Journal of Cutaneous and Aesthetic Surgery
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   Table of Contents - Current issue
Coverpage
January-March 2019
Volume 12 | Issue 1
Page Nos. 1-73

Online since Wednesday, March 20, 2019

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REVIEW ARTICLES  

Surgical smoke in Dermatology: Its hazards and management Highly accessed article p. 1
Saloni Katoch, Venkataram Mysore
DOI:10.4103/JCAS.JCAS_177_18  PMID:31057262
Surgical plume with vaporized tissue particles, pathogens, and toxic gases emanating during dermatosurgical procedures is an occupational hazard to the dermatosurgeon, and protective measures must be taken to prevent their inhalation. Smoke evacuators are devices that capture and filter the plume generated during electrosurgical procedures or laser procedures, thereby maintaining a safe environment for the surgical team and the patient. A smoke evacuation system should be appropriately selected depending on the need of the facility. The objective of this article is to outline the health hazards of the smoke by-product of electrosurgery and lasers and provide details about safety measures and smoke evacuation systems.
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Unconventional uses of laser hair removal: A review Highly accessed article p. 8
Saima Aleem, Imran Majid
DOI:10.4103/JCAS.JCAS_97_18  PMID:31057263
Laser hair removal since its availability has been primarily used for aesthetic purposes. Over the years, it has emerged as an important therapeutic modality in various dermatological and surgical disorders, both as an adjuvant and as a monotherapy. Depending on the skin type, all laser hair removal systems have been used with good results and minimal complications. We hereby review the diverse range of unconventional indications of laser hair removal.
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ORIGINAL ARTICLES Top

