Journal of Cutaneous and Aesthetic Surgery
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   Table of Contents - Current issue
Coverpage
October-December 2018
Volume 11 | Issue 4
Page Nos. 165-251

Online since Monday, February 4, 2019

Accessed 4,758 times.

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EDITORIAL  

Learning from the past, gleaning into future p. 165
Venkataram Mysore, Manjot K Marwah
DOI:10.4103/JCAS.JCAS_175_18  
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COMMENTARY Top

Overview of medical therapies and phototherapy in vitiligo based on their pathogenetic action and the role of platelet-rich plasma p. 167
Kabir Sardana, Gunjan Verma
DOI:10.4103/JCAS.JCAS_68_17  
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SYMPOSIUM: HAIR IN DERMATOLOGY Top

Logic of hair transplantation p. 169
Aniketh Venkataram, Venkataram Mysore
DOI:10.4103/JCAS.JCAS_183_18  
Hair transplant is a seemingly illogical process wherein we are using a small number of hairs to cover a large area of baldness. This is possible if one understands the logic of this equation. Understanding the pattern of hair distribution, and the sequence of balding, helps us learn the limitations of this technique and give the best possible results to the patient. In this article, we aim to give an understanding of all the processes associated with hair transplantation and the logic behind the same.
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Controversies in hair transplantation p. 173
Muthuvel Kumaresan, Venkatram Mysore
DOI:10.4103/JCAS.JCAS_118_18  
Hair transplantation being a relatively new field, several aspects raise issues and controversies. The issues refer to both ethics and evidence and how practitioners and the community need to deal with them. This article deals with few of such diverse issues as follicular unit transplantation versus follicular unit excision, safe donor area, platelet-rich plasma, and minimum qualification for performing hair transplantation.
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Complications in hair transplantation p. 182
Amit S Kerure, Narendra Patwardhan
DOI:10.4103/JCAS.JCAS_125_18  
Hair transplantation is a relatively safe surgery and is associated with very few complications. It is a cosmetic surgery so the complications may impact social and psychological aspect of the patient. Every hair transplantation surgeon should be aware of possible complications and techniques for the prevention and techniques of their management. Most of the complications are avoidable and can be minimized by proper surgical technique and wound care. Counseling and discussion with the patient before surgery help in proper planning and avoid patient dissatisfaction. Every patient should be individualized, planned, and operated with an aim to zero-down the complications and complaints.
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Donor harvesting: Strip dissection p. 190
Kapil Dua, Shraddha Uprety, Aman Dua
DOI:10.4103/JCAS.JCAS_119_18  
Hair transplant is a constantly evolving science. From the time that it was conceived by Dr. Norman Orentreich to the present state, the procedure of hair transplant has undergone multiple advancements. In this article, we discuss in brief regarding the strip follicular unit transplantation. We summarize the major points regarding the procedure of strip follicular unit transplantation along with some nuggets of experience that we have gathered over time. We briefly deal with the indications, anesthesia, procedure, and complications of strip follicular unit transplantation and some special scenarios like the repeat excision of strip.
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Donor harvesting: Follicular unit excision p. 195
Anil K Garg, Seema Garg
DOI:10.4103/JCAS.JCAS_123_18  
FUE or follicular unit excision is one of the methods for hair follicle harvesting in hair transplantation. FUE involves harvesting hairs from the donor area, under local anesthesia which is most commonly the scalp but occasionally beard, chest and other parts of the body, using a circular punch less than a mm, mounted on a manual handle or a motorized hand device or more recently a robotic device.First hair transplant was done by Dr Shoji Okuda in 1937. The term “follicular unit extraction” was coined by William Rassman in 2002. The modern era of FUE begins with the work of several surgeons Woods, Rassman, Cole, Harris and Rose. FUE has gone through various stages of development from manual to motorized and blunt to sharp, serrated trumpet and flared punches. Now the use of the robot in FUE with extraction and incision making is also in use.In 2017 nomenclature committee headed by Parsa Mohebi of ISHRS, recommended the term “FOLLICULAR UNIT EXCISION” is most appropriate as it explains the two steps of the process: incision and extraction and incision is done by a physician. FUE is a surgeon based time-consuming procedure with the long learning curve. Use of motorized device and sharp punches has certainly helped to increase speed in an experienced hand. FUE method of hair transplant is the most demanding procedure. If done properly it is a safe procedure. with the experience, use of better quality of instrument the disadvantages of FUE like transection can be reduced. The above informations were collected from various papers published in authentic journals and textbooks.
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Recipient area p. 202
Manjot K Marwah, Venkataram Mysore
DOI:10.4103/JCAS.JCAS_124_18  
Recipient area is the canvas in a hair transplant surgery, where the surgeon can truly display his artistic creativity and deliver an aesthetic masterpiece, after all hair transplantation is as much about art as science. There are four main steps in dealing with the recipient area. Marking the hairline and estimation of grafts is the most important steps to give a natural look. There are multiple anatomical markers that need to be addressed while drawing a hairline. The second step is the anesthesia and it should be as painless as possible. This is followed by implantation, which can be achieved by various techniques. There are multiple technicalities to be considered while implanting, such as density, angle, and direction. Once implantation is done, the final step is appropriate postoperative care. Each of these steps has been discussed in detail in this chapter.
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ORIGINAL ARTICLES Top

