Journal of Cutaneous and Aesthetic Surgery
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   Table of Contents - Current issue
Coverpage
April-June 2017
Volume 10 | Issue 2
Page Nos. 65-119

Online since Monday, July 31, 2017

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EDITORIAL  

Good bye, thank you, ethics and other things… p. 65
Niti Khunger
DOI:10.4103/JCAS.JCAS_82_17  
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CME ARTICLE Top

The science and art of eyebrow transplantation by follicular unit extraction p. 66
Jyoti Gupta, Amrendra Kumar, Kavish Chouhan, C Ariganesh, Vinay Nandal
DOI:10.4103/JCAS.JCAS_27_17  
Eyebrows constitute a very important and prominent feature of the face. With growing information, eyebrow transplant has become a popular procedure. However, though it is a small area it requires a lot of precision and knowledge regarding anatomy, designing of brows, extraction and implantation technique. This article gives a comprehensive view regarding eyebrow transplant with special emphasis on follicular unit extraction technique, which has become the most popular technique.
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ORIGINAL ARTICLES Top

Effectiveness of fibrin glue in adherence of skin graft p. 72
Konda Sireesha Reddy, Ravi Kumar Chittoria, Preethitha Babu, Senthil Kumaran Marimuthu, Sudhanva Hemanth Kumar, Elan Kumar Subbarayan, Vinayak Chavan, Devi Prasad Mohapatra, Dinesh Kumar Sivakumar, MT Friji
DOI:10.4103/JCAS.JCAS_100_16  
Background: Graft fixation is important for graft take. Fibrin glue has been proposed as an ideal material, because of its human origin and it provides firm adhesion in seconds or minutes. Objective: To evaluate the efficiency of fibrin glue, in increasing the take of skin graft. Assessment includes surgical time taken for graft fixation, haematoma/seroma formation, engraftment and wound closure by day 14. Methods: The study is an observational prospective study conducted in the Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, from January 2016 to June 2016. Sixteen patients who underwent split skin grafting were assessed during the study period. Fibrin glue was used on the recipient bed before grafting. Results: Better haemostasis and graft adhesion, with a significant reduction of surgical time, were noted. Conclusion: The safety profile of fibrin glue was excellent as indicated by the lack of any related serious adverse experiences. These findings demonstrate that it is safe and effective for attachment of skin grafts, with outcomes at least as good as conventional methods.
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Fractional carbon dioxide, long pulse Nd:YAG and pulsed dye laser in the management of keloids p. 76
Ashwini Annabathula, C Shanmuga Sekar, CR Srinivas
DOI:10.4103/JCAS.JCAS_136_16  
Background: Keloids are abnormal wound responses characterised by excessive deposition of collagen and glycoprotein. They are both aesthetically and symptomatically distressing for most of the patients. There are reports of keloid management with pulsed dye laser (PDL), fractional carbon dioxide (CO2) laser and neodymium-doped yttrium aluminium garnet (Nd:YAG) laser individually and also in combination of CO2 with PDL and CO2 with Nd:YAG. Here, we discuss a combination of all the 3 lasers as a therapy for keloids. Aim: This study aims to assess the efficacy of fractional CO2 laser, long pulse Nd:YAG laser and PDL in the management of keloids. Materials and Methods: Fifteen patients with keloids were treated by fractional CO2 laser, followed by PDL and long pulse Nd:YAG laser at monthly intervals. Four patients discontinued the study and were lost for follow-up. Photographs were taken at the beginning of the treatment and at the end of five sessions. Clinical improvement was analysed based on a visual analogue scale graded by three blinded observers after assessing the clinical photographs for the improvement in size, colour and aesthetic impression. Results: Of the 11 patients, one patient had excellent improvement, one patient had good improvement, four patients had moderate improvement, two patients had mild improvement and three had no improvement. Conclusion: Lasers may have a synergistic effect when combined with other modalities of treatment but cannot be used as monotherapy in the treatment of keloids.
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Simplified non-cultured non-trypsinised epidermal cell graft technique followed by psoralen and ultraviolet a light therapy for stable vitiligo p. 81
Dilip Kachhawa, Pankaj Rao, Gyaneshwar Kalla
DOI:10.4103/JCAS.JCAS_119_16  
Background and Aims: Stable vitiligo can be treated by various surgical procedures. Non-cultured melanocyte grafting techniques were developed to overcome the time-consuming process of culture while at the same time providing acceptable results. All the techniques using non-cultured melanocyte transfer involve trypsinisation as an integral step. Jodhpur technique used by the author is autologous, non-cultured, non-trypsinised, epidermal cell grafting. Settings and Design: The study was conducted on patients visiting the dermatology outpatient department of a tertiary health centre in Western Rajasthan. Materials and Methods: At the donor site, mupirocin ointment was applied and dermabrasion was done with the help of micromotor dermabrader till pinpoint bleeding was seen. The paste-like material obtained by this procedure containing melanocytes and keratinocytes admixed with the ointment base was harvested with spatula and was subsequently spread over the recipient area. Recipient site was prepared in the same manner by dermabrasion. After 10 days, dressing at both sites was removed taking utmost care at the recipient site as there was a theoretical risk of dislodging epidermal cells. Results: In a study of 437 vitiligo patches, more than 75% re-pigmentation (excellent improvement) was seen in 41% of the patches. Lesions on thigh (100%), face (75%) and trunk (50%) showed maximal excellent improvement, whereas patches on joints and acral areas did not show much improvement. Conclusions: This technique is a simplified, cost effective, less time-consuming alternative to other techniques which involve tryspsinisation of melanocytes and at the same time provides satisfactory uniform pigmentation.
