Journal of Cutaneous and Aesthetic Surgery
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   Table of Contents - Current issue
Coverpage
October-December 2020
Volume 13 | Issue 4
Page Nos. 265-373

Online since Thursday, November 26, 2020

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REVIEW ARTICLES  

Post-herpetic neuralgia: A systematic review of current interventional pain management strategies Highly accessed article p. 265
Anurag Aggarwal, Varun Suresh, Bhavna Gupta, Sidharth Sonthalia
DOI:10.4103/JCAS.JCAS_45_20  
Background: Post-herpetic neuralgia (PHN) is usually a constant or intermittent burning, stabbing, or sharp shooting pain with hyperalgesia or allodynia, persisting beyond the healing of herpetic skin lesions. This review was carried out in concordance to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We used PICOS (Population, Intervention, Control, and Outcome Study) design for inclusion of potential studies into this review. Online literature available in PubMed, Cochrane, and Embase was searched for studies from January 1995 till March 2020, which evaluated interventional treatments in PHN by an independent reviewer, using the relevant medical subject heading (MeSH) terms. We analyzed the following outcome parameters with regard to each intervention—pain status at predefined fixed intervals after the intervention, quality of sleep using any of the reported questionnaires, analgesic consumption, functional evaluation, and quality of life assessment after the intervention. Conclusion: Interventional pain management options provide effective and long-lasting pain relief to patients not responding to medical management. The choice of intervention will depend on the region involved, cost, and invasiveness. Simple procedures such as intercostal nerve blocks/neurolysis, stellate ganglion blocks, paravertebral neurolysis, epidural steroid injections, and dorsal root ganglion–radiofrequency ablation are effective interventions, and if they fail, spinal cord stimulators could be effective in the hands of experienced pain physicians.
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Tumescent anesthesia for dermatosurgical procedures other than liposuction Highly accessed article p. 275
Ruhi R Uttamani, Aniketh Venkataram, Jayashree Venkataram, Venkataram Mysore
DOI:10.4103/JCAS.JCAS_192_19  
Context: Tumescent local anesthesia is a form of local anesthesia, which is a technique in which a dilute local anesthetic solution is injected into the subcutaneous tissue until it becomes firm and tense. Originally developed to facilitate liposuction, the use of tumescent anesthesia has expanded to other dermatological and plastic surgery procedures, as well as to other disciplines, including endocrine and vascular surgeries. For infiltration local anesthesia, the conventional dosage of lidocaine is up to 4.5 mg/kg, and that with adrenaline is up to 7 mg/kg; however, in liposuction using tumescent anesthesia, the recommended maximum dose of lidocaine with adrenaline is up to 55 mg/kg. There are several important pharmacological, pharmacokinetic, and pharmacodynamic factors that need to be considered in the administration of tumescent anesthesia leading to considerable interdisciplinary differences of opinion with respect to the maximum dose of local anesthetic permissible. Although several studies and publications have studied these issues in liposuction extensively, the role of tumescent anesthesia in other indications has not been reviewed adequately. Aims and Objectives: The aim of this study was to discuss the science behind tumescent anesthesia, its applications, and safety considerations in different dermatosurgical procedures other than liposuction. Materials and Methods: For this review, a systematic literature search in PubMed, Embase, Web of Science, Cochrane Library, Central, Emcare, Academic Search Premier, and ScienceDirect was conducted for safety studies on tumescent anesthesia. Conclusion: Tumescent anesthesia is generally very well accepted by patients and is relatively safe at the recommended doses. Nonetheless, one must be vigilant about the signs and symptoms of LAST, as they may not manifest until several hours after the procedure. Lipid emulsion therapy should be readily available and could prove life-saving in such situations.