A randomized controlled, single-observer blinded study to determine the efficacy of topical minoxidil plus microneedling versus topical minoxidil alone in the treatment of androgenetic alopecia p. 211
Muriki K Kumar, Arun C Inamadar, Aparna Palit
DOI:10.4103/JCAS.JCAS_130_17  
Background: Androgenetic alopecia (AGA) is the most common form of hair loss in adults, which is generally progressive in the absence of treatment. As a head full of healthy hair adds to the cosmetic appeal of the individual, the consequences of AGA are predominantly psychological. Currently, topical minoxidil is the first-line treatment for AGA. Many adjuvant treatment modalities have been used synergistically with minoxidil. Microneedling is one among such adjuvant treatments, which works by various mechanisms to stimulate the dermal papillary cells that play a key role in hair growth. Aim: To compare the efficacy of microneedling along with topical minoxidil and topical minoxidil alone in the treatment of AGA in men. Materials and Methods: Sixty-eight men with Norwood–Hamilton grade III and IV AGA were recruited for the study. After randomization, one group was treated with weekly microneedling and twice daily application of 5% minoxidil solution and the other group was treated with twice daily application of 5% minoxidil solution alone. Global photographs were taken at baseline (pretreatment) and at end of the study duration. Trichoscopic images were taken from a targeted fixed area before treatment (baseline) and at end of the therapy from where hair count was also carried out. The two primary efficacy parameters were assessed: increase in the hair count from that of the baseline and patient self-assessment of hair growth at the end of the study. Results: The mean increase in hair count in the targeted area of one square inch at the end of the treatment was significantly greater for the combination treatment group (12.52/inch2) compared to that for the minoxidil alone group (1.89/inch2). Four patients in the “microneedling plus topical minoxidil” group reported a 50% improvement versus none in the “minoxidil alone” group. Conclusion: Our study showed that the combination of microneedling and topical minoxidil treatment was superior compared to topical minoxidil alone with regard to increase in the hair count and patient satisfaction, although the response achieved was not cosmetically significant.
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Fractional carbon dioxide laser in combination with topical corticosteroid application in resistant alopecia areata: A case series p. 217
Imran Majid, Shazia Jeelani, Saher Imran
DOI:10.4103/JCAS.JCAS_96_18  
Introduction: Intradermal steroid injections are used as treatment option in resistant alopecia areata. However, it is difficult and quite painful to treat large areas of alopecia with this modality. Objective: To assess the efficacy and safety profile of a combination of fractional carbon dioxide (CO2) treatment followed by topical corticosteroid application in resistant alopecia areata. Materials and Methods: Ten cases of resistant alopecia areata who had not responded to multiple treatment modalities were treated with fractional CO2 laser followed by topical application of triamcinolone spray (10mg/mL) on the resistant lesions. Patients received 4–8 sessions that were repeated at an interval of 3–4 weeks. Response to treatment was assessed on a quartile physician assessment scale and labeled as excellent (>75% regrowth), good (50%–75% regrowth), fair (26%–50% response), and poor (<25% regrowth). Results: Eight of these ten cases completed the treatment process. Seven of these eight patients had complete recovery of the area treated. One patient however did not show good response even after four sessions. No significant adverse effects were noted in any of the patients. Conclusion: Fractional CO2 laser in combination with topical triamcinolone can prove to be an effective treatment option in resistant alopecia areata.
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Injection lipolysis: A systematic review of literature and our experience with a combination of phosphatidylcholine and deoxycholate over a period of 14 years in 1269 patients of Indian and South East Asian origin p. 222
Mohan K Thomas, James A D’Silva, Ateesh J Borole
DOI:10.4103/JCAS.JCAS_117_18  
Background: Phosphatidylcholine and deoxycholate (PC–DC) injections have been used as nonsurgical alternatives to liposuction. DC as a constituent for lipolysis has recently been approved by the US Food and Drug Administration. Aim: PC and DC have independently been used in lipolysis. We hereby present a systematic review of literature on injection lipolysis and share our experience of using DC in combination with PC for injection lipolysis. We have retrospectively evaluated the effects of PC–DC treatments in varied age groups, both sexes, and over different target areas. Materials and Methods: This study spans over 14 years wherein 1269 patients of different age groups and sex were treated with injection lipolysis with PC–DC combination. The PC–DC cocktail injection was given to all patients for an average four sessions every 4 weeks, and the results were assessed after 8 weeks from the last session. Results: The effects were best appreciated over the face (malar, jawline, and submental areas) and upper arm, whereas average effect was observed on the thighs and around the knees. We have also used lipolysis as a primary modality as well as a touch-up modality following liposuction. The results are better appreciated in primary lipolysis. The need for follow-up sessions (1–2 sessions) of lipolysis and the quantification of results in subsequent sessions reveal that maximal improvement is achieved in the first session. Conclusion: PC–DC cocktail used for lipolysis as a local administration is effective for reducing unwanted fat. It shows great efficacy in treating localized fat, especially over the face and bra roll in the women of younger age group (20–30 years).
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CASE REPORTS Top

