbdulla andCristaE.Horton
139
Introduction
• BCC is most commonly found on sun-exposed areas of
the head and neck.
• BCC is more common in the Caucasian population, and
the incidence is inversely proportional to a country’s
geography, latitude, and inhabitant’s pigment status.
• Risk factors for development of BCC include sun expo-
sure, intense, intermittent exposure to UVB and UVA
radiation, particularly during adolescence, immune suppression, chemical exposure, ionizing radiation exposure,
and genetic susceptibilities such as xeroderma pigmentosa, unilateral basal cell nevus syndrome, and nevoid
BCC syndrome.
• P53 tumor suppressor gene is defective in 50% of cases,
with a latency period of 20–50 years.
• Multiple cellular signaling pathways are involved in the
development of BCC.
– The hedgehog signaling pathway is mutated in up to
90% of BCCs.
– In the presence of hedgehog signaling peptides, the
Patched receptor releases the transmembrane
Smoothened (SMO) protein, allowing SMO to initiate
a signaling cascade to activate multiple target genes.
– In the absence of hedgehog signaling peptides, the
Patched receptor inhibits SMO.
– Both activating mutations in SMO and inactivating
mutations in Patched have been linked to BCC due to
unrestricted growth signaling.
• There are no precursor lesions to BCC, unlike with SCC
and actinic keratoses.
• Appearance of BCC varies from skin nodules to large
nonhealing sores with draining and crusting.
• BCC has a slow growth rate, inltrates locally, and rarely
metastasizes.
A. Abdulla (*) · C. E. Horton
Department of Surgery, Broward Health Medical Center,
Fort Lauderdale, FL, USA
e-mail: chorton@browardhealth.org
• Metastasis of BCC is associated with advanced age and
large, untreated lesions.
• With metastatic BCC, the median survival decreases to <1
year.
• BCC has various subtypes.
– Nodular—most common
Well-dened, elevated lesion with a waxy appearance, with pearly pink opalescent nodules developing along the margins as it grows
Has features such as central depression; umbilication; ulceration; rolled edges; telangiectasia along
the surface or edges; can be pink, skin-colored,
brown, black, or pigmented; and can mimic a melanoma or benign mole
– Micronodular
Aggressive subtype. Several mildly elevated pink or
red lesions
More aggressive growth patterns—extend beyond
visible changes in the skin surface
– Inltrative
Aggressive subtype. Occurs on the head and neck in
the late 60s, at embryonic fusion lines
Opaque yellow-white color that blends with surrounding skin and no raised edges
– Cystic
Less common
Distinctive blue, gray, translucent appearance
– Supercial spreading
Macular growth pattern, at, pink, crusting, conned to the epidermis in a multicentric pattern.
These can ulcerate, with irregular margins, appearing similar to psoriasis, tinea, or eczema.
Occur commonly on the trunk and extremities, with
mean age of diagnosis of 57 years.
– Morpheaform
Aggressive subtype. 2–3% of all BCC
Most aggressive subtype, most locally invasive subtype that can penetrate deep into the underlying
subdermis
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_139
483
484
A. Abdulla and C. E. Horton
Indurate macule or papule with the appearance of
an enlarging scar, white, scarring
High rate of positive margins after excision
• Diagnosis of BCC can be done using dermoscopy to
image the lesion, and shave biopsy or punch biopsy of the
lesion can be done, followed by histopathologic identication of BCC.
• Histopathology of BCC is characterized by aggregates of
basal cells with small cytoplasm and large, hyperchromatic nuclei, with apoptotic cells in a bromyxoid stroma.
• Treatment
– Surgery—wide local excision with negative resection
margin of 4mm for small BCC on cosmetically sensitive areas and 4–6mm margins for high-risk lesions,
according to NCCN Guidelines.
– Mohs micrographic surgery—best for aggressive sub-
types with ill-dened borders. Only 1% recurrence
rate.
– Field therapies—radiation, cryosurgery, photody-
namic therapy, electrodessication and curettage, and
topical agents such as imiquimod.
