Procedural Dermatosurgery—A Step by Step Approach Savitha AS, Shilpa K, Manas Chatterjee, Biju Vasudevan, Shekhar Neema, Divya Gorur, Madura C, Harish Prasad, Sujala S Aradhya
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart and t refer to table.
A
Abdomen, lower 388f
Ablative lasers 578, 579
Absorbable sutures 28b, 29, 29f, 29t, 429f
Absorbent dressings 45
Acanthosis nigricans 563
Aceclofenac acetylsalicylic acid 307
Acetaminophen 386
Acetazolamide 376
Achalasia 619
Achilles tendon 275
Acid citrate dextrose tubes 201
Acne
form eruptions 609
keloidalis 335
nuchae 595, 595f, 596f, 602
necrotica 335
scars 131f, 137, 138f, 139, 236t, 462, 578, 582f, 583f, 622, 632, 633
classification of 135t, 578b
contraindications 140
grades of 581
grades of post 136
laser resurfacing, complications of 581b
managing 616fc
post 139f
preoperative care 139
remodeling of 579, 588f
severe 634f
steps of procedure 139
subcision 140
surgeries 14
surgical treatment of 135
technique 632
treatment of 135, 136
treatment, principles of 135
types of 135, 135f, 146t
surgery 462
vulgaris 135
Acral vitiligo 236
Acrochordon 489, 565
large 493f
removal 493f
Acrocyanosis 400
Acrylamide 273
Actinic keratoses 109, 505f, 570
Actinic telangiectasia 549
Adenoma sebaceum 109
Adrenaline 16, 354f
Adson's forceps 1, 288, 358
Advancement flaps 177
technique 177
types 177
Alae nasi 396f
Alexandrite lasers 546
Alkaline phosphatase 307
Alkalinization of lignocaine 286
Allergic
contact dermatitis 387
reaction 21, 459, 645
Allis forceps 1
Alopecia
areata 347, 353
chronic 348f
mucinosa 335
patches 637
traction 335
Alprazolam 376
Alveolar nerve, inferior 23
Amateur bindi tattoo 531f
Amateur tattoo 530t
Aminoglycoside antibiotics 620
Aminolevulinic acid-photodynamic therapy 553
Amiodarone 273, 376
Amniotic membrane 52f
Amyloidosis 273
Anastrozole 376
Anatomical snuff box 274
Androgenetic alopecia 130f, 131f
Anesthesia 110, 237, 308, 316, 564
before skin biopsy 59
beneath lesion 19f
choice of 216
infiltration of 276f, 354f
of donor area 309
of female external genitalia 436
of nail unit 284
Angiofibroma 557, 563, 566f
Angiokeratoma 549, 558f, 563
Anogenital dermatology 435
Antiandrogens 412
Antibacterial ointment 452
Antibiotics 307
Antifungal 376
Anti-inflammatory drugs 642
Antimicrobial dressings 45
Antiphospholipid syndrome 187
Antiretroviral drugs 273
Antiseptic cleansing 308
of donor area 308f
Antiseptic ointment 384f
Appendageal lesions-sebaceous adenoma 563
Appendageal tumors 69, 446
Areola 237
Arrector pili muscle, attachment of 325f
ARTAS robotic system 332
Arterial disease 187
Arterial injection 459
Arteriography 188
Arteriovenous fistula 323
Artery
dorsal digital 283
forceps 75f, 149, 149f, 317f, 358, 358f
Asepsis 254
Asian blepharoplasty 356f, 360, 361f, 367f, 368f
Asian eyelid 360f
Aspiration 438
cannula 393f
Aspirin 459
A-T plasty 181f
Atherosclerosis 187
Atraumatic technique 254
Atrichia, congenital 353
Atrophic acne scars 135
Atrophic scar 114f, 144f, 342f, 512f, 580, 587, 588t, 608f, 612f
laser treatment of 587
management of linear 628
mild 201f
post-traumatic 587f
Auditory canal, external 256
Auricular nerve
block, greater 24, 24f
greater 274
Auriculotemporal nerve block 255, 255f
Autoantibodies 188
Autograft postkeloid excision, use of 259
Autologous fat transfer 390, 398
indications 390
Autologous melanocyte cell suspension 237
Autologous minipunch grafting 208
Autonomous nervous system 400
Axilla 406
Axillary hyperhidrosis 406, 619, 620
B
Balanitis xeroticaobliterans 438
Bandaging 331
Bard-Parker handle 5t, 6
Barraquer needle holder 358
Basal cell
carcinoma 76, 109, 153f, 187, 453, 491, 517f, 518f, 645
large 451f
rich suspensions 221
Beard, anatomy of 340f
Becker's nevus 522, 529, 530f, 536, 596, 598f
Benzodiazepines 376
Bernard-Soulier syndrome 132
Berry-shaped keloid, excision of 262f
Bimodal compression dressing, final layer of 384f
Binocular stereo-microscopic dissection technique 316
Biopsy 274, 437
punches, half cut 478f
sample handling 274, 275t
site of 58
selection of 274
techniques 58t
Bipedicle advancement flap 179, 180f
Bites 187
Blade handles 149f
Bleeding 271
control 254
end point after dermaroller 137f
time 188, 307
Blepharitis 347
active 353
Blepharoplasty 356, 357
indications 356
instruments 358
lower 363
surgical anatomy 356
Blepharospasm 619, 623
treatment of 624f
Blister
dermatoses 58
disorders 187
formation of 212f
nonformation of 217
removal of 422f
Blood
sugar 307, 435, 436
postprandial 188
supply of lips 417f
urea 188, 307
vessels 435
Blood-tinged fluid, copious amounts of 385
Blue rubber bleb nevus 549, 557
Blunt punch 329, 329f
Blunt-tipped microcannula, use of 632
Blurring of pigment 642
Body hair transplant 332
Body mass index 375
Bone marrow 188
Borrelia neuropathy 273
Botulinum toxin 617, 620, 623
A 400, 404, 620
A injection 402, 404, 405f
A injection syringes 404
A injection technique 404
acts 622
B 400
dilution of 619t
in blepharospasm 623
in dermatosurgery 617
in lichen simplex chronicus 622
in palmar hyperhidrosis 621
in scars 622
indications of 619t
injection 624
interactions 617
preparation 617
storage of 619t
treatment 621
types of 617
Botulinum treatment 620
Bowen's disease 109, 437
Bowenoid papulosis 571
Boxcar scar 135, 136, 491, 578
Brain
injury, traumatic 619
tumors of 400
Breast, biopsy of 67
Bruising 368f
Buccinator muscle 373f
small portion of 372f
Buffy coat method 125, 201
Bupivacaine 436
Burn 335
scars 637
Burnt-out inflammatory alopecia 304
Bürrow's triangle 175, 179
Buruli ulcer 187
Butanediol diglycidylether 626
C
Cabrera method 460
Cadmium sulfate 642
Cadmium sulfide 637
Cafe-au-lait macule 526, 535
Caffeine 376
Calcific uremic arteriopathy 187
Calciphylaxis 187
Calcium
channel blockers 376
chloride 201
Callipers 358f
Cannula, entry of 632
Canthus of eye, lateral 371f
Capillary hemangioma 491, 506f
Capillary malformations 549
Carbon dioxide 579
Carcinoid tumors 400
Castroviejo's needle holder 7
Caucasian eye 360, 361
Caucasian upper eyelid 360f
Cavernosal veins 435
Cell
counting of 234
injury 471
separation technique 238, 238t
transfer 238f
Cell-based therapy, disadvantages of 235
Cellular grafting 10, 237
principles of 220
technique 220, 221
procedure of 221
types of 221
Cellulitis 187
Central centrifugal cicatricial alopecia 335
Central scalp necrosis 320
Centrifugation machine 222f
Cervical dystonia 619
Chalazion clamp 9, 67f, 269, 420f
Chalazion forceps 269f, 270f
Chang-Park classification 254, 254t
Charcot-Marie-Tooth disease 273
Cheatle forceps 2
Chemical matricectomy 464
Chemical nail avulsion 466
advantages 466
disadvantages 466
principle 466
procedure 466
Chemical peels 526
Chemical reconstruction of skin scars 136, 143, 462
Chemotherapy 347
Cherry angioma 483, 489, 549
Chickenpox scar 491, 512f, 632
Chloroquine 273
Choi/KNU implanter 353
Cholesterol 187
Chromated glycerin 457
Churg-Strauss syndrome 273
Cicatricial alopecia 335, 336, 337f
classification of 335t
primary 335, 338f
secondary 335
Cimetidine 376
Ciprofloxacin 376
Circumcision 438
anesthesia 438
complications 442
dorsal slit method of 440
early complications 442
indications 438
late complications 442
marking line of 439f
procedure 438
requirements 438
sleeve resection method of 440
Circumferential penile skin 444
Clarithromycin 376
Classic pseudopelade 335
Cleft lip surgery
post 632
scar 335
Clindamycin 412
Clonidine 308
Clopidogrel bisulfate 307
Clotting time 188, 307
CO2 laser 415, 561, 571, 574
Coagulation states 187
Cobbett modification 11
Cobble stoning 209
Cold air convection 600
Cold point burner 521
Cold steel surgery 94, 96, 96b, 97f
techniques of 96t
Cold trypsinization 226
Cole isolation
device 330f
technique 330
Collagen dressing of recipient area 227f
Collagenase 235
injections 264
Colle's fascia 435
Comedonal acne 493
Comedone extractor 9
Complete blood count 273, 456
Composite dressing 48, 48f
