Journal of Cutaneous and Aesthetic Surgery
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   Table of Contents - Current issue
Coverpage
April-June 2022
Volume 15 | Issue 2
Page Nos. 101-208

Online since Thursday, July 21, 2022

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REVIEW ARTICLES  

Microdroplet botulinum toxin: A review Highly accessed article p. 101
Rajat Kandhari, Ishmeet Kaur, Jyoti Gupta, Firas Al-Niaimi
DOI:10.4103/JCAS.JCAS_162_21  
Microbotox is the administration of multiple microdroplets of botulinum toxin in intradermal plane. It is increasingly becoming popular owing to its more favorable outcome and better safety profile than the conventional technique. The intention is to treat fine lines and wrinkles without imparting an undesired “frozen face like” appearance. Besides facial rejuvenation, it has found its way into the management of other indications such as rosacea, hyperhidrosis, keloid, and seborrhea. Being a relatively newer method, knowledge about the various dilution methods, desired volume, and correct depth of injection involved in this technique remain scarce. In this article, the authors have highlighted various indications, procedures, adverse effects, and contraindications of microbotox.
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Dermatologic and cosmetic procedures in pregnancy Highly accessed article p. 108
Adit Mohan Garg, Venkataram Mysore
DOI:10.4103/JCAS.JCAS_226_20  
Background: Patients may develop a need to undergo procedures while being pregnant and this requires a certain risk-benefit profiling to be done by the clinician. Skin changes during pregnancy such as melasma, striae, varicose veins, hirsutism, and increased skin growths may raise concerns for the lady. Although pregnancy-induced physiologic changes may prompt a surgeon to delay nonessential procedures until after delivery, certain skin conditions may require urgent intervention. Others that may be nonurgent, elective, or cosmetic may need careful analysis. Materials and Methods: Data were extracted from available literature through a PubMed search for the following keywords: “dermatological procedures in pregnancy,” “dermatosurgical procedures during pregnancy,” “aesthetic procedures in pregnancy,” “safety in pregnancy,” “teratogenicity of drugs,” “local anesthesia during pregnancy,” “physiological changes in pregnancy,” “cosmetic procedures during pregnancy,” and “lasers in pregnancy.”Results: Only procedures which are safe and necessary should be carried out in a pregnant woman. Electrocautery, radiofrequency, cryotherapy, and lasers for warts, particularly genital, surgical interventions for skin malignancies, and other small growths should be performed. Safe but cautious outlook is required for intralesional steroid injections, aesthetic procedures such as chemical peeling, botulinum toxin, microdermabrasion, and biopsies for questionable lesions. Absolutely contraindicated procedures include fillers, sclerotherapy, and liposuction.
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ORIGINAL ARTICLES Top

Management of pre-malignant and malignant non-melanoma skin cancers: A study from a Tertiary Care Hospital of North India p. 118
Yasmeen Jabeen Bhat, Sumaya Zeerak, Farhan Rasool, Saniya Akhtar, Iffat Hassan Shah, Atiya Yaseen
DOI:10.4103/JCAS.JCAS_241_20  
Introduction: The incidence of non-melanoma skin cancers (NMSCs) is increasing over the last few decades. This necessitates an early diagnosis which is nowadays aided by dermoscopy. Once diagnosed early, the treatment armamentarium is diverse and includes both topical and surgical modalities. Objective: Our aim was to diagnose pre-malignant and malignant NMSCs at an early stage and treat them as per the standard protocol. Materials and Materials: Out of 136 patients of pre-malignant and malignant tumors enrolled, 100 were taken up for treatment. These were then classified into various subtypes on the basis of clinical examination and dermoscopy. The selected patients were subjected to topical treatment or surgical modalities, wide local excision or flap excision, based on the type of tumor and its size. Results: The pre-malignant group included actinic keratoses, Bowen’s disease, and keratoacanthoma, whereas the malignant group included undifferentiated squamous cell carcinoma (SCC), differentiated SCC, pigmented basal cell carcinoma (BCC), nodulo-ulcerative BCC, and superficial BCC. Actinic keratoses, superficial BCCs, and five cases of keratoacanthoma were treated with topical therapies with a resolution of 90% in 86.8% cases. All the remaining cases (62 in number) were treated with conventional and flap surgery with 88% and 89.1% clearance rates, respectively, with complications in only 7 patients. Conclusion: A prompt identification of NMSCs can enable selection of the appropriate treatment modality for a specific lesion and thus reduce their associated morbidity and mortality.