Efficacy of 308-nm monochromatic excimer light in the management of halo nevi: An open label, pilot study p. 17
Swapnil D Shah, Amit Shah, Bhalachandra Ankad, Sharad Mutalik
DOI:10.4103/JCAS.JCAS_138_18  PMID:31057264
Introduction: Halo nevus (HN) affects approximately 1% of the population. Presence of hypo- or depigmented lesion carries tremendous psychosocial disturbance in the mind-set of population in the Indian subcontinent. Hence, HN requires intervention by any modalities. Here authors attempted to evaluate the efficacy of monochromatic excimer light (MEL) in treating HN. Materials and Methods: A total of 29 patients with HN were included in the study. A xenon chloride lamp emitting noncoherent, monochromatic 308-nm light that represents the natural evolution of the excimer laser was used. The initial dose was 100 mJ/cm2, which was increased by 100 mJ/cm2 per session. All the patients were followed up for 6 months. Results: A total of 29 patients with 10 males and 19 females (male to female ratio of 1:1.9) completed the study. The age of onset of HN ranged from 5 to 47 years and the mean age of the patients was 23 years. HN was seen on the face, back, neck, chest, trunk, and extremities in 5 (17.2%), 6 (20.7%), 4 (13.7%), and 6 (20.7%) patients, respectively. Outstanding response was noticed in 14 patients (48.2%), whereas 6 (20.6%) patients showed excellent improvement. Only 2 (6.8%) patients showed no response after 10 consecutive sessions. Conclusion: HN causes apprehension in the Indian population because of the social stigma associated with depigmented patches on the body. Mere observation and only counseling in the treatment protocol are not sufficient. MEL is a noninvasive procedure, which results in excellent repigmentation of HN without scarring.
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To study the outcome of three-flap technique in the management of pincer nail p. 25
Kanathur Shilpa, Gorur Divya, Leelavathy Budamakuntla, Loganathan Eswari
DOI:10.4103/JCAS.JCAS_140_18  PMID:31057265
Context: Pincer nail deformity is a transverse overcurvature of the nail. Though various conservative and surgical techniques have been described in the literature, very few studies are based on objective measurements. This study was undertaken to evaluate the outcome of three-flap technique in the management of pincer nail. Aim: To study the outcome of three-flap technique in the management of pincer nail. Settings And Design: Prospective interventional study. Subjects and Methods: Fifteen patients with pincer nail deformity, fulfilling inclusion and exclusion criteria were enrolled for the study. Routine X-ray was carried out for all patients to detect underlying bony abnormalities such as exostoses. Width and height indices were calculated before the procedure. A three-flap technique was performed on all affected toe nails and outcome was assessed at the end of 6 months and 1 year. Statistical Analysis Used: Paired t-test and P value. Results: Satisfactory cosmetic outcome and statistically significant improvement (P < 0.0001) were achieved in all patients. Conclusions: Three flap technique is an useful technique in the management of pincer nail.
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Assessment of safe donor zone of scalp and beard for follicular unit extraction in Indian men: A study of 580 cases p. 31
Kavish Chouhan, Rahulkrishna S Kota, Amrendra Kumar, Jyoti Gupta
DOI:10.4103/JCAS.JCAS_142_18  PMID:31057266
Context: Hair restoration surgery for androgenetic alopecia (AGA) essentially involves various forms of hair transplantation. There is paucity of studies assessing donor area in Indian men and also no simplified guidelines are available for the safe donor area for follicular unit extraction (FUE). Our study is an attempt to study the donor area in Indian men.Aims: To assess the density of follicular units (FUs) in the donor area, that is, both scalp and beard in Indian men, and to propose simplified guidelines for FUE.Materials and Methods: The study design was cross-sectional and was carried out for 2 years. All the consenting male patients with male pattern hair loss Hamilton Norwood grading III or more who consulted for a hair restoration surgery were recruited. FU density was assessed in the donor area of scalp by drawing a rectangle with its lower border being a straight line joining two points, which are 27–28mm from the line drawn perpendicular to tragus, passing through external occipital protuberance. Three squares of area 1cm2 were drawn within the rectangle. Average of the FUs and follicles in the three squares was calculated to obtain mean density in the donor area of the scalp. Total number of FU was assessed, considering 25% extraction, total average number of extractable follicles was assessed. Total donor area was divided into three areas (areas 1, 2, and 3) and average number of extractable FU was assessed in each. Donor area in the beard, below the jawline, was divided into a triangle and rectangle. Average number of FU, total number of extractable FU was calculated similarly.Results: A total of 580 male patients were recruited in the study. Mean FU density in the scalp and beard was 78.2/cm2 and 49.7/cm2, respectively. The total available number of FUs for extraction in the areas 1, 2, and 3 and beard considering 25% extraction was 2064, 3097, 3612, and 824, respectively. We propose three types of donor areas in the scalp, namely, limited, standard, and extended donor area.
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Cross-sectional study of dermatoscopic findings in relation to activity in vitiligo: BPLeFoSK criteria for stability p. 36
Balakrishnan Nirmal, Belavendra Antonisamy, CV Dincy Peter, Leni George, Anu A George, Gauri M Dinesh
DOI:10.4103/JCAS.JCAS_75_18  PMID:31057267
Background: Stability in vitiligo is an important concept in guiding patient management and a vital prerequisite before vitiligo surgery. Disease activity of vitiligo based on patient’s history is imprecise. It is practically impossible to perform biopsy from all lesions of vitiligo to ascertain stability. Dermatoscopy can be used to examine all clinical lesions in a patient of vitiligo. There is a need to validate many reported dermatoscopic findings for universal use. Aims: To analyze the significance of dermatoscopic findings in the activity of vitiligo and to devise a cutoff score for stable vitiligo. Materials and Methods: Dermatoscopic examination was performed in 85 patients clinically diagnosed with vitiligo. Six dermatoscopic parameters, namely, border, pigment network, perilesional hyperpigmentation, perifollicular pigmentation, satellite lesions, and micro-Koebner phenomenon (acronym: BPLeFoSK) were evaluated against Wood’s lamp findings as standard. Chi-square test was used to test association between categorical variables. Cutoff values for stability for these six parameters were plotted in receiver operating curve. Results: A total of 131 vitiligo lesions were analyzed with dermatoscopy. Absence of satellite lesions and absence of micro-Koebner phenomenon were the most sensitive parameters (96.7% and 100%, respectively). Sharp border and absent or reticulate pigment network within the vitiligo patch were the most specific findings (100% and 91.5%, respectively). Conclusion: A cutoff score of more than or equal to 1.5 using the “BPLeFoSK criteria” indicates stability in the vitiligo lesion.
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Correlation between clinical features, biochemical parameters, and histopathological findings in women with patterned baldness: Study from North India p. 42
Sidharth Tandon, Pooja Arora, Ram Krishan Gautam, Minakshi Bhardwaj, Umesh Garga, Neera Sharma
DOI:10.4103/JCAS.JCAS_30_18  PMID:31057268
Background: Androgenetic alopecia (AGA) is a non-scarring alopecia with a characteristic pattern in genetically predisposed men and women. Hormonal abnormalities namely hyperandrogenism, hair cycle defects, genetic predisposition, and follicular miniaturization have been implicated as the causative factors for AGA. Aim: To analyze women with patterned hair loss and correlate their clinical findings with the histopathology and biochemical parameters. Materials and Methods: Female patients between 18 and 45 years of age with a history of hair loss on the crown, temporal area, and recession of hairline were clinically examined. These patients were then subjected to histopathological examination, and on confirmation of diagnosis of female pattern hair loss (FPHL), they were included in the study. Their morning blood sample was taken on 3rd–5th day of the menstrual cycle for hormonal analysis. The study was carried out on 30 patients and 30 age- and sex-matched controls. Results: A statistically significant difference was observed between the mean values of dehydroepiandrosterone sulfate, prolactin, androstenedione, and free triiodothyronine of cases and controls. The most common histopathological finding in our study was an increase in the percentage of telogen hair. Conclusion: The biochemical findings in our study corroborate the role of hyperandrogenism as one of the major etiological factors in FPHL with the role of adrenal androgens being central, and therefore all female patients with FPHL should be evaluated for underlying hormonal imbalances. The role of histopathology in FPHL can be used as a prognostic marker.
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INNOVATIONS Top