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A spilt head study of efficacy of placebo versus platelet-rich plasma injections in the treatment of androgenic alopecia p. 86
Dilip Kachhawa, Gauri Vats, Durgesh Sonare, Pankaj Rao, Sandeep Khuraiya, Rohit Kataiya
DOI:10.4103/JCAS.JCAS_50_16  
Background: Platelet-rich plasma (PRP) is an autologous concentration of human platelets contained in a small volume of plasma with haemostatic and tissue repairing effects. Being enriched by various growth factors, PRP has become the focus of attention in numerous fields of medicine. Androgenic alopecia (AGA) is a common chronic hair loss disorder, characterised by progressive hair loss. Despite the therapeutic options available, there is low patient compliance and satisfaction rate. The topical and often systemic adverse effects of therapy has lead to the search of new treatment options for AGA. Recently, PRP has received growing attention as a potential therapeutic tool for hair loss. Aim: To compare the efficacy of placebo versus PRP injections in the treatment of male AGA. Patients and Methods: Fifty male patients with AGA (Grade III to VI) were enrolled in the study. PRP was prepared using the double-spin method and injected in the androgen-related areas of scalp on the left side. Normal saline was injected on the right side in a similar fashion. Treatment sessions were performed with an interval of 21 days, and six sittings were completed for every patient. Results: Hair loss reduced with evidence of new hair growth. Digital image analysis showed an overall improvement in hair density and quality as lanugo-like hair became thicker, normal hair. An improvement in hair density, quality and thickness on trichoscopy was noted. Conclusion: Our data suggest that PRP injections have therapeutic effect on male pattern hair loss with no major side effects and high patient satisfaction overall.
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Safety and efficacy of intralesional vitamin D3 in cutaneous warts: An open uncontrolled trial p. 90
Manjunath Kavya, Basavapura Madegowda Shashikumar, Muddanahalli Rajegowda Harish, Bhadbhade P Shweta
DOI:10.4103/JCAS.JCAS_82_16  
Background: Cutaneous warts are treated primarily with destructive methods such as cryotherapy or electrocautery. These modalities of treatment are time-consuming and may be associated with scarring in multiple warts. Immunotherapy is emerging as a new modality of treatment which acts on enhancing cell-mediated immunity against human papillomavirus for clearance of both treated and distant warts. Aims: This study aims to evaluate the safety and efficacy of intralesional Vitamin D3 for the treatment of cutaneous warts. Materials and Methods: Patients with multiple warts were selected for immunotherapy. Vitamin D3 (0.2 ml, 15 mg/ml) was injected to the base of warts after injecting with lignocaine (0.2 ml, 20 mg/ml). The injections were repeated 2 weeks apart for a maximum of 4 sessions or until complete clearance, whichever was earlier. A maximum of 2 warts were treated per session and patients were followed up for 6 months after the last injection. Results: Forty-two patients with multiple warts were recruited for the study who completed the 6-month follow-up period and were available for analysis. Of these, 23 had palmoplantar warts, 18 had verruca vulgaris and 1 patient had filiform wart. In total, 33 of 42 patients (78.57%) showed complete response, 6 patients (14.28%) showed moderate response and three patients (7.14%) showed mild response. Recurrence was observed in one patient with the palmoplantar wart. No serious adverse effects were reported. Limitations: Lack of control group was the main drawback in our study. Conclusion: Intralesional Vitamin D3 is safe and effective for treatment of multiple cutaneous warts.
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The clinical pattern of axillary hidradenitis suppurativa among Saudi Arabians: Mode of presentation and treatment challenges p. 95
Bader Hamza Shirah, Hamza Asaad Shirah
DOI:10.4103/JCAS.JCAS_80_16  
Background: Hidradenitis suppurativa is a chronic follicular occlusive disease affecting the folliculopilosebaceous unit. The clinical course is variable, ranging from mild to severe cases. Definitive evidence-based guidelines for the management are lacking. In addition, the multifaceted clinical features and the unpredictable course of the disease make a uniform approach to treatment impractical. As a result, there are multiple therapeutic approaches. Therefore, in this study, we aim to analyze the results of management of axillary hidradenitis suppurativa among the local community in Saudi Arabia. Materials and Methods: A retrospective cohort database analysis of 1369 patients diagnosed and treated for axillary hidradenitis suppurativa between January 2004 and December 2013 was done. Seven hundred and forty-one (54.12%) were females and 628 (45.87%) were males. All patients with Stage I disease favored the conservative method while all patients with Stage II chose the surgical approach. Results: The mean age was 25.5 years. Nine hundred and seventy-four (71.15%) patients were treated conservatively; the mean healing time was 5.5 weeks. Three hundred and ninety-five (28.85%) patients were treated surgically. One hundred and fourteen (28.9%) had incision and drainage, 281 (71.1%) had complete excision; all wounds eventually healed without significant scarring. The recurrence rate was 12.5% (122 patients) in the conservative method group and zero (0%) in the surgical method group. Conclusions: Hidradenitis suppurativa remains a challenging clinical condition for patients and physicians. Further studies need to focus not only on the etiology of this disease but also on the optimal treatment regimen. Public awareness programs are necessary to avoid late presentation and complications.
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SHORT COMMUNICATION Top

