Journal of Cutaneous and Aesthetic Surgery
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   Table of Contents - Current issue
Coverpage
April-June 2020
Volume 13 | Issue 2
Page Nos. 77-184

Online since Saturday, June 20, 2020

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ORIGINAL ARTICLES  

Recommendations for cutaneous and aesthetic surgeries during COVID-19 pandemic Highly accessed article p. 77
Venkataram Mysore, A Somaiah Savitha, Aniketh Venkataram, Arun C Inamadar, Aurangabadkar Sanjeev, Chandrashekar S Byalekere, Dinesh K Devaraj, Niti Khunger, Raghunatha R Reddy, Pangti Rashi, Thurakkal Salim, Sharad D Mutalik, Shehnaz Arsiwala, Shyamanta Barua, Somesh Gupta, Subodh Sirur, Swapnil Shah
DOI:10.4103/JCAS.JCAS_83_20  
Background: Amid the coronavirus disease 2019 (COVID-19) pandemic, dermatologists must be prepared to restructure their practice of procedural dermatology and cutaneous aesthetic surgeries. The COVID-19 pandemic has presented several challenges and has ushered in several changes in practice such as teledermatology, with many physicians adopting virtual consultations and treatments. Performing procedures in the times of COVID-19 pandemic presents challenges such as risk of transmission to doctors and staff due to potential aerosolization, release of virus droplets during the procedures, and risk of virus transfer through the instruments both in the peri- and postoperative period. This can have several medical, administrative, and legal implications. Objectives: This document aimed to outline best practices that can be followed in this scenario to perform cutaneous surgeries and procedures to ensure safer skin surgery. Recommendations: Standard precautions include social distancing of at least 1 m, hand hygiene, appropriate use of personal protective equipment (PPE), safe injection practices, sterilization and disinfection of medical devices, environmental cleaning, and respiratory hygiene. It is generally advisable to see patients only by appointments. Each clinic should have a special area at entry for screening patients and providing sanitizers and masks. Procedures, which are of short duration, performed on nonfacial areas are considered as low risk and require donning surgical mask. Procedures involved with minimal invasiveness and bleeding, short duration procedures on the face such as injectables, chemical peels, and aerosol-generating procedures on nonfacial areas are considered moderate risk. These procedures need apron with head cover, N95 mask, face shield, double gloves, and smoke evacuator with high-efficiency particulate air (HEPA) or ultralow particulate air (ULPA) filter. Aerosol and plume-regenerating procedures (such as ablative lasers on the face), prolonged surgeries on head (such as hair transplantation), intraoral, and intranasal procedures are considered high risk. These procedures must be carried out with full body cover with surgical gown, head cover, N95 mask, face shield, double gloves, and smoke evacuator. Physicians should be aware of local epidemiological situation and adhere to the relevant guidelines issued by the relevant governmental agencies.
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Global trends of botulinum toxin literature: A bibliometric analysis of botulinum toxin publications between 1975 and 2017 p. 95
Engin Senel, Ümran Muslu
DOI:10.4103/JCAS.JCAS_111_19  
Background: Botulinum toxin has been effectively used cosmetically and therapeutically for the last decades in a wide range of medical conditions. Although bibliometrics has been a popular and growing study area in recent years, medical literature lacks studies evaluating published botulinum toxin literature. Objective: The goal of our study was to evaluate bibliometric features and to perform a detailed trend analysis in the medical literature related to botulinum toxin. Materials and Methods: We analyzed all the published documents including the keywords “botulinum toxin” and “botulinum neurotoxin” and commercial brand names of botulinum toxin products between 1975 and 2017. We performed a detailed bibliometric and scientometric assessment in this field. Results: A total of 24,948 articles were retrieved from four databases provided by Web of Science, and most of which were original articles (76.19%). The United States ranked first and dominated literature with 8,729 documents (34.29%) followed by the United Kingdom, Germany, and Italy (14.61%, 11.18%, and 5.5%, respectively). The United Kingdom was detected to be the most productive country with the highest productivity (55.09) followed Switzerland, Denmark, and Germany (47.7, 34.01, and 33.98, respectively). The most studied area was neurology (56.1%) and University of California System was the most productive institution. We noted no correlation between publication number and citations by year. Conclusion: We found that all top 10 authors and institutions were from developed countries. Physician from developing and the least-developed countries should be supported to carry out novel studies on botulinum toxin.
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Comparative evaluation of therapeutic efficacy of intralesional injection of triamcinolone acetonide versus intralesional autologous platelet-rich plasma injection in alopecia areata p. 103
Priya Kapoor, Sumir Kumar, Balvinder K Brar, Neetu Kukar, Hobinder Arora, Sukhmani K Brar
DOI:10.4103/JCAS.JCAS_16_19  
Context: Alopecia areata is a chronic non-scarring alopecia that involves scalp and/or body. Corticosteroids are the most popular drugs for its treatment. Aim: The aim of the study was to evaluate the therapeutic efficacy of intralesional injection of triamcinolone acetonide and platelet-rich plasma (PRP) in alopecia areata and to compare the efficacy of these modalities in alopecia areata. Settings and Design: This was a randomized controlled comparative study. Subjects and Methods: Forty patients were enrolled from the outpatient department and divided into two groups of 20 patients each. Group A and B randomly received intradermal triamcinolone acetonide suspension (10 mg/mL) and PRP, respectively, into the lesion using an insulin syringe in multiple 0.1 mL injections 1cm apart. The injections were repeated every 3 weeks till 12 weeks. The patients were evaluated by Severity of Alopecia Tool (SALT) score and photographically every 3 weeks till the end of 12 weeks and then at the end of 6 months. Statistical analysis used descriptive analysis along with Pearson chi-square test or Fisher exact test, paired samples, and independent samples t test or their nonparametric analogs for continuous variables. Results: The reduction in SALT score at each visit with respect to baseline was greater in the triamcinolone group as compared to PRP group. This signifies greater effect of triamcinolone in alopecia areata. Around 50% patients in triamcinolone group and 5% patients in PRP group showed grade V improvement. Pain during intralesional injection was higher in the PRP group. Conclusion: Both intralesional triamcinolone and PRP were found to be efficacious in alopecia areata but the latter produced lesser improvement.
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REVIEW ARTICLES Top

