Journal of Cutaneous and Aesthetic Surgery
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   Table of Contents - Current issue
April-June 2019
Volume 12 | Issue 2
Page Nos. 75-151

Online since Tuesday, July 9, 2019

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Laser dermatology in the subcontinent: Coming of age! p. 75
Sanjeev J Aurangabadkar
DOI:10.4103/JCAS.JCAS_66_19  PMID:31413474
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Laser toning in melasma Highly accessed article p. 76
Swapnil D Shah, Sanjeev J Aurangabadkar
DOI:10.4103/JCAS.JCAS_179_18  PMID:31413475
Melasma is a common acquired disorder of hyperpigmentation. A variety of treatment options has been suggested for the management of melasma. A range of different lasers had been tried in the treatment of melasma. Q-switched Nd-YAG laser (QSL) is the most commonly used laser in the treatment of melasma. Recently, laser toning or low-fluence, multi-pass technique has become popular in treatment of melasma. Authors aimed to review the procedure, its effectiveness, combination therapies using laser toning, and complications of laser toning. A PubMed search was made using keywords such as laser toning, QSL, melasma, and lasers in melasma, and relevant articles were reviewed.
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Fractional carbon dioxide laser: Optimizing treatment outcomes for pigmented atrophic acne scars in skin of color p. 85
Shehnaz Z Arsiwala, Swasti R Desai
DOI:10.4103/JCAS.JCAS_171_18  PMID:31413476
Dark skin type has high propensity to acne scarring and is often complicated by persistent erythema or pigmentation at the base. Fractional lasers are available for the longest period and are able to improve most atrophic acne scars. Often pigmented scar bases and dark skin types limit the use of aggressive laser parameters. Long pulse mode is preferred over short pulse to prevent epidermal damage; low fluence is chosen versus high fluence and low density versus high density. Repeated treatments are needed to minimize complications and optimize results; all these must be achieved through a controlled stage of inflammation. Interventional priming with chemical peels and laser toning before ablative fractional carbon dioxide laser helps to reduce photodamage, recent tan, and pigment at scar base, thus minimizing the risk of post-inflammatory hyperpigmentation. Multiple recent literature evidence validates the combinations to optimize outcomes in atrophic acne scars as discussed in this review article.
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A prospective open-labeled study of tattoo removal with Q-switched Nd:YAG laser utilizing the R0 technique and correlation with Kirby–Desai scale p. 95
Sanjeev J Aurangabadkar, Swapnil D Shah, Deepak S Kulkarni, Madhavi S Auragabadkar
DOI:10.4103/JCAS.JCAS_72_19  PMID:31413477
Introduction: The Q-switched Nd: YAG (QSNY) laser is considered the standard device of choice for laser tattoo removal. Newer concepts such as R0 , R20 methods aided in faster clearance of tattoos. The Kerby-Desai scale [KD scale] has been proposed to predict the approximate number of sessions needed for tattoo clearance. Objective:
  1. To access the efficacy of R0 technique for tattoo removal in skin types IV to VI
  2. To evaluate the Kerby-Desai scale and its correlation to the number of sessions actually required for tattoo clearance
Material and Methods: Twenty-two patients with single colored amateur were treated using modified R0 technique and the number of sessions were corelated with Kirby Desai scale. Results: We found that R0 method require significantly less sessions than predicted by KD scale. Conclusion: Tattoo removal with the R0 technique using PFD allows faster clearing of tattoos and significantly cuts down the total treatment duration needed for tattoo removal.