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ORIGINAL ARTICLES Top

A prospective observational comparative study of novel autologous negative pressure epidermal harvesting system (ANPEHS or EHS) and suction blister grafting (SBG) in treatment of stable vitiligo p. 283
Sukriti Baweja, Satish Chand
DOI:10.4103/JCAS.JCAS_18_20  
Background: Vitiligo surgery has evolved a long way from punch skin grafts to the epidermal cell suspension and latest to the extracted hair follicle outer root sheath cell suspension transplantation (EHFORSCS). In the latest development, the novel technique autologous negative pressure epidermal harvesting system (ANPEHS) seems to be a good addition to the prevailing therapy in vitiligo. Aims and Objectives: The aim of this work was to study and compare novel ANPEHS and suction blister grafting (SBG) in the treatment of stable vitiligo. Materials and Methods: This was a prospective, single-centered, observational, open-labeled comparative study of the rate and final extent of repigmentation in ANPEHS or EHS and SBG in the management of stable vitiligo. The patients in this study were drawn from the outpatient Department of Dermatology of a Tertiary Care Hospital of the Armed Forces from July 1 2015 to December 31, 2016. A total of 40 patients with at least two comparable depigmented patches of 6 months’ stability were recruited. Both procedures were performed in the same patient on the same day. Informed consents were taken from all the patients. Each patient in the study had undergone a detailed clinical, general physical, systemic, and a dermatological examination. Clinical photographs had been taken before and after grafting, monthly for the first 6 months then bimonthly for the next 6 months. Donor site was preferably inner aspect of thigh. Statistical Analysis Used: “Chi-square test” and “statistical significance” (P value) methods. Results: Of total 80 patches, excellent results were seen in 82.9% patches by using the EHS method and 80% excellent results by using the SBG method. Similarly, very good results were seen in 2.9% patches and good results in 5.7% patches by using both methods. 11.4% patches showed poor results by using the SBG method and 8.6% patches showed poor results by using the EHS method. Conclusions: The EHS method is a simple, painless, less time-consuming, expensive but effective technique to produce homogeneous repigmentation without any donor site anesthesia and complication.
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Longevity of hair follicles after follicular unit transplant surgery p. 292
Muthuvel Kumaresan, Deepa M Subburathinam
DOI:10.4103/JCAS.JCAS_44_20  
Background: The longevity of the grafted hair follicles is still debated and there are limited literature available on this topic. Aim: To assess the longevity of transplanted hairs after follicular unit transfer (FUT). Materials and Methods: A total of 112 patients who had undergone FUT were included in the study and their results at the end of 4 years were compared with the 1 year post surgery results by standardized images. The reduction in the density of the grafted hair follicles was graded by a blinded observer in a grading scale. Results: Among 112 subjects 50.89% had grade 4, 46.42% had grade 5, 2.67% had grade 6 alopecia respectfully. The 4 year follow up grading of hair loss showed moderate reduction in transplanted hair density in 55.35%, slightly reduced density in 27.67% greatly reduced in 8.03% and no change in the density in 8.92% subjects. Conclusion: The hair grafts transplanted may not last permanently for all the subjects. Recipient site influence might affect the growth and long-term survival of the transplanted hairs.
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Facial reconstruction according to aesthetic units p. 298
José M Nunez Castaneda, Silvana L Chang Grozo
DOI:10.4103/JCAS.JCAS_9_20  
Context: The facial subunit principle organizes the facial skin into subunits. Facial reconstruction for skin cancer based on aesthetic units consists of replacing the entire subunit when a large part of a subunit has been removed. Aims: To determine the prevalence of facial skin cancer, their location by facial aesthetic units, and the type of facial reconstruction used in each of them. Settings and Design: An observational cross-sectional study was conducted at the Head and Neck Surgery Service of a general hospital between 2017 and 2018. Materials and Methods: A population census was conducted during this period. Statistical Analysis Used: The categorical variables were expressed as frequencies (percentages). Continuous variables were described as the means and standard deviations or medians and interquartile ranges. Results: The most common skin cancer was basal cell skin cancer, followed by epithelial skin cancer and, at last, melanoma. In general, the most frequent localization of these cancers was the nose. Conclusions: In spite of primary closure being the most common form of reconstruction, a considerable number of patients required facial reconstruction based on aesthetic facial units, with satisfying results.