Innovative paradigm in aesthetics medicine: Proposal for diagnostic morphological geometric by thirds, semiology in clinical applied to aging facial p. 112
Gladys J Velazco de Maldonado, Dubraska V Suárez-Vega, Víctor García-Guevara, Blanca Miller-Kobisher
DOI:10.4103/JCAS.JCAS_116_19  
The diagnosis of aging based on the morphogeometric changes experienced by the face, measured by the application of facial stratigraphic semiology by thirds, could become a novel approach that guarantees an efficient replacement of aged tissues through minimally invasive aesthetic medicine strategies. Facial aging should be analyzed by thirds, because not all thirds grow old at the same time. Owing to this is necessary go giving solve the aging problems each one of them, by means of therapies of the facial restructuring into sequential treatment appointments, with the purpose of being go giving time to the tissues rearrangement of the face, so that it is perceived as a subtle progressive reversal of aging and so generate a comfortable social acceptance of the resulting changes of said facial rejuvenation. This article intends to present the practical approach of the concepts and guidelines illustrated in the routine aesthetic diagnosis, the anatomical changes in the various tissue layers that are externally appreciated, but detailing them under a regional approach (upper, middle, and lower thirds). Our paradigm seeks that as professionals of aesthetic and regenerative medicine we identify facial aging not only as the obvious wrinkles and other changes in the skin, but that we diagnose according to the proposed parameters, so that when considering the rejuvenation treatment, we identify which are facial tissues that have changed due to aging and must therefore be restored to harmonize the face according to the ideal forms and proportions that must prevail (morphometry).
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Evidence-based surgical management of post-acne scarring in skin of color p. 124
Atula Gupta, Maninder Kaur, Suman Patra, Niti Khunger, Somesh Gupta
DOI:10.4103/JCAS.JCAS_154_19  
Acne scars are the reason for significant morbidity among dermatology outpatients. With more modalities being introduced every year, it is important to choose the best one suited for a particular type of scar for each patient to obtain an optimum result. Guidelines on acne scar management in the skin of color are not available where the therapeutic effect and side effect profile of the modalities can vary significantly. This narrative review looked at critical evaluation of the available modalities to find the level of evidence and therapeutic ladder of management of different types of acne scars. Treatment options for different types of scars have been described. Evidence level for each type of modality for the individual type of scar was calculated using the Strength of Recommendation Taxonomy (SORT) developed by editors of the US family medicine and primary care journals. In addition, various newer and emerging treatment options, such as dermal cell suspension, jet volumetric remodeling, and radiofrequency subcision, have been discussed. The highest level of evidence is available for microneedling, fractional radiofrequency, fractional CO2, and erbium:yttrium aluminum garnet laser for mild to moderate grade scars. Trichloroacetic acid chemical reconstruction of skin scars showed efficacy in ice pick scars. Grade 4 scars improve poorly with resurfacing procedures, where punch excision and punch elevation can be tried. Platelet-rich plasma therapy was effective in combination with lasers and microneedling. Overall there is lack of high-quality data in the management of post acne scars. Combination treatment has shown better efficacy compared to single modalities.
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CASE REPORTS Top

