Jaypee Brothers
In Current Chapter
In All Chapters
X
Clear
X
GO
Normal
Sepia
Dark
Default Style
Font Style 1
Font Style 2
Font Style 3
Less
Normal
More
ACS(I) Textbook on Cutaneous and Aesthetic Surgery
Mysore Venkataram
SECTION 1: BASIC PRINCIPLES OF CUTANEOUS SURGERY
1:
Skin: Basic Aspects
Introduction
Embryology
Epidermis (Figure 1-2)
Applied Anatomy
Skin Types
Applied Anatomy
Dermis
Epidermal Appendages
Hair Follicle (Figure 1-3)
Blood and Lymphatic Vessels (Figure 1-5)
Nerve Supply (Figure 1-5)
Conclusion
2:
Applied Surgical Anatomy in Relation to Facial Rejuvenation
Introduction
Regional Anatomy
Cosmetic Units of the Face
Nose
Ear
Lips (Figures 2-6 and 2-7)
Architecture of the Ideal Lip
Eye (Figure 2-8)
Facial Proportions and Facial Analysis
Relaxed Skin Tension Lines
Superficial Musculoaponeurotic System
SMAS in Sternocleidomastoid Region
SMAS in the Buccal Region
SMAS in the Oral Region
Applied Anatomy
Retaining Ligaments of the Face
Applied Anatomy
Fat Compartments of the Face
Applied Anatomy
Fat Compartments of the Neck
Applied Anatomy
Muscles of Facial Expression and Anatomical Landmarks
Frontalis Muscle
Applied Anatomy
Muscles in the Glabellar Complex
Applied Anatomy
Orbicularis Oculi
Applied Anatomy
Nasalis
Applied Anatomy
Levators of the Upper Lip
Applied Anatomy
Orbicularis Oris
Applied Anatomy
Depressors of the Lower Lip
Applied Anatomy
Mentalis Muscle
Applied Anatomy
Platysma
Applied Anatomy
Applied Anatomy of Facial Vasculature
Supratrochlear Artery
Superior and Inferior Labial Arteries
Angular Artery
Angiosome
Cutaneous Vascular Plexus
Applied Anatomy of Nerve Supply to the Face in Relation to Nerve Blocks
Sensory Dermatomes of the Head and Neck
Surgical Anatomy of the Midface
Applied Anatomy
Applied Anatomy of the Stenson's Duct
The Platysma and its Aponeurosis
Functions and Applied Anatomy of the Platysma
Acknowledgment
3:
Setting Up a Dermatosurgery Unit
Introduction
Nomenclature
Why the Need for Separate Dermatosurgery Unit?
Requirements of a Dermatosurgery Unit
The Dermatosurgery Unit Types
Unrestricted Zone
Restricted Zone
Laser Zone
Location of the Dermatosurgery Unit in the Office or Hospital
Layout of the Restricted Zone Type of Dermatosurgery Unit
Guidelines for the Restricted Type of Dermatosurgery Unit Complex
Common Features of the Operation Theater of Both Restricted and Unrestricted Type
Lighting of Theater
Operation Theater Light
Electrical Outlets
Air Conditioning
Operation Table
Instrument Trolley
Surgeons Stool
Waste Containers
Surgical Instruments
Advance Cardiovascular Life Support
Operation Room Records
Surgical Drapes and Attires: Mask, Caps, Suits, Gowns, Gloves, Patient's Suits
Disinfection and Sterilization of Theater Equipment
Cleaning Working Surfaces
Disinfection of Category “b” and “c” Items
Steam Sterilization (Autoclave)
Chemical Sterilization
Operation Theater Fumigation and/or Surface Disinfection
House Keeping of The Operation Theater
Operation Theater Etiquettes
Waste Disposal
Ergonomics
What is the Best Posture During Standing or Sitting?
Which Position is Better—Sitting or Standing?
Conclusion
4:
Disinfection and Sterilization
Introduction
Basic Principles of Disinfection and Sterilization
Important Definitions
Classification of Medical Devices
Critical Devices
Semi-critical Devices
Noncritical Devices
Antisepsis and Normal Bacterial Skin Flora
Hand Washing
Alcohol-Based Hand Scrubs
Factors Affecting the Efficacy of Disinfection and Sterilization
Number and Location of Micro-organisms
Innate Resistance of Micro-organisms
Concentration and Potency of Disinfectants
Physical and Chemical Factors
Types of Matter: Organic and Inorganic
Duration of Exposure
Cleaning
Methods of Cleaning
Validation of Cleaning Process
Disinfection
Sterilization
Methods of Sterilization
Heat
Low Temperature Sterilization Technologies
Other Sterilization Methods
Sterilization Cycle Verification
High-Level Disinfection of Dermatosurgical Operation Theaters
Air Conditioning Units
Conclusion
5:
Wound Healing
Definition
Phases in Wound Healing
Inflammatory Phase
Proliferative Phase
Remodeling Phase
Factors Resulting in Chronicity of Wound
Wound Healing in Dermatological and Esthetic Conditions and Procedures
Keloids and Hypertrophic Scars
Acne Scars
Wound Healing After Procedures
Cryosurgery
Chemical Peeling
Dermabrasion
Fractional Lasers
Conclusion
6:
Wound Management and Dressings
Introduction
Wounds Classification
Wound Assessment1
Factors that Affect Wound Healing and the Potential for Infection4
Wound Management
History of Wound Management and Use of Natural Products
Techniques of Wound Management
Wound Cleansing9
Management of Infected Wounds1
Wound Closure2,3,21
Primary Wound Repair2
Tissue Adhesives (2-octyl Cyanoacrylate)23
Contraindications for Use of Tissue Glue
Follow-Up
Complications
Wound: Secondary Healing2
Types of Debridement
Wound Dressings
Properties of an Ideal Dressing
Types of Dressings
Appropriate Wound Dressings in Different Types of Wounds30
Semipermeable (Polyurethane) Films (Figure 6-2)
Low Adherence Dressings
Hydrogels (Figure 6-4)
Hydrocolloids (Figure 6-5)
Hydrofibers (Figure 6-6)
Alginates (Figure 6-7)
Foams (Figure 6-8)
Collagen Dressings (Figure 6-9)
Antimicrobial Dressings (Figure 6-10)
Odor Absorbing Dressings
Hyaluronic Acid Dressings
Biological Dressings—Skin Grafts
Pinch and Split-thickness Grafts
In-Vitro Prepared Skin Grafts
Bandaging
Wound Management in Special Situations in Dermatosurgery
Bleeding Control in Dermatosurgery
Dressings after Specific Dermatosurgical Procedures
Adjuvants in Wound Management
Triage Based Wound Care
Creation of a Wound Care Service
Conclusion1
ANNEXURE 1 BANDAGING TECHNIQUES
General Principles of Bandaging
Bandage Technique
A. Triangular and Cravat Bandages
Triangle of Forehead or Scalp (Fronto-occipital) (Figure A1-2)
Triangle of Chest or Back (Figure A1-3)
Triangle of Shoulder (Figure A1-4)
Triangle of Hip (Figure A1-5)
Triangle of Foot (Figure A1-6)
Triangle of Hand (Figure A1-7)
Cravat of Head (Figure A1-8)
Cravat Bandage of Eye (Figure A1-9)
Shoulder-Armpit Cravat (Figure A1-10)
Cravat of Elbow (Figure A1-11)
Cravat of Knee (Figure A1-12)
Cravat of Leg (Figure A1-13)
Cravat of Palms (Figure A1-14)
B. Roller Bandages
Sizes Recommended (Figure A1-15)
Applying the Roller Bandage
Fastening the Bandage
Removing the Bandage
Types of Roller Bandages Based on Site of Application
Circular Bandage (Figure A1-17)
Spiral Bandage (Figure A1-18)
Recurrent Bandage of Head with One Bandage (Figure A1-19)
Shoulder Bandage (Figure A1-20)
Figure of Eight Bandage for Hand (Figure A1-21)
Figure of Eight Bandage for Elbow (Figure A1-22)
Front of Elbow Bandage (Figure A1-23)
Finger Bandage (Figure A1-24)
Foot Roller Bandage (Figure A1-25)
Figure of Eight Bandage of Foot (with heel exposed) (Figure A1-26)
C. Tailed Bandages
Four-Tailed Bandage of the Nose (Figure A1-28)
D. Special Bandages—Compression Bandaging
7:
Universal Precautions for a Dermatosurgeon
Introduction
Epidemiology
Modes of Occupational Exposure to Blood
Factors Affecting Occupational Exposure1
Interventions Under Universal Precautions by WHO
Hand Hygiene
Definition9-11
Indications for Hand Hygiene11
Hand Rub versus Hand Wash
Advantages of Hand Rub11
Disadvantages
Routine/Social Hand Washing9
Steps in Hand Washing
Hand Antisepsis/Decontamination9,11
Steps to Hand Wash
Surgical Hand Antisepsis
Recommendations for Surgical Hand Preparation11
Steps to Surgical Hand Antisepsis (Figures 7-3A and B)
Summary of Hand Hygiene
Personal Protective Equipment
Gloves
Gowns
Gown Donning13
Gown Removal13
Face Protection
Wearing a Mask and Safety Goggles13
