Journal of Cutaneous and Aesthetic Surgery
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   Table of Contents - Current issue
April-June 2014
Volume 7 | Issue 2
Page Nos. 73-139

Online since Thursday, August 07, 2014

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The dynamics and power of change: Changing practices in cutaneous and aesthetic surgery p. 73
Niti Khunger
DOI:10.4103/0974-2077.138323  PMID:25136205
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Management of infantile hemangiomas: Current trends Highly accessed article p. 75
Gomathy Sethuraman, Vamsi K Yenamandra, Vishal Gupta
DOI:10.4103/0974-2077.138324  PMID:25136206
Infantile hemangiomas (IH) are common vascular tumours. IH have a characteristic natural course. They proliferate rapidly during the early infantile period followed by a period of gradual regression over several years. Most of the uncomplicated IH undergo spontaneous involution, with a small proportion of cases requiring intervention. These are children with IH in life-threatening locations, local complications like haemorrhage, ulceration and necrosis and functional or cosmetic disfigurements. Systemic corticosteroids have been the first line of treatment for many years. Recently, non-selective beta-blockers, such as oral propranalol and topical timolol, have emerged as promising and safer therapies. Other treatment options include interferon α and vincristine which are reserved for life-threatening haemangiomas that are unresponsive to conventional therapy. This review mainly focuses on the current trends and evidence-based approach in the management of IH.
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Management of infantile hemangiomas p. 85
Kavitha K Reddy
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Fractional CO 2 laser resurfacing as monotherapy in the treatment of atrophic facial acne scars Highly accessed article p. 87
Imran Majid, Saher Imran
DOI:10.4103/0974-2077.138326  PMID:25136208
Background: While laser resurfacing remains the most effective treatment option for atrophic acne scars, the high incidence of post-treatment adverse effects limits its use. Fractional laser photothermolysis attempts to overcome these limitations of laser resurfacing by creating microscopic zones of injury to the dermis with skip areas in between. Aim: The aim of the present study is to assess the efficacy and safety of fractional CO 2 laser resurfacing in atrophic facial acne scars. Materials and Methods: Sixty patients with moderate to severe atrophic facial acne scars were treated with 3-4 sessions of fractional CO 2 laser resurfacing at 6-week intervals. The therapeutic response to treatment was assessed at each follow up visit and then finally 6 months after the last laser session using a quartile grading scale. Response to treatment was labelled as 'excellent' if there was >50% improvement in scar appearance and texture of skin on the grading scale while 25-50% response and <25% improvement were labelled as 'good' and 'poor' response, respectively. The overall satisfaction of the patients and any adverse reactions to the treatment were also noted. Results: Most of the patients showed a combination of different morphological types of acne scars. At the time of final assessment 6 months after the last laser session, an excellent response was observed in 26 patients (43.3%) while 15 (25%) and 19 patients (31.7%) demonstrated a good and poor response respectively. Rolling and superficial boxcar scars responded the best while pitted scars responded the least to fractional laser monotherapy. The commonest reported adverse effect was transient erythema and crusting lasting for an average of 3-4 and 4-6 days, respectively while three patients developed post-inflammatory pigmentation lasting for 8-12 weeks. Conclusions: Fractional laser resurfacing as monotherapy is effective in treating acne scars especially rolling and superficial boxcar scars with minimal adverse effects.