“An uncanny kin of the ingrown toenail”: Harpoon nail and the surgical challenge in its management p. 142
Ramesh Sandhiya, Raghavendra Rao
DOI:10.4103/JCAS.JCAS_99_19  
Ingrown toenails result from the painful conflict between the nail plate and the surrounding soft tissues. Ingrowing may be precipitated by improper nail cutting in most instances, and occlusive footwear and trauma, in others. The most common type of ingrown nail is the distal lateral variant. We report a relatively unique and rare case of ingrown nail—the harpoon nail, wherein the distal lateral spur arising from improper and incomplete trimming of the nail, pierced through the distolateral wall until it appeared over the tip of the toe. It is a cause of great morbidity to the patient and this report envisages the need for the correct surgical approach.
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Case report on rare clinical variant of porokeratosis: Disseminated superficial porokeratosis p. 145
Jagdish J Sakhiya, Dhruv J Sakhiya, Mehul R Patel, Feral R Daruwala
DOI:10.4103/JCAS.JCAS_35_19  
Porokeratosis is a genodermatosis, resulting from a disorder in keratinization due to an abnormal clone of epidermal precursor, presenting with various clinical manifestations but characterized histologically by the presence of cornoid lamella. Diverse clinical variants of porokeratosis exist, which are unified by this general histological feature, but differ in morphology, distribution, and clinical course. The typical lesions of porokeratosis are described by an atrophic center surrounded by an elevated keratotic rim formed by the cornoid lamella. The lesions can be found almost anywhere on the body. We report an unusual presentation of a rare clinical variant, disseminated superficial porokeratosis.
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SHORT COMMUNICATION Top

Two-stage ear reconstruction with a retroauricular skin flap after excision of trichilemmal carcinoma p. 149
Shashank Bhargava, Claudio Feliciani, Rosita Longo, Michele M Dominici
DOI:10.4103/JCAS.JCAS_110_19  
Trichilemmal carcinoma is a rare cutaneous tumor with a frequently good prognosis but without standard criteria for surgical treatment. We aimed to show the results of a two-stage surgical approach that preserves the anatomical features of the ear. We report a case of 82-year-old man with trichilemmal carcinoma of the ear that was treated with a two-stage surgical approach. We observed that 5 months after the surgeries, the ear appeared entirely healed and there were no signs of recurrence; hence, our two-stage surgical approach allowed the anatomy of the ear to be preserved after the complete excision of the tumor.
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PRACTICE POINTS Top

