Journal of Cutaneous and Aesthetic Surgery
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   Table of Contents - Current issue
Coverpage
July-September 2021
Volume 14 | Issue 3
Page Nos. 265-383

Online since Wednesday, October 20, 2021

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CME ARTICLE  

Hair transplant practice guidelines Highly accessed article p. 265
Venkatram Mysore, Muthuvel Kumaresan, Anil Garg, Aman Dua, Aniketh Venkatram, Kapil Dua, Mayank Singh, Madura C, Ram Chandran, Rajendra Singh Rajput, Sandeep Sattur, Sukhbir Singh
DOI:10.4103/JCAS.JCAS_104_20  
The field of hair transplant (HT) has grown exponentially in the past decade, especially after the introduction of follicular unit excision (FUE). There is much variation in criteria for case selection, the technique, pre- and post-procedure protocols, by different surgeons. Techniques continue to evolve and evidence in the form of controlled data is not available for all techniques and protocols being used; there is also a debate as to who can do what, what should be the training for staff, role of technicians. This has led to a situation wherein medico legal issues have cropped up as to what is minimum acceptable. An attempt is made to summarize standard protocols with the available evidence. It is emphasized that the objective of these guidelines is to recommend minimum standards for practice of hair transplantation. The principles outlined in these guidelines are of a general nature only, minimal in their level and are not meant to cover all situations. It should be understood that these recommendations are by no means binding and universal, represent minimum standards only and as in all surgical techniques, variations in techniques are possible. It is also further clarified that these are based on current literature, and as science evolves, these guidelines could also change in future. Where published evidence is not available, consensus expert opinion is presented. The task force emphasizes that each patient has to be treated on his/her own merit and that these guidelines do not limit the physician from making an appropriate choice or the necessary innovation for a given patient. The task force recognizes that the treating surgeon is best suited to decide what is needed for a given patient in a given situation. Innovations in medicine need flexibility in approach and these guidelines do not limit the surgeon from undertaking innovative research.
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REVIEW ARTICLES Top

Intralesional agents in dermatology: Pros and cons Highly accessed article p. 285
Jagdish Sakhiya, Dhruv Sakhiya, Jitesh Kaklotar, Bansi Hirapara, Madhav Purohit, Krishna Bhalala, Feral Daruwala, Nimish Dudhatra
DOI:10.4103/JCAS.JCAS_109_20  
Since introduced in 1961, intralesional (IL) agent has become an essential part of the dermatological practice. The term IL referred to the direct delivery of agent percutaneously into skin lesions. This therapeutic approach is relatively safe, easy to perform and applicable for a broad range of dermatological conditions. On the other hand, immediate side effects, including pain during administration, bleeding, high risk of infection and allergic reaction, and subsequent side effects involving skin changes such as atrophy, telangiectasia, pigmentary changes, and striae are usually associated with this modality. This review paper highlights the pros and cons of IL agents in modern dermatology practice.
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The role of adipose tissue in hair regeneration: A potential tool for management? p. 295
Suman Nepal, Aniketh Venkataram, Venkataram Mysore
DOI:10.4103/JCAS.JCAS_47_19  
Human adipose tissue (AT) is a rich and easily harvestable source of stem cells and various growth factors (GFs). It has been widely used hitherto for facial rejuvenation and volumization. Increasing evidence shows that dermal adipocytes are intricately associated with hair follicles (HFs) and may be necessary to drive follicular stem cell activation. Early published data have shown encouraging preliminary results for the use of adipocytes and their stem cells as a treatment option for hair growth. The aim of this review study is to analyze published literature on the effect of fat on hair growth and to summarize the current evidence.
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ORIGINAL ARTICLES Top