– Adjuvant radiation can be given for high-risk lesions
to reduce the risk of local recurrence.
– Lymph node evaluation is not necessary as lymph node
metastases are extremely rare.
– Systemic therapy—for rare advanced or metastatic
disease, targeting the hedgehog signaling pathway.
Small molecule inhibitors—vismodegib and
sonidegib
• Risk factors for recurrence
– Location/size
Low risk: Area L<20 mm, Area M<10mm
High risk: Area L>20 mm, Area M>10 mm, Area
H
*Area H: “mask areas” of the face (central face,
eyelids, eyebrows, periorbital nose, lips [cutaneous
and vermillion], chin, mandible, preauricular and
postauricular skin/sulci, temple, ear), genitalia,
hands, and feet. Area M: cheeks, forehead, scalp,
neck, and pretibial. Area L: trunk and extremities
(excluding pretibial, hands, feet, nail units, and
ankles). Aggressive growth pattern: having (mixed)
inltrative, micronodular, morpheaform, basosquamous, sclerosing, or carcinosarcomatous differentiation features in any portion of the tumor
– Borders
Low risk: well dened
High risk: poorly dened
– Primary vs recurrent
Low risk: primary
High risk: recurrent
– Immunosuppression
Low risk: no
High risk: yes
– Site of prior radiation therapy
Low risk: no
High risk: yes
– Pathologic subtype
Low risk: nodular, supercial
High risk: aggressive growth pattern
– Perineural invasion
Low risk: no
High risk: yes
• Follow-up
– Patients should undergo complete skin and lymph
node examination every 6–12 months to ensure no
other concerning lesions or lymphadenopathy.
– Counseling on the importance of performing monthly
self-skin examinations and sun safety techniques such
as avoiding sun between the hours of 11 a.m. and 4
p.m., wearing sun-protective clothing, and applying a
broad-spectrum sunscreen with an SPF 30 or higher.
– 66% of recurrences develop within 3 years, and the
remaining recur within 5 years of initial treatment.
A 62-year-old man presents with a round, raised lesion
with rolled borders and telangiectasias on the right side of
his nose that has been present for 6 months. What is the next
step in management?
• Given that it is not pigmented, a shave biopsy or punch
biopsy can be done to obtain a diagnosis. If the lesion was
pigmented and there was concern for melanoma, a full
thickness punch biopsy should be obtained, as utilizing
cryotherapy, cautery, or lasers to ablate the lesion or
obtaining a shave biopsy which is not full thickness is not
encouraged. Diagnosis of melanoma and determining
treatment and prognosis involves knowing the depth of
the lesion, which is not a factor in diagnosing BCC.
What are the treatment options for management after
obtaining a diagnosis of BCC such as in this patient
presented?
• Conduct a wide local excision with negative resection
margin of 4mm for small BCC, or 4–6mm in a less cos-
metically sensitive area with high-risk features according
to NCCN Guidelines. Mohs surgery for aggressive sub-
types or on cosmetically sensitive areas such as the face.
Other therapies such as cryosurgery, radiation, electrodes-
sication, and curettage. Topical imiquimod. Radiation or
adjuvant radiation. Without sentinel lymph node biopsy or
lymphadenectomy.
139 Basal Cell Carcinoma
485
What factors of BCC are considered high risk?
• Poorly dened borders; recurrent disease; perineural
invasion; site of prior radiation; immunosuppression; size
>2cm on trunk or extremities; size >1cm on cheeks, forehead, scalp, neck, and pretibial regions, or “mask areas”
of the face; aggressive pathologic subtypes including
micronodular, inltrative, and morpheaform.
How should you follow this patient long term?
• Follow up every 6–12 months for full body skin and
lymph node exam to evaluate for other melanoma or
non- melanoma lesions or lymphadenopathy. Patients
should be provided education and counseling on sun
safety measures such as avoiding sun between the hours
of 11 a.m. and 4 p.m., wearing sun-protective clothing,
and applying a broad-spectrum sunscreen with an SPF 30
or higher.
