Journal of Cutaneous and Aesthetic Surgery
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   Table of Contents - Current issue
Coverpage
October-December 2019
Volume 12 | Issue 4
Page Nos. 203-257

Online since Wednesday, December 18, 2019

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ORIGINAL ARTICLES  

Reconstruction following excision of malignant scalp tumors with split thickness skin graft with and without acellular dermal matrix: A comparative study p. 203
Javad Rahmati, Soheil Boroumand, Koroush Ghanbarzadeh, Shahriar Haddady Abianeh, Hojjat Molaei, Afshin Fathi, Arjang Ghahremani, Omid Etemad
DOI:10.4103/JCAS.JCAS_96_19  
Background: Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are the most common malignancies, which occur on the scalp. There are various therapeutic methods for managing these malignancies in which the standard treatment method of both is surgical excision with a good margin. Sometimes, the patients need full-thickness excision due to the deep invasion, so exposing the underlying calvarium may be a challenge for surgeons. Objectives: We evaluated the outcomes of using the combined therapy of acellular dermal matrix and split-thickness skin graft (STSG) in comparison with using only STSG in the treatment of defects caused by the excision of scalp malignant tumors among the patients who attended Imam Khomeini Hospital Complex and Razi Hospital of Tehran, Iran. We also evaluated the satisfaction of both surgeons and patients among these two methods of treatment. Materials and Methods: All the candidates were divided into the two groups, that is, of case and control, randomly. The case group underwent the treatment using acellular dermal matrix and STSG, whereas the control group underwent the treatment by only STSG on the wound. In both groups, BCC and SCC were excised with a margin of 6 and 10 mm, respectively, on the skull bone. Then, a layer of bone was removed by osteotomy in order to reach the bleeding points. All patients were followed up for 7, 30, and 90 days after the surgery, and the results were recorded. Results: A significant difference in Manchester Scar Scale, wound contour formation, the mobility of the repair site, and patients and surgeon satisfaction was observed among both groups based on visual analog scale. We found better outcomes in the case group, especially in wound contour formation during 90 days of follow-up. However, the satisfaction of both surgeons and patients was achieved in the case group. Satisfaction of surgeons was achieved in the case group with a relative superiority to the control group according to the Manchester Scar Scale.
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Radio-frequency ablation for matricectomy in the management of ingrown toenail: A pilot study p. 212
Archana Singal, Ishmeet Kaur
DOI:10.4103/JCAS.JCAS_3_19  
Introduction: Ingrown toenail is one of the most commonly encountered nail disorders that adversely affect the quality of life. The common surgical intervention includes partial nail avulsion with chemical matricectomy but it has a relatively longer recovery period. We attempted to study the efficacy and safety of radio frequency (RF) for matricectomy. Materials and Methods: Eight patients with total 10 ingrown toenails (grade 2) were recruited. Partial nail avulsion with RF ablation of matrix was performed. The radio-frequency electrode was placed over the lateral matrix horn for the duration of 3–5s, two to three times. Patients were followed up at regular interval. Outcome was measured in terms of ooze, erythema, pain, and swelling of the lateral nail folds. Results: Of the eight patients, six were males and two were females. Total 10 nails were treated as two patients had bilateral toenail involvement. Average number of days required for postprocedural healing was 7.5 days. Significant improvement was observed in terms of erythema, pain as well as swelling within 4 days of surgery. None of the cases showed any adverse effects or relapse within 3–5 months of follow-up. Conclusion: Matricectomy by radio-frequency ablation is a safe and effective method in the management of ingrown toenail with significant reduction in downtime.