Scar orientation: Principles in plastic surgery p. 152
Kavit R Amin, Christian M Asher, AAlexander E Hamilton, David Mowatt
DOI:10.4103/JCAS.JCAS_5_20  
For biopsy proven skin cancers that are deemed to be high risk, a wide local excision (WLE) is recommended to reduce the risk of local recurrence. For this reason, it is pragmatic to account for the likelihood of a WLE at the time of the initial biopsy. We illustrate a staged approach to excision of lesions to facilitate this, bearing in mind the optimal reconstruction is primary closure. In our experience as plastic surgeons, having to perform a locoregional flap or skin graft prevents the opportunity to perform a local anesthetic procedure. This increases the risk of postoperative complications, especially if adjuvant radiotherapy further exposes reconstructed tissues to radiation toxicity. Collectively, this often results in an inferior aesthetic outcome. We value the referrals from allied colleagues and want to share the principles we adhere to when planning an excision biopsy, which aid in the delivery of the optimal reconstruction.
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A basic algorithmic surgical approach for Nicolau syndrome p. 154
Ali Yeniocak, Osman Kelahmetoğlu, Mustafa Özkan, Metin Temel, Ethem Güneren
DOI:10.4103/JCAS.JCAS_139_19  
Background: Nicolau syndrome (NS) is a rare complication that develops after the administration of intramuscular diclofenac sodium. The etiology and surgical treatments of 11 patients with NS were evaluated and studies in the literature were examined. The aim of this study was to compose a basic algorithm for surgical approaches to treat NS. Materials and Methods: Eleven patients were evaluated for NS between December 2013 and January 2018. Two patients did not accept treatment, and nine patients underwent surgical debridement of necrotic tissues. The tissue defects of five patients were closed with a fasciocutaneous flap and, in four patients, the defects were repaired primarily. Results: No complications, such as wound infection, wound dehiscence, seroma, or flap necrosis, were encountered. Of the seven patients who received concurrent antibiotic therapy, no patient had any problems at their follow-up (2–30 months). The results were satisfactory from an aesthetic and functional point of view. Conclusion: NS was more frequent in women with a high body mass index and high fat in gluteal regions. We considered that any kind of medication could lead to NS. Different methods are discussed for treatment.
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INNOVATIONS Top