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Medial thigh contouring after massive weight loss: the Liposuction-Assisted Medial Thigh Lift (LAMeT) p. 305
Verdiana Di Pietro, Gianfranco Marcello Colicchia, Valerio Cervelli
DOI:10.4103/JCAS.JCAS_130_18  
Introduction: Following massive weight loss (MWL), medial contouring of the thigh is frequently requested to improve the appearance and function. Thigh lifting can be associated with significant complications if the medial thigh excess is removed en bloc. In this article, we describe the Liposuction-Assisted Medial Thigh Lift (LAMeT) and evaluate the outcomes and complications in a retrospective cohort study. Materials and Methods: A total of 54 females aged between 25 and 61 years with Grade 2 or 3 of thigh deformity on Pittsburgh Rating Scale (PRS) underwent medial thigh reduction. Vertical thigh lift with fascia suspension was performed in 25 patients with third degree of ptosis on PRS, horizontal thigh lift with fascia suspension was performed in 3 patients with second degree on PRS, LAMeT was performed in 26 patients with second and third degree on PRS. Results: Complications were observed in 35.7% of the patients that underwent the standard technique and in 3.8% patients that underwent the LAMeT. The most frequent complication was seroma. Hospital stay was significantly lower in the LAMeT group. Conclusions: Medial thigh lift is a safe and satisfying procedure because it provides aesthetic improvement in massive weight loss patients. The complication rate is higher when skin excess and laxity are removed en bloc because the resection of the excess tissue is poorly selective. The LAMeT preserves lymphatic and blood vessels and allows a more anatomical resection of the excess skin. Thus, the incidence of postoperative complications is lower and the patients heal faster.
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Comparative efficacy of 10% sodium hydroxide, 88% phenol, and 90% trichloroacetic acid as chemical cauterants for partial matricectomy in the management of great toe nail onychocryptosis p. 314
Sandhiya Ramesh, Shrutakirthi Damodar Shenoi, Sudhir U.K Nayak
DOI:10.4103/JCAS.JCAS_183_19  
Context: Lateral plate avulsion with chemical matricectomy is the treatment of choice for ingrown toenails. Phenol is the most widely used cauterant, followed by 10% NaOH and more recently trichloroacetic acid. Aims: To evaluate the efficacy of 10% NaOH, 88% Phenol, and 90% TCA in cauterizing the matrix with regular follow up post surgery and clinical photographs. Materials and Methods: Fifteen adult patients presenting with ingrowing toe nails were recruited to the study with prior consent. The NaOH group (Group A) had five patients and five nails treated, the phenol group (Group B) had five patients and six nails treated, and the TCA group (Group C) had five patients and six nails treated. A total of 17 great toe nails were treated. Following proximal digital block and partial nail avulsion, the matrix was curetted and the lateral horn cauterized with 10% NaOH (1 min), 88% phenol (3 min), and 90% TCA (3 min). Post-procedure follow-up was done at weekly intervals to evaluate post-operative pain, oozing, and wound healing. Statistical Analysis Used: Graph pad prism software was used for statistical analysis. ANOVA tests were used to test the statistical significance between post-operative parameters of each group. Results: Mean duration of post-op pain in Group A was 4.2 days; Group B was 8.6 days, and Group C was 1.2 days. Oozing occurred for a mean duration of 10.6 days in Group A, 14 days in Group B, and 5.6 days in Group C. Mean duration of tissue re-epithelization was 28.4 days in Group A, 40.5 days in Group B, and 27.4 days in Group C. Conclusions: TCA is an effective cauterant for chemical matricectomy with the advantage of less duration of post-op pain and faster healing.