Clean Kills
• Failing to get a detailed history of sun exposure, prior
radiation, and immunosuppression
• Failing to do a thorough head-to-toe physical exam for
other non-melanoma lesions or melanoma, with bilateral
cervical, axillary, and inguinal lymph node palpation/
examination
• Failing to resect with appropriate margins
Bonus Points
• Providing further education to patients regarding sun
safety measures and the importance of knowing their general risk of developing skin cancers
• Providing further education to patients regarding the
importance of self-examination of the skin as well as inofce follow-up skin exams every 6–12 months
• Prepare to discuss use of skin grafts/indications and
techniques
Words ofWisdom
The management of BCC is always evolving and there are
guidelines to support surgical resection for both low- and
high-risk lesions. All patients should undergo a thorough history to identify risks of developing these malignancies as
well as melanoma. Patients should all undergo a full head-totoe skin exam and evaluation for lymphadenopathy. An
appropriate diagnosis is needed prior to surgical intervention. BCC is very slow growing and highly treatable with
resection utilizing a variety of surgical techniques with minimal anesthesia in some cases. Resection margins should be
negative and vary between 4 and 6mm depending on risk
features of the lesion and patient. Locally invasive or metastatic disease is exceptionally rare with BCC, but the treatment for these lesions should involve adjuvant or neoadjuvant
radiation, or systemic chemotherapy may be used in these
cases. Unlike melanoma, non-melanoma lesions such as
BCC do not metastasize to lymph nodes, so operative treatment for or biopsy of lymph nodes is not necessary. It is
important to know the different subtypes of BCC and their
appearance on the physical exam. There are some studies
done to determine risk scores for non-melanoma skin cancers, but they are underdeveloped at this time and likely will
not be tested on the oral board exam.
Bibliography
Brunicardi F, Andersen DK, Billjar TR, Dunn DL, Kao LS, Hunter JG,
Matthews JB, Pollack RE, editors. Schwartz’s principles of surgery.
11th ed. McGraw Hill; 2019.
Quazi SJ, Aslam N, Saleem H, Rahman J, Khan S.Surgical margin of
excision in basal cell carcinoma: a systematic review of literature.
Cureus. 2020;12:e9211.
Score: basal cell carcinoma module. https://www.surgicalcore.org/
chapter/366449#366519.
Townsend JCM, Beauchamp RD, Evers BM, Mattox KL.Sabiston text-
book of surgery. 20th ed. Elsevier-Health Sciences Division; 2016.
Verkouteren JAC, Ramdas KHR, Wakkee M, Nijsten T.Epidemiology
of basal cell carcinoma: scholarly review. Br J Dermatol.
2017;177:359–72.
Necrotizing Soft Tissue Infections
StefanLeichtle andAbdullahWafa
140
Concept
“Necrotizing fasciitis” is still the commonly used term for
these infections, but necrotizing soft tissue infection (NSTI)
is a better description for an infection and necrosis that often
include structures other than fascia, such as subcutaneous
fat, muscle (incl. fascia), and bone (Stevens et al. 2021;
Sartelli etal. 2022). While the diagnosis of an NSTI may be
obvious in some patients with skin necrosis, bullae, crepitus,
and sepsis, NSTIs can easily be misdiagnosed as “simple”
cellulitis, chronic ulcers, or abscesses in the initial stages. A
delayed or missed diagnosis of NSTI is detrimental
(Kobayashi etal. 2011) to a patient and on the oral boards.
The treatment for NSTIs is debridement, which is often
extensive, and may include bone and neurovascular structures, sometimes requiring extremity amputation. Board
questions will probe your ability to differentiate an NSTI
from severe cellulitis or a supercial surgical site infection
and your understanding that urgent, radical operative
debridement is the single most important aspect of treating
NSTIs. Typical scenarios may include a chronically ill
patient with diabetes presenting with progressive “cellulitis”
of an extremity, a morbidly obese patient with an “abscess”
in the perineal area, or a postoperative patient whose recent
laparotomy incision has erythema and drains “dishwater
uid.”