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Fat injection and its clinical applications p. 124
Chetan Satish
DOI:10.4103/JCAS.JCAS_242_20  
Fat injection has been in application for more than two decades, and its usefulness has been well documented. In our article, we want to highlight the various applications and usefulness of this versatile technique. We also want to showcase the methods to ensure good results and maximize the uptake of fat grafts with minimal absorption. Our results in our series of 110 consecutive cases have been very encouraging, with excellent patient satisfaction.
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The use of botulinum toxin-A as an adjunctive treatment for facial atrophic and hypertrophic scars after surgical correction p. 131
Anagha Samarth, Leelavathy Budamakuntla, Kanathur Shilpa
DOI:10.4103/JCAS.JCAS_8_21  
Background: Facial wounds, especially the ones lying perpendicular to the Lines of Langer, heal poorly. Several methods have been attempted to rectify this, but most of them do not target the underlying pathological process of scarring. Botulinum Toxin-A (BTA) has been successfully used for atrophic and hypertrophic scars. Materials and Methods: This is a prospective study, where 30 patients who were operated for facial scar revision were divided into two equal groups: The first group was injected with BTA, but the second group was not. They were followed up for three months, and the results were analyzed. Results: Manchester scar scale (MSS) was used to assess the scars. In all the cases, the MSS score reduced after surgical correction, which further reduced after the injection of BTA in the first group of patients. The results are statistically significant (P < 0.01). Conclusion: The BTA plays an important role in the treatment of scars after scar revision surgeries.
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A randomized comparative study of intralesional tranexemic acid and Kligman’s regimen in Indian patients with melasma p. 135
Pawan Gupta, Shital Poojary, Lily Dubey
DOI:10.4103/JCAS.JCAS_1_21  
Context: Melasma is an acquired chronic disorder of hyperpigmentation. Tranexamic acid (TXA) has been shown to be effective in reducing the severity of melasma. Aims: The aim of this study is to compare the efficacy of intralesional TXA with topical Kligman’s regimen in the treatment of facial melasma and to assess their safety profile. Settings and Design: A double arm open-labeled randomized controlled trial was conducted at a tertiary care center in western India. Materials and Methods: Sixty-eight cases of facial melasma of either sex and age ≥ 18 years were randomized into two groups. Group A received intradermal injections of TXA 4 mg/mL, whereas group B received topical Kligman’s therapy. Patients were evaluated at baseline, 4th, 8th, and 12th week semi-objectively using modified melasma area severity index (mMASI) score, physician’s global assessment scale, and patient’s global assessment scale. Statistical Analysis: Data were analyzed using SPSS v16 software. Mann–Whitney U-test, Friedman’s analysis of variance test, and Pearson’s χ2 test were used. P-value less than 0.05 was considered as statistically significant. Results: Fifty-nine patients completed the study. The decrease in mean mMASI score was statistically significant at 4th, 8th, and 12th week for both groups. On intergroup comparison, a statistically significant difference was observed between both the groups at 12th week (P < 0.01), with group B showing better response to therapy but no difference at baseline and at 4th and 8th week. Group A showed no significant side effects, whereas group B showed erythema, burning, and hypopigmentation in nine, six, and three patients, respectively. Conclusion: Kligman’s regimen remains the gold standard for melasma but with multiple serious adverse effects. Intralesional TXA is a safe and promising modality in the treatment of melasma. It can be used in non-responding cases and in those who develop side effects of Kligman’s regimen.
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A simple option added for reconstruction of posterior neck defects p. 142
Salim Al Lahham, Ghanem Aljassem, Rand Y Omari, Zaki Alyazji, Ruba Sada, Sara Alharami, Habib Albasti
DOI:10.4103/JCAS.JCAS_101_21  
Background: Posterior neck defects are uncommon and are mainly caused by infections or tumors. Consequently, the reconstruction options are limited in the literature. They vary according to the size and type of the defect, and options range from grafts to free flaps. In this article, we present a series of cases where we used a transpositional locoregional flap as a simple and effective way for the coverage of posterior neck defects. Materials and Methods: In a series of 11 patients, we designed locoregional transpositional flaps unilaterally or bilaterally, according to the defect size. Dissection was carried on a subfascial plane. Results: All flaps survived without necrosis. We had two incidents of minimal wound gaping that healed without any intervention. Conclusion: In this series, we introduce a new option and its algorithm to reconstruct moderate-sized posterior neck defects using locoregional transpositional flaps, either unilaterally or bilaterally. It is simple, easy to conduct, and has a better color match and less complication rate than other options mentioned in the literature.