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Bleomycin sclerotherapy in massive macrocystic lymphatic malformation: minimal complications with maximum results p. 319
Ankur Bhatnagar, Zafar Neyaz, Brajesh Singh, Ashwani Mishra, Yusuf , Vijai Datta Upadyayaya, Basant Kumar
DOI:10.4103/JCAS.JCAS_108_20  
Introduction: Cystic lymphangioma (CL) is a multiloculated congenital malformation of the lymphatic system occurring in approximately 1 in 6,000–12,000 births, and it mostly presents at birth. The CL is of a variable size and it can be found at any age and in any part of the body. This study was carried out to observe the effect of intralesional aqueous bleomycin on giant CL presenting in adult and pediatric cases. Materials and Methods: This is an observational study conducted in the department of pediatric surgery and plastic surgery from January 2012 to January 2020. All the diagnosed cases of lymphangioma measuring more than 5 cm in size and managed during this period were reviewed. The cases who had lesions with a vascular component or who had any history of previous surgery or any form of treatment were excluded from the study. A total of 19 cases were included in the study. The primary mode of management of CL at the present center is intralesional bleomycin sclerotherapy (IBS). This is the standard protocol followed at our center to treat the cases with CL. Relevant demographic and clinical data of all the included patients were collected on a structured proforma, and data were analyzed. Result: Four cases had a favorable outcome in a single session, seven cases showed a favorable response after the second session, and three cases showed a favorable response after the third session. Two cases showed a partial response even after the fourth session and were considered nonresponders, one of whom was operated on and the other who was satisfied with a partial response and was not willing to undergo surgical excision. No major complications were observed in the present series. A few cases developed mild pain with or without fever, but none of them required hospitalization. Conclusion: Intralesional bleomycin sclerotherapy (IBS) is a safe, effective, and economical treatment option for the management of large cystic lymphangiomas and it avoids surgery-related complications.Level of Study: IV evidence studyType of Study: Retrospective observational study
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Comparative study in efficacy and safety of intralesional injections of vitamin D3, measles rubella (MR) vaccine, and purified protein derivative (PPD) in the management of cutaneous warts p. 326
Rehna Ahmed, Shweta P Bhadbhade, Badrinath Noojibail, Sachin M Shetty, Aiswarya Varghese
DOI:10.4103/JCAS.JCAS_39_20  
Introduction: Cutaneous warts caused by human papillomavirus are the most common dermatological diseases being contagious, recurrent, and recalcitrant. Most routinely used treatment modalities are destructive and can cause scarring. Immunotherapy is emerging as new modality of treatment, which enhances cell-mediated immunity against human papillomavirus for clearance of both treated and distant warts. Aims: The aim of this study was to compare efficacy between intralesional Vitamin D3, measles rubella (MR) vaccine, and purified protein derivative (PPD) injection in cutaneous warts. Settings and Design: This was a hospital-based interventional study. Materials and Methods: A total of 50 patients diagnosed with cutaneous warts were selected and divided into three groups with 15 patients in each. Treated with Vitamin D3 2 units of 6,00,000IU (15 mg/mL), 0.5 mL/dose 2 units of MR vaccine, and 10 TU of tuberculin PPD (0.1 mL) with 2 units of injections, respectively, with minimum three injections at 2-week intervals given. Follow-up of patients were done for 4 months. Statistical Analysis Used: A total of 45 patients were enrolled in the study and divided into three groups containing 15 patients each with the help of computer-generated random numbers. Results: Patients treated with Vitamin D3 showed complete clearance (12/15) with 3–4 sessions; side effect was pain at the site of injection. Injection with PPD was effective with complete clearance (10/15) but the number of session was higher. MR vaccine needs 6–8 sessions for complete clearance (3/15). Palmoplantar warts were more responding to treatment. Conclusion: Intralesional Vitamin D3, MR vaccine, and PPD are equally efficient in treating verrucae, although Vitamin D3 can be considered safe.
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INNOVATIONS Top

Modification in 26-gauge needle p. 333
Vaishali Laleshkumar Nahata
DOI:10.4103/JCAS.JCAS_23_20  
Needles are the most widely used medical device. A 26-gauge hypodermic needle is a simple hollow instrument; however, its use in dermatologic procedures are numerous. Needle can be used as a cutting instrument and can be used as an extractor. Here, I present a simple innovation that makes the grip of fingers firm over the needle and thus extraction of lesions becomes easy and faster. Insert the tip of the needle in the front portion of the lead pencil and one can hold the needle like a pen which makes the removal of lesions easy. The front portion of a pen is made up of metal and thus it can be sterilized in an autoclave. A video demonstration of this innovation is attached.