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Approach to hair transplantation in advanced grade baldness by follicular unit extraction: A retrospective analysis of 820 cases Highly accessed article p. 215
Kavish Chouhan, Gillian Roga, Amrendra Kumar, Jyoti Gupta
DOI:10.4103/JCAS.JCAS_173_18  
Background: In advanced grade baldness (Norwood 5–7), hair restoration has been considered difficult due to the donor recipient area mismatch. In this article, we have given a comprehensive methodical approach to manage these cases. Objective: To assess the outcome and challenges faced with follicular unit extraction (FUE) and to plan a successful management in advanced grade baldness in 820 cases of androgenic alopecia. Materials and Methods: A retrospective analysis of 820 male patients with advanced grade of baldness (grade 5–7) treated by FUE. The patients were divided into five groups based on the extent of scalp coverage, for example, frontal coverage, frontal + mid-front coverage, vertex, full coverage, and frontal forelock only. The results were analyzed at 6, 9, 12, and 24 months. Results: At 12 months, 94% patients were satisfied with the results, whereas 62% wanted another sitting for increasing the coverage area/density. Conclusion: Hair transplantation can give natural and aesthetic results even in advanced baldness. Beard and body hairs can be used to augment results in cases with limited donor supply. A mature hairline with an adequate density in a gradient, from front to back helps in achieving a satisfactory response even in extensive cases of advanced baldness.
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Autologous fat graft for soft tissue camouflage in craniofacial microsomia p. 223
Sheeja Rajan, K Ajayakumar, Sarita Sasidharanpillai, Biju George
DOI:10.4103/JCAS.JCAS_99_18  
Introduction: In India, a large majority of patients with craniofacial microsomia are unable to undergo complex reconstructions owing to unaffordability, lack of access to good craniofacial centers, or reluctance of parents to accept the surgical risk. There is also considerable social stigma attached to the resultant facial scars of surgery, especially in a girl child. Hence, we have explored autologous fat graft transfer as a “stand-alone” reconstructive option for soft tissue camouflage and aesthetic correction of facial deformity in unilateral craniofacial microsomia of Pruzansky–Kaban Grades I and II. Materials and Methods: Twelve patients who were seeking aesthetic correction of facial deformity in unilateral craniofacial microsomia of Pruzansky–Kaban Grades I and II, and who had adequate fat in the preferred donor sites of lower abdomen and antero-medial thighs, were selected. Patients with Grade III deformity, facial palsy, and previous skeletal surgeries were excluded. Autologous fat harvesting was done with the standardized Coleman’s technique and injected after decantation. Volumetric augmentation was assessed by clinical comparison with normal side for facial symmetry, skin pinch thickness at four reference points, and by two-dimensional analysis of pre- and postoperative standardized photographs at periodic intervals. Results and Analysis: Eleven of our patients were female and one was a male (N = 12). In each session, 20–40mL (mean 28.75 ± standard deviation [SD] 5.69) fat was aspirated and 12–35mL (mean 23.67 ± SD 6.07) fat was injected. The average operating time was 35min (mean 32.91 ± SD 4.05). Majority of our patients needed three sessions (mean 2.8 ± SD 1.03) of serial fat injections to achieve bilateral facial symmetry. Increase in skin pinch thickness was 6.4167 ± 1.31 mm. The mean patient satisfaction score was 8.83 ± SD .717. Conclusion: Based on our results, we conclude that autologous fat transfer, when used for soft tissue camouflage, is a versatile, easy, effective, and inexpensive method for obtaining consistent long-term aesthetic goals in mild to moderate cases of craniofacial microsomia.
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Evaluation of prevalence and morphology of dimple among population of Sullia taluk p. 227
Mahabaleshwara Chalathadka, Kiruba K Shankar, Vijaya G Lakshmi, VM Nithin, Sneha Kulkarni, Mulla Firdousbano
DOI:10.4103/JCAS.JCAS_109_19  
Background: Dimple is one of the special indentations in skin of the face, which is considered as a sign of beauty. Dimpleplasty/surgical creation of dimple is a cosmetic procedure done by surgeons. Determining accurate position of dimple to create maximum beauty is always challenging to surgeons. Aims and Objectives: This study aimed at evaluating the prevalence and morphology (position and size) of naturally occurring dimple among population of Sullia taluk. Materials and Methods: In total, 1462 people were screened for the occurrence of natural dimples in face. Among them, 121 were found to have natural dimples. Prevalence of dimple, position of the dimple, and the variation in distance from the Khoo Boo-Chai’s (KBC) point to the naturally occurring dimple was assessed. Results: Among 121 patients with dimples, unilateral cheek dimples (72.88%) were more common than bilateral (27.11%). Ninety-one dimples (60.66%) were at KBC point and 59 dimples (39.33%) occurred anterior to KBC point at a mean distance of 9.86 mm. The mean size of dimple superoinferiorly on the right side was 8.29 mm and on the left side it was 8.96 mm. The mean size anteroposteriorly on the right side was 6.48 and on the left side it was 6.51 mm. Conclusion: The mean measurements in size and position of the dimple might help the surgeon in creating dimples resembling naturally occurring dimples.
