Journal of Cutaneous and Aesthetic Surgery
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   Table of Contents - Current issue
Coverpage
July-September 2020
Volume 13 | Issue 3
Page Nos. 185-263

Online since Friday, September 11, 2020

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REVIEW ARTICLES  

Importance of choke vessels in injectable fillers p. 185
Hina Jajoria, Aniketh Venkataram, Venkataram Mysore
DOI:10.4103/JCAS.JCAS_73_19  
Knowledge of facial anatomy is indispensable for dermatologists and plastic surgeons practicing aesthetic medicine, especially for those using fillers, as injection of fillers may be associated with serious complications such as vascular occlusion and blindness. Angiosome and choke vessels play an important role in vascular incidents occurring after filler injections. The objective of this article was to outline the anatomy and pathophysiology of choke vessels, a concept which is not well known to dermatologists.
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Full-thickness skin graft fixation techniques: A review of the literature p. 191
Lloyd Steele, Alistair Brown, Fangyi Xie
DOI:10.4103/JCAS.JCAS_184_19  
Multiple techniques for skin graft fixation have been proposed, but the evidence underlying these techniques is unclear. This study aimed to review the literature for full-thickness graft fixation techniques. PubMed was electronically searched to identify relevant studies. The search strategy identified 91 relevant articles. These consisted of 2 randomised controlled trials (RCTs), 10 observational cohort studies (8 retrospective, 2 prospective), and 79 descriptive studies (case series, case reports, or expert opinion articles). Both identified RCTs compared the tie-over dressing against a modified tie-over dressing. The tie-over dressing was also included in all identified observational studies, and comparisons were made against quilting/mattress suturing (4 studies, 181 grafts in total), simple pressure dressings (3 studies, 528 grafts), non-tie-over dressings non-specifically (1 study, 71 grafts), hydrocolloid dressings (1 study, 62 grafts), and double-tie over dressings (1 study, 43 grafts). No significant differences were found between fixation methods for graft take, haematoma rate, and infection rate. No studies have found a significant difference between tie-over dressings and alternative graft fixation technique, with the most evidence for simple pressure dressings and quilting/mattress suturing. However, the evidence base consists mostly of small, retrospective observational studies. This article describes the current evidence base and this should be considered when planning future reports in the field.
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ORIGINAL ARTICLES Top