Boots/Shoe Covers
Occlusive Bandage
Adverse Reactions to Gloves
Safe Practices to Use Sharps and their Disposal
Risk of Various Sharps Causing Injuries in a Hospital Setup
Guidelines for Safe Practices by CDC for Handling Sharps
Safe Recapping Procedures16
Other Sharps6
Health Care Waste Management and Disposal17
Precautions Against HIV Infection
Postexposure Prophylaxis
Step 1
Step 2
Assessing Risk of Transmission
Step 3
Step 4
Step 5
Step 6
Postexposure Prophylaxis of Hepatitis B
Routine Hepatitis B Immunization of All HCP1,22
Efficacy of PEP for Hepatitis B Virus
Postexposure Prophylaxis of Hepatitis C
Summary of Universal Precautions22
Conclusion
Glossary
Abbreviations
8:
Basic Dermatologic Surgery Instruments
Surgical Equipment
Operating Table
Trolley and Stands
Waste Containers
Monitoring Equipment
Medical Gases
Emergency Equipment
Basic Surgical Instruments
Scissors
Scalpels and Blades
Forceps
Needle Holders
Hemostats/Artery Forceps
Retractors
Skin Hooks
Arrangement of Instruments
Maintenance of Instruments
9:
Wound Closure Materials and Techniques in Dermatosurgery
Introduction
History
Sutures
Characteristics of an Ideal Suture
Properties of a Suture to be Assessed Before Selection6-9
Suture Size (As per the United States Pharmacopeia Classification System)6
Tissue Response to Suture Materials
Classification of Suture Materials
a. Based on Type of Filament (Tables 9-1 and 9-2)
b. Based on Absorbable Property (Tables 9-1 and 9-2)
Different Suture Materials and their Properties
Absorbable Suture (Table 9-3)
Nonabsorbable Sutures (Table 9-4)
Suture Selection
a. Based on Tensile Strength
b. Based on Absorbable Property
c. Based on Type of Filament
d. Based on Size of Suture Material
Needles
Ideal Surgical Needle Characteristics6
Anatomy of Needle
Point
Body
Swage
Advantages of Eyeless or Swaged Needles
Silicone Coating
Needle Measurements
Chord Length
Needle Length
Radius
Diameter
Needle Types
Commonly Used Cutting Needles in Dermatosurgery
Needle and Needle Holder Interaction
Surgical Glove Selection
Principles of Suturing
Techniques of Needle Holding and Suture Placement
Key Precautions
Knot Tying
Suturing Techniques
Interrupted Sutures
i. Simple Interrupted Sutures
ii. Vertical Mattress Sutures
iii. Horizontal Mattress Suture
Continuous (Running) Sutures
i. Simple Running Sutures
ii. Running Horizontal Mattress Sutures
iii. Running Locked Sutures
iv. Dermal-Subdermal Sutures
v. Running Subcuticular Sutures
vi. Running Subcutaneous Sutures
Special Suturing Techniques
Tip Sutures
Purse-string Suture
Barbed Sutures
Suture Removal
Alternative Wound Closure Methods
Skin Tapes
Procedure
Advantages
Disadvantage
Staples
Procedure
Advantages
Disadvantages10,34
Surgical Adhesives
Procedure
Advantages
Contraindications3
Laser Wound Closure
Conclusion
10:
Local Anesthesia
Introduction
History
Pharmacology
Chemical Structure
Mechanism of Action
Factors Influencing the Potency of Local Anesthetic Agents
Chemical Properties of Local Anesthetic Agents
Charge of the Local Anesthetic Agents
Local Vasculature
Dosage of Local Anesthetic Agents
Mixture of Local Anesthetic Agents
Type of Nerve
Tachyphylaxis
Local Anesthetic Agents
Cocaine
Procaine
Benzocaine
Tetracaine
Chloroprocaine
Lidocaine
Bupivacaine
Mepivacaine
Ropivacaine
Prilocaine
Etidocaine
Dibucaine
Articaine
Pramoxine
Dyclonine
Capsaicin
Diphenhydramine
Doxepin
Metabolism of Local Anesthetic Agents
Evaluation of Patients for Administration of Local Anesthesia
Method of Administration of Local Anesthesia
Topical Anesthesia
Infiltration Anesthesia
Tumescent Anesthesia
Cryoanesthesia
Nerve Blocks
Local Anesthetics During Pregnancy
Measures to Alleviate the Pain of LAA Injection
Measures to Achieve Rapid Anesthesia and Analgesia
Measures to Prolong the Duration of Action of LAA
Vasoconstrictors and LAA
Epinephrine
Levonordefrin
Phenylephrine
Complications During Local Anesthesia
Syncope
Hypersensitivity Reactions
Skin Testing
Alternatives for Anesthesia in Patients with Lidocaine Hypersensitivity
Methemoglobinemia
Central Nervous System Toxicity
Cardiovascular Toxicity
Other Side Effects
Bruising
Vasoconstriction
Myonecrosis
Safety Tips when Administering Local Anesthesia
Other Uses of LAA
Neuropathic Pain
Premature Ejaculation
Others
Preprocedure Preparation
Local Anesthetic Failure
Conclusion
11:
Hemostasis in Dermatologic Surgery
Introduction
History
Definition
Mechanisms of Hemostasis
Primary Hemostasis
Secondary Hemostasis
Types of Bleeding in Dermatologic Surgery
Depending on Time of Bleeding
Depending on Source of Bleeding
Approach to Effective Hemostasis in Dermatologic Surgery
Preoperative Evaluation
Intraoperative Measures
Role of Anesthesia in Preventing Intraoperative Bleeding
Measures to Reduce Blood Flow to the Site of Operation
Postoperative Care and Instructions
Postoperative Bleeding
Anticoagulants and Blood Thinners during Cutaneous Surgery13
Conclusion
12:
Resuscitation in Dermatosurgical Emergencies
Introduction
Anaphylaxis
Syncope
Management of Syncope
Lignocaine Related Issues
Breathlessness
Chest Pain
Bleeding
Acute Stroke
Status Epilepticus
Collapse
Hypotension
Management
Hypertension
Hypoxemia
Management
Cardiac Arrest7,23
Nerve Injury
General Resuscitation Plan at the Dermatologic Office
List of Resuscitation Equipment
Documentation of the Events
Conclusion
13:
Antibacterial Agents in Dermatosurgery
Introduction
Factors Responsible for Increased Risk of Infection
Factors Related to Patient
Factors Related to Disease
Factors Related to Dermatosurgical Procedure
Organisms Causing Infections in Dermatosurgery
Role of Antibacterial Agents in Dermatosurgery
Prevention of Surgical Wound Infection
Treatment of Infected Wound
Special Situations in Dermatosurgery
Topical Antibiotics
Conclusion
14:
Analgesics and Anxiolytics in Dermatosurgery
Introduction
Pathophysiology of Pain
Analgesics
Classification
Opioid Analgesics
Adverse Effects
Contraindications
Drug Interactions
Drugs Used in Dermatosurgery
Nonsteroidal Anti-inflammatory Drugs
Mechanism of Action
Dosage
Adverse Effects
Drug Interactions
Anxiolytics
Diazepam
Lorazepam
Midazolam
Recommended Dosage
Clonidine
Use of Analgesics and Anxiolytics in Dermatosurgery Patients
Pain and Patient Counseling
Analgesics and Hemostasis
Choice of Analgesic
Additional Modalities for Pain Relief
Acknowledgments
SECTION 2: STANDARD CUTANEOUS SURGICAL TECHNIQUES
15:
Simple Excisions
History of Cutaneous Surgery
Introduction
Indications
Contraindications
Requirements: Equipments and Materials
Preoperative Preparations
Counseling
Preoperative Evaluation of Patients
Prophylactic Antibiotics
Universal Precaution
Surgical Preparation of Site
Local Anesthesia
Technique of Elliptical Excision
Planning the Ellipse
Incision
Dissection of Lesion
Undermining the Defect
Methods of Undermining
Hemostasis
Closure of the Wound
Postoperative Care and Wound Dressing
Complications and their Management3,16
Methods of Dog-ear Correction
Linear Repair
Summary of Dog-ear Repair
Conclusion
16:
Simple Dermatosurgical Procedures: Biopsy, Curettage and Chemical Cautery
Introduction
Skin Biopsy
History
Basic Anatomy
Indications for Skin Biopsy8,9
Contraindications
Site Selection8
According to the Pathogenesis of the Lesion
According to the Size of the Lesion
For Special Procedures
Points to Remember while Choosing the Site for Biopsy10
Tips for Getting Better Results8
Types of Skin Biopsy Techniques
Choice of Procedure
Shave Biopsy
Punch Biopsy
Excisional Biopsy
Incisional Biopsy
Pre-procedure Counseling
Chemical Hemostatic Agents
Transport Medium
Steps Common to All Minor Procedures