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Evaluation of microneedling fractional radiofrequency device for treatment of acne scars p. 93
Byalekere Shivanna Chandrashekar, Rashmi Sriram, Rajdeep Mysore, Sapnashree Bhaskar, Abhishek Shetty
DOI:10.4103/0974-2077.138328  PMID:25136209
Background: Various treatment modalities including non-invasive methods such as chemical peels, topical retinoids, microdermabrasion, minimally invasive techniques such as microneedling, fractional lasers, microneedling radiofrequency devices and invasive procedures such as acne scar surgeries and ablative lasers are used for acne scars, each with its own unique advantages and disadvantages. This study is a retrospective assessment of efficacy and safety of microneedling fractional radiofrequency in the treatment of acne scars. Methods: Thirty one patients of skin types III-V with moderate and severe facial acne scarring received four sequential fractional radiofrequency treatments over a period of 6 months with an interval of 6 weeks between each session. Goodman & Baron's acne scar grading system was used for assessment by a side by side comparison of preoperative and post- operative photographs taken at their first visit and at the end of 3 months after the last session. Results: Estimation of improvement with Goodman and Baron's Global Acne Scarring System showed that by qualitative assessment of 31 patients with grade 3 and grade 4 acne scars, 80.64% showed improvement by 2 grades and 19.35% showed improvement by 1 grade. Quantitative assessment showed that 58% of the patients had moderate, 29% had minimal, 9% had good and 3% showed very good improvement. Adverse effects were limited to transient pain, erythema, edema and hyperpigmentation. Conclusion: Microneedling fractional radiofrequency is efficacious for the treatment of moderate and severe acne scars.
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Efficacy of triple therapy in auricular keloids p. 98
Reuben F De Sousa, Bijitesh Chakravarty, Alok Sharma, M Alam Parwaz, Anil Malik
DOI:10.4103/0974-2077.138347  PMID:25136210
Background: Keloids are characterised by their continued growth following trauma, extension into normal tissue and their high recurrence rate following excision. Auricular keloids are common following ear piercing or flame burns. These lesions are highly conspicuous and cosmetically unappealing. Multiple methods including surgery, radiotherapy, antimitotic agents, silicone sheet, pressure clips and cryotherapy have been advocated. The risk of recurrence and the need to prevent distortion of the three-dimensional structure of the ear following resection is a challenge to the cutaneous surgeon. Objectives: To devise a standard protocol for management of auricular keloids with minimal distortion and recurrence. Setting and Design: The patients underwent day-care surgery and subsequent out-patient follow-up for a minimum period of 1 year. Methods: Ten patients presenting with 22 ear keloids were enrolled into a keloid protocol: (a) surgical excision and keloid rind flap cover with (b) intra-operative and post-operative intra-lesional steroid and (c) silicone sheet application. Subjective assessment on follow-up was using Patient Observer Scar Assessment Scale and objective assessment was by Beausang scale. Statistical Analysis used: Microsoft Excel and Statistical Package for the Social Sciences (SPSS). Kaplan-Meier survival analysis curve used to calculate Recurrence Free period. Results: Two out of 22 (9.1%) keloids developed post-excision recurrence after a mean follow -up period of 16 months. The average keloid recurrence free interval was 21 months. Conclusion: Triple combination therapy for keloids on the ear is a simple technique for management with preservation of contour of the ear and a low recurrence rate.
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Outcomes of staple closure of the donor area during hair transplant by follicular unit transfer p. 103
Kumaresan Muthuvel, Sornakumar Lakshmikanthan, Deepa Subburathinam
DOI:10.4103/0974-2077.138351  PMID:25136211
Background: Donor area closure in hair transplantation by follicular unit transfer (FUT) is being done by various techniques. This study aims to assess the outcomes of staple closure for donor area in FUT. Aim: To study the outcome, efficacy and complications of staples in donor area closure for FUT. Materials and Methods: A total of 50 consecutive patients who underwent staple closure for donor area in FUT were included in the study and their data were collected retrospectively. Patients were followed up one year after the surgery and photographic documentation of the scar at the donor site was done. Objective measurement of the width of the scar was done for all the patients. Results: The average length of the donor area was 22 cm. The average width of the scar was 1.82 mm. There was no infection or tissue necrosis at the staple closure site in any of the patients. Conclusion: Staple closure resulted in cosmetically acceptable scar, but post operative discomfort was the major limitation. The potential to conserve the hair follicles along the line of closure makes using staples worthwhile if conservation of follicles is the goal.