Mini-punch skin excision: A newer novel approach for tattoo removal p. 49
Jyoti Gupta, Kavish Chouhan, Amrendra Kumar, Ketan Garg
DOI:10.4103/JCAS.JCAS_133_18  PMID:31057269
Q-switched Nd:YAG laser remains the gold standard for tattoo removal, but still some tattoos are not completely removed in a specified period as desired by the patient. Herein, we present a case report of 23-year-old patient who came to the outpatient department for tattoo removal. The tattoo measured around 20cm × 18cm and was located on the back. Nine to 12 sessions of 1064-nm Q-switched Nd:YAG laser were planned at 4- to 6-week interval. After the completion of nine sessions, all the shades of the tattoo disappeared, but the lines persisted. A trial of increased laser energy and multiple-pass R20 treatment was performed, which rather increased the scarring and no improvement in tattoo clearance was noticed. We tried mini-punch skin excision for clearing the remnant tattoo lines. The tattoo was cleared successfully without significant scarring. Mini-punch skin excision is a very promising technique, similar to the follicular unit extraction technique of hair transplant, for tattoo removal of the patients who want immediate results as compared to lasers that take almost a year, provided the patient accepts the risk of scarring.
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CASE REPORTS Top

A case report on use of cog threads and dermal fillers for facial-lifting in facioscapulohumeral muscular dystrophy p. 52
Aman Dua, Bhawna Bhardwaj
DOI:10.4103/JCAS.JCAS_128_18  PMID:31057270
Long-standing facial paralysis induces degenerative facial muscle changes on the involved side, thus making the individual seem older than their actual age. Furthermore, contralateral facial hypertrophy aggravates facial asymmetry (Sulamanidze MA, Fournier PF, Paikidze TG, Sulamanidze GM. Removal of facial soft tissue ptosis with special threads. Dermatol Surg 2002;28:367-71). The introduction of absorbable barbed thread has proved to be a good alternative for treating facial asymmetry. It also allows the association with other nonsurgical procedures, such as botulinum toxin use and/or dermal fillers in facial remodeling (Atiyeh BS, Dibo SA, Costagliola M, Hayek SN. Barbed sutures “lunch time” lifting: evidence-based efficacy. J Cosmet Dermatol 2010;9:132-41 and Kaminer MS, Bogart M, Choi C, Wee SA. Long-term efficacy of anchored barbed sutures in the face and neck. Dermatol Surg 2008;34:1041-7.). The aim of the treatment (threads) of the mid and lower third of the face was to promote the mechanical effect (lifting) and biological effect (neocollagenesis) with the improvement of the nasolabial folds, jaw, and jawbone contour.
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Extended bifurcated superficial temporal artery island flap for the reconstruction of a periorbital burn: A case report p. 56
Tarek M Elbanoby, Usama A Abdelfattah, Gaber M Aly, Mohab Abdulkafy, Amr M Elbatawy
DOI:10.4103/JCAS.JCAS_65_18  PMID:31057271
A 47-year-old man with severe thermal burn injury to the face, including bilateral periorbital regions, presented with bilateral upper and lower ectropion with loss of both eyebrows. The periorbital area was reconstructed with the extended bifurcated superficial temporal artery flap with two islands extending out of territory to restore both eyebrows, lower eyelid, and add length to upper eyelid. After 12 months of the operation, the patient showed complete resolution of postburn sequels in addition to a high grade of satisfaction.
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PRACTICE POINTS Top