Comparison of two types of tapes for taping after breast reconstruction using silicone materials p. 305
Naohiro Ishii, Jiro Ando, Tomoki Kiuchi, Takahiro Uno, Kazuo Kishi
DOI:10.4103/JCAS.JCAS_113_20  
Background: Several kinds of tapes are used for postoperative wounds, which occasionally cause contact dermatitis and result in noticeable pigmentation. A comparison of the postoperative course between different tapes has not been reported. This study aimed at investigating the differences between two postoperative tapes used after breast reconstruction with silicone materials for simple mastectomy. Materials and Methods: Eighty-eight nonconsecutive patients undergoing tissue expander operation and 75 nonconsecutive patients undergoing tissue expander and silicone breast implant operations were included in this prospective study. Two postoperative tapes were used: a nonwoven surgical tape (Yu-ki ban®) or a hypoallergenic polyester-woven fabric tape (Atofine TM), which have different base materials, a removed keratinocyte area, and moisture permeability. We determined the differences in the incidence of skin complications, scar width, and aesthetic results with respect to scarring between the patients using Yu-ki ban and those using Atofine. Results: Statistically similar results were achieved for the patients who underwent reconstruction using either the tissue expander or silicone breast implant. Scar width was similar between the groups; however, the incidence of skin complications was significantly lower in patients using Atofine than in those using Yu-ki ban. Aesthetic results with respect to scarring were better in patients using Atofine than in those using Yu-ki ban, with a significant difference in the incidence of pigmentation between the groups. Conclusion: The tape with higher moisture permeability and a lower removed keratinocyte area should be used to reduce the incidence of contact dermatitis and achieve better aesthetic results with respect to scarring.
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Intra-individual right-left comparative study of combined therapy of intramatricial triamcinolone and platelet-rich plasma vs. intramatricial triamcinolone only in lichen planus-associated nail dystrophy p. 311
Fozia Rehman, Kewal Krishan, Insha Latif, Ekta Sudan, Javeed Sultan, Iffat Hassan
DOI:10.4103/JCAS.JCAS_156_20  
Background: While intramatricial triamcinolone is the most commonly used treatment option for onychodystrophy due to lichen planus, the role of platelet-rich plasma (PRP) in the treatment of onychodystrophy is not established. So we combined the two treatment modalities to assess the synergistic action on nail dystrophy. Aims and Objectives: The aim of this article is to compare the effect of combination of intramatricial triamcinolone and PRP vs. intramatricial triamcinolone alone in the treatment of onychodystrophy. Materials and Methods: This study was done in 26 and 25 pairs of symmetrical dystrophic nails in hands and feet, respectively. The patients received intramatricial injection of triamcinolone and PRP on one side of finger and toe nails and triamcinolone on the contralateral side. Results: Statistically significant improvements in grades of dystrophy according to the Nail Dystrophy Grading System (NDGS) in the finger and toe nails treated with combined therapy were obtained (P < 0.001 and = 0.002, respectively). According to the physician global assessment, response to combination therapy was statistically significant between the two comparison groups of finger and toe nails (P = 0.001 and = 0.004, respectively). Similarly, according to the patient satisfaction score, statistically significant difference was found between the comparison groups of combination therapy and single therapy (P < 0.001). Conclusion: Addition of PRP significantly improved the nail quality. Intramatricial PRP is a safe and effective therapeutic modality in refractory nail dystrophies.
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Carbon dioxide laser plus topical 5% luliconazole: A better combination therapeutic modality for onychomycosis p. 318
Shahnawaz Bashir, Iffat Hassan, Syed Mubashir
DOI:10.4103/JCAS.JCAS_70_20  
Background: Onychomycosis has always been a therapeutic challenge because of longer treatment duration, potential adverse effects of oral antifungals, and limited efficacy of topical agents. During the past few years, the emergence of laser therapy has been the topic of discussion as a newer, safe, minimally invasive modality of treatment. Aim: The aim of this study was to evaluate the role of fractional CO2 laser and topical luliconazole 5% lotion in the treatment of onychomycosis, as a combined treatment and as independent modalities. Materials and Methods: This was a prospective, randomized, triple-limb comparative observational study in which 106 patients with KOH and culture-proven onychomycosis were randomly assigned to three groups. Group A received fractional CO2 laser (10,600nm) triweekly for four sessions (0, 3, 9, and 12 weeks) plus topical luliconazole 5.0% lotion applied twice daily on the affected nail plates and nail folds for 12 weeks. Group B received only fractional CO2 with the same frequency of sessions and laser parameters as in group A. Group C received only topical luliconazole 5.0% solution twice daily for 12 weeks. Treatment outcome was evaluated using onychomycosis severity index (OSI) score, mycological parameters, and level of satisfaction of patients. Results: The degree of clinical improvement, mycological cure, and patient’s satisfaction was significantly better in the combined group than individual modalities. There were no severe adverse effects that warranted the discontinuation of the treatment in any of these patients. Conclusion: Fractional CO2 laser combined with topical luliconazole 5% lotion is a safe and effective treatment for onychomycosis especially in those who have contraindications to oral antifungals.
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Efficacy of fractional carbon dioxide laser (FCO2) with intralesional 5-fluorouracil (5-FU) in the treatment of keloids p. 323
Nabeel Kadhim Alhamzawi
DOI:10.4103/JCAS.JCAS_153_20  
Context: Managing keloids remains a challenge in clinical practice. Many therapeutic options are available, but none is universally accepted or without recurrence. Therefore, an effort is required to choose the treatment with maximal outcomes. Aims: To evaluate the effectiveness of combining fractional carbon dioxide (FCO2) laser and intralesional 5-fluorouracil (5-FU) for the treatment of keloids. Materials and Methods: In this prospective open-label study, 24 patients received FCO2 laser treatment, started at baseline, for a total of six sittings. The patients also received 1 mL/cm2/keloid of 5-FU (50 mg/mL) intralesionally, following irradiation, at identical time points. The primary outcome evaluated was the clinical response concerning height, pliability, vascularity, and pigmentation, using the Vancouver Score Scale (VSS). Adverse reactions and recurrences were recorded as secondary outcomes. Results: A significant reduction was observed in the VSS in terms of pliability and height after three treatment sessions. The mean VSS reduction was 65%, from 8.45 ± SD 0.93 at baseline to 3 ± SD 1.8 one month after the last treatment (P < 0.05). Most patients (79.1%; n = 19) showed a satisfactory response to treatment, with 57.8% (n = 11) achieving an excellent result. Adverse reactions included post-inflammatory hyperpigmentation in four patients and ulceration in two. Recurrences were reported in 21% of the patients who responded well. Conclusions: Combination therapy with FCO2 laser and intralesional 5-FU showed a promising effect in the treatment of resistant keloids, with an acceptable safety profile and low recurrence rate.