Efficacy of topical 5% 5-fluorouracil with needling versus 5% 5-fluorouracil alone in stable vitiligo: A randomized controlled study Highly accessed article p. 197
Fatima T Zahra, Mohammad Adil, Syed S Amin, Mohd Mohtashim, Roopal Bansal, Hania Q Khan
DOI:10.4103/JCAS.JCAS_12_20  
Background: Vitiligo is a chronic disease of great cosmetic concern presenting with depigmented macules and patches. It is often recalcitrant to medical treatment. Aim: The aim of the study was to study the efficacy and safety of topical 5% 5-fluorouracil with needling versus topical 5% 5-fluorouracil alone in stable vitiligo. Materials and Methods: This interventional prospective study was conducted from July 2018 to June 2019. Total of 60 patients, with stable vitiligo of age older than 10 years, were randomly assigned into two groups of 30 patients each. Group A was treated with needling followed by topical 5% 5-fluorouracil over vitiligo patches. The procedure was performed every 2 weeks for 3 months. Group B was treated with topical 5% 5-fluorouracil alone. Clinical improvement was assessed monthly till 6 months by serial clinical photographs and grading score. Results: Initiation of repigmentation started at 1 month in 76 patches (65%) in Group A, whereas in group B, it was seen in 45 patches (38.7%), which was statistically significant (P = 0.0001). Excellent improvement (>75% repigmentation) was noted in 55 patches (47%) in Group A as compared to 5 patches (4.3%) in group B at the end of 6 months (P = 0.03). Conclusion: Needling with 5% 5-fluorouracil appears to be simple, safe, and effective treatment in vitiligo. It can be used in poor responders to conventional therapy.
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A comparative study between follicular unit transplantation and autologous non-cultured non-trypsinized epidermal cells grafting (Jodhpur technique) in stable vitiligo p. 204
Anand Lamoria, Aditi Agrawal, Pankaj Rao, Dilip Kachhawa
DOI:10.4103/JCAS.JCAS_189_19  
Introduction: Several modalities are currently available for the treatment of vitiligo, but generally they do not result in complete cure of the disease. Despite the limitations and some side effects, surgical modalities appear to be the method of choice in recalcitrant stable vitiligo. Both Jodhpur technique (JT) and follicular unit transplantation (FUT) are simpler and cheaper methods, requiring minimal infrastructure. Materials and Methods: Hundred patches in 30 patients were divided into Group A and Group B, that is, hair follicle transplantation and autologous non-cultured non-trypsinized epidermal cell suspension grafting (JT), respectively. Fifty patches were included in each group. Efficacy of both the techniques, extent of pigmentation, and color match assessment were the main objectives. Results: Excellent repigmentation (>75%), at the end of 20 weeks post surgery, was observed in 70% lesions in FUT group and 72% of lesions in JT group. Good response (extent of repigmentation of 50%–75%) was seen in 18% of lesions in FUT group as compared to 26% in JT group. JT and FUT technique were almost equal in producing excellent repigmentation. Color match was same for both the groups, that is, 49 of 50 patches showed same color as surrounding in both groups at the end of 20 weeks. Repigmentation of the depigmented hairs occurred in 11 of 46 patients with associated leukotrichia. Conclusion: Our study indicates that both JT and FUT are safe and effective techniques in terms of repigmentation but JT is somewhat superior to FUT in producing excellent and good repigmentation, side effects, patient satisfaction, and dermatology life quality index reduction, while the color match was almost same with both techniques.
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A morphological study of acne scarring and its relationship between severity and treatment of active acne p. 210
Dipty A Agrawal, Niti Khunger
DOI:10.4103/JCAS.JCAS_177_19  