Procedure of Biopsy
Shave Biopsy
Steps (Figures 16-2A to H)
Alternative Methods
Punch Biopsy
Excisional Biopsy
Incision Biopsy (Wedge Biopsy)
Other Techniques9
Complications of Biopsy
Curettage
Introduction
Historical Aspect3
Common Indications
Contraindication
Instrument
Procedure16,17
Choice of Anesthesia
Techniques of Curettage15,16
Postoperative Care
Complications
Summary
Chemical Cautery
Introduction
Historical Aspects
Trichloroacetic Acid
Phenol19,20
Podophyllin
Conclusion
17:
Electrosurgery
Introduction
History
Fundamentals
Electrosurgical Terms
Electrosurgical Units
Monopolar Electrosurgery
Bipolar Electrosurgery
Electrical Current and the Human Body
Electrosurgical Methods
Electrodessication
Electrofulguration
Electrocoagulation
Electrosection
Electroepilation
Blended Currents
Procedure
Indications
Contraindications
Preoperative Preparation
Anesthesia
Procedure
Electrosurgery in Different Situations
Choice of Electrodes
Postoperative Instructions
Complications
Precautions
Sterilization of Electrosurgical Probes
Electrosurgery in Patients with an Implantable Electronic Device
Conclusion
18:
Radiofrequency in Dermatology
Introduction
History2
Mechanism of Action of Radiofrequency Waves
Radiosurgical Unit (Figure 18-3)
Indications for Radiofrequency4-15
Radiofrequency in Combination with Other Modalities5,16
Patient Selection
Anesthesia
Procedure
Factors Affecting the Results of Radiofrequency17
Method of Sterilization of Electrodes6
Precautions18-21
Complications
Advantages
Conclusion
19:
Cryotherapy
Introduction
History of Cryotherapy
Mechanism of Cryoablation
Cryotherapy Facility
Cryosurgery Equipments (Figure 19-1)
Methodology of Cryosurgery
Counseling and Consent
History Taking and Examination
Preoperative Preparation
Treatment
Post-treatment Care
Indications of Cryotherapy
Complications
Acute
Subacute
Protracted
Common
Uncommon
Contraindications to Cryotherapy
Absolute
Relative
Conclusion
Acknowledgment
20A:
Surgical Management of Cutaneous Cysts and Lipomas
Introduction
Punch Removal Technique
Incisional Surgical Technique
Elliptical Excision Technique
Excision and Second-intention Healing Technique
Surgical Techniques for Different Types of Cysts
a. Epidermoid Cysts
b. Infected or Inflamed Cysts
c. Milia
d. Steatocystoma Multiplex
e. Mucous Cysts
f. Dermoid Cyst
Conclusion
Stab Incision Squeeze Technique
Distant Incision Technique
20B:
Melanocytic Nevi: Treatment Modalities
Introduction
Clinical Features
Acquired Melanocytic Nevi
Management
Pre-procedure Counseling
Procedure
Elliptical Excision10
Contraindications
Advantages
Disadvantages
Punch Excision11
Indications
Contraindications
Advantages
Disadvantages
Shave Excision12
Indications
Contraindications
Procedure
Advantages
Disadvantages
Radiosurgery9,13,14
Indications
Contraindications
Procedure
Advantages
Disadvantages
Laser Surgery
Conclusion
Acknowledgement
21:
Flaps for Facial Reconstruction
Introduction
Historical Background
Basic Concepts of Flaps
Definition
Classification
Random Pattern Flaps
Non-random Pattern Flaps
Flap Anatomy and Flap Design
Flap Physiology
Preoperative Care
Anesthesia and Surgical Techniques
Postoperative Care
Complications of Flap Surgery
Details of Basic Flaps and their Application
Advancement Flaps
V-Y Advancement Flap
Transposition Flaps
Details of Rhomboid Flap Design and Reconstruction
Bilobed Flap5
Rotation Flaps
Axial Pattern Flaps
Midline Forehead Flap
Nasolabial Flap
Conclusion
22:
Scar Revision
Introduction
Definition
Patient Expectations and Counseling
Ideal Scar
Factors Affecting Wound Healing2,6
Timing of the Scar Revision Surgery1,2,4,5
Scar Analysis and Planning
Preoperative Preparation
Techniques2,6
Nonsurgical Methods
Dermabrasion
Lasers
Surgical Methods
Preoperative Planning
Local Anesthesia
Markings
Instruments and Sutures
Restoration of Anatomical Landmarks
Direct Excision (Simple Excision)
Serial Excision
Reorientation Techniques for Scar Revision Surgeries
Trapdoor Deformity Repair
Postoperative Care
Tips for Getting Best Results and Pitfalls to be Avoided
Conclusion
23:
Dermabrasion
Introduction
History
Indications9–21
Contraindications1–7,9,13–16,22–26
Preoperative Procedures1–3,8,13,38–43
Patient Information
Equipment
Preoperative Workup
Facial Dermabrasion
Operative Procedure44–48,
Postoperative Management47
Side Effects
Complications
Advantages and Disadvantages
Regional/Spot Dermabrasion
Advantages
Disadvantages
Combination Technique (Author's Modification)50
Conclusion
SECTION 3: SPECIAL CUTANEOUS SURGICAL PROCEDURES
24A:
Overview of Vitiligo Surgery
Introduction
History
Principle of Surgical Treatment
Methods of Surgery
Factors to be Considered for Patient Selection
Concept of Stability in Vitiligo
Duration of Stability
Stability
Test Grafting
Koebner's Phenomenon (KP)
Longevity of Stability
Induced versus Spontaneous Stability
Cellular Stability
Case Selection
Patient Counseling and Information
Patient Examination
Preoperative Investigations
Choice of Method of Surgery
Conclusion
24B:
Autologous Mini Punch Grafting in Vitiligo
Introduction
Punch Instrument
Evolution of Mini Punch Grafting
Test Grafting
Procedure of Minigrafting32,42–44 (Figures 24B-2 and 24B-3)
Follow-Up and Course of Events
Complications22,42–44
Analysis of Special Features
Conclusion
Acknowledgments
24C:
Suction Blister Roof Grafting
Introduction
Indications
Instruments
Procedure4–11
Preparation
Application of Suction
Recipient Site Preparation
Application of Graft to the Recipient Area
Graft Fixation
Removal of Dressing
Complications
24D:
Thin Split Thickness Skin Grafting for Vitiligo
Introduction
History
Definition
Principle of Split Thickness Skin Grafting
Graft Take and Adherence
Graft Revascularization
Contracture
Patient Selection Criteria
Equipment
Technique
Preoperative Preparation
Harvesting the Graft
Donor Site Preparation and Anesthesia
Graft Harvesting Technique
Donor Area Dressing
Recipient Site: Preparation, Graft Placement and Immobilization
Preparation
Dermabrasion
Placement of Graft
Immobilization
Postoperative Care
Expected Outcomes
Complications
At the Recipient Site
Graft Rejection
Textural Abnormalities
Hyperpigmentation
Perigraft Halo
Hypertrophy
Milia
Secondary Infection
Reactivation of Vitiligo
Complications at the Donor Site
Post-inflammatory Hyperpigmentation
Scarring
Recurrence or Koebnerization
Advantages and Disadvantages of STSG
Technique Modifications at Special Sites
Conclusion
24E:
Epidermal Noncultured Cell Suspension in Vitiligo
Introduction
Procedure
Harvesting of Skin Graft
Cell Separation Technique (Box 24E-1)
Dermabrasion of the Recipient Site
Transplantation Technique
Postprocedure Instructions
Onset of Pigmentation
Modifications of the Procedure
Conclusion
24F:
Cultured Melanocyte Transplantation
Introduction
Background and History
Patient Selection
Technique
Technique of Culture
Collection of the Samples
Processing of the Graft (Flow chart 24F-1)
Surgical Techniques
Cryopreservation
Modifications and New Developments
Amniotic Membrane as a Scaffold for Melanocyte Transplantation
Hyaluronic Acid Micropore Sheets as Scaffold6
Preparation of Recipient Site
Conclusion
24G:
Phototherapy with Grafting Procedures in Vitiligo
Introduction
PUVA and PUVASOL
Narrowband UVB
Excimer Laser and Targeted Phototherapy
Conclusion
24H:
Complications of Vitiligo Surgery
Introduction
Specific Complications
Color Mismatch (Hyperpigmentation and Hypopigmentation)
Perigraft Halo and Achromic Fissures
Cobblestoning (Raised Grafts) and Sinking Pits (Sunken Grafts)
Graft Hypertrophy
Scarring at Donor Site
Hypertrophic Scars or Keloids