Composite grafts 49
Compound nevus 94f, 96f, 97f, 99f, 102f, 103f, 105f
Compressive device, application of 264f
Condyloma acuminata 483, 496f, 563
Cone/tower technique 630
indication 630
Congenital vascular malformations 187
Conjunctiva 356, 363
completed incision of 364f
starting incision of 364f
suturing 364f
Connective tissue diseases 187
Conservative sharp wound debridement 189
Conventional dressings 45
advantages of 45t
disadvantages of 45t
Corn over foot, multiple 92f
Corn, excision of 90
Cornea 348
Corneal spring scissors 358
Cosmetic
indications 619
tattoo 530
Cottle's hook 8
C-reactive protein 188
Crescentic incision 299
Crest syndrome 549
Crile-Wood needle holder 7
Cross-hatching technique 629, 630f
Crural vein 435
Cryo forceps 476f
Cryogen storage device 472
Cryoglobulinemia 187
Cryogun/cryogen spray canister 471, 472f
Cryoprobe technique 475
Cryospray 478f
nozzles 472f
Cryosurgery 251, 438
equipment 471
Cryotherapy 377, 470, 471, 471f, 473, 475, 478f, 479, 479f, 481f, 482
complications of 480
indications 470
mechanism of action 470
protocol 472
Cultured melanocyte 221
Curette biopsy 63
Curette technique 189
Current laser devices 524
Curvature of needle 31f
Cut finger guard 127f
Cutaneous
lesions, range of 563t
lupus erythematosus, chronic 335
necrosis 459
nerve
exposed, thickened radial 280f
radial 274, 279f, 280f
surgery 28
vascular lesions, treatment of 544
Cyanoacrylate
adhesive 213f
tissue glue 51, 52f
use of 142f
Cyclosporine 376
Cyproterone acetate 412
Cyst 69, 333, 430f, 570
benign 437
classification of 69
excision of 69, 82f
of milia, intraepidermal inclusion 74f
Cystic acne 462
D
Danazol 376
Dapsone 412
Darier's disease 109
Davol dermatome 12
Deep vein thrombosis 187, 388, 459
De-epithelialization, superficial 423f
Deformity
assessment of 628
step off 40f
Depigmentary macules 610
Depigmentation 611f
Depigmented mucosa, excision of 426f
Depot technique 630, 631f
indication 630
Dermabrasion 94, 108, 113f, 241, 242
contraindications 109
deeper level of 112f
equipment 109
indications 109
level of 112f
modifications 114
operative procedure 111
order of 111f
principles of 108, 109f
step-by-step 109
types of 108f
Dermal
fillers 123, 626, 628
grafting 143
conventional technique 143
procedure 143
growths
ablation of 615fc
benign 565
injury, deep 254
pigmented lesions 526, 528
replacements 49
tissue 372f
Dermaroller treatment 138f
Dermatochalasis 367f
Dermatofibrosarcoma protuberans 645
Dermatography 637
Dermatologic surgery, office-based 16
Dermatoses papulosa nigra 467, 493, 563, 564
Dermatosurgery 44, 49, 462, 484, 626
Dermatosurgical
instruments, classification of 1t
procedure 259
technique 108
Desert sore, acute 187
Desmarres retractor 358
Detrusor hyperreflexia 619
Dewar can 473f
Dextrose 457
Diabetes 187, 640
mellitus 452, 456
Diamond block technique 255f
Diathermy 227
Diazepam 376
Digital block, proximal 24, 284, 294, 296, 297, 298, 299, 300
Digital nerves, palmar and dorsal 25f
Diltiazem 376
Dimple
anatomy of 370
creation 370, 371f
positioning of 370, 371f
postoperative care 372
principle 370
surgery, complications of 374t
surgical technique 370
Diode laser 579
Dipstick application method 474, 474f
Dipyridamole 307
Disease process, active 577
Disposable electrocautery equipment 520f
Disposable otoscope specula 474f
Dissected sural nerve 278f
Dissecting cellulitis 335
Distal digital block 24, 285, 286f
Dizziness 385
Dog ear
correction of 75, 77f
deformity 75
formation 262, 262f
Donor area 345, 348
evaluation 305
full trim of 326f
marking 308
necrosis of 334
sutured 154f
Donor hair 336
Donor site wound, management of 153
Donor strip 314f
excision 309, 309f
marking 308f
Donor wound closure 310, 312f
Doppler ultrasound 188
Doxycycline 609
Draining cyst 463f
Dressing
compression 410f, 421f
materials collagen 238f
postoperative 289f
removal of 152, 241, 243, 245
techniques 228f
types of 45
Drug induced hyperpigmentation 529
Dry mucosa of lip 417
Dual plane technique 630, 631f
indication 630
Dulbecco's modified eagle medium 221, 222f, 230, 239
Dumbell ear keloid 260f
Dynamic cryogen cooling 600
Dyschromia 494f, 501f
post-therapy 587
Dysesthesia 275
Dystonia, occupational 619
Dystrophic nails 297f
E
Ear keloid 259, 264, 507, 511f
classification of 254
etiology of 254t
management of 256
postsurgery, recurrence of 263
surgery, principles of 254, 255t
Ear lobe
cleansing of 267f
clefts 266
draping of 267f
inferior margin of 268f, 271f
keloids, surgical management of 254
notching of 271
piercing 266
repair 266, 469, 507
advantages 469
chemical 469
disadvantages 469
procedure 469
tear
complete 266, 272f
incomplete 269f
partial 266
prevention of 272
tract intact 271
Ecchymosis 557
Eccrine hidrocystoma, multiple 625
Eclipse blood collection needle 129f
Ectodermal dysplasia 347
Ectropion 366
Eczema 519f
Edema 368, 386
Electric circuit 484
complete 485f
type of 484
Electrocautery
applications 521
machine 520f
Electrocoagulation 489, 502f
Electrodes, polarity of 486
Electrofulguration 487f
Electro-optical synergy 605
technology of hair removal 609
Electroporation 17f
Elliptical excision 71f
advantages of 103t
disadvantages of 103t
principles of 101b
S-shaped modification of 162f
Elliptical incision 429f
Emboli 187
En-bloc nail biopsy 297, 299f
Endo-oral method 23
Endothelial cells 390
Enoxaparin 307
Entropion 366
Enzymatic technique 145
Epidermal
cell suspension 541f
making 232
closure 30f
cyst 571, 645
fractions 239f
grafts 48, 221
growths, ablation of 615fc
necrosis 262
necrotic debris, microscopic 139
nevus 109, 503f, 563
pigmented lesions 524
suspensions, noncultured
melanocyte grafting of 433
Epidermoid cyst 81, 563
Epidermolysis 253
bullosa 335
Epinephrine 436
Epithelial cysts 333
Epithelial tract
excision of 267f
incision of 267f
Epithelium 328f
Erbium-doped yttrium-aluminum-garnet laser 189, 563, 567, 571, 574, 579
Ergotamine 187
Erythema 122f, 525f, 573, 613f
Erythematous scars 549
Erythrocyte sedimentation rate 188
Erythromelalgia 400
Erythromycin 376
Erythronychia, longitudinal 291f
Erythroplasia of Queyrat 437
Eschar formed after necrosis 323f
Ethanolamine oleate 455
Ethylenediaminetetraacetic acid 223
solution 221, 222f
Excimer lamp therapy 541f, 542f
Excimer laser 538
complications 539
contraindications 539
indications 539, 539b
procedural technique 539
Excised tissue 153f
Excision 421, 438
biopsy 58, 63, 64f
of basal cell carcinoma 517f
complications 79
principle of 76
types of 76
Exercise 332
Exophytic lesions 561
Extramarginal excision 256
Extraoral technique 23
Eyeball 363f
Eyebrow 237, 345, 446, 641
anatomy 342
complete
cosmetic enhancement of 347f
reconstruction of 347f
design 345
hair 353
micropigmentation of 642f
parts of 344f
transplant 345f
transplantation 342, 344, 345, 348f
counseling 345
vitiligo 351f
hairy areas of 351f
Eyelash
implantation of 355f
leukotrichia of 347, 353
loss of 353
transplantation 347, 349, 349f, 350t, 353, 354f, 355
complications 355
contraindications 353
indications 353
post-procedure care 354
procedure 353
techniques 353
types 353
Eyelid 446
anatomy 347, 348f
lower 357
upper 356
blepharoplasty
lower 363, 365, 367f, 368f
upper 357, 367f
central portion, retraction of lower 363f
lower 363f
marking of 357
resurfacing of 241f
sagittal cross-section of upper 357f
surgery 347
double 360, 361f
upper 237
F
Face, biopsy of 67
Facial
erythema 549
flushing 386
hyperhidrosis 405, 619
rejuvenation, part of 367f
scar 507
depressed 491
telangiectasia 548, 549, 549f
Familial amyloid neuropathy 273
Familial benign pemphigus 518f
Fanlike needle use 632
Fanning technique 629, 630f
indication 629
Fascia 413f
blunt dissection of 277f
superficial 435
Fascial layers 435
Fashion, linear 77f
Faster healing 423f
Fasting blood sugar 188
Fat
aspiration 381, 382f
excision of 364, 364f
filling, multiple sessions of 398
harvesting 390, 392
herniation of 112f
injection of 391, 396f