Practical tips and techniques for injection rhinoplasty p. 60
Sukhbir Singh
DOI:10.4103/JCAS.JCAS_137_18  PMID:31057272
Background: Nose is an important part of facial aesthetics and needs to be restored as part of overall facial rejuvenation. Nasal fillers containing hyaluronic acid give immediate results with minimal or no downtime. Materials and methods: The aim of this article was to give an insight and practical tips to enhance results with nasal fillers and at the same time minimize complications. All the procedures were performed at the author’s private clinic and by the author himself. Results: Dorsal correction has been the most common indication for nasal fillers, followed by the tip and alar correction. The patients are highly satisfied if proper care is taken during injections, which leads to gratifying results. Conclusion: Hyaluronic fillers are very effective for nasal reshaping for patients not willing for rhinoplasty and even for those with minor defects after rhinoplasty. They give immediate results with very minimal downtime.
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SHORT COMMUNICATIONS Top

A randomized controlled study comparing the efficacy of topical 5% tranexamic acid solution versus 3% hydroquinone cream in melasma p. 63
Manasa S Janney, Radhakrishnan Subramaniyan, Rajeshwari Dabas, Sandeep Lal, Niyor M Das, Satish K Godara
DOI:10.4103/JCAS.JCAS_40_18  PMID:31057273
Background and Aims: Melasma is a common, relapsing, acquired, symmetrical facial hypermelanosis with no universally effective therapy. Hydroquinone (HQ) is considered the gold standard in the treatment of melasma till date. Tranexamic acid (TA) is an upcoming molecule being explored in melasma therapy and has shown optimistic results in preliminary trials. This study aimed to compare the efficacy of topical 5% TA solution with 3% HQ cream in the treatment of melasma in Indian skin. Material and Methods: This was a prospective, randomized, single-blind study of 12 weeks’ duration. Hundred eligible patients randomly divided into two intervention groups were analyzed after screening 346 patients with melasma. Serial photographs, Melasma Area Severity Index (MASI), and adverse effects were documented at monthly intervals. Patient satisfaction score was noted at the end of 12 weeks. A repeated measurement analysis of variance, independent t-test, and χ2 tests were used for statistical analysis. A P-value of <0.05 was considered to be statistically significant. Results: Our study population consisted of 84 females and 16 males. Mixed melasma had the highest prevalence (63%) followed by epidermal (22%) and dermal types (15%). Percentage reduction of MASI was 27% and 26.7% in the TA and HQ group, respectively, at the end of 12 weeks, and the difference between the two groups was not significant (P > 0.05). However, patient satisfaction score was significantly higher in TA group (P value = 0.03) in view of lesser adverse effects. Conclusions: Topical 5% TA solution is as effective as 3% HQ cream in melasma with enhanced patient satisfaction.
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Lymphatic obstruction as a rare complication of morphea and response to intralesional steroid p. 68
Ishmeet Kaur, Archana Singal, Deepak Jakhar, Deepika Pandhi
DOI:10.4103/JCAS.JCAS_155_18  PMID:31057274
Morphea is a rare sclerosing disorder of the skin. Linear morphea is commonly seen in children and can affect head, neck, trunk, or limbs. It may extend to involve deeper structures such as muscles, bones, and joints. Involvement of lymphatics or the vasculature is very rare. We report a case of a 20-year-old woman presenting with linear morphea involving the nape of the neck and scalp. The lesion gradually developed two linear thick cord-like structures within the lesion of morphea because of secondary lymphatic obstruction causing restriction of neck movements. The patient was given intralesional steroid that led to softening of the skin lesions including that of cords, resulting in improvement of neck movements.
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Perialar semilunar advancement flap for the reconstruction of nasal sidewall defects: Our experience p. 71
Adelina Costin, Ana M António, João Goulão
DOI:10.4103/JCAS.JCAS_156_18  PMID:31057275
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