Curling of Borders with Beaded Appearance of the Periphery of Grafts
Thick Margins or Stuck-on Tyre Appearance
Inclusion Cyst and Milia Formation
Graft Rejection or Failure of Graft Uptake
Variegated Appearance
Infection
Koebner's Phenomenon
Individual Transplant Procedures and their Complications
Tissue Grafts
Thin and Ultrathin Split-thickness Skin Grafts
Suction Blisters Epidermal Grafts
Mini Punch Grafts
Hair Follicular Grafts
Cellular Grafts
Autologous Noncultured Epidermal Cell Suspension
Transplantation of Cultured Autologous Melanocytes
Autologous Cultured Epithelial Graft (CEG)
Review of Literature
Conclusion
24I:
Other Methods of Treating Vitiligo and Tips for Vitiligo Surgery
Tattooing
Surgical Removal of the Depigmented Areas
Therapeutically Wounding
Donor Dermabrasion to Obtain Melanocytes and Keratinocytes
25A:
Overview of Acne Scarring
Introduction
Epidemiology
Psychosocial Impact of Acne Scarring
Pathogenesis of Acne Scarring
Inflammation
Granulation Tissue Formation
Matrix Remodeling
Classification
Atrophic Acne Scars
Icepick Scars
Rolling Scars
Boxcar Scars
Hypertrophic Scars
Grades of Acne Scarring
Prevention of Scarring
25B:
Surgical Management of Acne Scars
Introduction
Microneedling
Indications
Contraindications
Procedure
Postprocedure Care
Outcome
Practical Tips
Subcision
History
Principle
Indications
Treatment Procedure
Complications
Practical Tips
Punch Techniques
Punch Excision
Indication
Procedure
Punch Flotation
Indications
Procedure
Punch Replacement Grafting
Indications
Procedure
Limitations of Punch Techniques
Practical Tips
Chemical Reconstruction of Skin Scars
Principle
Indications
Procedure
Complications
Practical Tips
Dermal Grafting31–33
Advantages of Using Dermal Graft
Procedure
Conventional Technique
Enzymatic Technique
Practical Tips
Other Modalities for Treatment of Acne Scar
Chemical Peeling
Microdermabrasion
Soft Tissue Augmentation (Fillers)
Scar Revisions
Cryotherapy
Conclusion
Tips and Pearls for Acne Surgeries
25C:
Management of Acne Scars—Lasers
Introduction
Indications of Laser Treatment in Acne Scars
Types of Lasers Used for Acne Scars
Ablative Lasers
Nonablative Lasers
Fractional Photothermolysis
Preparation of Patient for Fractional Laser Resurfacing
Post-procedure Care
Complications of Lasers and How to Deal with them
Conclusion
25D:
Approach to Management of Post-acne Scars
Introduction
Pretreatment Considerations
Isotretinoin and Acne Scar Management
26A:
Mohs Micrographic Surgery
Introduction
History
Indications
Basal Cell Carcinoma
Squamous Cell Carcinoma
Dermatofibrosarcoma Protuberans
Microcystic Adnexal Carcinoma
Leiomyosarcoma
Atypical Fibroxanthoma
Extramammary Paget's Disease
Lentigo Maligna Melanoma
Mohs Suite (Surgical Facility)
Mohs Micrographic Surgery Technique
Step 1: Preoperative Assessment
Step 2: Excision of First Mohs Layer and Mapping of the Tumor
Step 3: Tissue Grossing, Embedding and Sectioning
Step 4: Tissue Fixation and Staining
Step 5: Interpreting the Frozen Section
Slow Mohs Micrographic Surgery
Cost-effectiveness of Mohs Micrographic Surgery
Conclusion
Potential Errors and Limitations of Mohs Micrographic Surgery
26B:
Melanoma
Introduction and History
Epidemiology
Etiology
Clinical Variants of Primary Cutaneous Melanoma
Superficial Spreading Melanoma
Nodular Melanoma
Lentigo Maligna Melanoma
Acral Lentiginous Melanoma
Histopathology
Staging and Microstaging of Melanoma
Breslow Thickness
Ulceration
Mitotic Rate Count
Regression
Tumor-Infiltrating Lymphocytes
Tumor (Micro) Satellites
Diagnostic Methods in Melanoma
Prognosis
Surgical Management
Sentinel Lymph Node Biopsy
Medical Management for Advanced Melanomas
Treatment in the Adjuvant Setting
Treatment of Stage IV Melanoma
Immunotherapy
Cytokine Use
Vaccinations
Monoclonal Antibodies (Antibody-based Approaches)
Adoptive Cell Transfer
Target Therapies (Targeting Molecular Pathways)
Conclusion
27A:
Varicose Veins: An Overview
Introduction
Venous Anatomy
Superficial Veins
Deep Veins
Perforator Veins (Figure 27A-2)
Venous Pathophysiology
Primary Venous Insufficiency
Chronic Venous Insufficiency
Risk Factors for Development of Varicose Veins
Symptoms of Varicose Veins
Examination
Inspection
Clinical Tests
Brodie-Trendelenburg Test
Tourniquet Test
Fegan's Test
Schwartz's Test
Classification
Investigations
Standard Doppler
Duplex Doppler
Management
Pharmacological Therapy
Compression Therapy
Sclerotherapy
Endovenous Techniques
Radiofrequency Ablation
Endovenous Laser Ablation (Figures 27A-8 to 27A-10)
Surgical Methods
Saphenofemoral Ligation
Great Saphenous Vein Stripping
Phlebectomies (Figure 27A-14)
Subfascial Ligation of Perforators
Results
Other Methods
Subcutaneous Endoscopic Perforator Surgery
Ambulatory Conservative Hemodynamic Management
Transilluminated Powered Phlebectomy
Cryosurgery
Conclusion
27B:
Sclerotherapy
Introduction
History
Objectives and Mechanism of Sclerotherapy
Indications of Sclerotherapy in Varicose Veins5
Contraindications6
Sclerosing Solutions5,7
Detergent Agents
Osmotic Agents
Chemical Irritants
Sodium Tetradecyl Sulfate
Polidocanol
Hypertonic Saline
Sodium Morrhuate
Pre-procedure Assessment6
Case Selection
History
Examination
Investigations
Duplex Doppler Ultrasonography11
Procedure
Materials Required12 (Figure 27B-2)
Sclerosant Concentrations10
Principles of Varicose Vein Sclerotherapy4
Patient Preparation12
Techniques
Sclerotherapy Techniques for Large Veins
Fegan's Technique
Sigg's Technique
Sclerotherapy of Reticular Veins
Post-sclerotherapy Compression4,13,14
Side Effects and Complications of Sclerotherapy
Post-sclerotherapy Hyperpigmentation
Matting
Cutaneous Necrosis
Superficial Thrombophlebitis
Pulmonary Embolism
Arterial Injection
Allergic Reaction
Foam Sclerotherapy
Techniques of Foam Sclerotherapy22
Advantages and Disadvantages of Foam Sclerotherapy
Laser Treatment of Telangiectasias and Reticular Veins
Endovenous Ablation
Summary
27C:
Sclerotherapy for Vascular Malformations
Definition
Indications for Interventional Management
Absolute Indications
Relative Indications
Sclerotherapy
Procedure
Preoperative Preparation and Counseling
Anesthesia
Immediate Post-procedure Management
Patient Follow-Up
Foam Sclerotherapy
Complications
Minor Local Complications
Major Local Complications
Major Systemic Complications
28:
Leg Ulcers
Introduction
Causes of Leg Ulcers
Clinical Features of Leg Ulcers
Venous Ulcers
Pathophysiology of Venous Ulcers
Pathogenesis of Arterial Ulcers
Pathogenesis of Neuropathic Ulcer
Laboratory Evaluation of Leg Ulcers
Treatment
Venous Ulcers
Wound Care for Leg Ulcers
Dressings
Debridement
Topical Treatment
Systemic Treatment
Biophysical Treatment Modalities
Surgical Options for Covering the Wound
Skin Substitutes
Laser for Leg Veins
Endovenous Laser and Radiofrequency Treatment
Indications for Surgical Intervention in Leg Ulcers Secondary to Chronic Venous Insufficiency
Ambulatory Phlebectomy
Treatment of Arterial Ulcers
General Measures
Treatment of Neuropathic Ulcers
Conclusion
Tips and Pitfalls
29:
Surgery of Nails
Introduction
Relevant and Applied Anatomy
Nail Plate
Nail Matrix
Nail Bed
Hyponychium
Proximal Nail Fold
Proximal and Lateral Nail Grooves
Blood Supply1,13,14
Nerve Supply15
Indications for Nail Surgery1,16,17
Contraindications17
Preoperative Evaluation
Surgical Setting
Anesthesia
Anesthetic Agent
Digital Anesthesia
Distal Digital Block
Proximal Digital Block
Instruments
Sutures
Hemostasis
Intraoperative
Operative Procedures / Techniques
Nail Plate Avulsion
Indications
Surgical Avulsion1,26,27
Nail Plate Repositioning1
Proximal Nail Fold Reflection
Biopsy
Nail Plate Biopsy
Nail Bed Biopsy
Nail Matrix Biopsy