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Histological analysis of the effect of nanofat grafting in scar rejuvenation p. 147
Dasari Madhu VinayKumar, Subair Mohsina, Satyaswarup Tripathy, Ramesh Kumar Sharma, Alka Bhatia
DOI:10.4103/JCAS.JCAS_106_21  
Introduction: The morphology and tissue response to macro- and micro-fat grafting have been widely studied in both clinical and experimental settings; the histological effects of the nanofat graft, however, remain largely unexplored. Aims: This study was carried out to evaluate the histological changes leading to scar rejuvenation in a fine scar following nanofat grafting. Materials and Methods: This was an experimental study carried out on guinea-pig fine-line scar models. Nanofat prepared from abdominal fat of the animal was injected into scar on right legs (NFG) at 1 month whereas left acted as controls (CG). Punch biopsies from all scars were analyzed at 2, 4, and 6 months by Hematoxylin&Eosin, Masson’s trichrome, and Picrosirius red stains to evaluate dermal/epidermal regeneration, collagen fiber orientation, pattern of distribution, and amount of mature and immature collagen. Results: Nine animals were included in the final analysis of the study. On histological analysis, the amount of inflammatory infiltrate, collagen fiber orientation, pattern and total histological score at 2, 4, and 6 months were similar between the groups. There was an increased trend for earlier appearance of organized and mature forms of collagen in the NFG group. The distribution of collagen was similar at 2 months; however, there was a significant increase in collagen distribution in NFG at 4 months (NFG: 46.11±11.6, CG: 31.16±9.9; P = 0.010) and at 6 months (NFG: 63.48± 6.6, CG: 49.9 ±8.8; P = 0.002). Conclusion: Nanofat grafting is associated with an accelerated and increased production of mature collagen with proper alignment in fine-line scars.
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Clinical and dermoscopic evaluation of periorbital melanosis p. 154
Ashwini R Mahesh, Krishna Phaneendra Prasad Arumilli, Sravanthi Kotha, Rajitha Alluri, Bala Vaishnavi Lingamaneni, Seetharam Anjaneyulu Kolalapudi
DOI:10.4103/JCAS.JCAS_109_21  
Background: Periorbital melanosis (POM) describes the light-to-dark-colored, brownish-black pigmentation surrounding the eyelids. It can affect an individual’s quality of life. Dermoscopic features of POM are not frequently reported in the literature. Materials and Methods: This study comprised 100 patients aged above 16 years, who attended our outpatient department (OPD) from November 2018 to October 2019. A detailed history, clinical features, and the dermoscopic study of color, pattern of pigment, and pattern of the blood vessel were recorded with the Dermlite-3N dermoscope (3Gen, San Juan Capistrano, California). On the basis of the eyelids’ pigmentation and involvement, patients were clinically graded as Grade 0 to 4, with 4 being deep dark color extending beyond the infraorbital fold. The clinical patterns and the dermoscopic features were correlated. Results: Most patients were women (76) and the common age group was 16–25 years. Most of the patients had both the eyelids involved (58%), followed by lower eyelids (28%). The majority of the patients were having POM of grade 2 (47%). Seventeen patients (17%) had a positive family history of POM. The most common clinical form of POM observed was constitutional type (77) followed by postinflammatory type (12). Of 100 patients, 52 had pigmentary, 15 had vascular, and 33 had mixed pigmentary-vascular pattern. Cell phone usage (>4 h) and refractory errors (38% each) were the common risk factors observed. Stress and respiratory allergy were significantly associated. In the pigmentation patterns, epidermal (54%), dermal (14%), and mixed (17%) subsets were observed. The reticular pattern was the most common vascular pattern (65%). Conclusion: POM is a multifactorial entity. Multiple risk factors play a role in the pathogenesis and aggravation. Clinical forms did not show any specific dermoscopic patterns. Dermoscopy of POM helps to know the underlying pathology, which in turn paves the way to the effective treatment.