over-resection 366
pad 373f
processing techniques 391
transfer 392
anesthesia 392
complications 396
preparation 392
preprocedure 392
principles of 390
procedure 392
rationale of 391
steps of procedure 393
Feet, dorsum of 236
Fegan's technique 457, 458
Felodipine 376
Female genitalia surgeries 444
Female pattern hair loss 304
Fibroblasts 390
Fibroepithelial polyp 572f
Fibrokeratoma, digital 74f
Fibrous papules 557
Fibular nerve 274
Fillers
bruises, post 557
characteristics of 627t
classification of 626t
principle of 626
semi-permanent 626
types of 626
Film dressings 48f
Finasteride 412
Fine needle aspiration cytology 273
Fine touch desiccation 489
Finesse cannula 382f
Fingers, dorsum of 243f
Fitzpatrick darker skin type 547
Flap 188, 204, 451
advantages 204
basic design of 174f
classification 204
color mismatch of 263, 263f
complications 204
disadvantages 204
necrosis 262
surgeries 173, 174
basic steps of 174
classification of 173
complications of 184
configurations 173
location 173
preoperative evaluation 174
vascular supply 173
survival 204
Flat scars, managing 616fc
Flow vascular malformations, low 455
Fluconazole 376
Fluoxetine 307, 376
Flurazepam 376
Fluvoxamine 376
Foam over liquid sclerosants, advantages of 461
Foam sclerotherapy 460
advantages of 461
disadvantages of 461
techniques of 460
Follicle depth 325
Follicular melanocytes 220
Follicular transection rate 325
Follicular unit extraction 229, 304, 325, 338, 350, 351f
principle 325
procedure 326
technique 335
Follicular unit grafting 315f, 353
double 353
Follicular unit structure 304
Follicular unit transplant 304, 350
principles of 304
procedure of 308
Follicular unit, removal of 326f
Folliculitis 322f, 334
decalvans 335
Foramen, infraorbital 419f
Forceps 1
epilation 2
guided method 440
iris 3
multiple 440f
sponge holding 2
technique 474
Fordyce spots 565, 565f
Forehead lipomas 89
Forehead vitiligo 210f
Foreign body granulomas 645
Foreskin
grasping of 440f
retraction of 438
Fox-Fordyce disease 109
Fractional CO2 on posttraumatic scar 610f
Fractional laser resurfacing, principles of 139
Fractional lasers 579
Frazier skin hook 8
Freckles 491
advantages 469
disadvantages 469
procedure 469
Frenular artery 442
Frenulectomy 442
Frenuloplasty 442
indications 442
procedure 442
Frenulum breve 442
Frontal fibrosing alopecia 335
Frozen tissue 449f
Frullini method 460
Fungal infections 187
Fungating tumor 187
Fusiform biopsy 296
Fusiform incision, longitudinal 298
G
Gamjee and Coban dressings 384
Gamjee roll dressing 384, 384f
Ganglionitis 273
Gauze strip tourniquet 287, 288
Gauze swabs 384f
General instruments 1
forceps 1
scalpels 5
scissors 3
Geneticin 234
Genital leiomyomas 437
Genital melanomas 437
Genital skin loss 444
Genitalia 236
simple surgical techniques over 437
surgeries of 435
Giant axonal neuropathy 273
Giant molluscum contagiosum 497f
Glandular tissue 406
removal 407
Glomus tumor 292f, 293f, 300, 549, 557
excision 301f
Glycerol-3-phosphate dehydrogenase 391
Glycine xylidide 378
Glycogen storage disorders 273
Glycolic acid 609
Glycopyrrolate 400
Golgi and endoplasmic reticulum 220
Gollicular unit extraction 325
Goodman and Baron qualitative global acne scarring grading system 579t
Gracilis muscle biopsy 274
Graft
adjusting position of 316
contraction 155
dissection, stages of 314
extraction, manual 330
failure 155, 338
causes of 156t
handling of 217
harvesting of 149, 221, 229f, 238f, 237, 334
immobilization of 213f
insertion of 316
out of body time of 331
preparation 311, 314
proper positioning of 209f
removal of 330
revascularization 193
techniques 193
transfer of 218
type of 433
uptake, steps of 147, 148f
Graft-versus-host disease 187, 335
Graham little syndrome 335
Grasping graft 316
Grasping tarsal plate 362f
Gravimetry test 400, 401, 401f
Guidewire punch technique 271
Guillain-Barré syndrome 274
Guthrie skin hook 8
H
Haber spreader 8
Hailey-Hailey disease 109, 518f
Hair
bearing skin flaps 602
crooked 338
excessive 592
follicles 230f, 234
entire 592
extracted 229
follicular unit
anatomy of 325f
grafts 316f
growth
cycle of 602t
poor 322
implantation of 354f
line, poor 319
loss
congenital causes of 304
male pattern 304
misdirection of 338
removal 592t, 605
removal devices 596
intensepulsed light systems 599
long-pulsed ruby laser 596
restoration surgery 307
transplant, post 598f
transplantation 13, 55, 304, 325, 335, 336, 338f
implanters 13
Hair-bearing skin flaps and grafts 596
Hairy Becker's nevus 602
Hand dermabrasion 240f
Hand, dorsum of 236, 243f
Hansen's disease 273, 274, 279
Harris safe technique 330
Harvesting cannula, selection of 391
Headache 619
Heart diseases 400
Hemangioma 549, 554, 555f
Hematological disorders 187
Hematolymphoid tumors 69
Hematoma 155, 275
acute 40f
formation 171, 423f
large 298
small 298
Hemifacial spasm 619
Hemoglobin 188
nonselective lasers 545
selective laser 545
Hemogram 188, 307
Hemostasis 311f
Hemostat technique 309
Hepatitis 473
B 392
C 392
Hereditary hemorrhagic telangiectasia 549
Hereditary motor neuropathies 273
Hereditary sensory neuropathies 273
Herpes labialis 580
Herpes simplex 114, 273, 600, 604
infection 573f, 609
virus
infection 578
reactivation of 610
Herpes virus reactivation 610f
Herpes zoster 273
Hidradenitis suppurativa 412414, 415t, 563, 596, 597, 602
incision and drainage 413
management of 413, 414
surgical therapy 412
treatment of 412
Hidradenoma papilliferum 437
Hirsutism 593f, 594f
Hori's macules 529, 536
Hormone replacement therapy 455
H-plasty 181f
Human immunodeficiency virus 273, 392
disease 473
Human papilloma virus 565
Humby's knife 10, 148, 149, 149f, 150, 151f, 194
Hurley staging system 412
Hyalorunic acid 626
concentration of 627
filler 626
Hyaluronan 626
Hyaluronic acid 226
Hyaluronidase injection 627
Hydrocolloid 46
Hydrofilm dressings 53
Hydrogel 46
dressings 57
Hydroquinone 526, 609
Hydroxy methylcellulose gel 227f
Hydroxycarbamide 187
Hyperesthesia, postoperative 339
Hyperhidrosis 400, 400t, 620
disease severity scale 400, 402
local surgical procedures 406
procedures 402
severity of 402
surgical
management of 400
procedures 406
Hyperhidrotic field 620
Hyperhomocysteinemia 187
Hyperkeratotic lesions 109
Hyperpigmentary disorders, treatment of 522
Hyperpigmentation 171, 603
Hyperpigmented disorders 523t
Hypertension 187, 456
Hyperthyroidism 400
Hypertonic saline 457
Hypertrichosis 593, 600
Hypertrophic lichen planus 109
Hypertrophic scar 114, 115f, 135, 146, 171, 248, 322f, 338, 491, 507, 549, 558f, 586, 586f, 586t, 611f, 616fc, 623
linear 577
tendency of 59
Hypoesthesia, postoperative 339
Hyponychial block 286
Hypopigmentary disorders, treatment of 538
Hypopigmentation 573, 603
disorders 9
Hypopigmented scars 578
I
Iatrogenic alopecia 353
Iatrogenic tattoo 530
Ibuprofen 307
Ice pick scars 135, 136, 146, 578
Idiopathic calcinosis cutis 437
Iliac veins, internal 435
Immune cells 390
Implantation 316, 338
direction of 346
Implanters 316, 318
Incision 358
biopsy 63
small 509f
Incontinentia pigmenti 335
Indian Association of Dermatologists, Venereologists and Leprologists 208
Indinavir 376
Indomethacin 307
Infections 187, 271, 300, 335, 339
Infiltrating cells, type of 58
Inflammatory demyelinating polyradiculoneuropathy, chronic 273
Infraorbital foramen, region of 419f
Infraorbital ridge, superior border of 23f
Ingrown nail, management of 293
Inherited tumor syndromes 69
Instruments sterilization methods, sterilization of 14
Intense pulse light 546, 580, 607
Intradermal
botulinum toxin A injection 621f
injection 400
nevus 94f, 493
Intralesional corticosteroids 415
Intralesional cryosugery using needle cryoprobe 251
Intralesional cryotherapy 475, 476f
steps of 252f
Intralesional injection 248
steps of 249
Intralesional platelet rich plasma 131f
Intralesional verapamil injection 263
Intramarginal excision 256
Intraoperative hydration, maintaining 218
Iododerma 187