Matrixectomy1,16,17
Modalities
Ingrown Nail (Onychocryptosis)
Management
Surgery for Subungual Hemorrhage
Nail Unit Infections
Surgery of Nail Unit Tumors, Cysts and Growths
Warts
Myxoid Cyst (Myxoid Pseudocyst)
Pyogenic Granuloma
Glomus Tumors
Miscellaneous Lesions
Postoperative Dressing and Care
Conclusion
30:
Keloid and Hypertrophic Scar
Introduction
History
Epidemiology
Pathophysiology
Clinical Features
Histopathology
Treatment
Corticosteroids
Surgical Excision
Cryotherapy
Laser Therapy
Pressure Therapy
Silicone Material
Radiotherapy
5-Flourouracil
Bleomycin
Imiquimod
Radiofrequency Device
Verapamil
Onion Extract and Heparin
Botulinum Toxin
Emerging New Drugs for Scar Reduction
Growth Factors and Cytokines
Basic Fibroblast Growth Factor
Transforming Growth Factor-β (TGF-β 3)
Interferon
Interleukin-10
Extracellular Matrix Modulators
Other Product s and Therapies
Topical Tamoxifen
Tranilast
Prostaglandin (PGE2)
Tacrolimus and Rapamycin
Pentoxyphylline
Retinoic Acid
Prevention
31:
Cleft Earlobe Repair
Introduction
Anatomy (Figure 31-1)
Causes for Cleft Earlobe
Types of Earlobe Tears
Repair Techniques
Nonsurgical
Surgical
Instruments and Materials Required
Preoperative Preparation
Nonsurgical Techniques for the Cleft Earlobe Repair
Surgical Technique
Anesthesia
Partial Cleft Repair
Punch Excision (For Defects < 4 mm in Length) with Simple Closure
Wedge Excision with Z-Plasty
Repair of Partial Earlobe Cleft Using a“Purse-String” Repair (As Described by Justin Vujevich and Suzan Obagi)1
Complete Cleft Repair
Excision Followed by Unilateral Z-Plasty
Excision Followed by Unilateral Z-Plasty and Advancement Flap3 (Figures 31-4 to 31-6)
Postoperative Precautions and Instructions
Complications and their Prevention12,13
Prevention of Earlobe Tears1–6
Conclusion
32:
Hidradenitis Suppurativa
Introduction
Pathogenesis
Clinical Features
Prognosis and Complications
Disease Association
Treatment
Medical Treatment
Conservative Measures
Botulinum Toxin
Radiotherapy
Cryotherapy
Lasers and Light Devices
Surgical
Deroofing
Excision
Conclusion
33:
Circumcision
Introduction
Indications
Instruments Required
Preoperative Investigations
Anesthesia
Procedure
Dorsal Slit Technique7-11
Guided Forceps Technique
Sleeve Resection Technique
Postoperative Care
Circumcision in Infants9,11
Complications12,13
34:
Leprosy Surgery
Introduction
Indications for Surgical Intervention in a Case of Hansen's Disease Patient
Nerve Biopsy
Procedure
Complications
Nerve Decompression Surgery
Management of Internal Compression
Management of External Compression
Reconstructive Surgery
Reconstructive Surgery of the Hand
Surgery for the Foot Drop Correction
Surgery for Correction of Facial Deformities
Neuropathic Foot Ulcers
Ulcer Management
Newer Investigations to Diagnose High Plantar Pressures
Conclusion
SECTION 4: ESTHETIC PROCEDURES
35A:
Aging Skin
Introduction
Classification of Aging
Intrinsic Aging versus Extrinsic Aging
Intrinsic Aging
Etiopathogenesis
Clinical Features
Histopathological Features
Factors Contributing to Skin Wrinkling
Changes in Muscles
Gravitational Forces
Alterations in Subcutaneous Fat
Loss of Substance of Facial Bones and Cartilage
Extrinsic Aging
Aging in the Indian Skin
Conclusion
35B:
Approach to Management of Aging Skin
Introduction
Patient Evaluation
Management
Level I (Primary Intervention)
Level II (Secondary Intervention)
Level III (Tertiary Intervention)
Medical Therapy
Surgical Therapy
Noninvasive
Minimally Invasive
Invasive
Combination Treatment9
Conclusion
36:
Cosmeceuticals for Aging Skin
Introduction
Different Categories of Cosmeceuticals
Evaluation of Cosmeceuticals
Different Cosmeceuticals and their Uses
Retinoids
Antioxidants
Alpha-Lipoic Acid
Dimethylaminoethanol
Omega-3 Fatty Acids
Hyaluronic Acid
Copper Peptide
Coenzyme Q10
Hydroxy Acids
Alpha-Hydroxy Acids
Lactic Acid
Beta-Hydroxy Acid
Polyhydroxy Acids
Botanicals
Soy
Curcumin
Silymarin
Pycnogenol
Kinetin
Other Botanicals
Skin Lightening Agents
Phenolic Agents
Hydroquinone
N-Acetyl-4-S-Cysteaminylphenol
Arbutin
Nonphenolic Agents
Kojic Acid
Liquorice Derivative
Niacinamide
Azelaic Acid
Aloe
L-Ascorbic Acid
Enzymes
Growth Factors
Topical Hormones
Proteins
Allergies
The Future
Conclusion
37:
Microdermabrasion
Introduction
History of Microdermabrasion
Pathophysiological Changes in Microdermabrasion
Histological Changes in Epidermis
Histological Changes in Dermis
Microdermabrasion Unit and its Working
Technical Aspects
Diamond Tome Microdermabrasion
Hydradermabrasion
Indications for Microdermabrasion
Anecdotal Uses of Microdermabrasion
Advantages of Microdermabrasion
Contraindications
Relative
Absolute
Preoperative Preparation
Pre-procedure Counseling, Consent and Photography
Patient Preparation
Procedural Techniques
Post-procedure Instructions
Factors Affecting the Level of Removal of Epidermis/Dermis During Microdermabrasion
Complications
Combination with Other Esthetic Procedures
38:
Microneedling
Introduction
Principle
Instrument
Histopathology
Indications
Contraindications
Precautions
Preprocedure Preparation
Technique
Postprocedure Care
Complications
Advantages of Microneedling
Other Uses of Microneedling
Disadvantages of Microneedling
Variations in the Instrument
Conclusion
39:
Glycolic Acid Peels
Introduction
History
Glycolic Acid
Basic Biochemistry
Mechanism of Action
Formulations
Indications8,9
Contraindications
Basic Principles of a Peel Procedure
History and Examination
Counseling
Photography
Procedure
Preparation (Priming)
Instruments
Peel Procedure
Correlation between Skin Appearance and Depth of AHA Peel
Contact Time for a Glycolic Acid Peel
Neutralization
Postprocedure Care
Complications
Combination with Other Esthetic Treatments
Conclusion
40A:
Non-glycolic Acid Peels—Salicylic Acid and Trichloroacetic Acid Peels
Introduction
Salicylic Acid
Indications2-4
Contraindications
Procedure
Complications
Trichloroacetic Acid
Indications6-11
Contraindications
Procedure
Complications
Jessner's Peel
Indications1
Contraindications
Procedure
Complication
Conclusion
40B:
Newer Superficial Peels
Introduction
Newer Formulations
Salient Features of Each Peeling Agent
Lactic Acid
Mechanism of Action
Indications4
Procedure
Advantages
Disadvantages
Mandelic Acid
Mechanism of Action
Indications7
Procedure
Advantages
Disadvantages
Retinoic Acid (Tretinoin)
Mechanism of Action
Indications
Specific Contraindications
Procedure
Advantages
Disadvantages
Phytic Acid3
Indication
Procedure
Advantage
Disadvantage
Kojic Acid
Mechanism of Action
Indication
Procedure
Side Effects
Arginine
Mechanism of Action
Indications
Side Effects
Pyruvic Acid
Mechanism of Action
Indications
Procedure
Advantage
Disadvantages
Ferulic Acid
Mechanism of Action
Indications
Procedure
Beta-Lipo Hydroxy Acid
General Principles for all Peel Procedures
Contraindications3,29,30
Preoperative Preparation and Instruments
Procedure
Postoperative Instructions and Complications34-37
Complications3,33,38,39
Combination Peels
Gel Peels
Combination with Other Esthetic Treatments
Conclusion
41A:
Cosmetic Uses of Botulinum Toxin
Introduction
History
Pharmacology of Botulinum Toxin Type A
Preparations
Cosmetic Indications
Contraindications9-11
Absolute Contraindications
Relative Contraindications
Preoperative Counseling and Informed Consent1
Reconstitution and Handling
Procedure
Standard Guidelines for the Use of BTX A1
The Glabellar Complex and Vertical Frown Lines10,18-29
Treatment Pearls
Adverse Effects
Horizontal Forehead Lines10,18,19,25,27,28,30-34
Treatment Pearls
Adverse Effects
Crow's Feet19,21,35-39
Treatment Pearls
Adverse Effects
Bunny Lines10,19,39-41
Treatment Pearls