Deoxycholate (ATX-101) mixed with lidocaine to minimize pain/discomfort in nonsurgical treatment of submental fullness appearance p. 229
Raffaele Rauso
DOI:10.4103/JCAS.JCAS_9_18  
In the present study pain/discomfort reduction in submental fullness treatment with the injections of a DC based drug (ATX-101, Allergan, Dublin, Ireland) premixed with lidocaine 2% on a sample of 12 patients retrospectively evaluated has been performed All patients indicated improvement in skin tightening from the 2nd month postinjection. Three patients had minor ecchymoses at the injection sites, which resolved spontaneously within 10 days posttreatment. One patient experienced dysesthesia of the treated area, which lasted approximately 40 days and resolved spontaneously. No other complications—such as nerve paresis or alopecia—were recorded. No patient required analgesic drugs postinjection.
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Is prophylactic immunosuppressive therapy for patients with a history of postsurgical pyoderma gangrenosum necessary? p. 234
Christina Nicole Canzoneri, Dustin L Taylor, Daniel J Freet
DOI:10.4103/JCAS.JCAS_98_17  
Postsurgical pyoderma gangrenosum (PSPG) is a rare but serious surgical complication with a predilection for the breast and abdomen. Immunosuppression is the mainstay of treatment of PSPG. In addition, it has become a common practice for clinicians to prophylactically treat patients with a history of PSPG with corticosteroids or immunomodulators during subsequent operative procedures to prevent recurrence. Although many practitioners have reported successful outcomes with these measures, currently no protocol exists for prophylactic perioperative therapy. Here, we present the clinical course and 10-year follow-up of a woman who developed PSPG after undergoing body-contouring surgery, subsequently underwent multiple operative procedures without prophylactic immunosuppression, and has not experienced recurrence of PSPG. This case suggests that prophylactic therapy may not be necessary in all patients with a history of PSPG and shows that further research into the use of perioperative immunosuppression to prevent PSPG recurrence may be warranted.
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Impacted foreign bodies in the maxillofacial region–A series of three cases p. 237
Pulkit Khandelwal, Vikas Dhupar, Francis Akkara, Neha Hajira
DOI:10.4103/JCAS.JCAS_114_17  
Penetrating injuries to the maxillofacial region are very common. Foreign bodies embedded deep in the maxillofacial region due to these injuries pose a challenge to an oral and maxillofacial surgeon. These objects may become a potent source of pain and infection. Early diagnosis of these foreign bodies can be achieved by the use of plain radiographs, ultrasonography, computed tomographic scans, and magnetic resonance imaging. Once diagnosed and located, these foreign bodies should be removed. Here, we report three such cases where early diagnosis of these foreign bodies embedded in the maxillofacial region lead to their early and successful removal without complications.