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Global trends of sunscreen research literature: A bibliometric analysis over the period of 2010–2020 p. 161
Manjula S Naik, Rajat J Polad, Mahika M Joshi, Virendra S Ligade
DOI:10.4103/JCAS.JCAS_110_21  
Objective: To date, little effort has been devoted to summarizing worldwide research trends in sunscreen publications. The present study aimed to quantitatively analyze research trends in sunscreen publications over the past period from 2010 to 2020. Materials and Methods: The required bibliometric information was extracted and downloaded from the Scopus database. Documents including the keywords “Sunscreen” and “Sunscreens” were extracted from the database. A total of 1466 articles were retrieved from the database as on May 14, 2021. Data analysis and visualization were performed through RStudio. The bibliometrix package was accessed through the RStudio application to compute and process the bibliotec file. Results: Over the last decade (2010–2020), marked progress has been made in the area of sunscreens research. The overall increase in publications and citations reflects a growing research interest in the sunscreens field. The United States was the most prolific organization productive country with (n = 861) published documents, followed by Brazil (n = 273), Australia (n = 220), and France (n = 220). The most active institution was the Universidade Federal do Rio de Janeiro with publications (n = 30). Journal of the American Academy of Dermatology was the leading journal in the sunscreen literature with a total of (n = 55) documents. Conclusion: The main strength of the study is the use of the bibliometric analysis method and visualization of data to review the entire literature on sunscreens. The United States, Brazil, the United Kingdom, Australia, France, and China were active in most of the research parameters included in the study. These findings serve as a guide and road map for scholars in the field. This research can also be beneficial to academics, policymakers, and educational use.
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Incobotulinum toxin A with a one-year long-lasting effect for trapezius contouring and superior efficacy for the treatment of trapezius myalgia p. 168
Napamon Supornpun, Paisal Rummaneethorn, Thamthiwat Nararatwanchai, Tawee Saiwichai, Sirinthip Chaichalotornkul
DOI:10.4103/JCAS.JCAS_68_21  
Context: Based on various Botulinum toxin A products, reports of the lower efficacy of Incobotulinum toxin A compared with Onabotulinum toxin A for muscle contouring were observed. In addition, complications of trapezius myalgia and shoulder contouring treatment from malpractice have been reported. Aims: The study aimed at comparing the efficacy between Incobotulinum toxin A and Onabotulinum toxin A; research was conducted on a safe treatment technique for trapezius hypertrophy and trapezius myalgia. Materials and Methods: A split-shoulder, double-blind, randomized controlled trial was performed. Twenty volunteers with trapezius hypertrophy and trapezius myalgia were randomly injected with 30 units of Incobotulinum toxin A and Onabotulinum toxin A in each trapezius muscle guided by ultrasound. Results: The trapezius thickness among those receiving treatment with Onabotulinum toxin A and Incobotulinum toxin A on day 60 was 7.35 ± 1.11 and 7.33 ± 1.21 mm, respectively, which did not portray a significant difference (P = 0.991). Compared with the muscle size from day 60 to one year, the size of the trapezius muscle that had been treated by Onabotulinum toxin type A regained a significantly larger size compared with that treated by Incobotulinum toxin A (P = 0.027). On comparing the size of the trapezius muscle treated by Incobotulinum toxin A between one year and day 0, it was observed that the trapezius thickness at one year had significantly decreased (P < 0.001). On comparing the pain score from day 60 to day 0, it was observed that the pain scores of trapezius myalgia treated by Onabotulinum toxin A and Incobotulinum toxin A significantly differed (P = 0.003). Conclusions: Incobotulinum toxin A had the same efficacy but a longer lasting effect for the trapezius size contouring and a higher efficacy for trapezius myalgia treatment compared with Onabotulinum toxin A.