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Revisiting rhombic flaps for aesthetic facial resurfacing: Addressing a surgical conundrum p. 330
Neeraj Kant Agrawal
DOI:10.4103/JCAS.JCAS_63_20  
Background: Facial resurfacing is a surgical and aesthetic challenge, as it requires soft, pliable, and stretchable donor skin with a good match of color, texture, and thickness and minimum donor scarring. Rhombic flap is a highly versatile flap that has the aforementioned properties. Careful flap planning and execution is vital for successful outcomes. Aims: The aim of this work was to study the geometry of the classic rhombic flaps; to evaluate their versatility and technical finesse as well as their application to resurface defects over various regions of the face. Materials and Methods: Overall, 42 patients with facial scars due to trauma, malignancies, small nevi, and mature scars of the face were studied and operated on. Of the four rhombic flaps that were possible, choosing the best option required careful attention to camouflage of scar and proximity to vital deformable anatomical structures. Geometrical planning of the flap was the essence of the entire surgical exercise. Results: Outcome of rhombic flaps were meticulously and critically analyzed. The study consisted of 36 females (85.71%) and only 6 males with a mean age of 23 years. Defects were created on 27 mature scars (64.29%) and 11 burn scars (26.19%). Defects over the cheek and lateral canthus of the eye were especially problematic. It is a safe flap with excellent results as far as visible scarring and traction deformities are concerned. Scars elsewhere on the face fared better than on the bony prominence. Conclusion and Significance: Rhombic flaps offer an excellent alternative to resurface facial scars and defects in a selected subset of patients.
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Efficacy of surgical excision and adjuvant high-dose rate brachytherapy in treatment of keloid: Our experience p. 337
Kalapurmat N Manjunath, Mysore Srinivas Venkatesh, Ramcharith Alva, Keerthi Koushik, Veena Waiker, Kumaraswamy Mohan, Shanthakumar Shivalingappa
DOI:10.4103/JCAS.JCAS_120_16  
Background: Keloids are dermal tumors that are due to increased production of collagen caused by abnormal and prolonged wound healing. The incidence of recurrence is extremely high if only conservative measures are used. This study was conducted to evaluate the feasibility and efficacy surgery and high dose rate brachytherapy as an adjuvant therapy for treatment of keloids. Materials and Methods: 50 patients with clinically diagnosed 71 keloids were treated with excision of keloid and post-operative high-dose rate brachytherapy were studied. Complete excision of the keloid till the healthy skin margin was excised. The wound were closed in 2 layers. Subcutaneous tissue closed using absorbable suture, over which a 6F flexible polyethylene tube was placed. High dose rate cobalt-60 brachytherapy was administered. Total of 15 Gy in divided dose, 5 Gy in 3 fractions were administered. Results: 50 patients with 71 keloids were studied. Out of the 50 patients, 12 were male (24%) and 38 were females (76%). Age of the patients ranged between 14 and 71 years. Recurrence rate was 2% with 2 keloids recurring at 5 months interval. 4 patients scored the results as unacceptable, remaining 45 patients rated their results as excellent during their follow up at 10 days, 3 months and 6 months. Conclusion: Treatment of keloids in the plastic surgeon’s practice even today is still challenging. Many therapies have been described, but recurrence rate is high with mono-therapy. Combination therapy especially surgical excision with postoperative radiotherapy is best in preventing recurrence.
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Minimal Incision Technique For Gynecomastia p. 344
Souvik Adhikari
DOI:10.4103/JCAS.JCAS_96_20  
Background: Gynecomastia or enlargement of the male breasts affects a large proportion of males, with most patients requiring surgical intervention as only a few lesions are actually resolved with medical management alone. Surgery cures the patients of their problems, albeit, at the cost of scarring and other cosmetic problems in some patients. Therefore, refinements in the surgical process are still ongoing so as to provide the best results with minimal scarring. Aims and Objectives: To find out the feasibility of a minimal incision technique for glandular excision after liposuction in patients with gynecomastia so as to decrease the final visible scars in these patients. Materials and Methods: From July 2018 to September 2018, eight patients were subjected to gynecomastia surgery employing liposuction and gland removal through a single transverse 5–7 mm incision in the nipple. All the patients subjected to this technique had Grade IIa gynecomastia as per Simon’s scale. The Global Aesthetic Improvement Scale, comprising a 5-point Likert scale, was employed to find out the satisfaction level of the patients 12 months after surgery; this level was compared with that of a similar population of patients being operated on by employing liposuction and subcutaneous mastectomy by the periareolar technique. Results: The mean operating time was 110 min, and there was minimal bleeding during the procedure. Complications were also negligible, and all patients achieved an excellent chest contour with restoration of protective nipple sensation when evaluated 12 months after surgery. The difference in mean between the 2 patient groups was 0.125 with a p-value of 0.64. Conclusions: Glandular excision through a single transverse incision made through the nipple is a safe approach in selected patients and it produces excellent cosmetic outcomes. However, it requires patience on the part of the surgeon to achieve the desired goals of the surgery.
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Repair of gauged earlobes: Case series and review of two techniques according to size p. 351
Brian L Scott, Yvette Anderson, Myriam Loyo, Michael M Kim
DOI:10.4103/JCAS.JCAS_116_20  
Background: Earlobe stretching is a common body modification typically performed in individuals under 30 years old. Individuals may later desire restoration of a natural earlobe contour. There is a paucity of literature regarding technique and outcomes for repair of the gauged earlobe defect. Aims and Objectives: The primary aim of this study was to provide a strategy to assess stretched earlobe defects and choose between the repair techniques of de-epithelialization and closure or excision and rotation. The secondary aim of this study was to evaluate complication rates of the two techniques. Materials and Methods: Retrospective review of all patients who underwent repair of stretched (gauged) earlobes at a single institution from 2012 to 2019. Patient demographics, maximum earlobe size, motivation for seeking repair, surgical technique, and complication rate were recorded. Results: Fifty-three patients underwent stretched earlobe repair. The average age was 25.9 years old; 60.0% of the patients were male. Defects repaired with de-epithelialization and closure had been stretched to an average of 12.4 (SD = 3.2) mm compared to 29.3 (SD = 10.9) mm for excision and rotation. The minor complication rate was 12.5% with de-epithelialization and 10.8% for excision and rotation. Motivations for seeking repair included a desire to look more professional for work (34.0%), personal preference (30.0%), and joining the military (23.0%). Conclusion: Smaller earlobe defects (<15 mm) with nonptotic lobules can be repaired with de-epithelialization and primary closure, whereas larger earlobes (>15.0 mm) with ptotic lobules require excision and rotation. Stretched earlobe repair is a well-tolerated procedure, although a significant number of patients will require minor revisions.
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PRACTICE POINTS Top