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Noncultured extracted hair follicle outer root sheath cell suspension versus noncultured epidermal cell suspension in the treatment of stable vitiligo p. 105
Ashraf Mahmoud Hamza, Tarek Mahmoud Hussein, Hadir AbdelGawad Ragab Shakshouk
DOI:10.4103/JCAS.JCAS_136_18  PMID:31413478
Background: Various treatment modalities exist for vitiligo, yet none of them are curative. Vitiligo is still considered a challenging disease to manage. Surgical treatment offers an excellent option for patients with stable vitiligo, especially those who fail to respond to medical treatment. Cell suspension techniques carry the advantage of covering large surface areas. Objective: To compare noncultured extracted hair follicle outer root sheath cell suspension (NCORSHFS) and noncultured epidermal cell suspension (NCES) in producing repigmentation. Subjects and Methods: Twenty patients were randomly allocated into two groups. They were objectively evaluated for the extent of repigmentation (after 1, 2, and 3 months), complications, cosmetic outcome, and satisfaction. Results: In NCORSHFS group, 10% showed excellent pigmentation, 20% showed good pigmentation, 50% fair, and 20% poor pigmentation. In NCES group, 10% showed excellent pigmentation, 10% good pigmentation, 40% fair, and 40% poor pigmentation. This difference was not statistically significant. Excellent color match was observed in 80% of NCORSHFS and in 70% of NCES. Donor area complications were absent in NCORSHFS group, whereas in NCES, mild scarring in 20% and hyperpigmentation in 40% of patients was observed. The difference in patients’ satisfaction between the two groups was not statistically significant. Conclusion: Both NCORSHFS and NCES are effective in producing good repigmentation with perfect color match and patients’ satisfaction. NCORSHFS has no donor area complications because it is a scarless procedure.
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Does the optimal layer of the skin include the orbicularis oculi muscle when elevating cheek rotation flap? p. 112
Naohiro Ishii, Masayoshi Takayama, Shigeki Sakai, Kazuo Kishi
DOI:10.4103/JCAS.JCAS_56_18  PMID:31413479
Background: The cheek rotation flap is widely used as an optimal technique for lower eyelid reconstruction; however, the elevation layer of the skin including the orbicularis oculi muscle (OOM) remains unresolved. Materials and Methods: Between February 2006 and October 2012, 11 patients who underwent repair of partial-thickness defects of the lower eyelids using the cheek rotation flap were included in this prospective study. We investigated the influence of elevating the layer of skin including the OOM on the incidence of perioperative complications, operation time, long-term postoperative morphology, and function of the lower eyelid. The layer of flap elevation was deep to the OOM in four patients (deep to OOM cases) and superficial to the OOM in seven (superficial to OOM cases). Results: The superficial to OOM cases had a similar incidence of perioperative complications including flap congestion as the deep to OOM cases. However, the superficial to OOM cases required a significantly longer operation time. Furthermore, lid retraction was found in all of the deep to OOM cases and none of the superficial to OOM cases. In addition, the postoperative results in all the superficial to OOM cases showed satisfactory contours of the lower eyelid without revision surgery. However, many of the deep to OOM cases needed revision surgery to improve lid retraction. Conclusion: The cheek rotation flap should be elevated in superficial to the OOM cases because postoperative lid retraction occurred significantly more in the deep to OOM cases than in the superficial to OOM cases, although elaborate dissection may prolong the operation time.
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A comparative study on the rate of anagen effluvium and survival rates of scalp, beard, and chest hair in hair restoration procedure of scalp p. 118
Jyoti Gupta, Kavish Chouhan, Amrendra Kumar, Ariganesh Chandrasegaran
DOI:10.4103/JCAS.JCAS_49_18  PMID:31413480
Background: The use of non-scalp donor hair is considered in situations of a relative or absolute lack of head donor hair supply. Till now, very few published works are present on body hair transplant. None of them have compared scalp and non-scalp hair in terms of survival as well as characteristics. Objective: To compare the characteristics such as rate of anagen effluvium and survival rates of scalp, beard, and chest hair in hair restoration procedure of scalp. Materials and Methods: Three blocks of 1cm2 were marked on a non-frontal area. Thirty slits with a 0.9mm blade were made in each block. Single follicular unit was taken from scalp, beard, and chest area and was implanted simultaneously in each block, respectively. The areas were evaluated for any graft loss, anagen effluvium, and survival rate. Results: During initial period of 2 months, anagen effluvium in scalp (40%) and beard (30%) were significantly less than body (53.3%) hair with excellent survival rate of beard (95%), followed by scalp (89%) and then followed by chest hair (76%) at 1 year. Conclusion: Non-scalp hair can become an excellent source of donor area for hair restoration procedure.