Background: Scarring is one of the most dreadful complications of acne for which patients seek surgical treatment. Objective: The aim of this research was to study the morphological features of acne scarring and the relationship between severity of acne and its treatment with type and severity of acne scars. Materials and Methods: This was a hospital-based, noninterventional, cross-sectional study carried out over a period of 1 month on 100 patients with post-acne scarring. A morphological evaluation of the types, sites, and severity of acne scars was done, and details of the severity and treatment of acne were recorded. Results: Of 100 patients included in the study, 61 were male and 39 were females. Females had an earlier onset of acne (15.8 years) as compared to males (16.5 years). The mean duration of active acne was longer in males (99.3 months) than that in females (74.4 months). Male patients had more severe acne vulgaris as compared to females (P = 0.0001). Of 100 patients, 52 started treatment 1 year after the onset of acne, and 18 patients had never taken any anti-acne medication. Morphologically, majority of post-acne scars were ice pick scars in 94% patients, followed by rolling scars in 86%, boxcar scars in 54%, and keloidal scars in 10% patients. Male patients had more severe acne scarring than females (P < 0.05). Of 54 patients with severe acne, 22 progressed to moderate grade and 32 patients progressed to severe grade of acne scarring. Significant reduction in the severity of acne scarring was observed in patients who received isotretinoin as compared to that in patients who received oral antibiotics. Conclusion: Majority of patients with active acne delay treatment, which leads to increased acne scarring. Ice pick scars are the most common type of acne scars, and keloidal scars are more common in males. Males have a longer duration of acne, they delay treatment, and have more severe acne scarring. Early introduction of oral isotretinoin may help to reduce the severity of acne scarring. Public education is essential to urge patients to seek early and appropriate treatment of acne that can reduce the incidence and severity of acne scarring and its psychosocial consequences.
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Comparison of intralesional measles, mumps, rubella vaccine and needling in the treatment of recurrent warts p. 217
Surabhi R Kolte, Vidyadhar R Sardesai
DOI:10.4103/JCAS.JCAS_164_19  
Context: Warts constitute 21% of all the cases in a dermatology clinic. Their causative agent is the human papillomavirus (HPV). Most of the cutaneous warts are cosmetically disfiguring and their treatment requires patience by both the practitioner and the patients. Aim: This study aimed to compare the efficacy of intralesional measles, mumps, rubella (MMR) vaccine and needling in the treatment of recurrent warts. Settings and Design: This was a prospective, comparative, and interventional study. Subjects and Methods: This hospital-based study was conducted in a tertiary health-care center from September 2017 to August 2019. Overall 40 patients of recurrent warts were included in the study. Statistical Analysis: Fisher test, Student t test, and chi-square test were used for statistical analysis. Results: Improvement was noted in patients belonging to both the groups. However, after applying chi-square test, it was found that results were statistically significant in the needling group only. When both the groups were compared using chi-square test, needling showed statistically significant results after 4 and 6 weeks. Conclusion: Needling was observed to be a better treatment modality as compared to intralesional MMR vaccine at the end of 4 and 6 weeks. More number of sessions were required in the intralesional MMR vaccine group for complete clearance of the lesions as compared to needling. Hence, the response was better and faster in the needling group as compared to the intralesional MMR group.
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CASE REPORTS Top