Iontophoresis 400
technique, disadvantages of 17
Iron oxide 637
Ischemic heart disease 456
Ischiorectal fossa 436
Isoniazid 376
Isotretinoin 412
Itraconazole 376
J
Jessner's solution 468
Jeweller's forceps 3, 288, 288f, 354
Joseph's double skin hook 8
Junctional nevus 104f
Juvenile neuroaxonal dystrophy 273
K
Keloid 114, 171, 248, 254, 259, 271, 483, 563, 581, 586, 586t, 616fc, 623
borders of 249f
core extirpation 257
dermatosurgical
management of 248, 248t
excision of 263f
management of 248
minor 577
of helical rim 258
recurrence of 263
surgeries 256
surgical excision of 251
treatment of 248, 248t
Keloidectomy, standard 256, 256f
Keratinocyte
grafts 221
growth media 232
Keratinocytic tumors 69
Keratoacanthoma 645
large 446
Keratoses 491, 502, 563
actinic 489, 491, 502
follicularis spinulosa decalvans 335
seborrheic 489, 491, 502
Ketoconazole 376
Ketoprofen 307
Keye's punch 209f
Kidney function tests 307
Klein's formula 392
Kleins’ tumescent anesthesia solution 378f
Klinefelter's syndrome 187
Klippel-Trenaunay syndrome 187f
Kocher's forceps 194
Kojic acid 609
L
L specular plasty 270
Labia majora 237, 246
Labia minora 246
Lactic acid 466
Laminar air flow 238f
Laminar flow hood 221f
Laser
choice of 578
debridement 191
over mechanical debridement, advantages of 192
devices 546, 561
hair reduction 607, 608f
complications 607
hair removal 592, 596, 605b, 608f
bacterial infection 604
complications of 603
diverse applications of 593
infections 604
mechanism of 592
pain control 605
parameters 602t
safety 604
treatment guidelines 600
treatment technique 601
imprint 554f
in cysts 571b
in dermatosurgery 522, 538, 544, 561, 577, 578, 592, 607
complications 607
safety 607
principles 522, 561
procedure, steps of 580
safety 613
measures 607
surgery 55, 106
advantages of 107t
technique 271
tissue interaction 561, 562f
types of 546b, 579t
Led dermarollers 119
Leg ulcer 50, 187t, 202f, 204f
chronic 188, 205
curette debridement of 191f
laser debridement of 192f
management of common 188
nonhealing 47f
scalpel debridement of 190f
surgical management of 187, 188
Leg veins 554
treatment 555b
Leishmaniasis 187
Lentigenes 109
Lentigo maligna 446
Leprosy 187, 273
Lesion
benign 417
superficial 429
type of 574
Leukocyte 130
Leukoderma 538
Leukoplakia 438
Leukotrichia 212f, 236
Leukotrichic eyelashes, removal of 354f
Levator aponeurosis 360f, 361, 361f
identification of 362f
lower attachment of 360f
Lichen planopilaris 335
Lichen planus pigmentosus 533f
Lichen simplex chronicus 109, 622, 622f
Lichenified eczema, chronic 516
Lid spatula 358f
Lidocaine 612
Lignocaine 17, 61f, 223f, 402, 515f
Linear threading 628f
technique 628
Linear verrucous epidermal nevus 109, 113f
Lip 236, 237, 243, 446, 641
enhancement surgery 417
incised margin of 427f
infiltration of 424f
leukoderma 433
mucosa, lower 426f
nerve supply of 417f
permanent makeup for 642f
retract lower 419f
stabilization of 420f
topical anatomy of 418f
vitiligo 209f, 417
presurgical photo of 421f
Lipobodysculpting 375
consent 377
examination 376
investigations 376
plan 376
preoperative 377
procedure 375
Lipodissection 375
Lipodystrophy 632, 633f
Lipoma 87
excision 33f
frontalis-associated 89
over back 36f
postoperative care and advice 87
preoperative preparation 87
procedure 87
special situations and modifications 89
steps 87
Liponots 387
Liposuction 55, 391, 407, 408
cannula 407f, 409f
instruments 407
procedure 407
Lipotrops 387
Liquid nitrogen 470f, 471
Livedoid vasculopathy 187
Liver function test 188, 307
Local anesthesia 16, 255, 338, 358, 361, 363f, 424f
administration of 267f
eutectic mixture of 17, 59
infiltration of 267, 269f
of lower eyelid 364f
of upper eyelid 358f
Lorenzo Tessari's tourbillon technique 460
Luer lock syringe 392, 396
Lupus erythematosus 347
cell test 188
Lyme disease 273
Lymphangioma circumscriptum 557, 563, 567
M
Macrolide antibiotics 376
Macular disease 579
Male external genitalia, anatomy of 435
Malnutrition 640
Maneksha's manual dermabrader 9, 110f
Mantis microscope 313f
Matricial block 285
Matrix horn resection 296
selective 294
Matrix metalloprotease 253
Mattress suture
half buried vertical 34f
horizontal 33f
running horizontal 35, 35f
Mayo-Hegar needle holder 7
Mucus cyst 429f
Medical tattoo 530
Melanocyte 233f
culture 232, 233f
procedure of 231
grafts 221
source of 220
transfer of 234
Melanocytic nevus 106, 491, 528, 528f, 567, 568f
congenital 36f, 106, 106f
treatment of 528, 536
Melanocytic tumors 69
Melanoma 187
in situ, malignant 446
malignant 645
Melasma 109, 526, 535
Menstrual cycle, irregularity of 387
Mental nerve 23
block 423f
Mepitel dressings 54f
Merkel cell carcinoma 446
Meshing graft 152f
advantages of 152t
disadvantages of 152t
placement of 152f
Mesotherapy 118
Metabolic disorders 273
Metallic dermabradors 109
large 114
Metastatic primary neoplasm 335
Metatarsal block, step-by-step procedure 285
Metatarsophalangeal joint 285
Methemoglobinemia 612
Methyl N-butyl ketone 273
Methylene blue 317f
Metronidazole 376
Metzenbaum scissors 407
Michel's solution 65
Miconazole 376
Microcannular lipobodysculpting 376
Microdermabrasion
steps of 477f
tips 476f
Microneedling 117, 136
advantages of 122, 137
complications 121
contraindications 118, 137
disadvantages 122
histopathology 118
indications of 117, 136
innovations 123
instruments 118
postprocedure care 121, 137
preoperative care 120
preprocedure preparation 120
Micropigmentation 246, 637639, 644f
basic principles 637
contraindications 639
in miscellaneous conditions 639
indications 638
inks for 638f
instruments 637
preparation of pigment 640
preprocedural counseling 639
preprocedure work-up 639
procedure steps 640
Microwave device 411
Midazolam 376
Migraine 619
Milia 493, 645
formation 573
Minipunch grafting 208
Minocycline 609
Minor's starch iodine test 401, 401f, 620
Mitomycin-C 264
Mobilized mucosal flap 427f
Moh's defect 447, 448f, 450, 451, 452
complex linear closure of 451f
repair of 451f, 452f
scalp size of 452f
Moh's micrographic surgery 79, 81, 437, 446, 451f, 453
advantages 453
complications 452
disadvantages 453
indications 79, 446
modifications 79
postoperative care 452
principles of excision 79
technique 446
Moh's procedure 453
Moh's surgery 446
post 452
Moh's technique 453
Mole
artificial 641
excision of 50f
Mole removal 107b, 500f, 501f
contraindications 95t
indications 95t
steps of 500f
Mole surgery 94, 95, 104
complications of 104, 104t
dermabrasion 95
procedure 95
types of 95
Molluscum contagiosum 489, 493, 557
multiple 497f
Molluscum lesion 498f
Molluscum, removal of 495f
Monfreux method 460
Monoclonal gammopathy 273
Monoethylglycinexylidide 378
Monofilament sutures, properties of 30t
Monopolar function 487f
Morning-after-liposuction syncope 385
Morphea 391
Moth eaten appearance 332, 333f
Motor dermabraders 110f
Motor neuron disease 274
lower 274
Moustache hair transplantation 339, 342f
Mouth, angle of 237
M-plasty 169f
Mucocele removal 506
Mucosal advancement flap 425, 433
principle of 426f
Mucosal fibroma 571
Mucosal lesions 506
Mucous cyst 417, 427, 430f, 460f
blanching of 430f
over lower lip 428f
Muller's muscle 356
Multiblade scalpel 309
Multifilament sutures, properties of 30t
Mupirocin 452
Muscle 373f, 617
herniation 275
spasm 619
Muscular injury 387
Mycobacteria 187
Myeloproliferative disorders 187
Myofascial pain syndrome 619
Myxoid cyst 563
N
N-acetylglucosamine 626
Nail
avulsion 290
distal 290
partial 292, 293f, 294, 295f, 296
proximal 290, 292f
technique of distal 291f
types of 290
bed 283
biopsy 296, 297f
plasty 296
biopsy 67, 296
indications 296
types of 296
fold
arcade, dorsal 283
lateral 285
proximal 283, 285, 301f, 302f
ingrown 293
matricectomy electrode 516f
matrix 283, 515f
biopsy 297, 298f
lateral horns of 294, 295f, 296
phenolization, lateral 294f
plate 283, 290, 298
avulsion 290, 292
biopsy 296, 296f
distal half of 295f
distal two-thirds of 296