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Wound closure in large neural tube defects: Role of rhomboid flaps p. 124
Digamber Chaubey, Vijayendra Kumar, Vinit K Thakur, Ramdhani Yadav, Zaheer Hasan, Ramjee Prasad, Sandip K Rahul
DOI:10.4103/JCAS.JCAS_158_18  PMID:31413481
Background: Large wounds following surgery for neural tube defects are difficult to close; physical wound characteristics such as position and dimension would serve as a guide for their surgical closure. Aim: To study how wound dimension determines the choice between primary and rhomboid flap closure of skin defects following surgery for neural tube defects. Materials And Methods: A retrospective study was carried out on cases of neural tube defects operated in the department of paediatric surgery at a tertiary center for 3 years from January 2015 to December 2017. Data regarding clinical features, location, wound dimensions following surgery, any bony deformity, method of closure used, distance of wound from anus, and postoperative complications were collected and analyzed. Results: A total of 114 cases were operated during this period; 86/114 had primary closure, whereas 28/114 needed rhomboid flap for tension-free cover. Primarily closed wounds had a biphasic distribution of (long axis)/(short axis) ratio (with values either >1.65 or <0.63), whereas those covered by rhomboid flaps had a mean ratio of 1.25 (range, 0.71–1.45). All six cases with bony deformity needed rhomboid flaps. Although all lipomeningomyelocele defects could be primarily closed, all rachischisis needed flap cover. Infected lesions had a mean wound distance of 5.3cm from posterior anal margin. Conclusion: Defect’s position, its size and shape, and any bony deformity determine the choice of closure of postoperative wound. The versatile, safe, and universal rhomboid flap is an aesthetic solution to the large skin defects in patients of neural tube defects.
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NBUVB phototherapy at the donor site can enhance the graft uptake in the nonhealing ulcers of mycosis fungoides: A case report p. 128
Imran Ahmad, Rajesh K Maurya, Sushama Sushama, Ali A Mahmud
DOI:10.4103/JCAS.JCAS_77_18  PMID:31413482
Mycosis fungoides is a rare form of non-Hodgkin’s lymphoma, which is formed of mature, skin homing, clonal, malignant T lymphocytes. It can sometimes present with skin ulcers that are difficult to heal because of the presence of large number T lymphocytes and antigen-presenting cells. We present a case of nonhealing ulcers in a patient with mycosis fungoides, which was treated by narrow band ultraviolet B targeted phototherapy followed by split-thickness skin grafting. The graft uptake was well and the donor area also healed without any complications.
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Human skin allograft: Is it a viable option in management of burn patients? p. 132
Saurabh Gupta, Devi P Mohapatra, Ravi K Chittoria, Elankumar Subbarayan, Sireesha K Reddy, Vinayak Chavan, Abhinav Aggarwal, Likhitha C Reddy
DOI:10.4103/JCAS.JCAS_83_18  PMID:31413483
Tangential excision and autologous split-thickness skin grafting is the standard management of the burn wound, but autograft has limitation of donor-site availability and morbidity. Human skin allograft is an alternate option of wound coverage when autograft is not available. Various synthetic skin substitute dressings are now available in the market, and thus use of human skin allograft has decreased. This case report explores the role of human skin allograft in burn wound management. Allograft facilitates excision of burn wounds during acute phase of burn injury in pediatric patients. It is cost-effective, reduces pain and risk of infection, and avoids frequent dressing changes. Availability of allograft and risk of infection are the two main constraints in its regular use.