A novel technique to improve accuracy of Mohs mapping for large stages with a small tumor burden p. 160
Atieh Jibbe, Heidi Donnelly
DOI:10.4103/JCAS.JCAS_75_19  
Precision of the Mohs micrographic surgery (MMS) process during orientation, microscopic analysis, tissue mapping, and tumor clearance of specimen margins is essential for MMS to attain high cure rates; however, this elaborate process is subject to error. Large tumor stages with a small tumor burden present an avenue for error during MMS mapping. We present a novel technique to improve the accuracy of MMS mapping using an MMS slide marked for residual tumor superimposed onto a mobile device photograph of the surgical defect. This is taken to better identify location of residual tumor both on the digitalized MMS photomap and surgical defect. This novel technique decreases recurrence rates by decreasing the inevitable subjectivity involved with the superimposition of residual tumor foci from a microscopic view onto the digitalized MMS photomap then onto the surgical defect particularly in larger stages with a small tumor burden.
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“Combination grafting” of scalp and body hair to enhance the visual density of hair transplant and coverage of higher grade of baldness p. 163
Anil K Garg, Seema Garg
DOI:10.4103/JCAS.JCAS_89_18  
Hair transplant is becoming the most common cosmetic procedure across the world with demand for higher density and coverage of baldness. This needs more number of donor hair follicles. Scalp donor has limitations to fulfill the required number of follicles for Norwood Grade VI and VII baldness. The body hair follicles can be used to cover up the deficit. The objective of this study was to observe the use of body hair follicles to increase the visual density and for better coverage for higher grades of baldness as an adjuvant to scalp hair follicles. Materials and Methods: A total of 16 patients were evaluated for the availability of body donor hair, and consent for body hair harvesting was obtained from them. The beard was the first preference and then chest and abdomen hair follicles were used in combination with scalp hair follicles to cover bald area of Norwood grade IV and above baldness. Body hairs were harvested using follicular unit extraction (FUE) technique. Postoperative pictures were taken, and patient satisfaction, doctor’s observation, and global photographic evaluation was carried out. Observations: The patient’s photographs were taken after 4, 8, and 12 months of hair transplant. The results were analyzed on the basis of global photography. The use of body hair with scalp has enhanced the visual density, leaving to better coverage in even higher grades of baldness.
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Botulinum toxin for paramedian interpolated forehead flaps p. 170
Matthew J Lin, Danielle P Dubin, Hooman Khorasani
DOI:10.4103/JCAS.JCAS_56_19  
The forehead skin closely resembles the texture and color of the midface region. As such, the use of a paramedian forehead flap to repair a midface defect provides optimal cosmesis; however, the donor forehead site may be left with an undesirable scar in a highly visible region of the face. Cutaneous surgeons possess a variety of traditional techniques intended to minimize scarring. We have found that the addition of 50 units of botulinum toxin at the time of wound closure has improved scar outcomes for patients undergoing reconstruction with paramedian interpolated flaps. Possible mechanisms for the efficacy of botulinum toxin lie in its ability to chemically paralyze the frontalis muscle and glabella complex. This immobilization leads to a reduction in unwanted wound tension during the most vulnerable first few days of healing.
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Crab claw reduction cheiloplasty: The Indian way p. 173
Sneha Puri, Jayshree Nandanwar, Akash Kasatwar, Akhilesh Shewale
DOI:10.4103/JCAS.JCAS_95_19  
The goals of lip reduction surgery are to reduce the volume of the lips and restore an aesthetic labial contour and to maintain an ideal volume relationship between upper and lower lips. The aim of this study was to minimize the excessive large lips by modifying the incision and to get more Indian appearance of the lips by using crab claw technique. A total of nine patients (six males and three females) of age-group 21–22 years, having aesthetic concern due to excessive large lips, were treated in the case series. The distance from the vermilion border to the lip line was recorded at midline and 6–7 mm apart from the either side, and the distance between two peaks corresponding to the philtral ridges at baseline and at 6 months follow-up. A mean reduction of approximately 10 ± 0.70 mm at midline, 10.11 ± 1.05 mm on the right side, and 9.55 ± 0.72 mm on the left side of the lip was obtained in all the nine cases. No postoperative complication was observed in any of the patients, and all the patients were satisfied with the result, which was carried out through a survey completed by all the patients. The lip reduction surgery using crab claw technique proved to be successful in achieving decreased lip volume while restoring anatomical morphometric pattern of lip to look more Indian way.
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QUIZ Top

A late presentation of hand pain with skin changes p. 178
Fady P Marji, Grant M Kleiber
DOI:10.4103/JCAS.JCAS_162_19  
A middle-aged homeless man presented with ongoing left-hand pain and worsening cutaneous phalangeal color changes. On examination, digital ischemia was observed with associated dry gangrene. Doppler examination showed impaired distal arterial flow. Angiography showed irregular digital perfusion. The patient later provided vital information to secure the diagnosis without further clinical workup. This quiz discusses the presentation, differential diagnosis, and treatment of a rare clinical scenario.
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CORRESPONDENCE Top

Basal cell carcinoma camouflaged by rhinophyma p. 181
Adelina Costin, João Goulão
DOI:10.4103/JCAS.JCAS_34_19  
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Unusual presentation of congenital dermoid fistula of the anterior chest region p. 183
Marko Baskovic, Antun Kljenak
DOI:10.4103/JCAS.JCAS_63_19  
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