lateral strips of 294, 296
partial loss of 297f
proximal third of 299
separation of 296f
structure 282f
spatula 288, 288f, 292f, 297
splitter 288f
surgery 12, 53, 55, 55f, 282, 288, 300, 464, 563, 571
anatomy of 282, 282f
freer septum elevator 12
instruments 288f
procedures 290
spatula 12
splitter 12
unit anesthesia 284, 290, 292
Naproxen 307
Nd:YAG potassium titanyl phosphate, frequency-doubled 546
Necrobiosis lipoidica 187
Necrotizing fasciitis 187
Necrotizing leukocytoclastic vasculitis 187
Needle 30
holder 6, 288, 358
parts of 31f
Nefazodone 376
Nelfinavir 376
Neodymium-doped yttrium aluminum garnet (Nd:YAG) 415, 579
laser 544, 546
Nerve
biopsy 273275, 281
complications of 275t
indications 273
preparation 273
site of 274t
block 22
advantages 22
anesthesia 418
digital 24
disadvantages 22
drawbacks of 403
infraorbital 23
median 403, 403f
radial 402, 403, 403f
supratrochlear 22, 23f
compression, chronic 273
conduction 273
damage 453
innervations 435
ischemic injury of 273
of clitoris, dorsal 436
supply 283, 436
supraorbital 22
supratrochlear 22
tumors
primary 273
secondary 273
Neural tumors 69
Neurofibroma 563, 568
baseline multiple 570f
removal of 570b
Neuroma 275
Nevus 563, 567
congenital 528, 568f
depigmentosus 538, 643f
of Ota 528, 529f, 535, 611f
recurrence of larger 106f
sebaceous 563, 568
along hairline 569f
simplex 552
spilus 527, 527f, 535
treatment of 615fc
Nicardipine 376
Nifedipine 376
Nipples 236
Nitrous oxide 471
Nodulocystic lesions 463f
Nonabdominal fat 390
Nonablative lasers 579
Nonabsorbable suture 29, 29b
properties of 30t
Nonanimal stabilized hyaluronic acid (NASHA) 632
Noncollapsible silicon rubber tubing 381
Nonculture melanocyte transplant 228
Nondominant hand, index finger of 418f
Nonequilibrium gels 627
Nonfacial areas 547
Nonhealing traumatic ulcer, chronic 131f
Nonpressure dressings 49
Nonsteroidal anti-inflammatory drugs 241, 386, 456
Norfloxacin 376
Nose 446
Numbness 332
O
Obesity 400, 640
Oblique muscle palsy, inferior 366
Occipital nerve block, greater 24f
Occlusive dressings, properties of 46t
Office radiofrequency surgery 489
Office surgery 484
Omeprazole 376
One stroke excision biopsy 517f
On-off technique 217, 217f
Onycholysis, permanent 300
Oozing 332
Open spray techniques, types of 474f
Open technique 361
Oral
biopsy 67
cavity, anatomy of 417f
isotretinoin 140
mucosa
anesthesia 418
principles of procedures 418
surgeries of 417, 431, 431t
Orbicularis muscle 356
Orbital fat 362, 362f
removal 358, 359f
Orbital septum, exposure of 362f
Osteomyelitis 187
Osteophyte, traction 296
Oxybutynin 400
Oxygen, role of 44
Oxyhemoglobin 544
Oyster shells, fixing of 264f
P
Pachyonychia congenita 621
Padgett dermatome 12
Paget's disease 437
extra-mammary 446
Pain 275, 300, 573
Palms 237, 406
analgesia of 402
biopsy of 68
nerve block of 402
Palmar digital nerves innervates index 283
Palmar hyperhidrosis 405f
Palmoplantar hyperhidrosis 619
Palpate mental foramen 418f
Pandermal necrosis 555f
Papillary dermis 246f
Papillary hidradenoma 437
Papillomas 571
Papular acne scars 146
Papular lichen amyloidosis 109
Papular scars 563, 572f, 573f, 584f
Paracetamol 386
Paradoxical hair growth 604, 604f
Paradoxical hypertrichosis 604, 608f
Paraffin embedded nonadherent sterile gauze 53f
Paraffin gauze dressing 420f
Paraneoplastic neuropathy 273
Paraphimosis, management of 443
Paresthesia 275, 332
Paronychia
acute 299
chronic 299
Paronychial surgery 298
Paroxetine 376
Patch grafting, steps of 199f, 198f
Peau d’ orange, appearance of 18
Pedunculated keloids 256
Pedunculated lesions 483
treatment of 475
Pemphigoid 187
Pen holding grip 111f
Penile
anesthesia 435, 436
biopsy 67
block 436, 439f
dressing technique 441
nerves, dorsal 436
skin loss 444
Pentoxifylline 307
Perineal nerve 436
Periorbital region 241
Periorbital syringomas 567f, 574, 574f
Peripheral nerve sheath tumors, malignant 273
Peripheral vascular diseases 400
Periungual fibroma 300, 301f
Peroneal nerve, superficial 274
Persistent erythema 573, 610f
Petri dish 222f
Phenol 468
Pheochromocytomas 400
Phimosis 441
Phosphate buffered saline 221, 222f
Photoplethysmography 188
Photosensitization allergy 642
Picosecond lasers 532
Pigment
depth of 522f
paste, application of 641f
specific pulsed dye laser 524
Pigment laser 610
complications 610
Pigmentary lesions 109
managing 615fc
treatment of 524t
Pigmented hair follicle 592
Pillar and bridge technique 631, 631f
Pilomatricomas, small 563
Pilonidal sinus 602
disease 596, 597f
Pincer nail 294
surgery 295f
Pinch graft 151, 196
Pinch test 383f
Pinpoint white scars 332
Piroxicam 307
Planning bilobed flap 452f
Plastibell clamp 14
Platelet 187
activation of 129
concentrates 188, 200
dysfunction syndrome 132
rich fibrin 130
matrix 188, 203
matrix treatment 204f
rich plasma 124, 127f, 130, 131f, 188, 200
action of 200
classification of 130
complications 132
contraindications 132
delivery, techniques of 129
indications of 130
infiltration of 127f
method 125
modified syringe technique 127
preparation of 125
procedure 125
procedure, basic principle of 125
therapy, pathophysiology of 124
vacutainer technique 125
Plexiform neurofibroma excision, partial 40f
Pocket technique 143
Podophyllin 466
Poikiloderma 532f
of civatte 532, 549, 550, 552f
Polidocanol 429, 455, 457
Polka dot appearance, prevention of 211
Polyangiitis, microscopic 273
Polyarteritis nodosa 187, 273
Polycythemia rubra vera 187
Polyhexamethylene-biguanide 45
Polyiodinated iodine 457
Polypropylene
6–0 simple interrupted sutures 268f
deep 271
suture 30f
Porokeratosis 109
Port wine stain 544, 552, 553f
color of 554
Postage stamp grafting 198, 200f, 201f
Postburns keloids 253
Postherpetic neuralgia 623
Postinflammatory
depigmentation 574f, 611f
hyperpigmentation 109, 122f, 464f, 522, 573, 573f, 608f, 609
hypopigmentation 574, 608f
Post-laser
depigmentation 609
instructions 573
Post-liposuction
edema 388
panniculitis 387
Postradical keloidectomy 257f
Postresurfacing dyschromia 513
Postsclerotherapy hyperpigmentation 459
Potassium
hydroxide 66
titanyl phosphate 544, 610
Povidone iodine wick, application of 294
Power dermatome 11, 149f
Power driven dermatome, advantages of 151
Preanesthesia marking of vermilion border 419f
Preputioplasty 443
indications 443
Pressure
alopecia 335
earrings 251f
infusion bag 380f
sores 51
therapy 251, 264
Prilocaine cream 612
Probanthine hydrochloride 400
Progressive systemic sclerosis 187
Prolidase deficiency 187
Protease inhibitors 376
Protein
C deficiency 187
S deficiency 187
Prothrombin time 307
Protuberant lesions 502, 502f
Prurigo nodularis 109
Pruritus 332
Pseudo dog ear formation 76
Pseudofolliculitis 333f, 602
barbae 593, 595f, 602
Pseudosyphilitic appearance 332, 333f
Pterygium 300
Pudendal block 436
Pulley sutures 35
Pulse
duration 523, 600
dye laser 250, 544, 546, 586
lasers, long 524
oximetry 188
Punch
circular 393f
grafting, miniature 420, 433
selection of 329
shaft length of 330f
sizes of 61f
types of 61f
Punch biopsy 58, 61, 61f, 63, 63f
technique 61f
Punch excision 98, 99f, 141
and closure 98, 100t
and grafting 100, 100f, 100t
advantages 100
disadvantages 100
of corn 92f
of keloid 258f
of smaller nevus over nose 97f
single sided 257
steps of 99f
surgery 98, 98b
procedure 98
Punch floatation 141
indications 141
procedure 141
Punch replacement grafting 142
contraindications 142
indication 142
postprocedure care 142
procedure 142
Punch technique 141, 271
modified 271
Purse string sutures 38
Pustular dermatosis 335
Pustules, postoperative 320
Pyoderma gangrenosum 187
Pyogenic granuloma 73f, 491, 505f, 506f, 549, 557, 563, 612
Q
Q-switched
alexandrite laser 524
Nd:YAG
induced neocollagen 587
laser 524
laser for tattoo removal 611f
ruby laser 523, 524
Quinidine 376
R
Radial cutaneous nerve
anatomy of 279f
biopsy, marking site of 279f
Radial nerve biopsy, distal superficial 278
Radiation 187, 347
dermatitis 549