Assessment of the efficacy and safety of hyaluronic acid gel injection in the restoration of fullness of the upper lips p. 101
Taraneh Yazdanparast, Aniseh Samadi, Hournaz Hasanzadeh, Saman Ahmad Nasrollahi, Alireza Firooz, Mansour Nassiri Kashani
DOI:10.4103/JCAS.JCAS_115_16  
Background and Aim: Lips have a significant role in face aesthetic perception, and lip augmentation is one of the most commonly requested aesthetic procedures. Non-permanent dermal fillers, such as hyaluronic acid (HA), are used for augmenting the lips. This article presents the results of Phase II, before – after designed study, assessing the safety and efficacy of a soft tissue HA filler, for upper lip augmentation.Materials and Methods: Investigators treated 10 healthy adult women 28–45 years old, using a single injection of Hyamax Kiss soft tissue HA filler (a product from Hyamed Laboratories, Switzerland) for upper lip augmentation. The primary efficacy endpoint was an increase in lip fullness at least one grade on Medicis Lip Fullness Scale at 2, 12 and 24 weeks post-treatment. Furthermore, the effectiveness and durability of filler were assessed using a 5-point Investigator's Global Assessment (IGA). Adverse events and volunteers' satisfaction were reported using visual analog scale.Results: Response to treatment (as defined above) after 2, 12 and 24 weeks were observed in 80%, 70% and 80% of patients, respectively. No statistical difference was found in response to treatment rate between follow-up visits (P = 0.83). The mean value of IGA score in weeks 2, 12 and 24 were 3.4 ± 0.96, 3.3 ± 0.67 and 3.3 ± 0.67, respectively. The study subjects were almost all satisfied with their lip improvement. Reported adverse effects were temporary and mostly mild in severity.Conclusion: Soft tissue HA filler tested in this study was well tolerated, efficient and durable when used for upper lip augmentation.
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INNOVATION Top