Adverse Effects
Perioral Wrinkles19,21,39,42,52
Treatment Pearls
Adverse Effects
Melomental Rhytids (Marionette Lines)1,19,39,43
Treatment Pearls
Adverse Effects
Dimpled Chin (Peau D'orange)9,21,24,28
Treatment Pearls
Adverse Effects
Jaw Line Rejuvenation—The Nefertiti Lift44–47
Adverse Effects
Platysmal Bands48-52
Treatment Pearls
Adverse Effects
Chemical Brow Lift53
Widening of the Palpebral Fissure54
Facial Contouring and Correction of Masseter Hypertrophy54 58
Treatment Pearls
Adverse Effects
Calf Muscle Contouring59,60
Treatment Pearls
Adverse Effects
Conclusion
Acknowledgments
41B:
Non-cosmetic Dermatological Indications of Botulinum Toxin
Introduction1-3
Nonesthetic Dermatological Indications of Botulinum Toxin
Hyperhidrosis
Mechanism of Action of Botulinum Toxin in Hyperhidrosis
Indications and Contraindications of Botulinum Toxin in Hyperhidrosis
Preparations Before Procedure3,10
Dose
Axillary Hyperhidrosis
Anesthesia
Dilution and Dosage
Procedure10,13
Side Effects
Palmar and Plantar Hyperhidrosis
Anesthesia
Topical Anesthesia
Vibration Anesthesia
Jet Injection
Nerve Blocks27,28
Bier's Block
Other Anesthetic Procedures
Procedure
Complications of Botulinum Toxin Injection at Palms and Soles 30,31,33
Frontal Hyperhidrosis
Dilution
Procedure
Side Effects
Gustatory Hyperhidrosis (Frey's Syndrome)
Procedure
Side Effects36,37
Hypertrophic Scars and Keloids
Mechanism of Action
Anesthesia
Procedure
Botulinum Toxin in Management of Painful Scars
Anesthesia
Dose and Dilution42
Procedure42
Botulinum Toxin in Facial Scar Management43
Procedure
Postherpetic Neuralgia42
Mechanism of Action42
Anesthesia
Dilution
Procedure42,44
Botulinum Toxin and Post-acne Scars47
Breast Lift42
Dilution
Procedure
Side Effects
Others
Hidradenitis Suppurativa
Multiple Eccrine Hidrocystomas50,51
Leiomyoma-Related Pain52,53
Pachyonychia Congenita and Epidemolysis Bullosa Simplex with Sweat-Worsened Foot Problem54,55
Raynaud's Phenomenon
Lichen Simplex Associated Pruritus60
Chronic Anal Fissure61
Vulvodynia and Vestibulodynia
42A:
Soft Tissue Augmentation: Hyaluronic Acid Fillers
Introduction
History
Aging Skin
Physiology of Facial Wrinkles
Type II
Type III
Type IV
Autologous Fat
Injectable Fillers
Based on Longevity (Table 42A-1)6
Based on Site of Placement
Based on Origin of Filler Material
Hyaluronic Acid (HA) Fillers
Hyaluronic Acid Dermal Filler Properties
History of Hyaluronic Acid
Hyaluronic Acid Products
Case Selection and Assessment
Indications
Indications in Facial Areas
Indications in Extrafacial Areas
Contraindications
Counseling
Photography
Preoperative Preparation
Equipment Needed
Informed Consent
Anesthesia
Topical Anesthesia
Nerve Block Anesthesia
Alternative Comfort Techniques
Procedure
Technique of Injection
Postoperative Instructions
Soft Tissue Augmentation and Management of Complications14
Surgical Implants—Soft Form
Enhancing Patient Comfort
Avoiding Necrosis
Inappropriate Placement
Layering of Multiple Injectants
Conclusion
42B:
Non-hyaluronic Acid Fillers
Introduction
Classification
Semipermanent Fillers
Calcium Hydroxylapatite
Introduction
Mechanism of Action
Safety and Efficacy
Indications2
Contraindications
Storage
Anesthesia
Technique
Post-treatment Care
Side Effects
Advantages of CaHA
Disadvantages
Poly-L-lactic Acid
Introduction
Mechanism of Action
Safety and Efficacy
Indications20,28
Contraindications
Pre-treatment Patient Education
Storage
Reconstitution40
Pre-treatment Preparation41
Anesthesia41
Injection Technique42
Post-treatment Instructions
Side Effects
Advantages
Disadvantages
Permanent Fillers
Polymethylmethacrylate
Mechanism of Action44
Storage
Indications
Contraindications
Technique2
Longevity
Side Effects
Advantages
Disadvantages54
Polyacrylamide Gel
Indications
Injection Technique
Adverse Effects
Advantages
Disadvantages66
Platelet Rich Plasma
Introduction
Mechanism of Action
Indications
Technique69
Side Effects
Advantages
Disadvantage
Conclusion
43A:
Follicular Unit Hair Transplantation
Introduction
Background Information
Etiology of Pattern Baldness
Mechanism of Baldness
History of Hair Transplantation
Concept of Follicular Unit
Rationale and Features of Follicular Unit Transplantation
Mathematics of Hair Transplantation
Role of Microscopic Dissection
Factors Determining Outcome in Hair Transplantation
Donor Hair Characters
Technical Factors
Donor Scars
Mega Sessions and Giga Sessions
Steps in Hair Transplantation Surgery
Case Selection, Counseling and Informed Consent
Preoperative Examination
Local Anesthesia
Donor Strip
Recipient Site Anesthesia
Recipient Insertion
Avoiding Popping
Automation
Hairline
Monitoring
Postoperative Care
Natural Course of Events After Transplantation
Wound Care
Complications
Immediate Complications
Late Complications
Manpower Requirements
Conclusion
43B:
Newer Methods in Hair Transplantation
Introduction
Follicular Unit Extraction
Principle of Follicular Unit Extraction
Role of FUE in Current Hair Transplantation Scenario
Procedure of Follicular Unit Extraction
Preparation
Techniques of Extracting the Grafts
One-Step Procedure
Two-Step Procedure
Three-Step Procedure
Tips to Avoid Transection
FOX Test
Complication in Follicular Unit Extraction
Automated Follicular Unit Extraction Hair Transplantation
Postoperative Course after Follicular Unit Extraction
Transplantation in Difficult Areas
Vertex Transplantation
Hair Transplantation in Other Areas
Transplantation in Women
Body Hair Transplantation
Long Hair Transplantation
Robotics
Conclusion
43C:
Non-hair Transplantation Methods of Surgical Hair Restoration
Introduction
Historical Background
Surgical Considerations of Scalp Anatomy
Understanding Scalp Laxity
Concept of Creep
Scalp Flaps
Rotation Flaps
Transposition Flaps
Temporo-Parieto-Occipital/Juri Flaps (Figures 43C-5A and B)
Patient Selection for Temporo-Parieto-Occipital Flaps
Anesthesia
Concept of Delay
First Delay
Second Delay
Transposition of the Flap
Complications
Lateral Scalp Flaps
Temporal Vertical Flaps
Temporo-Parieto-Occipital Free (Microsurgical) Flap
Alopecia Reduction
Major Reductions
Alopecia Reduction with Prior Scalp Extension (Nonvolumetric)
Alopecia Reduction with Prior Tissue Expansion (Volumetric)
Alopecia Reduction with Intraoperative Stretching (Volumetric and Non Volumetric)
Complication of Alopecia Reduction
Surgical Complication
Cosmetic Complication
Current Role of the Methods
44:
Liposuction
Introduction
History of Liposuction
Structure of Fat
Indications for Liposuction1
Methods of Liposuction1,2
Conventional Liposuction
Microcannular Tumescent Liposuction
Other Methods of Liposuction
Power Assisted Liposuction
Ultrasound-assisted Liposuction
Laser Lipolysis and Laser-assisted Liposuction
Principle of Tumescent Anesthesia
Procedure of Tumescent Liposuction
Patient Selection
Counseling
Preoperative Instructions
Preparation of Patient
Use of Other Drugs for Analgesia and Tranquilizing Effect
Instrumentation
Tumescent Anesthesia
Aspiration
Intraoperative and Postoperative Monitoring
Postoperative Dressing and Follow-up
Complications
Safety of Tumescent Liposuction
Breast Reduction
Satisfaction After Liposuction
Conclusion
45:
Fat Transplantation
Introduction
History
Indications and Types of Fat Transplants
Case Selection, Pretreatment Assessment and Planning
Patient Examination and Evaluation
Techniques
Harvesting, Refinement and Transplant
Harvesting
Refinement of Fat and Preparation for Transfer
Centrifugation
Recipient Area, Injection and Placement
Stability of Transplanted Fat
Postoperative Care
Complications
Other Considerations
Longevity
Use of Frozen Fat
Future Trends
Conclusion
46A:
Periorbital Rejuvenation
Introduction
Anatomy
Pathophysiology of Aging Changes
Clinical Signs of Periorbital Aging
Approach to Management
Treatment
Sunscreens
Topical Bleaching Agents
Topical Vitamin K Preparations
Chemical Peels
Laser Resurfacing
Botulinum Toxin
Soft Tissue Fillers
Nonablative Radiofrequency
Mesotherapy
Maintenance
Treating Blepharochalasis
Fat Transfer
Conclusion
Acknowledgments
46B:
Blepharoplasty and Periorbital Surgical Rejuvenation
Introduction
Upper Face
Upper Eyelid Blepharoplasty
Indications
Preoperative Evaluation
Anesthesia
Surgical Technique
Postoperative Care
Complications
Endoscopic Brow-Lift and Brow Volume Augmentation
Indications
Assessment of the Eyebrow
Brow Volume Augmentation
Brow-Lift
Surgical Technique
Ptosis Surgery
Indications
Preoperative Evaluation
Surgical Technique
Midface
Lower Eyelid Blepharoplasty
Surgical Procedure
Transcutaneous Lower Lid Blepharoplasty
Lower Eyelid Fat Repositioning
Surgical Technique
Midface Lift
Surgical Technique
Orbital Decompression for Prominent Eyes
Conclusion
47:
Melasma and its Esthetic Management
Introduction
History
Etiology
Clinical Features
Differential Diagnosis
Severity of the Diseases
Investigations
Treatment Modalities
Medical Management
Combination Medical Therapy
Systemic Medical Therapy
Procedural Management
Chemical Peels
Dermabrasion
Laser Therapy
Ablative Lasers
Q-Switched Laser
Intense Pulsed Light Laser
Copper Bromide Lasers
Nonablative Fractional Resurfacing
Laser Toning
Treatment of Melasma in Pregnancy
Quality of Life in Melasma
Counseling
Conclusion
48:
Cosmetic Problems of Nails and their Management
Introduction
Sources of Nail Cosmetic Problems
Materials, Procedures and Equipment
Materials
Procedures
Salon Equipment
Strategies for Prevention and Treatment
Simple Safe Pedicure Practices
Conclusion
SECTION 5: LASER, LIGHTS AND OTHER TECHNOLOGIES
49:
History and Physics of Lasers: Dermatologic Lasers and their Evolution
Introduction
Prologue
Building of the First Laser
Rainbow of Lasers
Clinical Application of Lasers in Dermatology (1960-1980)—The Dark Ages
Dr Leon Goldman—Father of Laser Surgery and Medicine
The Early Decades of “Disease” Laser Dermatology
CO2 Laser Evolution
Theory of Selective Photothermolysis (1983)—The Evolution of Art of Laser to Science
Dawn of Laser Cutaneous Resurfacing
Rebirth of Q-Switched Laser for Pigmentary Disorders
Birth of Desire Dermatology—Hair Reduction By Laser
Nonablative Dermal Remodeling—Fountain of Youth or High Tech Snake Oil?
Fractional Resurfacing—Nonablative and Ablative
Lasers—A Solution Looking for a Problem
50:
Setting Up a Laser Theater
Introduction
Facility
Laser Procedure Room (Figure 50-1)
Equipments
Mobile Laser Unit
Cleaning of Laser and Other Devices
Sterilization12-16
Records
Safe Laser Practices
Etiquettes
Safe Operation Practices and Emergency Protocols
Fire Precautions
Tips for Safe Laser Practice21-23
Laser Eye Protection Evidence Level B
Accident Procedure
Dermatosurgical Operation Theater Guidelines
Acknowledgments
51:
Laser and Light-assisted Hair Removal
Introduction
Definition of Laser Hair Removal
History
Laser-tissue Interactions and Principle of Laser Hair Removal
Photothermal Destruction
Wavelength
Pulse Duration
Fluence
Spot Size
Cooling
Photomechanical Destruction26
Photochemical Destruction26
Relevant Hair Anatomy
Trichogenic Stem Cells23,24
Melanin
Hair Growth Cycle
Indications for Laser Hair Removal
Contraindications
Treatment Approach
Preprocedure
Procedure41
Laser Safety
Postprocedure Protocol50
Removal of Gray Hairs
Side-effects or Adverse Effects
Available Hair Reduction Systems
Fitzpatrick Classification Scale55
Ruby Lasers
Long-Pulsed Alexandrite Laser
Semiconductor Diode Lasers
Neodymium:YAG Laser
Intense Pulsed Light Sources
New Technologies
Super Hair Removal (650–950 nm)76
Treatment Technique
Electro-optical Synergy Technology77,78
Electro-optical Synergy (ELòS) Combines Optical Energy (Light / Laser) and Electrical Energy—Bipolar Radiofrequency with Cooling
Tips and Pitfalls in Hair Removal
Conclusion
52:
Carbon Dioxide Laser
Introduction
History
Principles and Components of CO2 Laser Machine
Components of CO2 Laser Machine
Important Components
Beam Generation
Energy Calculations
Modes of CO2 Laser
Types of CO2 Laser
Continuous Wave Laser
Pulsed Wave Laser
Tissue Interaction with Laser
Indications2
Nonesthetic Indications
Esthetic Indications
Contraindications
Materials Needed Prior to Procedure
General Instructions for the Operation of Laser
Laser Specification for Each Indication
Warts
Erbium:YAG Laser
Indications of Erbium:YAG Laser
Advantages Over the CO2 Laser
Disadvantages of Erbium:YAG Laser
Bleeding Control
Postoperative Care and Follow-up
Complications54
Conclusion
53:
Lasers for Pigmented Lesions and Tattoos
Introduction
History
Laser Basics and Systems
Mechanism of Action of QS Lasers
Definition of Q-Switch or Quality Switch
Indications
Contraindications7-9
Absolute Contraindications
Relative Contraindications
Patient Selection and Counseling6,8-10
Preoperative Preparation
Sun Protection
Oral Retinoids
Test Patch
Eye Protection
Anesthesia
Laser Procedure
Fluence
Spot Size
Endpoint of Treatment
Laser Technique
Number of Sessions
Interval Between Sessions
Treatment of Individual Lesions
Epidermal Lesions
Café-au-Lait Macules
Lentigines/Solar Lentigo
Freckles
Nevus Spilus
Dermatosis Papulosa Nigra and Pigmented Seborrheic Keratoses
Dermal Lesions
Nevus of Ota
Nevus of Ito
Hori—s Nevus (Acquired Bilateral Nevus of Ota-like Macules)
Blue Nevus
Tattoos
Epidermal and Dermal Pigmentation
Melasma
Becker—s Nevus
Nevocellular Nevi
Postinflammatory Hyperpigmentation
Postoperative Instructions
Complications and their Management
Conclusion
54:
Lasers for Vascular Lesions
Introduction
Principles of Laser for Vascular Lesions
Laser Physiology
Factors Affecting the Absorption of Laser
Diameter of Vessels
Depth of Vessel
Site of Lesions
Age of Patients
Skin Type
Spot Size
Fluence
Role of Epidermal Cooling
Classification of Vascular Lasers
Flash-Lamp Pumped Pulse Dye Laser
Neodymium:Yttrium-Aluminum-Garnet Laser
Intense Pulsed Light (IPL)
Fractional Photothermolysis
Carbon Dioxide Laser
Anesthesia
Preoperative Counseling and Case Selection
Contraindications for Vascular Lesions
Absolute Contraindications
Relative Contraindications
Complications of Laser Treatment of Vascular Lesions
Prelaser Treatment Care
Postlaser Treatment Care
Port Wine Stain
Options for Treatment-Resistant Port Wine Stains47
Hemangioma
Facial Telangiectasia
Rosacea-Associated Telangiectasia and Erythema
Poikiloderma of Civatte
Pyogenic Granuloma
Venous Lakes
Cherry Angioma
Leg Veins
Conclusion (Table 54-6)
Credits
55:
Fractional Lasers
Introduction
Principle of Fractional Photothermolysis
Choosing a Machine
Indications for Fractional Laser Treatment
Patient Selection and Preoperative Management
Pre-treatment History
Contraindications for Fractional Lasers
Anesthesia
Postoperative Care
Complications of Fractional Lasers
Conclusion
56:
Nonablative Lasers, Lights and Other Technologies in Dermatology
Introduction
Evolution of Nonablative Technologies
Basic Mechanism of Operation of Different Nonablative Technologies
Machines and Details
Indications for Nonablative Laser
Contraindications
Case Selection
Counseling
Consent
Treatment Facility
Preoperative Preparations
Intraoperative Strategies
Postoperative Care
Complications
Current Status of Nonablative Technologies
Conclusion
Abbreviations Used in the Text
SECTION 6: MISCELLANEOUS TOPICS
57:
Patient Satisfaction in Esthetic Dermatology and Surgery
Introduction
What is Patient Satisfaction?