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Capecitabine-induced bilateral ectropion: A rare ocular manifestation requiring surgical intervention p. 241
Sedat Tatar, Can E Yalçın, Billur Sezgin, Ayşe Y Taş, Orkun Müftüoğlu, Selahattin Özmen
DOI:10.4103/JCAS.JCAS_5_18  
It has been established that many chemotherapeutic agents are associated with a variety of ocular side effects. As an antineoplastic agent, 5-fluorouracil (5-FU) is the chemotherapeutic agent that is frequently linked with cicatricial ectropion. Capecitabine is a prodrug of 5-FU and has a more favorable side effect profile than 5-FU. Frequent side effects of capecitabine include gastrointestinal events and hand–foot–mouth syndrome; cicatricial ectropion is rather uncommon. Enzyme deficiencies affecting the capecitabine metabolism have been reported to be associated with exaggerated generalized systemic and cutaneous side effects; however, there are no cases in the literature reporting capecitabine-induced isolated bilateral-progressive ectropion. Although cessation of the agent is frequently sufficient for the treatment of ectropion, close follow-up is indicated in such patients as permanent damage may occur if the problem is left untreated. We report a case of capecitabine-induced bilateral cicatricial ectropion refractory to treatment cessation, ultimately requiring surgical treatment.
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SPOT THE DIAGNOSIS (QUIZ) Top

Asymptomatic pinkish-red nodule over the posterolateral tongue p. 245
Mahima Agrawal, Sidharth Sonthalia, Abhijeet K Jha, Mohamad Goldust
DOI:10.4103/JCAS.JCAS_93_18  
A young otherwise healthy male presented with asymptomatic pinkish-red nodule over postero-lateral tongue with the suspicion of having developed oral cancer. Biopsy from the lesion showed multiple circumscribed nodules in the lamina propria comprised of numerous oval and spindle-shaped cells. Abundant lymphatic tissue with germinal centres were also observed. Differentials included mucosal neuroma, traumatic neuroma, subgemmal neurogenous plaque, neurofibroma, and lingual tonsils. This quiz discusses the diagnosis and approach to the differential diagnoses in such a clinical setting.
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CORRESPONDENCE Top

“Jigsaw puzzle” advancement flap p. 248
Maria M Sanches, Ana I Pinto, Paulo L Filipe, Joao M Silva
DOI:10.4103/JCAS.JCAS_38_18  
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ERRATUM Top

Chemical peeling for nail disorders: Author response to the published comment p. 250
Deepashree Daulatabad, Soni Nanda, Chander Grover
DOI:10.4103/JCAS.JCAS_170_18  
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