Role of phenytoin in diabetic foot ulcers p. 222
Padmalakshmi Bharathi Mohan, Uday Kumar Chapa, Ravi Kumar Chittoria, Vinayak Chavan, Abhinav Aggarwal, Saurabh Gupta, Chirra Likhitha Reddy, Imran Pathan, Shijina Koliyath
DOI:10.4103/JCAS.JCAS_48_19  
Of the complications of diabetes mellitus, foot ulcers are the most dreaded complications, as they can progress at an alarming rate and can be very difficult to treat. Various modalities have been described in the treatment of diabetic foot ulcers. One such modality of phenytoin therapy uses the disadvantage of the drug, that is, gingival hyperplasia to the advantage of wound healing. We hereby report a case of diabetic foot ulcer managed with injection phenytoin sprayed topically over the wound.
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Pseudo-dense hair transplantation: Strategy of “less inside, more outside” and central bulking with curled chest hairs as treatment for scalp scars p. 226
Amir Feily, Ahmad Feily, Jacob S Alexander, Muhammad J Niaz, Serena Gianfaldoni, Torello Lotti, Marigdalia K Ramirez-Fort
DOI:10.4103/JCAS.JCAS_104_19  
Hair transplantation in areas of scalp scars is a clinical challenge. However, by creating the visual illusion of central bulking with the use of peripherally transplanted curled chest hairs, cicatricial alopecia can perhaps be cosmetically improved. In a case of a 34-year-old affected man, this strategic procedure was implemented with positive results, as the transplantation was successful, the scar was far less noticeable, and the patient was satisfied with the results. The “pseudo-dense hair transplantation” method can be applied to similar patients, noting that a more succinct procedure will need to be elucidated for the varying etiologies of cicatricial alopecia.
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The curious case of fibrofatty conversion of cystic hygroma treated with bleomycin sclerotherapy p. 229
Anjuna Reghunath, Rohini G Ghasi, Suchana Kushvaha
DOI:10.4103/JCAS.JCAS_152_19  
Cystic hygroma is a congenital malformation of the lymphatic system that mostly presents at birth. Though the classic treatment of this condition is surgical excision, recent alternative treatment modalities such as injection of sclerotherapeutic agents (e.g., bleomycin and OK-432) into the lesion has gained popularity due to its safe and effective response profile with minimal side effects. We report a rare complication of repeated bleomycin sclerotherapy in a follow-up patient of cystic hygroma, where the lesion underwent fibrolipomatous conversion with insinuation into multiple fascial planes, causing mass effect by encasement and compression of major vascular and airway structures. This is the first time such a complication of bleomycin sclerotherapy has been reported in literature. Such an unusual presentation reminds us that, in any patient presenting with recurrent gradually increasing swelling with worsening of symptoms following bleomycin sclerotherapy, a possibility of fibrolipomatous conversion of cystic hygroma should be borne in mind.
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A rare case of nasal glial heterotopia in an infant p. 233
Karishma Tahlan, Nadeem Tanveer, Harresh Kumar, Himanshi Diwan
DOI:10.4103/JCAS.JCAS_148_19  
Glial heterotopias are the displacement of neuroglial tissue in extracranial sites. Nasal glial heterotopias can be of three types-extranasal, intranasal and mixed. Root of the nose is the most common location. These are rare anomalies with an incidence of 1 case in 20,000–40,000 live births. Here we report the case of a 6-month-old infant with a congenital mass located at the root of the nose. Non-contrast computed tomography studies showed no evidence of intracranial communication of the lesion. The mass was excised, and on histopathological examination, it showed glial tissue with astrocytes in a fibrillary background and fibroconnective tissue. Masson’s trichrome stain showed the red staining of the glial tissue, whereas the background fibrosis was stained blue. On immunohistochemistry, glial fibrillary acidic protein was positive. Hence, the diagnosis of nasal glial heterotropia was made. The patient had an uneventful postoperative period.
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Keloid scars arising after follicular unit extraction hair transplantation p. 237
Nabeel K Alhamzawi
DOI:10.4103/JCAS.JCAS_181_19  
Hair transplantation is considered safe compared to other cosmetic procedures. However, scarring is still an inevitable potential complication. Keloid scarring is a rare complication of hair transplantation and usually associated with strip harvesting rather than follicular unit extraction (FUE). A case of keloids at the donor site following FUE hair transplantation is presented. Hair transplant practitioners should be aware of the risks of the procedure when considering hair restoration to ensure safer outcomes.
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Iatrogenic injury of facial skin due to formocresol: A case report p. 240
Rakhi Issrani, Namdeo Prabhu, Mohammad Khurseed Alam
DOI:10.4103/JCAS.JCAS_151_19  
A detailed history and complete clinical examination of the patient with the soft tissue injury are needed to identify and diagnose the most probable underlying cause of that specific injury. The presented case is of a chemical burn due to formocresol, presenting with moderate pain and burning sensation with respect to a patch of darkly discolored skin. This case is reported because of the rarity of such lesions and the paucity of information concerning them in the dental literature. It is suggested that all the pediatric endodontic procedures should be performed along with essential preventive isolation methods.
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SHORT COMMUNICATION Top