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Outcome, complications, and body mass index correlation of horizontal and combined horizontal and vertical thigh lift: A 16-year single-center experience p. 231
Shafreena Kuhn, Alana Klettenheimer, Lara Küenzlen, Marcus Kiehlmann, Torsten Schlosshauer, Gabriel Djedovic, Ulrich M Rieger
DOI:10.4103/JCAS.JCAS_115_18  
Background: Thigh lift is a procedure used within the aesthetic as well as the post-bariatric field of surgery as it focuses on reducing excess lipodermal tissue within the medial thigh area. Depending on the specific area of excess tissue, common thigh lifting procedures include horizontal (H) and combined horizontal and vertical (HV) tissue reduction. Aims and Objectives: The aim of this study was the analysis of outcome of H and HV thigh lift procedures, including evaluation of comorbidities and complications. Subjects and Methods: Over a 16-year period, all thigh lift procedures performed at our department were assessed for comorbidities and outcome through our hospital documentation system. Results: A total of 151 thigh lifts have been performed over 16 years. Of which, 124 were performed using the HV technique and 27 thigh lifts were performed using H tissue excision only. Of all the patients, 9 of 10 were female, the overall average age was 43 years. Approximately 48% of the HV group of patients had previously undergone bariatric surgery, the mean body mass index (BMI) was 29.3 kg/m2 for this group. Around 19% of the H patient population had previously undergone bariatric surgery. This group had a mean BMI of 25.1kg/m2. Wound-associated problems occurred in 48%, for these patients, surgical revision was necessary for 12%. Remaining excess tissue was an issue for 20% of all patients, for this reason, 14% needed revision surgery. Age was found to be a significant cofactor for wound-associated complications (P = 0.02) and nicotine abuse for scar-related problems (P = 0.032). Conclusion: The rate of overall complication for thigh lifts is high, although surgical revision rate is low. Remaining excess tissue and wound-associated problems are most common, possibly reflecting a too restrictive and radical surgical approach, respectively. Increasing BMI increases the risk for development of complications.
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CASE REPORTS Top

Autologous dermal filler derived from cultured dermal fibroblasts and plasma gel (Fibrogel): One-year follow-up of a case p. 237
Yasemin Oram, Gursel Turgut
DOI:10.4103/JCAS.JCAS_122_19  
In recent years, autologous fibroblast injections or plasma gel filler applications have been used in the treatment of facial contour deformities. In this case report, we describe a new method of autologous filler material derived from cultured dermal fibroblast and plasma gel. The plasma gel, which is the bioskeleton of the filler, is prepared from the patient’s plasma, which provides a dense environment for a three-dimensional configuration of dermal fibroblasts. Although the plasma gel provides immediate volume effect, the fibroblasts synthesize extracelluar matrix proteins to promote skin rejuvenation. The filler effect occurs immediately after the first injection and persists 12 months after the third injection, without any complication. Long-term result of the presented case is promising for the concept of autologous filler development.
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Lip repositioning, aesthetic crown lengthening, and gingival depigmentation: A combined approach for a gummy smile makeover p. 240
Rishi A Bhimani, Nabila D Sofia
DOI:10.4103/JCAS.JCAS_25_19  
This clinical report describes the successful use of aesthetic crown lengthening, lip-repositioning technique as well as gingival depigmentation for the reduction of excessive gingival display and dark gums, respectively. Lip-repositioning technique was performed with the main objective of reducing gummy smile by limiting the retraction of elevator muscles (e.g., zygomaticus minor, levator anguli oris, orbicularis oris, and levator labii superioris) during smiling, thereby restricting the upper lip from shifting apically while smiling. This technique includes removing a strip of mucosa from the maxillary labial and buccal vestibule, creating a partial-thickness flap between mucogingival junction and upper lip musculature, and suturing the lip mucosa with mucogingival junction, resulting in a narrow vestibule and restricted muscle pull, thereby reducing gingival display. The results obtained with lip repositioning for the treatment of gummy smile are substantial and it is a simple and effective procedure, well accepted by patients. Proper case selection is important for using this procedure.