Use of 27-gauge tuberculin syringe for trichloroacetic acid chemical reconstruction of skin scars (TCA-CROSS) p. 357
Debdeep Mitra, Gautam K Singh, Teghveer Singh, Barnali Mitra
DOI:10.4103/JCAS.JCAS_147_20  
Chemical Reconstruction of Skin Scars (CROSS) is a minimally invasive, safe, and cost effective technique for the management of ice pick acne scars that are otherwise generally resistant to treatment. 100% trichloro acetic acid (TCA) is usually applied using toothpicks and the end point is white discoloration of skin. The concentrated caustic agent quite often spills onto surrounding normal skin leading to superficial burns and post-inflammatory pigmentation. Use of 27-gauge tuberculin syringe gives a much more controlled access to apply TCA leading to better cosmetic outcome and fewer adverse effects.
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Practice Points from Prof. Lawrence M. Field—Father of Modern Dermatosurgery: Bi-level anesthesia and blunt dissection p. 359
Nilesh N Goyal
DOI:10.4103/JCAS.JCAS_220_20  
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INNOVATIONS Top

Bridging the gap: Innovative use of disposable syringe and platelet-rich fibrin for treating planter fissures p. 362
Vikas Pathania, Siddharth Bhatt
DOI:10.4103/JCAS.JCAS_98_20  
Deep plantar fissures are a common, painful condition, which are often recalcitrant to multiple modalities. Autologous platelet-rich fibrin is a reservoir of supraphysiological concentration of platelets housing various growth factors shown to accelerate wound healing. This unique form factor affords a novel advantage of its ability to be applied over and within these fissures under occlusion. We report the innovative use of disposable syringes to fashion platelet-rich fibrin casts for management of these deeper fissures.
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Innovative application of ziplock tags for external tissue expansion p. 364
Padmalakshmi Bharathi Mohan, Saurabh Gupta, Ravi Kumar Chittoria, Abhinav Aggarwal, Chirra Likhitha Reddy, Imran Pathan, Shijina K
DOI:10.4103/JCAS.JCAS_103_19  
Tissue expansion is a technique, which uses the biomechanical properties of skin and thereby aiding in wound closure. Commercially available devices for external expansion are not cost-effective. Hence, in this article, we would like to share our experience of innovative use of ziplock as external tissue expansion.
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CASE REPORTS Top