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Management of rhinophyma with radio frequency: Case series of three patients p. 136
Swagata A Tambe, Chitra S Nayak, Priyal Gala, Uddhao Zambare, Amol Nagargoje
DOI:10.4103/JCAS.JCAS_16_18  PMID:31413484
Rhinophyma is the most common form of phymatous rosacea, typically seen in men. It may appear de novo (without preceding inflammatory changes) or occur in patients with preexisting papulopustular rosacea. It is characterized by slow, bulbous, reddish-purple, painless enlargement of lower two-third of nose with rugose peau d’orange surface resulting from the enlargement of the sebaceous glands and subcutaneous tissue, which does not resolve spontaneously. Though benign, it causes lot of cosmetic and psychological concern. Commonly used treatment modalities include debulking by surgical excision, electrosurgery, carbon dioxide laser ablation, cryosurgery, or dermabrasion. Here we report a case series of three patients with Grade 3 rosacea as per National Rosacea Society grading, treated by radio frequency with good improvement.
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Kerure clamp: A new age tool to improve extraction technique in follicular unit extraction p. 141
Amit Kerure, Shaurya Rohatgi, Narendra Patwardhan
DOI:10.4103/JCAS.JCAS_185_18  PMID:31413485
Background: Follicular unit extraction (FUE) has caused evolution in the management of pattern baldness. FUE methods is less traumatic with faster healing and minimal scarring. FUE is still evolving and many innovations are possible in the future. Aims and Objectives: To address the usefulness of Kerure clamp, an innovative tool for FUE method of hair transplantation. Materials and Methods: The clamp was used on 20 consecutive patients undergoing FUE for male-pattern baldness. Part of the donor area was divided into test side where extraction was done with clamp in situ and the control where clamp was not used. Follicular transection rate (FTR) was calculated as a percentage for each side and subjected to statistical analysis. Result: We found an improvement in the FTR scores on the test side, and this difference was statistically significant (t = 9.63, P < 0.0001). Conclusion: A low-cost instrument has been devised by the authors which was shown to improve the the scoring of grafts and also aid in surgeon’s efficacy and efficiency.
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In vitro degradation of polydioxanone lifting threads in hyaluronic acid p. 145
Dubraska V Suarez-Vega, Gladys J Velazco de Maldonado, Reynaldo L Ortíz, Víctor J García-Guevara, Blanca Miller-Kobisher
DOI:10.4103/JCAS.JCAS_150_18  PMID:31413486
Recently, some clinicians have proposed implanting polydioxanone (PDO) threads imbibed in hyaluronic acid (HA), arguing that this may reinforce the lifting effects. However, this is controversial because PDO sutures are hydrophilic and the presence of HA could increase the rate of hydrolysis. The aim of this study was to demonstrate the degradation of PDO lifting threads in HA through ultramicroscopy. It was a qualitative research and preclinical trial. Three, 1-cm-long, segments of 23-G PDO threads were immersed in 1.5-mL non-crosslinked HA in previously labeled, sterile microcentrifuge tubes. These were observed by ultramicroscopy at 4× and 10× after 24, 48, and 72 h. Microphotographs taken after 24 h show structural changes in the fibers, presenting an increase in interlaminar spaces and dilution of violet pigmentation. At 48 h, degradation continues. PDO hygroscopy is observed as aqueous content between the peripheral layers and the central core of the thread. At 72 h, as the pigment is released, larger empty spaces are observed in the central column of the thread, and there is disorganization of the peripheral fibrils with fraying all along the fiber. HA induces rapid biodegradation of the PDO thread by hydrolysis beginning 24 h after contact of the thread with the biomaterial. The non-crosslinked HA is a powerful catalyzing agent for hydrolytic degradation of the PDO thread, because this thread is highly hydrophilic. Clinically, embedding PDO threads in HA accelerates biodegradation of the suture.
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Innovative application of drone in monitoring the ICU patients avoiding personal visits p. 149
Padmalakshmi Bharathi Mohan, Ravikumar Chittoria, Vinayak Chavan, Abhinav Aggarwal, Saurabh Gupta, Chirra Likhitha Reddy, Imran Pathan, Mohamed Ishaq
DOI:10.4103/JCAS.JCAS_6_19  PMID:31413487
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