Way Questions May BeAsked?
“A 52-year-old patient with morbid obesity and poorly controlled diabetes presents to the ED with cellulitis involving
the scrotum, perineum, and proximal thigh. On exam, the
patient is tachycardic, appears ill, and has blisters on the
proximal thigh.” Cellulitis with blisters or crepitus is an
S. Leichtle (*) · A. Wafa
Division of Trauma and Acute Care Surgery, Inova Fairfax Medical
Campus, Falls Church, VA, USA
e-mail: stefan.leichtle@inova.org; abdullah.wafa@inova.org
obvious and ominous sign pointing toward NSTI, but the
presentation may also omit these pathognomonic ndings.
“On POD#2, a 36-year-old patient who underwent total
colectomy for complications from ulcerative colitis develops
a fever to 102°F and progressive erythema around the stapled midline laparotomy incision.” More obvious signs such
as gray uid draining from the incision may be given, but
may also require you to rst remove some staples, or the
local ndings may still be hidden underneath the surgical site
dressing until you ask to remove it.
“A healthy 24-year-old presents to the ED with a 3-inch
laceration and surrounding erythema on the calf. The patient
reports that the injury was sustained while boating 2 days
prior. In the last few hours, there was progression of the erythema and increasing chills and malaise.” Patients without
underlying health problems can also suffer from NSTIs
caused by highly virulent organisms such as Vibrio vulni-
cus, a highly aggressive bacteria found in brackish water.
How toAnswer?
History
• Recent injury or procedure
• Diabetes, immunocompromise
• History of MRSA infections
• Body habitus (obesity, morbid obesity)
• Systemic signs of infection (fever, malaise)
• Signs of septic shock (hypotension, tachycardia, organ
failure)
Physical Examination
• Vital signs.
• Look for erythema, crepitus, bullae, and skin
discoloration.
• Remember that initial exam ndings may be difcult to
distinguish from simple cellulitis, chronic skin changes
such as venous stasis disease, or ulcerations associated
with diabetes.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
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S. Leichtle and A. Wafa
Diagnostic Tests
• In general, the diagnosis of an NSTI is primarily a clinical
one and diagnostic workup should never delay surgical
debridement.
• Full laboratory panel with focus on white blood cell count
(WBC, signicantly elevated), sodium levels (hyponatremia commonly associated with NSTI), and markers of
organ dysfunction such as elevated creatinine indicating
acute kidney injury.
• If WBC, hemoglobin, sodium, creatinine, glucose, and
C-reactive protein (CRP) levels are available, the
Laboratory Risk Indicator for Necrotizing Fasciitis
(LRINEC) score can be calculated (Wong et al. 2004).
Traditionally, a score of 6 or higher suggests an at least
moderate risk for NSTI and a score of 8 or higher a high
risk for NSTI.However, systematic reviews demonstrate
a low sensitivity of the LRINEC score and therefore low
scores should not be used to rule out NSTI (Wong etal.
2004; Fernando etal. 2019).
• X-rays can alert to a diagnosis of NSTI if they demonstrate soft tissue air, but its absence does not rule out
NSTI.
• CT imaging is more sensitive than X-ray to assess for soft
tissue air or other signs of soft tissue inammation and
infection, but in cases where there is a high index of suspicion for NSTI or if the patient is in septic shock, surgical debridement should not be delayed to obtain
cross-sectional imaging.
• MRI should not be obtained due to the time-sensitive
nature of diagnosing and treating NSTIs.
• In cases of high index of suspicion for NSTI, “surgical
exam” via skin incision (under local anesthesia) and dissection down to and opening of the fascia, especially
when involving an extremity, is a rapid and effective way
of diagnosing NSTI, which may be done at the bedside.