An unusual case of neonatal perianal lesion and its management p. 367
Jayalaxmi Shripati Aihole
DOI:10.4103/JCAS.JCAS_191_20  
Infantile hemangiomas (IHs) are common vascular tumors occurring in infants. The IHs have a characteristic natural course. Most of the uncomplicated IHs undergo spontaneous involution, with a small proportion of cases requiring intervention. Perianal hemangiomas are rarely reported in infants.
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Role of burn blister fluid in wound healing p. 370
Saurabh Gupta, Ravi K Chittoria, Vinayak Chavan, Abhinav Aggarwal, Likhitha C Reddy, Padmalakshami B Mohan, Shijina Koliyath, Imran Pathan
DOI:10.4103/JCAS.JCAS_90_19  
Blisters are characteristic finding of second-degree superficial burns. Varied opinions for the management of burn blisters are available in literature. Most accepted one is to puncture it in a sterile way, keep the overlying skin as a biological cover, and over that put a moist sterile biological dressing. Fluid in the blister is ultrafiltrate of the plasma, which is rich in proteins such as immunoglobulins, various cytokines, prostaglandins, and interleukins. This fluid is pro-inflammatory, and the evidence regarding its effect on wound healing is varied. Instead of drainage, the burn blister fluid can be aspirated and immediately sprayed over the other areas of the same wound. We found this method feasible as an adjuvant therapy for second-degree superficial burn wounds. In this case report, we share our experience of the same.
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Unusual presentation of trichoblastoma p. 374
Lakshmi Prabha Ponmariappan, C Shanmuga Sekar, Reena Rai, V Chaithra
DOI:10.4103/JCAS.JCAS_174_20  
We report a 39-year-old man who presented with skin-colored plaque over the glabella and root of the nose. Histopathology revealed the diagnosis of trichoblastoma. This case is reported to emphasize the rare presentation of trichoblastoma as it usually presents as an isolated nodule.
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CORRESPONDENCE Top

Successful outcome of follicular unit extraction in a patient with alopecia due to Hansen’s disease p. 377
Prince Yuvraj Singh, Sunmeet Sandhu, Shekhar Neema, Vikas Pathania
DOI:10.4103/JCAS.JCAS_125_20  
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Pain and anxiety management practices in Mohs micrographic surgery: A UK national survey p. 379
Brogan Kelly Salence, Stela Ziaj, Sarah J Felton
DOI:10.4103/JCAS.JCAS_167_20  
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Pigmentation in plexiform neurofibroma following Blaschko’s lines: A new observation p. 381
Madhubari Vathulya, Neirita Hazarika, Riti Bhatia, Ambadivalappil Jayaprakash Praveen
DOI:10.4103/JCAS.JCAS_148_20  
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