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Improvement in the quality of life of a patient of ectodermal dysplasia with reconstructive surgeries p. 244
Kirti Deo, Yugal K Sharma, Bhavika Shah, Preeti Kothari, Dhanraj Chavan, Sakshi Sitaniya, Aayush Gupta
DOI:10.4103/JCAS.JCAS_17_19  
Ectodermal dysplasias are a complex group of heterogenous, heritable disorders entailing two or more developmental abnormalities in ectodermal structures, such as hair, teeth, nails, and/or sweat glands. The most common subtype of these disorders is X-linked hypohidrotic that significantly impairs the quality of life of its sufferers. A 15-year-old boy, who sought the treatment for protuberant lips, saddle nose, dental anomalies, fine sparse hair, decreased sweating, intolerance to heat and photosensitivity, experienced dramatic improvement in his quality of life and confidence with aesthetic correction comprising autologous fat grafting, rhinoplasty, lip reduction, microblading and comprehensive prosthodontic and orthodontic treatments undertaken in collaboration with dental and plastic surgery departments and expert psychological counseling.
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INNOVATIONS Top

Creating a microdissection cautery tip using disposable needle p. 248
Ranjit K Sahu, Manojit Midya
DOI:10.4103/JCAS.JCAS_67_19  
The use of electrocautery is universal in modern day surgery. Through decades electrocautery has reformed from larger electrodes to smaller ones. The latest modification is the micro-dissection cautery with a fine electrode tip. We have modified the electrocautery tip to replicate the usage of micro dissection-cautery using readily available, low cost disposable needle. The idea is to replicate the benefits of micro-dissection needle with a low cost construct which can be learned easily, used widely to provide optimum surgical results to the wider sections of the society. A video demonstration for creation of the micro-dissection cautery construct is also demonstrated.
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Use of implanters in premade recipient sites for hair transplantation p. 250
Arika Bansal, Pradeep Sethi, Abhinav Kumar, Alok K Sahoo, Priyadarshini Das
DOI:10.4103/JCAS.JCAS_33_19  
Background: Techniques of hair transplantation are evolving with time both in terms of use of better methods of graft harvestment and implantation. The result of the procedure ultimately depends on the tenderness with which grafts are handled. Aims: The aim of this study was to evaluate efficacy and feasibility of using implanter in premade slits for implantation of the graft. Materials and Methods: This technique was used in 104 patients who were willing to undergo hair transplantation by follicular unit extraction. After administration of local anesthesia, the recipient sites were created. Thereafter, the processes of scoring the skin with a motorized punch, graft extraction, and implantation using implanter into the premade slits were performed simultaneously. These patients were followed up to look for the time period of initiation of hair growth. Improvement was assessed by comparing basic and specific classification (BASP) at the baseline and during subsequent follow-up. Results: Of 104 patients, 103 (99%) were men and one (1%) was woman. According to pretransplant BASP score, 98 (94.2%) patients were having severe type and 6 (5.8%) were having mild type. As per the posttransplant BASP score, patients having severe and mild type were 24 and 80, respectively. Improvement in the BASP score (from severe to mild type) was seen in 74 (71%) patients and no change was seen in 30 (29%) patients. Hair growth started becoming visible after two to five months and “good” results were obtained in all except two patients after a follow-up period varying from 8 to 18 months. Conclusion: Placement of the grafts into premade slits using implanter will help in improved results because of minimal graft handling, more graft placement in less time, and thereby reducing body out of time. Limitation: No objective assessment was carried out to document regrowth of hair in our study.
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QUIZ Top

A translucent yellow-brown papule on the nose p. 255
Keshavmurthy A Adya, Arun C Inamadar, Aparna Palit, Ravindrakumar S Pattar
DOI:10.4103/JCAS.JCAS_37_19  
The adult counterpart of juvenile xanthogranuloma is a relatively uncommon and although benign, the condition is not self-regressing as the juvenile form. Hence, surgical management becomes necessary. Herein we describe the characteristic clinical, dermoscopic and histological features of a solitary xanthogranuloma in a 35 year old male that was effectively managed surgically and present to the readers as a quiz.
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