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Propranolol followed by a foam sclerotherapy for treatment of tufted angioma over neck: A novel therapeutic approach p. 335
Vijay Zawar, Gayatri Karad, Manoj Pawar
DOI:10.4103/JCAS.JCAS_106_19  
Tufted angioma is a rare vascular tumor with cutaneous angiomatous proliferation, commonly localized in the skin and subcutaneous tissues. Most cases are usually acquired in childhood, having protracted course with minimal tendency for spontaneous regression. Various treatment modalities have been described in the literature in the management of tufted angioma with variable response. Thus, there is an urge for simple yet effective and less invasive procedure for tufted angioma, particularly involving aesthetically important areas such as face, head, and neck. We report a case of a large tufted angioma over the neck of a young girl, successfully treated with a combined approach of oral propranolol and foam sclerotherapy.
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Ready-to-use device for dermabrasion in vitiligo surgery p. 338
Karalikkattil T Ashique, Feroze Kaliyadan, Puravoor Jayasree
DOI:10.4103/JCAS.JCAS_28_20  
Adequate dermabrasion of recipient site is a crucial step in vitiligo surgery. We suggest the use of a commercially available mechanized abrader as an economical and efficient tool for dermabrasion especially in resource poor settings.
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CASE REPORTS Top

Autologous platelet-rich plasma enriched pixel grafting p. 340
Padmalakshmi Bharathi Mohan, Saurabh Gupta, Ravi Kumar Chittoria, Abhinav Aggarwal, Chirra Likhitha Reddy, Imran Pathan, Shijina Koliyath
DOI:10.4103/JCAS.JCAS_112_19  
Autologous platelet-rich plasma contains concentrated platelets after graded centrifugation, which has various applications. Skin grafting is an age-old procedure, which has been used for wound coverage. But the healing process is longer and may be difficult, depending on the wound site, skin defect size, and patient comorbidities, and is difficult to be carried out in patients who have limited donor sites, such as in burns or those who are not fit for long procedures. Hence, pixel grafting can be used in these areas. Platelet-rich plasma can be used to aid the graft take, and thereby decreasing patient morbidity and improve the surgeon’s efforts.
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Far from luck’s way: A concurrence of Kaposi sarcoma and cutaneous angiosarcoma in the setting of chronic lymphocytic leukemia p. 344
Billur Sezgin, Yesim E Yigit, Sedat Tatar, Fatih Selcukbiricik, Nulifer Durankus, Ibrahim Kulac, Pinar Atasoy
DOI:10.4103/JCAS.JCAS_127_19  
Kaposi sarcoma and cutaneous angiosarcoma are rare forms of skin malignancies that are vascular in nature and are frequently encountered in the immunosuppressed population. Although synchronous angiosarcoma and Kaposi sarcoma have been documented, to our knowledge, the coexistence of these vascular malignancies with underlying chronic lymphocytic leukemia has not been previously reported. A 51-year-old male patient with chronic lymphocytic leukemia presented with Kaposi sarcoma located on his left ankle. Shortly after, the patient presented with de novo lesions located on the plantar region of the right foot, reported as angiosarcoma. Following a multidisciplinary decision, treatment with adjuvant chemotherapy consisting of paclitaxel and carboplatin with consolidation radiotherapy was planned. The patient’s Kaposi sarcoma has remained unchanged throughout this period.In such cases, the treatment is advised to be planned around the more aggressive malignancy. These patients should also be followed-up by dermatology due to the higher risk of secondary cutaneous malignancies.
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PRACTICE POINTS Top

Approach to a patient with cutaneous malignancy in the time of COVID-19 pandemic p. 349
Suvashis Dash, Shivangi Saha, Somesh Gupta, Maneesh Singhal
DOI:10.4103/JCAS.JCAS_65_20  
The world is facing an unprecedented crisis of COVID-19 pandemic. This disease has weakened the economy, paralyzed the healthcare system, and worn out the human resources. Patients with cutaneous malignancy or skin cancer comprise a substantial part of the patient population and they need appropriate management of the cancer as they face the risk of COVID-19. In the wake of COVID-19 pandemic, the approach to management of cutaneous malignancy needs to be reassessed. The challenges in the management of skin cancer during COVID-19 are discussed in this article. Risk stratification considering the type and nature of malignancy, age, comorbidity, and treatment option is crucial in making the suggestions. Patient care, adequate infection control, safety of healthcare worker, and rational use of resources are the cruxes of management in this trying time.