induced alopecia 335
therapy 250, 263
Radical keloidectomy 256, 256f, 257f
Radical skin excision 406
Radiocautery technique 271
Radiofrequency 484, 486t
application 489
equipment 484
functional features of 485
functioning 485
parameters of 489t
surgery rehearsal 488
surgical modality 484
technique 484, 485
tissue volume reduction 265
Radiosurgery
advantages of 96t
disadvantages of 96t
Raising suction blisters, method of 211f
Randomised controlled trials 250
Raynaud's disease 400
Raynaud's phenomenon 456
Recalcitrant lip vitiligo 643f
Recalcitrant stable vitiligo 638
Rectal fissure 619
Rectal nerve, inferior 436
Recurrent sessile keloid 257f
Refrigerant topical anesthesia 110
Relaxed skin tension line 60, 63f, 157
Residual thermal damage 563f
Residual tumor postbiopsy, site of 447f
Resistance hygrometry 400
Resurfacing lasers 524
Reticular veins 458
Reticulate erythema 604, 609
Reticulohistiocytoma lesion photos 504f
Retinoic acid 526
Retinoids 412
Rheumatoid
arthritis 273
disease 187
factor 188
Rhinophyma 112f, 491, 513, 563, 568
ablation of 568
resection 513
Rhinophymatous mass 516f
Rhombic flap 182
indications 182
technique 182
Rhomboid flap 183f
results of 186f
steps of 185f
Rhynophyma, nodules of 563
Rifampicin 412
Ring block 285
technique 436
Ringers lactate 311, 338
Ritonavir 376
Robotic hair transplant 332
Rosacea 549, 550, 551f
Rotational flap 175, 175f
double 177f
indications 175
results of 176f
steps of 176f
technique 175
Rule of halves 76f
Running sutures 35
Ryder needle holder 7
S
Safety razor grip 111f
Salicylic acid 466
Salmon patch 552
Sandwich technique 630, 631f
Saphenous vein 277f
Saquinavir 376
Sarcoidosis 273
Sartorius staging system 412
Scalp 305
biopsy 66
laxity exercises 306
micropigmentation 641
rollers 119
tumor 73f
Scalpel blades 149
Scar 109, 117, 387, 494f, 563, 573, 577, 604
alopecia 304, 335
analysis 158
closure 99f
depressed 146, 507
evaluation 135
grading system, qualitative 136t
greater contrast of 333f
large 163f
linear 161f, 168f
location of 577
postsurgical 580
depressed 399f
post-traumatic 339, 585f
punch excision 142f
revision
anesthesia 158
complications of 171, 171t
dressing 160
everted wound edges 160
excision 158
fusiform elliptical excision 160
general principles of 157
geometric broken-line closure 169
incision 158
layered wound repair 159
M-plasty 169
prevention 171t
serial excision 160
suture material 159
suture techniques 159
techniques 157, 157t,
timing of 157
tissue handling 158
undermining 158
V-Y plasty 170
W plasty 164
Y-V plasty 171
Z-plasty 161
rolling 135, 136, 146, 578
serial excision of 162f
surgical 623
traumatic 623
type of 146
vascular component of 587
widening 171
Scarpa's fascia 435
Scissors
dressing scissors/nurses 3
excision 98
iris 4
Lister bandage 4
Mayo 4
Metzenbaum 4
O'brien 4
spencer 5
Scleroderma 187
localized 634
Sclerosant 455
injection 430f
Sclerotherapy 429, 554, 455, 456t
absolute contraindications 456
advantages of 461
complications 459
contraindications 455
indications 455
mechanism of action 455
postprocedure care 458
preprocedure work up 455
procedure 457
relative contraindications 456
special techniques of 460
Scoring incision, superficial 310f
Scrotal fascio-myocutaneous flap 444
Scrotal skin, layers of 435
Scrotal steatocystomas 90
Scrotum 237, 245, 435
Sebaceous cyst 81, 82f, 491
advantages 81
disadvantages 81
excision 508f
hydrodissection of 86f
indications 81
modifications 81
principles of excision 81
removal 85f, 506, 507
steps 81, 87
traditional wide excision 81
types of excision 81
Sebaceous glands 580
of Zeis 353
Sebaceous hyperplasia 557, 563, 571
Seborrheic
keratoses 59f, 109, 467, 503f, 504f, 565
melanosis 613f
Secretory gland 617
Seitelberger disease 273
Senile comedones 489, 493
Senn retractor 8
Sensation, loss of 187
Serial puncture technique 629, 629f
Seroma 155, 388
formation 388f
Serotonin reuptake inhibitors, selective 376
Sertraline 376
Serum
albumin 188
bilirubin 307
creatinine 188, 307
electrolytes 188
proteins 307
Sewing technique 353
Sexually transmitted infections 438
Sharp punch 329, 329f
Shave biopsy 5860
technique 59f
Shave excision 97
advantages of 98
disadvantages of 98
method 490
Shelley's procedure, modified 407
Short incision technique 362
Sialorrhea 619
Sickle cell disease 187
Siegel handle 6
Silicone gel sheet 264
application of 264f
Silver
knife 10, 148, 149, 149f, 194
nitrate 60
white glistening fascia 362f
Simple elliptical excision 69, 77f
complications 75
modifications 69
principles of procedure 69
steps 69
Single blade scalpel 309
Single hair grafts 316f
Single punch technique 296
Sip biopsy 66f
Skin 356
biopsy 13, 231, 515
derma blade 13
punch 13, 91f
biopsy techniques 58, 59
complications 66
contraindications 58
indications 58
cancer 187
closure 366f
cooling 600
disease 578
chronic 640
disorders 187
excision 413f
limited 406, 407
flaps, local 444
grafting 147, 188, 193, 239f
camouflaged 644f
classification of 147, 147f
complications 155
contraindications 155
donor site selection 148
full thickness 147, 148, 155, 193, 194, 196, 444, 452f
indications 147
postoperative care 155
preprocedure work up 148
procedure 148
steps of 195f
thin and ultrathin split thickness 433
thin split thickness 212
hook 8, 270, 310f
technique 309
incisions 358
necrosis, overlying 387
permeation enhancers 17
preparation of 438
prolonged numbness of 386
rejuvenation 117
retractors 8
surface 641f
biopsy 65, 66f
suture 360f
tag 489, 491, 520f, 565
tapes 40
tumors 571
type 577
undermining of 365f
Slit and place technique 316
Sliver 315f
Small tumors 69
Smooth muscle cells 390
Snip biopsy 65
Sodium
chloride 617
hydroxide 465
morrhuate 455, 457
tetradecyl sulfate 429, 455, 457
Soft tissue
cylindrical fragment 372f
tumors 69
Soles 237, 406f
biopsy of 68
Sonophoresis 18f
Sparse eyelashes 347
Spasmodic dysphonia 619
Spasticity 619
Spermatic fascia 436
Spherocytosis 187
Spider
angiomas 550
angiomata 549
telangiectasia 556f
Spina bifida 187
Spinal anesthesia 444
Spinal cord diseases 400
Split thickness graft 148t, 149
types of 148f
Split thickness skin graft 9, 147, 148, 155, 193
variants of 193
Spoke wheel aspiration 381
Sponge holding forceps 265f
Spray cryotherapy 252, 251
Spray freeze technique 473
Spreader technique 309, 310
Squamous cell carcinoma 187, 438, 446, 645
in situ 109
Stabilizing earlobe 270
Stable resistant zosteriform vitiligo 212f
Starch iodine
negative 621f
test 620, 620f
Steatocystoma 571
multiplex 89, 563
differential diagnosis 90
management of 90, 438, 438t
of scrotum 91f
surgical techniques 90
Stem cells 390
Sterile glove tourniquet 287
Sterilizing skin biopsies 232
Stings 187
Stone and metallic burrs 110f
Storage disorders 273
Strabismus 617, 619
Straight needle 489
Stratum basale 240f
Stretch marks 589
Striae 117
rubra 557
Strip harvesting, methods of 309t
Strip, dissection of 314f
Stucco keratoses 563
Styloid process, radial 279f
Subciliary incision 365f
Subconjunctival hemorrhage 368f
Subcutaneous
curettage 409f
island pedicle flap 259
suture, running 37, 38f
Subcuticular stitch, running 36f
Subcuticular suture 366f
running 35
Subepidermal plane 632
Sublingual keratosis 571
Submucous cyst 491, 506, 507f
Subtraction angiography, digital 188
Subungual hematoma 520f
surgical management of 298
Suction blister grafting 421, 433
for eyelids 244f
Suction blister roof grafting 211
Superficial growths, removal of 429
Sural nerve 277f
anatomy of 275, 276f
biopsy 275
block 403, 404f
distal 274
medial 274
surface marking of 276f
Surgery
principle of 360
time of 336
Surgical blades, sizes of 6f
Surgical dressings 45
Surgical technique, principle of 220
Suture
continuous 35
material 28
vertical mattress 34, 34f
Suture removal 38
technique 39f
timing of 39, 39t
Suturing technique 28, 31, 39, 361
Suturing wound edges 28
Swelling over tongue 432f
Syphilis 187
Syringoma 109, 437, 489, 493, 563, 566, 567b