Bio-filler: an effective facial rejuvenation tool—easy on pocket p. 243
Sumit Gupta, Priyanka Borde Bisht, Charisma Kannan
DOI:10.4103/JCAS.JCAS_172_19  
The Plasma Bio-Filler Facelift is an exciting aesthetic process being introduced in dermatology. The dermal filler gel is autologous and easy to obtain. It works well for fine rhytides reduction as well as to volumize, contour and rejuvenate the face, neck and hands. The consistency and autologous nature of plasma bio-filler are better accepted by patients than the high density hyaluronic acid fillers.
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INNOVATIONS Top

Modifications of Multi Slit Knife for enhanced versatility in balding and vertex area hair transplant p. 247
Pradipkumar R Atodaria, Kuldeepsinh P Atodaria
DOI:10.4103/JCAS.JCAS_69_19  
In hair transplantation, recipient-site creation is an important step. It is a repetitive and time-consuming step, which increased the “out-of-body time” for the grafts, which could hamper their survival. To solve this problem, we had devised an instrument called the Multi Slit Knife (MSK). The MSK has advantages of creating a high-density brick pattern of recipient sites in significantly less time. It had the undesirable side effect of damaging the preexisting hair follicles while making slits in the balding region. The MSK had some limitations. It was also difficult to maneuver the MSK in the vertex region where maintaining the natural whorl pattern of hair is important to obtain optimal aesthetic results. To overcome the shortcomings of the original MSK, we made a few changes to it to make a new modified MSK. It has fewer knives and a smaller platform as compared to the original MSK, better ergonomics, and more customizability with choices for blade sizes, number, and spacing. It tries to retain the advantages of the original MSK while reducing the damage to the preexisting hairs in the recipient regions. It is also better adapted at creating the recipient sites in a whorl pattern, closely mimicking the natural direction and angles of the hair in the vertex region. The modified MSK can be used singly or in combination with the original MSK, based on the patient’s recipient areas, making it a versatile set of instrument for making multiple coronal slits for hair transplant.
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Biopsy techniques for skin disease and skin cancer: A new approach p. 251
Azize Kilic, Ali Kilic, Ali E Kivanc, Abdullah Sisik
DOI:10.4103/JCAS.JCAS_173_19  
Skin biopsies provide physicians with valuable information in the evaluation of many dermatologic diseases. It becomes increasingly important for physicians to be proficient at performing skin biopsies because of the prevalence of skin malignancies and other dermatologic diseases in general population. The most common techniques include the punch, shave, excisional, and incisional biopsies. Each procedure has advantages and disadvantages, depending on the dermatologic diseases. The choice of biopsy type depends on the suspected disease’s pathology and lesion location. Performing time-saving and economically convenient techniques is more favorable for both physicians and patients. For this purpose, for the past 10 years, we used a technique that provides hemostasis and substitute suturing without using any suture material for patients who are suitable for punch and incisional biopsies. We aim to share this easy, cheap, and time-saving procedure.
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Shave biopsy instrument: An ergonomic modification of razor blade p. 255
Sabha Mushtaq
DOI:10.4103/JCAS.JCAS_191_19  
The razor blade has been used by dermatologists as an alternative tool for performing shave excision and biopsy owing to its superior sharpness and flexibility. It is inexpensive and freely available but the bare blade design carries the risk of accidental injury to the operator and patient. We describe an easy modification of the razor blade for better grip, control, and safety in obtaining cutaneous shave specimens.
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Intraoperative electrosurgical depilation of a skin graft p. 257
Danielle P Dubin, Ethan T Routt, Matthew J Lin, Richard L Torbeck, Hooman Khorasani
DOI:10.4103/JCAS.JCAS_31_20  
Full-thickness skin grafts harvested from hair-bearing areas may negatively impact cosmetic outcomes if the recipient site is hairless. Intraoperative depilation of unwanted hair follicles using an electrosurgical device can permanently remove hair with a single treatment and improve overall cosmesis.
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CORRESPONDENCE Top

Cryosurgical management of symptomatic vulvar vestibular papillomatosis p. 259
Jenny Mathew, Simin Muhammed Kutty
DOI:10.4103/JCAS.JCAS_187_19  
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CORRESPONDENCES Top

Acquired periungual fibrokeratoma looks like a supernumerary digit: An uncommon soft tissue tumor p. 261
Mohd Altaf Mir, Madhubari Vathulya, Sameer Mahakalkar, Nishank Manohar
DOI:10.4103/JCAS.JCAS_2_20  
Acquired digital fibrokeratoma is an uncommon, benign fibrous tumor that usually occurs in adults as a solitary lesion with a typical size of less than 1 cm. We present a case with periungual growth and nail plate deformity. The growth was completely excised after raising the epinychial flap and the fold was reconstructed. The histological results confirmed the digital fibrokeratoma. The rarity of digital fibrokeratoma and its unique morphological appearance of the tumor makes it interesting. Acquired periungual fibrokeratoma, an uncommon benign fibrous tumor of an unknown etiology, typically found at the distal end of the digits, may present with nail plate deformation due to chronic pressure, and in order not to damage the matrix, the tumor should be excised carefully, which can cause permanent nail dystrophy. In addition, we emphasize the importance of ruling out other causes of abnormal growths and of considering fibrokeratoma during differential diagnoses.
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