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SHORT COMMUNICATIONS Top

Surgical management of oral mucocele: Experience with marsupialization p. 353
Chander Grover
DOI:10.4103/JCAS.JCAS_133_20  
Oral mucoceles are a common and nagging problem. They are proposed to be a result of damage to the minor salivary gland structure, resulting in retention or extravasation of saliva which leads to these cystic lesions. The lesions may often resolve spontaneously but frequently recur, or even epithelialize over long periods of time. This study reports the results of surgical management of oral mucocele by marsupialization. Even though, a complete surgical removal is considered the treatment of choice for oral mucocele, it has associated disadvantages including a longer recovery period and potential for ductal damage, which can lead to scarring, recurrence, and development of further satellite lesions. As the study shows, marsupialization is a simple surgery which ensures faster healing, minimizes postoperative complications, and is associated with a minimal risk of recurrence or development of new lesions. Owing to the satisfactory response to marsupialization, it may be considered as first line therapy in the management of oral mucoceles.
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Dermatoses occurring after parlor procedures p. 357
Seetharam A Kolalapudi, Ashwini R Mahesh, Prasad C Arumilli, Sravanthi Kotha, Aparna Krishna Snigdha G, Satya Saka
DOI:10.4103/JCAS.JCAS_43_20  
Background: Cosmetic procedures are on the rise and practiced by all age groups, especially by teenagers. These procedures enhance the individual appearance and confidence levels, but they are not without side effects. Aims and Objectives: The aim of this study was to evaluate the side effects occurring after various parlor procedures such as facials, threading, waxing, and laser hair reduction. Setting and Design: A prospective study for 12 months in a tertiary hospital. Materials and Methods: Patients attending the department of dermatology at a tertiary care hospital for 12 months (July 2018–June 2019) were evaluated for any skin lesions, developed after one of the above parlor procedures. Detailed history, clinical examination, and correlation with the parlor procedure were noted. Results: A total of 102 patients were found to have dermatoses after various parlor procedures during the 1-year study period (81 F and 21 M). Acneiform eruptions 26 (25.4%), followed by post-waxing folliculitis 17(16.7%), and hyperpigmentation of face 15 (14.7%) were the most common dermatoses. Molluscum contagiosum, verrucae plana, and tinea faciei were observed in 11, 6, and 3 patients, respectively. Conclusion: Side effects are not uncommon after parlor procedures. Awareness of these is necessary and educating the patients is extremely important to avoid these unwanted complications.
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Effect of COVID-19 outbreak on hair transplant field of India p. 361
Amit S Kerure, Venkataram Mysore
DOI:10.4103/JCAS.JCAS_73_20  
World Health Organization declared the novel coronavirus (COVID-19) infection a global pandemic. All cosmetic, aesthetic, and hair transplant (HT) surgeries are stopped as elective surgeries may become the reason for infection spread. Most of the HT clinics have stopped surgeries or postponed till lockdown date limit. This pandemic situation has caused financial implications for these setups. India is still working to flatten the curve of the pandemic. Once the peak of the pandemic is over, virus may become endemic, and the risk of transmission of the disease to the HT team is also a possibility. HT field of India is thus in an extremely challenging position. We did a survey among the members of Association of Hair Restoration Surgeons of India (AHRS) to know the current status of the HT field of India and surgeon’s perspective toward the situation.
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The dermoscopy of pigmented basal cell carcinoma p. 365
Boina Kinnera, Vukkadala N Devi, Vella V.V Satyanarayana
DOI:10.4103/JCAS.JCAS_186_19  
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CORRESPONDENCES Top

Periosteal anchoring sutures: A simple method to prevent postoperative ectropion p. 368
Diogo Cerejeira, Frederico Bonito, Joao Goulao
DOI:10.4103/JCAS.JCAS_17_20  
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Papillary eccrine adenoma in a 5-year-old girl altered by application of Thuja ointment p. 370
Betsy Ambooken, Mikhin Thomas, KT Jisha
DOI:10.4103/JCAS.JCAS_51_20  
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LETTER TO THE EDITOR Top

Neurofibroma of external ear: The updates p. 372
Neha Shakrawal
DOI:10.4103/JCAS.JCAS_74_20  
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