Benefits of a High Patient Satisfaction
Special Features of Esthetic and Dermatosurgery Practice
Methods of Achieving Service Excellence
Doctor
Patient
Hospital
Telephone Service
Office Appearance
Waiting Time
Doctor-Patient Interaction
Patient Education
Problem Solving
Feedback
Limitations of Patient Satisfaction Surveys
Conclusion
58:
Psychological Issues in Esthetic Surgery
Introduction
Psychosomatic Problems and Cosmetic Surgery
Body Dysmorphic Disorder (Dysmorphophobia)2,6,7
Personality Disorders10,11
Schizoid Personality Disorder
Paranoid Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Borderline Personality Disorder2
Depression2,5,15
Anxiety Disorders2,15
Obsessive-Compulsive Disorders2,15
Somatoform Disorders
Münchhausen Syndrome and Surgery Addiction
Management of Psychosomatic Patients Seeking Cosmetic Surgery
Conclusion
59:
Evidence-based Medicine in Cutaneous and Esthetic Surgery
Introduction
Increasing Scope of Esthetic Procedures
Spa Culture
Need for Ethical Guidelines for Esthetic Medicine Based on Evidence
Evidence-based Medicine
Cochrane Collaboration and Cochrane Skin Group
Marketing Power of Testimonials or Anecdotal Data
Concepts in Critical Appraisal of Medical Literature
Surgical Myths and Beliefs versus Evidence-based Medicine: Lessons Learnt
Factors Contributing toPerceived Improvements
Application of EBM in Practice of Dermatosurgery in India: Iadvl Dermatosurgery Task Force
Further Scope
Conclusion
60:
Accreditation
Introduction
Definitions and Nomenclature
History
Accreditation Process
International Organization for Standardization
National Accreditation Board for Hospitals and Healthcare Providers
Advantages of Accreditation
Criticisms for Accreditation
Conclusion
61:
Medicolegal Issues in Esthetic Surgery
Introduction
How is Esthetic Surgery Different from Other Surgeries?15-18
Esthetic Surgeon's Legal Duties to Patients20,21
Duty of Care in Deciding Whether to Undertake the Case
Duty of Care in Deciding What Treatment to Give
Duty of Care in the Administration of Treatment
Selection of Clients for Esthetic Surgery
Counseling
What is Consent?
Why Should One Take Consent?
What Constitutes a Valid Consent?
What is an Appropriate Consent for Esthetic Surgery?
Importance of Documentation
Confidentiality of Medical Data
Negligence
Medical Negligence42
Negligence of an Esthetic Surgeon
What is Standard Care in Esthetic Surgery?42,48-52
Legal Liability of an Esthetic Surgeon53-55
Medical Malpractice53-55
Res Ipsa Loquitor42
Liability of the Health Care Institution42,58
Contributory Negligence42,53,59
Criminal Liability42
Legal Defense for Esthetic Surgeon42,61,62
Technical Defenses
Factual Defenses
Conclusion
62:
Clinical Photography in Surgical and Esthetic Dermatology
Introduction
History of Photographic Documentation in Cosmetic Surgery
Importance of Good Imaging
Basic Principle of a Digital Camera(Anatomy and Physiology)
Equipment (Gear)
Camera—Digital Single-Lens Reflex (DSLR) versus Point-and-Shoot
Camera Resolution
Other Equipment and Setting
Patient Positioning and Preparation
Face
Torso
Hands
Lower Extremity
Magnification, Perspective and Depth of Field
Magnification
Depth of Field
Background
Lighting
Other Accessories
Frames
Display Devices
Framing Tips2,11,13
Flash-On-Off/Flash Diffuser
Storage2,15
Cataloging of Clinical Images
Ethics and Legal Issues
Consent, Image-Tampering, Copyright
General Recommendations—Summary and Tips2
Future
Useful Websites and Links
63:
Teledermatology in Esthetic Surgery
Introduction
Need for Teledermatology
System and Tools of Telemedicine
Models for Teledermatology
Store and Forward Technique
Conventional Model—Store and Forward Technique
Integration Model—Store and Forward Technique
Complete Store and Forward Technique Care
Live-Interactive Teledermatology
Hybrid Model
Mobile or Cellular Teledermatology
Satellite Communication Network
Home-based Teledermatology
Connectivity
Applications of Telemedicine
Patient Information Record (PIR)
Educational Tool and Teleconferencing
Challenges in Adopting Teledermatology
Telesurgery
Telefollow-up or Supervision
Teledermatology in Esthetic Surgery
Future Directions
Legal Aspects
Conclusion
ANNEXURE36
Informed Consent for Telemedicine Services (For Teleconsultation within India only)
1.1. Introduction
1.2. Possible Limitations
1.3. Patient Consent to the Use of Telemedicine
64:
Tips for Setting Up Clinics and Establishing Practice
Introduction
Tips to Establish a Successful Esthetic Clinic
Have a Success Formula
Starting an Esthetic and Laser Clinic
Start Slowly
Get the Best Quality Equipment
Hire Right Kind of Staff
Choosing the Right Location
The Premises
Designing the Signboard and Logo
Capital Investment and Expenditure
Taking Loans
Taking on Laser Clinic Franchisee
Insurance and Legal Requirements
The Client is King and Queen
Conclusion—One-Stop Service
Essential Equipments for a Trichology Clinic
Special Equipments
Dermascope
Phototrichogram
Polarized Light Microscopy
Conclusion
Introduction
Develop a Marketing Plan
External Marketing
Print Media Marketing
Radio
Networking
Networking Through Community Involvement
Seminars
Internet Marketing
Search Engine Optimization
Social Media Marketing
Internal Marketing—Retaining Your Clients
Ethical and Legal Issues in Marketing
Conclusion
65:
Dermatosurgery Made Easy—Tips for Beginners
Preparation of the Operative or Procedure Site
Local Anesthesia
Cryotherapy
Radiofrequency Surgery
Acne and Scars
Hemostasis—Tourniquet, Clamps
Vitiligo Surgery
Wound Closure
Ingrowing Toe Nail Surgery
Dressing
References
Conclusion
Local Anesthesia
Cryotherapy
Nail Surgery
Ear Surgery
Laser Surgery
Vitiligo Surgery
Punch Grafting11-14
Blister Grafting
Melanocyte Keratinocyte Cell Grafting
Hypertrophic Scars and Keloids
Topical Trichloroacetic Acid in Dermatosurgery
Dermaroller
Instruments
Other Pearls
Acknowledgments
66:
Suppliers Details for Laser Machines, Dermatosurgical and Esthetic Equipment/Products
DERMAINDIA, CHENNAI
MIKRO SCIENTIFIC INSTRUMENTS PVT LTD, DELHI AND BENGALURU
LUMENIS INDIA PVT LTD, GURGOAN
ALMA LASERS INDIA PVT LTD, MUMBAI
GULZAR IMPEX PVT LTD, DELHI
COHERENT MEDICAL SYSTEMS, MUMBAI
TIMPAC HEALTH CARE PRODUCTS, DELHI
FRAXEL RELIANT TECH, USA
GEOSOMATIC COSMECEUTICALS, PUNE
V-CARE MEDICAL SYSTEMS PVT LTD, BENGALURU
SAMIR SURGITECH PVT LIMITED, VADODHRA
FULCRUM COSMETECH, CHENNAI
ALLERGAN INDIA PVT LTD, BENGALURU
RANBAXY LABS, MUMBAIa
PERCOS, DELHI
MEDICURE PVT LTD, MUMBAI
AESTHETIX—DR REDDY LABS PVT LTD, HYDERABAD
GLENMARK COSMECARE
PARULEKAR SURGICAL INDUSTRIES, MUMBAI
SHREE BALAJI SURGICALS, DELHI
ALL INDIA SURGICAL MFG CO, MUMBAI
BASCO INDIA, CHENNAI
aDERMATECH INSTRUMENTS, MUMBAI
DELTA SCIENTIFIC, MUMBAI
DERMA COLOR, DELHI
NORMA DND PRODUCTS, DELHI
GLOSSARY OF LASER TERMINOLOGY ……………………
ABSORPTION
APERTURE
BEAM DIAMETER
COHERANCE
COLLIMATION
CONTINUOUS AND PULSED MODES OF OPERATION
CO2 LASER
DOSIMETRY
ENERGY
ER:YAG LASER
EXTINCTION LENGTH
FREQUENCY
FLUENCE
GROTHUS—DRAPER LAW
GROUND STATE
IRRADIANCE/POWER DENSITY
Calculation of Power Density
LASER
LIQUID LASER
LONG PULSED LASER
ND:YAG LASER
PHOTON
POWER
PULSE DURATION
PUMPING
Q-SWITCHING
SAFETY CLASS OF LASER
SEMICONDUCTOR LASERS
SOLID STATE LASER
SPONTANEOUS RADIATION
STIMULATED ABSORPTION
STIMULATED EMISSION
THERMAL RELAXATION TIME
ULTRASHORT PULSED LASER
WAVELENGTH
YAG
INDEX
TOC
Index
×
Chapter Notes
Save
Clear