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A prospective study to compare the efficacy of cryotherapy versus intralesional steroid in alopecia areata p. 175
Sahil Sardana, Tarang Goyal, Pragya Kushwaha, Parinita Jha
DOI:10.4103/JCAS.JCAS_166_20  
Background: Alopecia areata (AA) is an autoimmune disease that results in the loss of hair on the scalp and elsewhere on the body. The present study was conducted to compare the intralesional steroid and cryotherapy in the treatment of AA. Materials and Methods: The present clinical study was conducted in the Department of Dermatology, Venereology, and Leprology, Muzaffarnagar Medical College. The simple random sampling technique was used for randomly dividing the subjects into two groups: group I (local cryotherapy) and group II (intralesional corticosteroid). Results: A positive response was significantly more among the intralesional steroid group (86.0%) when compared with the cryotherapy group (62.0%). There was a significant difference in relapse between intralesional steroid group (22.0%) and cryotherapy group (16.0%). An excellent response was significantly more among the intralesional steroid group (44.0%) when compared with the cryotherapy group (18.0%). Poor response was significantly more among the cryotherapy group (18.0%), compared with the intralesional steroid group (0.0%). The mean pre-treatment, post-treatment, and the change from pre- to post-treatment Severity of Alopecia Tool [SALT] were compared between cryotherapy and intralesional steroid groups using the unpaired t-test. The mean pre-treatment, post-treatment, and the change from pre- to post-treatment SALT were significantly more among the intralesional steroid group when compared with the cryotherapy group. Conclusion: The authors found that superficial cryotherapy could be a meaningful adjuvant treatment option for AA patients. There was a significantly less relapse rate with cryotherapy. Among the currently available topical modalities for the treatment of AA, the best response was to the intralesional steroids followed by cryotherapy.
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Plasmacytoid Dendritic Cell marker (CD123) expression in scarring and non-scarring alopecia p. 179
Suganthi Krishnamurthy, Rajalakshmi Tirumalae, YK Inchara
DOI:10.4103/JCAS.JCAS_126_19  
Classification of scarring alopecia poses a major problem, as there is considerable clinicopathologic overlap, particularly between lupus erythematosus (LE) and lichen planopilaris (LPP), especially in later stages. CD123 positive plasmacytoid dendritic cells (PDC) have been shown recently to be present in all forms of LE and are touted to be useful in differentiating LE from other scarring alopecias. Their distribution in non-scarring alopecia is not well documented. This is the first study that examines the PDC in both scarring and non-scarring alopecias. Objective: To study the expression patterns of PDC in cases of both scarring and non-scarring alopecia. Materials and Methods: A total of 69 cases of alopecia (48 scarring, 21 non-scarring) were studied for CD123 expression by immunohistochemistry. Results: Among the scarring alopecias, 17/20 LE cases showed PDC in contrast to 1/22 LPP cases. This difference was statistically significant (P = 0.0001). 1/2 cases of folliculitis decalvans showed PDC. None of the cases of unclassified scarring alopecia were positive. In the non-scarring group, 19/20 cases of alopecia areata and a single case of trichotillomania lacked PDC. Conclusion: The finding of CD123 expressing PDC appears to be a promising parameter in distinguishing LE from other forms of alopecia.
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INNOVATIONS Top

Who has got your back? A modification of selfie stick examination p. 183
Feroze Kaliyadan, Jayasree Puravoor, Karalikkattil T Ashique
DOI:10.4103/JCAS.JCAS_10_21  
We describe the use of screen mirroring, as a modification of the previously described “selfie-stick examination” method for the examination of skin lesions on the back of the patient. This would be especially useful in the context of patient initiated tele-dermatology for lesions over the back.
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Surgical pearl: disposable syringe as modified customized comedone extractor p. 185
Muhammed Mukhtar, Sanjeev Gupta
DOI:10.4103/JCAS.JCAS_112_21  
The conventional comedone extractors available are not able to evacuate contents properly, because of their vertical pressure. So, the comedone extractor which can exert pressure simultaneously in vertical and oblique direction for complete evacuation is the need of the hour.
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Parallel vibrating kinetic anesthesia devices to reduce pain with scalp injections p. 187
Brett Neill, Cameron Chesnut
DOI:10.4103/JCAS.JCAS_135_21  
The scalp is a frequent site of dermatologic procedures, and a patient’s experience with the dermatologic procedure is often shaped by the pain associated with it. In this article, a technique using multiple kinetic anesthesia devices is described to both reduce pain and improve patient satisfaction with scalp injections.