Reconstructions of small scalp defects with step flap p. 106
Ali Ebrahimi, Nasrin Nejadsarvari, Azin Ebrahimi
DOI:10.4103/JCAS.JCAS_138_16  
Introduction: Defects of the scalp arise from several aetiologies including trauma, burn, injury, infection, radiation and surgical excision of tumours. Multiple options for reconstruction of scalp defects exist that included primary closure, skin grafts, local flaps, regional and distal free flaps.Patients and Methods: This was a prospective case-series study, which was carried out in the Department of Plastic Surgery of our Hospital. Step flap was used for small (2.5 cm × 2.5 cm) scalp skin defects reconstructions after skin tumour ablations. In this 2 years study, 15 patients (7 female , 8 male), ranging from 40 to 72 years (mean, 53 years), underwent an operation with local step flap for reconstruction of scalp defects caused by basal cell carcinoma or squamous cell carcinoma excision.Results: The patients who present with small scalp malignant tumours need complete resection and perfect reconstruction. This study showed that step flap with sufficient releasing was an effective method for reconstruction of small scalp defects due to skin malignancies. We had no case of flap complications such as ischaemia or necrosis.Conclusion: We recommend this local flap (z-flap) as a new approach for small scalp defect reconstruction in all areas of hair-bearing scalp.
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BRIDGING THE GAP Top

A simplified reconstructive technique for full-thickness central defects of the auricle with the use of a post-auricular folded flap p. 109
Ioannis Papadiochos, Eleni Bourlidou, Doxa Mangoudi
DOI:10.4103/JCAS.JCAS_139_16  
Background: Post-auricular flaps have proved very effective in the reconstruction of most types of partial auricular defects. However, few reports exist regarding the reconstruction of centrally located perforating defects of the auricle. Objectives: This paper aimed to describe a one-stage technique including a post-auricular folded flap (PAFF) for reconstruction of full-thickness defects of central auricular sites. Patients and Methods: Between March 2010 and November 2014, five male patients were treated with this reconstructive technique under local anaesthesia. At the time of surgery, patients' age ranged from 76 to 86 years (mean age, 79.8). The patients suffered from a central and full-thickness defect owing to surgical excision of a skin malignancy or failed reconstruction procedures secondary to surgical excision of a skin malignancy. Results: Healing was uneventful for all the included patients, without signs of dehiscence, necrosis, hematoma and infection. The defects were completely repaired, without the need of further operations. During the follow-up period, all the patients remained satisfied with the aesthetic outcome. Conclusions: This technique constitutes an immediate, effective and low-morbidity procedure to repair full-thickness central defects of the auricle. Since PAFF requires only one surgical operation under local anaesthesia, patients with burdened medical history may profit from this technique.
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CORRESPONDENCE Top

Giant pedunculated tumour on the finger p. 113
Keshavmurthy A Adya, Arun C Inamadar, Aparna Palit
DOI:10.4103/JCAS.JCAS_13_17  
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Glomus tumour with intramedullary bone cyst: A rare presentation p. 114
Abhijeet Kumar Jha, Rajesh Sinha, Anil Kumar, Smita Prasad
DOI:10.4103/JCAS.JCAS_54_15  
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Successful management of angiolymphoid hyperplasia with eosinophilia by radiofrequency p. 116
Swagata Arvind Tambe, Chitra Shivanand Nayak
DOI:10.4103/JCAS.JCAS_91_16  
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Aesthetic correction of smoker's lip using 1064 nm Q-switched neodymium-doped yttrium aluminium garnet laser p. 118
Shricharith Shetty, Sathish Pai
DOI:10.4103/JCAS.JCAS_103_15  
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