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Platelet-rich plasma in androgenic alopecia: Myth or an effective tool Highly accessed article p. 107
Swapna S Khatu, Yuvraj E More, Neeta R Gokhale, Dipali C Chavhan, Nitin Bendsure
DOI:10.4103/0974-2077.138352  PMID:25136212
Platelet-rich plasma (PRP) has become a newer method for the treatment of various types of alopecia. In this prospective study, safety, efficacy and feasibility of PRP injections in treating androgenic alopecia were assessed. Eleven patients suffering from hair loss due to androgenic alopecia and not responding to 6 months treatment with minoxidil and finasteride were included in this study. The hair pull test was performed before every treatment session. A total volume of 2-3 cc PRP was injected in the scalp by using an insulin syringe. The treatment was repeated every two weeks, for a total of four times. The outcome was assessed after 3 months by clinical examination, macroscopic photos, hair pull test and patient's overall satisfaction. Results: A significant reduction in hair loss was observed between first and fourth injection. Hair count increased from average number of 71 hair follicular units to 93 hair follicular units. Therefore, average mean gain is 22.09 follicular units per cm 2. After the fourth session, the pull test was negative in 9 patients. Conclusion: PRP injection is a simple, cost effective and feasible treatment option for androgenic alopecia, with high overall patient satisfaction.
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Platelet rich plasma in androgenic alopecia: Where do we stand? p. 110
Kiran Godse
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Role of combined circumareolar skin excision and liposuction in management of high grade gynaecomastia p. 112
Arindam Sarkar, Jayanta Bain, Debtanu Bhattacharya, Raghavendra Sawarappa, Kinkar Munian, Gouranga Dutta, Ghulam Jeelani Naiyer, Shamshad Ahmad
DOI:10.4103/0974-2077.138354  PMID:25136214
Introduction: High-grade gynaecomastia (Simon IIb and III) has tissue excess (skin excess, enlarged areola, and displaced nipple), which is best managed surgically; however, results of conventional breast reduction surgeries and liposuction is not very good. Aim of our study was to describe a combined technique to manage these problems to produce a good result. Material and Method: This was a 2-year study among 12 patients of high grade gynaecomastia. Clinical and laboratory findings were normal. Pre-operatively in standing position, diameter of breast and areola, position of nipple, and amount of skin excess were marked. Under general anaesthesia, tumescent infiltration, circumareolar de-epithelisation of skin excess, and liposuction was completed. Redundant portion of the breast was sharply dissected and pulled out. Areola was fixed over pectoralis fascia at mid humerus level, just medial to the mid-clavicular line. Outer borders of the de-epithelised area were apposed by the purse-string effect of a subdermal suture, and further apposed by few half buried horizontal mattress sutures. Drains for 24 hour and compressive dressings for 6 weeks were used. Result: Mean age of presentation was 25.8 year; emotional discomfort was the chief complaint. Among 12 patients, 10 patients had bilateral gynaecomastia and 8 patients had enlarged and displaced nipple-areola complex. Average hospital stay was 2.41 days and recoveries were usually uneventful. Conclusion: The problem of tissue excess and tissue displacement in high grade gynaecomastia can be well managed by this combined circumareolar skin reduction and liposuction technique to achieve a scar-less flat male chest.
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Gynaecomastia surgery: Should it be individualised? p. 116
Wagih Mommtaz Ghnnam
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Targeted cryotherapy using disposable biopsy punches p. 118
Avitus John Raakesh Prasad
DOI:10.4103/0974-2077.138357  PMID:25136216
Cryotherapy is a commonly used office procedure that causes destruction of tissue by cryonecrosis due to rapid freezing and thawing of cells. The limitation in treating plantar warts and deeper dermal lesions is that the freeze time should be longer to penetrate deeper, which results in collateral damage to normal skin surrounding the lesion. This results in unwanted side effects of prolonged pain, blistering and haemorrhage and increased healing time. The cone spray technique was used to reduce collateral damage, but deeper penetration is difficult to achieve. An innovative technique using disposable biopsy punches is described that ensures deeper freezing as compared to the plastic cone. The metal cutting edge of the punch enters deeper into the lesions as the liquid nitrogen is passed, sparing damage to surrounding skin.