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CASE REPORTS Top

Solitary neurofibroma over lower lip: A rare manifestation p. 189
Shishira R Jartarkar, B Spoorthy, Sruthi Kareddy
DOI:10.4103/JCAS.JCAS_100_21  
Neurofibromas are common nerve sheath tumors, occurring either sporadically or associated with Von Recklinghausen’s disease. Only 6.5% of solitary lesions are seen to involve the oral cavity without any features of neurofibromatosis type 1 (NF-1). It presents as a soft, skin-colored nodule with a characteristic buttonhole invagination. Histologically, it is an unencapsulated lesion consisting of proliferated neural elements, with a background of mucin and mast cells. Surgical excision is the treatment of choice. A 49-year-old female patient presented with a 35-year history of single, asymptomatic lesion over the lower lip, with no features of NF-1. On the basis of the history, histopathological findings, and dermoscopy, a diagnosis of neurofibroma was made and the lesion was excised, with no recurrence over a period of 1 year. The present case report has been reported for its interesting presentation and unusual site of involvement.
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Facial laceration: A fight against a bite! p. 193
Tanvi E Malankar, Sonal B Shah, Aishwarya A Gangawane
DOI:10.4103/JCAS.JCAS_118_21  
Background: Facial bite injuries can cause functional, emotional, and psychological distress to the victim. Dog bites are the most commonest injuries of all mammalian bites. We as oral and maxillofacial surgeons have reported a case of 75-year-old man with a dog bite injury on his face. Step-wise management of the wound and required anti-rabies therapy has been discussed. Materials and Methods: The patient was immediately given anti-rabies prophylaxis and thorough debridement of the wound was done with various antiseptic solutions. After satisfactory debridement, margins of the wound were freshened and closure of wound was done with resorbable and non-resorbable sutures. Post-operatively, the patient was put on antibiotic regimen. Results: Not only esthetic but also functionally acceptable results were achieved. Locally applied antiseptic solutions and anti-rabies prophylaxis proved its efficacy in infection control. Conclusion: Each bite injury will have different treatment outcomes. Hereby we discuss one of the methods in the management of facial dog bite with most easily available medicaments.
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Imprint cytology can be a better option for diagnosis of mammary Paget’s disease!!!: A case report with review p. 196
Pranita Mohanty, Prateek Das, Ajit S Mohapatra
DOI:10.4103/JCAS.JCAS_145_21  
Mammary Paget’s disease (MPD) is a rare form of pruritic eczematous skin lesion involving the nipple areola complex usually associated with an underlying in-situ or invasive carcinoma of breast, accounting ≤ 4% of overall breast carcinoma. The patient may present with nipple discharge, eczema, plaque, or nipple destruction with or without a lump which is resistant to common remedies. Diagnosis of MPD is usually accomplished by a punch biopsy, but imprint cytology is found to be an effective modern technique yet less explored. Cytological diagnosis is advantageous over surgical excisional biopsy; advantages being easy practicability, cost-effective, quick non-invasive, and above all can lead the physician for breast-preserving surgeries in selective cases rather than more aggressive standard mastectomies. We report one such case of MPD in a 52-year-old female diagnosed on imprint cytology with the aim to emphasize that imprint cytology can be a better option to improve the treatment protocol.
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LETTER TO EDITOR Top

Dermoscopic clues to syringocystadenoma papilliferum p. 199
Gargi Taneja, Aditi Dhanta, Michael Leonard Anthony, Neirita Hazarika
DOI:10.4103/JCAS.JCAS_103_21  
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CORRESPONDENCE Top

Absorbable vs. non-absorbable sutures in plastic and dermatologic surgery procedures during the COVID-19 pandemic: Which would you prefer? p. 202
Giuseppe Lanzano, Mario Faenza, Giuseppe Lanzano, Sara Izzo, Giuseppe Andrea Ferraro, Giovanni Francesco Nicoletti
DOI:10.4103/JCAS.JCAS_130_21  
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Giant fibroepithelial polyp of the nipple with dermatitis neglecta p. 204
Shyam Bhanushankar Verma
DOI:10.4103/JCAS.JCAS_131_21  
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Repair of a large upper lip and malar defect p. 207
Aline Alves Domingues, Elsa Stella Mosquera Belalcazar, Letícia Dupont, Fernando Eibs Cafrune
DOI:10.4103/JCAS.JCAS_170_21  
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