Treatment
The most important intervention for NSTI is operative
debridement. Additionally, broad antibiotic coverage should
be initiated immediately. Unless the organism is known,
antibiotic coverage needs to include methicillin-resistant
Staphylococcus aureus (MRSA) and all aerobic, anaerobic,
gram-positive, and gram-negative bacteria. A commonly
used regimen includes vancomycin and piperacillintazobactam. The former can be exchanged for linezolid or
daptomycin, and the latter for cefepime and metronidazole,
and other combinations are possible in case of allergies or
known resistances. Additionally, clindamycin, which inhibits toxin production of group A streptococcus (GAS), is frequently given, until the presence of streptococcus has been
ruled out via culture results (Stevens et al. 2021; Sartelli
etal. 2022).
Once an NSTI is diagnosed, patients need to undergo
operative debridement emergently, as each hour of delay in
care is associated with increased mortality. Patients or their
families/decision makers should be counseled that debridement may be extensive, involve permanent loss of function
or limb, and require multiple operations. Depending on
patient demographics and condition, goals of care discussions may be indicated.
In the operating room, all nonviable tissue needs to be
debrided, which may include large areas of the epidermis,
subcutaneous fat, muscle, tendon, but also nerves or vasculature if clearly involved. Tissues of questionable viability may
be left in situ for a second-look operation within 24 h to
minimize the morbidity of radical debridement. Patients frequently need to undergo multiple operations, and all patients
with ongoing or worsening hemodynamics, leukocytosis, or
local ndings after initial debridement(s) need to return to
the operating room for reassessment.
NSTIs involving the perineal and perirectal area often
require creation of a diverting stoma to protect the site of
debridement from ongoing contamination, though this
should not be done during the index operation. Finally,
patients may require prolonged and complex wound care,
wound vacuum devices, or skin grafts and aps to achieve
soft tissue healing and coverage once the surgical site is no
longer infected.
Common Curveballs
• NSTI involves the scrotum and requires debridement and
relocation of testicles into a thigh pouch.
• NSTI extends into the peritoneal cavity, bladder, or
rectum.
• Source control requires amputation or hip
disarticulation.
• Patient refuses radical debridement such as amputation.
• Presumed NSTI turns out to be skin malignancy or
calciphylaxis.
Clean Kills
• Missed diagnosis (e.g., not removing fresh postoperative
dressing in patient with sepsis on POD#1 after laparot-
omy) or misdiagnosis as cellulitis or abscess
• Delay in treatment due to extensive imaging requests such
as MRI
• Grossly inadequate surgical debridement, e.g., only per-
forming an I&D
140 Necrotizing Soft Tissue Infections
489
• Ignoring indications for second look or take back at any
time such as worsening sepsis, leukocytosis, and lactic
acidosis
Summary
NSTIs can easily be misdiagnosed as simple soft tissue
infections. Delays in diagnosis and treatment dramatically increase the risk of complications and death.
Clinical exam, high index of suspicion, and a low threshold for operative exploration of a patient with suspected
NSTI are essential for the successful management of
NSTIs.
Laboratory markers such as severe leukocytosis or
hyponatremia as well as scoring systems like LRINEC
can be helpful in raising suspicion for the presence of an
NSTI, but their results should never supersede clinical
concerns. Operative debridement, often in multiple
stages, is the single most important step in the treatment
of NSTIs, in addition to broad antibiotic coverage.
Patients with severe underlying comorbidities or history
of frequent use of healthcare facilities often present with
multi-microbial infections including MRSA, while base-
line younger and healthier patients often present with
highly virulent single organisms such as GAS or Vibrio
vulnicus.
Bibliography
Fernando SM, Tran A, Cheng W, Rochwerg B, Kyeremanteng K, Seely
AJ, Inaba K, Perry JJ.Necrotizing soft tissue infection: diagnostic
accuracy of physical examination, imaging, and LRINEC score: a
systematic review and meta-analysis. Ann Surg. 2019;269(1):58–65.
https://doi.org/10.1097/SLA.0000000000002774.