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How to practice dermatosurgery safely? p. 121
KH Satyanarayana Rao
DOI:10.4103/0974-2077.138361  PMID:25136217
Dermatosurgery has become an integral and essential component of current dermatology practice. No surgery can be totally risk free, only the level of risk varies. Patient safety has to be ensured by following standard protocols and taking appropriate precautions to prevent complications and mishaps. Mismatch between patient's expectations and outcome can lead to litigation. A dermatosurgeon should take care of his legal safety by obtaining informed consent and meticulously documenting and preserving medical records. Importance of communication and maintaining of fiduciary relationship with the patient cannot be overemphasized.
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Buying a laser - Tips and pearls p. 124
Sanjeev J Aurangabadkar, Venkataram Mysore, E Suhail Ahmed
DOI:10.4103/0974-2077.138363  PMID:25136218
Lasers and aesthetic procedures have transformed dermatology practice. They have aided in the treatment of hitherto untreatable conditions and allowed better financial remuneration to the physician. The availability of a variety of laser devices of different makes, specifications and pricing has lead to confusion and dilemma in the mind of the buying physician. There are presently no guidelines available for buying a laser. Since purchase of a laser involves large investments, careful consideration to laser specifications, training, costing, warranty, availability of spares, and reliability of service are important prerequisites. This article describes various factors that are needed to be considered and also attempts to lay down criteria to be assessed while buying a laser system that will be useful to physicians before investing in a laser machine. Practice points
  • Meticulous planning of the type of machine, specifications, financial aspects, maintenance and warranties is important.
  • It is wise to sign a contract or agreement between the buyer and seller before purchase of a laser which covers key aspects of installation, after sales service and maintenance of the machine.
  • Adequate training is essential; understanding laser physics and laser-tissue interaction goes a long way in getting the best out of the machine.
  • The credibility of the dealer and company should be ascertained in order to be assured of after-sales service.
  • Buying used machines, sharing of equipment to offset high initial investments is a good option but even more care is required to ensure proper functioning and maintenance.
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Primary bilateral extramammary Paget's disease of the axillae: Another case of this strange disease p. 131
Chiummariello Stefano, Del Torto Giuseppe, Maffia Romano, Alfano Carmine
DOI:10.4103/0974-2077.138365  PMID:25136219
Primary extramammary Paget's disease of the axilla is a rare variant with the capability of mimicking other more common conditions. We present a case of a 65-year-old woman with inflammatory skin lesions of both axillae clinically unresponsive to long-term conventional topical therapy. We decided to excise and reconstruct the resulting soft tissue defect of the major lesion by using a thoraco-dorsal artery perforator-based Limberg's flap. The histopathological examination showed intracellular mucin, signet cells, and glandular structures, the typical pattern of the EMPD. This was a very interesting case of a per se rare condition.
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Favre-racouchot syndrome with bilateral mechanical ptosis: An unusual presentation p. 135
Anupama A Kakhandaki, Leena Raveendra, Pradeep A Venkataramana, Jyoti S Khandre
DOI:10.4103/0974-2077.138366  PMID:25136220
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Re: Superficial large basal cell carcinoma over face, reconstructed by V-Y plasty p. 136
Vishal Madan
DOI:10.4103/0974-2077.138368  PMID:25136221
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Author's reply p. 137
Palak Deshmukh
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Re: Propranolol for infantile haemangiomas: Early experience from a tertiary center p. 137
Anand Pandey, Shailendra P Singh, Rajesh Verma, Vipin Gupta
DOI:10.4103/0974-2077.138372  PMID:25136223
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Author's reply p. 138
Vaibhav Pandey, AN Gangopadhyay, Preeti Tiwari, DK Gupta, SP Sharma, Vijayendar Kumar
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Reply to expert comments - A study of donor area in follicular unit hair transplantation p. 139
Balakrishnan Nirmal, Savitha Somiah, Sarvajnamurthy A Sacchidanand
DOI:10.4103/0974-2077.138374  PMID:25136225
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