Systemic anticholinergic drugs 400
Systemic corticosteroids 308
Systemic disease 456
Systemic lupus erythematosus 187
T
Targeted cryotherapy 475
advantages of 479
immediate complications 480
instruments 475
permanent complications 482
postprocedure 479
procedure 475
prolonged-temporary complications 482
temporary complications 482
uncommon complications 482
Tarsal plate 356
Tattoo 109, 530, 535, 571
color of 532
decorative 530
professional 530t
multicolor 531f
reconstructive 530
removal 532t, 615fc
traumatic 530
types 530b
Telangiectasia 489, 547, 549, 550
generalized essential 550, 550f
Telfa rolling 391
Temporary fillers 626
Temporary hair loss 323
Test patch 534
Test tube holders 478f
Thalassemia 187
Thermal necrosis 562
Thermal relaxation time 562, 592
Thoracic
outlet syndrome 619
sympathectomies 406
Thrombocytopenia 132
Thrombophlebitis, superficial 459
Thyroid disease 347
Tibial nerve block, posterior 403, 403f
Tip suture 38, 38f
Tissue grafting 9, 237
techniques 208
modifications of 216
Tissue handling 256
Tissue methods of grafting 214t
Tissue reconstruction 450
Toe brachial pressure index 188
Toe-nails, ingrowing 464, 465f, 513
Tongue depressor 269
Toomey syringes, large volume 382f
Topical anesthesia 1618, 18f, 547, 612
advantages of 18
indications of 18
thick uniform layer of 216f
Torn earlobes 266
Towering technique 631f
Toxic
melanosis 533f
neuropathies 273
Tranexamic acid 307, 308
Transconjunctival blepharoplasty 363
Transconjunctival lower blepharoplasty 363
Transcutaneous lower lid blepharoplasty 363
Transcutaneous oxygen 188
Transected ends of nerve 278f
Transplantation technique 240
Transthecal block 285
Trauma 187, 335, 347
Triamcinolone acetonide 336
injection, intraoperative 263
intraoperative dose of 263f
Triangular myocutaneous flap 365f
Trichloroacetic acid 60, 136, 466, 467, 609
Trichoepithelioma 109, 491
Trichophytic closure 311f, 311t
method 310
Trichostasis spinulosa 596, 598f
Trichotillomania 335, 347, 353
Trypan blue 233f
Trypsin solution 232
Trypsinization of melanocytes, differential 232
Tumescent anesthesia 19, 392f, 407, 408, 408f
solution, infiltration of 380f
Tumescent infiltration 327
Tumescent solution 391
Tumor 109, 273, 447f, 450f
cells 187
classification of 69
removal of 451f
Tunica vaginalis 436
Two punch technique 296
U
Ulcer 187, 202
nonhealing 44
treatment 52f
Ulnar nerve 402
block 402, 403, 403f
dorsal cutaneous branch of 274
Ultrasonic abrasion 227
Ultrathin epidermal grafting 53f
Ultrathin graft 425
Ultrathin split thickness graft 425f
Unipedicle advancement flap 178, 179f
steps of 180f
Upper limb neuropathy 274
V
Vaginal skin tightening 444
Vaginoplasty 444
Vancouver scar score 253
Varicose veins 187, 456, 458f
Vascular keloids 557
Vascular laser 612
classification 545b
complications 612
Vascular lesions 437
treatment of 544, 547
Vascular malformations 456
Vascular tumors, benign 456
Vasculitis 187, 274
Vein
dorsal 435
large 457
Vellus hairs, treatment of 604
Venography 188
Venous
hypertension 187
lakes 549, 557
malformations 549
obstruction 187
Verapamil 376
Vermillion border 163
Verruca 481f, 483, 565
filiformis 483
over glans penis 481f
plana 483, 489
vulgaris 483, 489, 491, 493, 495f, 498f
multiple 495f
Vesicles, nonformation of 217
Vessels, diameter of 545
Viable melanocytes 233f
Viral infections 132, 466
Vitamin 120
C 123
C creams 120
Vitiligo 208, 220, 216, 236, 347, 350, 637
eyelids 241f, 242f
of areola 644f
patch 236, 426f
repigmentation of 540f
recalcitrant lesions of 642
segmental 210f, 236, 246f
site of 237
surgery 9, 51, 54f, 109, 220
surgery over lip mucosa 420
procedures 420
surgical management of 353
Volkmann double ended scoop 9
V-plasty 270
Vulvo-vaginal rejuvenation 444
V-Y plasty 170f, 181f, 183f
steps of 182f
W
Warts 498f, 549, 557, 563
removal of 495f
Watson modification 11
Widening incision site 280f
Widespread hypertrophic scar 577
Wiskott-Aldrich syndrome 132
Wound
closure 40
dehiscence 171
dressings
complications of 55
principles of 44
edge tension 159
infection 275
margin, accurate approximation of 254
mini hole technique, linear closure of 82f
repair, layered 159f
surgical incision 49
suturing of resulting 414f
W-plasty 166f, 168
Writer's cramp 619
X
Xanthelasma 489, 563, 566
around eyes 566f
palpebrarum 467
treatment of 468f
treatment 507
Xylocaine 354f
hydrochloride 425
testing 307
Y
Y-V plasty 171f
Z
Z plasty, modifications of 164
Zimmer dermatome 194
Z-plasty 163f, 164t, 165f, 270, 271f
×
Chapter Notes

Save Clear


Essential Dermatosurgical InstrumentsCHAPTER 1

Rajesh Verma,
Aneesh KP,
Ankan Gupta
 
INTRODUCTION
A surgical instrument is a designed tool or device used for carrying out desired actions during a surgery, e.g. cutting a biological tissue, holding it or to provide access for viewing a deeper lying structure. Some surgical instruments are designed for general use in surgery, while there are some which are tailor-made for a specific role in a specific procedure, e.g. instruments for nail procedures, implanters in hair transplantation, dermatomes for taking a skin graft, etc. (Table 1.1).
Surgical equipment is as important to the procedure as to the doctor. Faulty and ineffective instruments can do just as much damage as an unqualified doctor could. High quality precision equipment can considerably influence the outcome of any procedure, more so in case of cosmetic procedures involving face and exposed parts of the body. Utmost care must be taken in selecting the correct instrument for a particular step; however, the surgeon must not be obstinate and learn to improvise with instruments like using a chalazion clamp in oral mucosal procedures.
 
GENERAL INSTRUMENTS
 
Forceps
This is a handheld, hinged instrument used for grasping and holding objects. The arms of the forceps are used as extensions of thumb and index finger in stabilizing or holding the tissue, sutures or dressings. The free tips of the forceps are modified for various uses. There are two basic type of forceps—the nonlocking type and locking type which are also known as clamps.
Table 1.1   Classification of dermatosurgical instruments.
General instruments
1. Graspers/Forceps
2. Cutters (Scalpel, scissors, cutters, trocars, splitters)
3. Retractors/Distractors
4. Clamps/Occluders
5. Sealers (Staples, sutures)
6. Scopes and probes
7. Measuring devices (Rulers and calipers)
8. Markers (Skin marking pens)
Special instruments
1. Vitiligo surgery instruments
2. Hair transplant instruments
3. Nail surgery instruments
Adson's Tissue Forceps
zoom view
Description
A type of dissecting forceps with wider blade and better grip.
Uses
Hold wound edges during exploration and suturing.
Removing recipient plugs in hair transplant.
Remarks
Easy to control as the blades provide better grip.
Allis Forceps
zoom view
Description
A surgical instrument with sharp teeth, used to hold or grasp heavy tissue.
Two straight blades with interdigitating teeth at the tip.
Handle has a ratchet with 3 catches.
Uses
Corn enucleation surgery.
Remarks
Can damage tissues, if used inappropriately, hence it is used to hold the tissue which has to be removed.
2
Cheatle Forceps
zoom view
Description
Forceps with long handles with complete ring at one end and partial at other.
Uses
To pick up sterilized articles/gauze pieces from tray.
Remarks
The tips are kept dipped in antiseptic solution.
Epilation Forceps
zoom view
Description
A kind of small spring forceps, used for removing unwanted hair.
Uses
In electroepilation to pull out destroyed hair.
Remarks
Various types are available. For example, Beer epilation forceps, Douglas forceps.
Dissecting Forceps (Toothed/Plain)
zoom view
Description
Forceps with toothed or plain tips and variable types of grip. Plain forceps have horizontal serrations at the tip and toothed ones have two teeth on one jaw and interdigitating tooth on the other.