Kobayashi L, Konstantinidis A, Shackelford S, et al. Necrotizing
soft tissue infections: delayed surgical treatment is associated with increased number of surgical debridements and morbidity. J Trauma. 2011;71(5):1400–5. https://doi.org/10.1097/
TA.0b013e31820db8fd.
Stevens DL, Bryant AE, Goldstein EJ. Necrotizing soft tissue infec-
tions. Infect Dis Clin N Am. 2021;35(1):135–55. https://doi.
org/10.1016/j.idc.2020.10.004.
Sartelli M, Coccolini F, Kluger Y, et al. WSES/GAIS/WSIS/SIS-E/
AAST global clinical pathways for patients with skin and soft
tissue infections. World J Emerg Surg. 2022;17(1):3. https://doi.
org/10.1186/s13017- 022- 00406- 2.
Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC
(Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for
distinguishing necrotizing fasciitis from other soft tissue infections.
Crit Care Med. 2004;32(7):1535–41. https://doi.org/10.1097/01.
ccm.0000129486.35458.7d.
Wound Dehiscence
HamzaA.Bhatti andLindseyL.Perea
141
Supercial Wound Dehiscence
Concept
The majority of questions will be related to postoperative
wound complications which will aim to assess your underlying knowledge regarding phases of wound healing, risk factor recognition and optimization, physical exam ndings,
and appropriate management.
Way Question May BeAsked?
“A 52-year-old male presents to an outpatient clinic with
complaints of wound issues after recent open appendectomy
surgery. He reports increasing pain, redness, and sensation of
‘pulling’ around the incision site.”
This is a straightforward description of a patient present-
ing after a recent surgery for postoperative follow-up with
wound complications.
How toAnswer?
History
• Diabetes mellitus
– High blood glucose is associated with wound compli-
cations. Wound dehiscence may occur in as high as
44% of patients with high glucose levels before sur-
H. A. Bhatti
Microsurgery, Plastic and Reconstructive Surgery, Mercy Medical
Center, Baltimore, MD, USA
e-mail: hbhatti@mdmercy.com
L. L. Perea (
Trauma and Acute Care Surgery, Penn Medicine Lancaster General
Health, Lancaster, PA, USA
Department of Surgery, Philadelphia College of Osteopathic
Medicine, Philadelphia, PA, USA
e-mail: Lindsey.Perea@pennmedicine.upenn.edu
*)
gery compared to 19% without. Optimizing blood glucose levels and HgbA1c pre- and postoperatively is
key in prevention of wound complications.
• Obesity
– There is an increased risk of infection and wound
dehiscence in morbidly obese patients ranging from a
2- to 4.4-fold increase compared to normal body
weight. It is imperative to consider weight loss strategies prior to elective surgery.
• Hypertension
– High blood pressure causes restriction of blood ow
through the small blood vessels that carry oxygen to
the site of the wound. The goal should be to achieve
and maintain normal blood pressure.
• Malnutrition
– Hypoalbuminemia is a well-studied risk factor for
wound complications including dehiscence due to
impaired wound healing and reduced tensile strength.
• Immunocompromised
– Immunosuppressive medications inhibit T cell produc-
tion and differentiation. This reduces immunoglobulin
production and decreased IL-2 secretion. Consider
reducing or withholding immunosuppressive agents
(in select cases) until complete wound healing has
occurred.
• Advanced age
– Changes to the skin are an inherent part of aging and
can directly inuence wound healing. The epidermis
becomes thin and the number of melanocytes
decreases.
• Corticosteroid use
– Steroids interfere with formation of granulation tissue
and in turn disrupt wound healing. Receiving steroids
postoperatively and for a longer duration has been
shown to result in higher risk of abdominal wound
dehiscence compared to preoperative steroids.
• Tobacco use
– Nicotine is a known vasoconstrictor and results in
decreased blood ow to the wound resulting in
increased risk of wound dehiscence.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_141
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