Spring tension at one end holds the grasping ends apart until pressure is applied. This allows one to quickly and easily grasp small objects or tissue to move and release it, or to grasp and hold tissue with easily variable pressure.
Uses
Plain dissecting forceps are used for holding delicate structures like blood vessels, nerves, etc.
Toothed dissecting forceps are used for holding tough tissues like skin, fascia, tendon, etc.
Remarks
Various types of dissecting forceps have been designed according to the use
For example, Plane dressing forceps, Adson forceps, Bonney's forceps, Gillie's forceps, Lane's forceps, Mc'Indoe's forceps, DeBakey's forceps, Gerald's forceps, Bayonet's forceps, etc.
Sponge Holding Forceps
zoom view
Description
Large size hinge forceps with fenestrations/hole at the tip of the blades.
The handles are ratcheted as well as looped.
Sponge holding forceps can either be curved or they may be straight.
Transverse inner surface is serrated to provide better grip.
Uses
Hold sponges and/or cotton wool swabs in preparing the surgical site.
Hemostatic Forceps/Artery Forceps
zoom view
Description
Forceps with gradually tapering blades towards the tip with serrations at the tip. Commonly referred to as “Artery forceps”.
The tip may be either straight or curved.
They are available in three different sizes; large, medium and small. The small size artery forceps is also referred to as “Mosquito artery forceps”.3
Uses
Catch cut end of blood vessels.
Blunt dissection in lipoma and sebaceous cyst excision.
Crushing pedicles of skin tag and DPN.
To hold the free ends of suture in ear lobe repair and nerve biopsy.
Three point traction in circumcision.
Remarks
Medium and small sizes are commonly used in dermatosurgery.
Iris Forceps
zoom view
Description
A kind of fine spring forceps originally used in ophthalmic surgery to hold iris tissue. But it also finds application in fine surgeries like skin grafting, hair transplant, etc.
The tip may be straight/curved or plane/toothed.
Uses
Miniature punch grafting.
Split thickness skin grafting.
Blister grafting.
Remarks
Various designs are available with different names. Common ones used in dermatosurgery are illustrated.
Iris forceps—Graefe
zoom view
Iris forceps—Stevens
zoom view
Iris forceps—Bishop Harman
zoom view
Iris forceps—Forester
zoom view
Iris forceps—Gill
zoom view
Iris forceps—Mod- Tuebingen
zoom view
Jeweler Forceps
zoom view
Description
A small thumb forceps with very fine pointed blades, used to grasp tissues in microsurgical procedures.
Uses
Miniature punch grafting.
Punch biopsy. Implantation of follicular units in hair transplantation.
Remarks
The tip may be straight, bent or curved.
 
Scissors
Scissors are cutting instruments with two blades hinged together at a fulcrum. These are available in various sizes and types. Scissors can be classified as having sharp or blunt edges and as straight and curved.
Dressing Scissors/Nurses Scissors
zoom view
Description
The lower blade is blunted and the upper blade is sharp.
Uses
To cut the dressing without injuring the skin.
4
Lister Bandage Scissors
zoom view
Description
Thick blunt plate at the tip of the lower blade to avoid injury.
The blades are curved to an angle for ease of use.
Uses
To cut the dressing without injuring the skin.
Mayo Scissors
zoom view
Description
A type of surgical scissor with flattened blades.
Blades may be straight or curved.
Uses
Straight: Cutting dressing, Vaseline impregnated gauze, suture materials, dressing pads, etc.
Curved: Removal of warts after electrocautery, cutting skin tags, sample taking out the biopsy from tough areas.
Remarks
Was developed by Mayo Clinic.
Most often used to cut fascia in general surgery.
Metzenbaum Scissors
zoom view
Description
Surgical scissors designed for cutting delicate tissue and in blunt dissection.
Have a relatively long shank-to-blade ratio.
Uses
Cutting skin tags.
Skin biopsy.
Split thickness skin grafting.
Iris Scissors
zoom view
Description
Very small scissors with an extremely sharp and fine tip.
The tip may be curved or straight.
Uses
To cut delicate tissue.
Ideal for cutting mucous membranes.
Skin biopsy.
Enucleation of cyst/lipoma.
Remarks
Originally designed for the fine detail work of ophthalmic surgery.
Gradle Scissors
zoom view
Description
Short blades with thin pointed ends.
May be curved or straight.
Uses
Cut delicate tissues especially in periorbital area.
Cut skin tags.
O'Brien Scissors
zoom view
Description
Small scissors with angled short blades with pointed edges.
Uses
Cut suture in delicate or tight areas.
5
Spencer Scissors
zoom view
Description
Small scissors with a small hook shaped tip on one blade.
Uses
Suture removal.
Remarks
The small hook shaped tip on one blade slides under sutures to slightly lift them before cutting for removal. This hook also holds the suture, so it does not slip off the blade of the scissors prior to cutting.
Double S-Shaped Curved Scissors
zoom view
Description
Small scissors with two curves which form the alphabet “S”.
Uses
Useful to operate at a depth.
Miniature punch grafting at recipient site.
Hair transplantation surgery to cut deeper donor grafts.
Undermining Scissors
zoom view
Description
Small scissors with longer shanks.
Distal part is flattened to provide thinner operating edge.
Uses
In surgeries where considerable undermining is required.
Remarks
For example, Ragnell dissecting scissors.
Castroviejo Spring Scissors
zoom view
Description
Small scissors with thin short blades and spring action.
The tip may be curved or straight.
Uses
For fine work involving delicate tissue like face.
To cut the graft in blister grafting and split thickness skin grafting.
Remarks
The unique design features allow extremely smooth cutting of fine and coarse tissue with reduced trauma.
 
Scalpels
Consists of disposable steel blades which can be fitted on to reusable stainless steel handles. Some handles are designed to fit a specific hand hold. For example, Beaver style handle is shaped like a pen and is suited for close, precise cuts; other handles, such as Bard-Parker style are flatter. A particularly common type of handle, called the No. 3 Bard-Parker style, has a metric ruler to measure precise cuts. Another common type of handle is the rounded Siegel style, designed for curved incisions. The Bard-Parker handle (BP handle) is the commonly used handle in dermatosurgery.
The sizes of surgical blades which fit into various sizes of BP handle is given in Table 1.2. Various sizes and shapes of blades available are listed in Figure 1.1. Commonly used blades in dermatology and their uses are enumerated in Table 1.3.
Table 1.2   Bard-Parker handle and surgical blades.
Size of BP handle
Size of blade
Handle #3
10, 11, 12, 13, 14, 15, 15B, 15C, 16, 17
Handle #4
20, 21, 22, 22A, 23, 24, 25, and 36
Handle #7
10, 11, 12 and 15
Handle #9
6, 9, 10, 11, 12, 15 and 16
Handle #B3
6, 9, 10, 11, 12, 12D, 13, 14, 15
6
zoom view
Fig. 1.1: Sizes of surgical blades.
Bard-Parker Handle
zoom view
Description
Flat blade holders of various sizes.
Different sizes are suited for particular blade sizes.
Handle #3 has a metric ruler to measure the size of the incision.
Uses
For handling the surgical blade safely and precisely during procedures like skin biopsy, enucleation/excision of cyst, etc.
Remarks
The flat design is helpful to have a better grip of the knife.
Longer handles are denoted by the letter L after the size of the handle. For example, 3L, 4L, etc.
Siegel Handle
zoom view
Description
Round bodied blade handle designed to hold standard surgical blades.
The distal end has a prominence similar to that of Bard-Parker handle.
Also referred to as handle #7.
Uses
To hold the knife like a pen.
Remarks
The round design is helpful in holding the knife like a pen and in performing precise cuts in difficult areas.
Table 1.3   Commonly used blades in dermatosurgery.
Size of blade
Common uses
15
Most commonly used in dermatosurgery.
For procedures with incision < 5 cm.
15D
Incision < 5 cm in delicate areas like face.
11
To drain abscesses.
To perform shave biopsies.
10, 21
Procedures with incision > 5 cm.
In areas with thick skin (trunk and scalp).
For excision of large lesions, wound debridement.
Beaver Handle
zoom view
Description
Round bodied blade handle shaped like a pen.
The distal end has a slit into which the blade can be placed and fixed.
Specific set of blades referred to as “Beaver mini blades” are available for use with this type of handle.
Uses
To hold the knife like a pen.
For close and precise cuts.
Remarks
The round design is helpful in holding the knife like a pen and in performing precise cuts in difficult areas.
 
Needle Holder
It is a surgical instrument used for grasping the needle during suturing. Most needle holders have a clamp mechanism to lock the needle in place. The size of the needle holder to be used should be determined by the size of the needle and the anatomical site of the surgery. The jaws of a needle holder are textured and short to maintain a firm grip on the needle.7
Mayo-Hegar Needle Holder
zoom view
Description
Larger size needle holder with long shanks.
Serrated tips with central longitudinal depression.
Uses
For holding larger size needles—3.0 and 2.0 suture needles.
For performing sutures involving larger areas like trunk, limbs, etc.
Remarks
The cross serrations help to provide better hold on the needle used.
Crile-Wood Needle Holder
zoom view
Description
Smaller size needle holder than Mayo-Hegar with long shanks.
Serrated tips with transverse groove to accommodate the needle.
Uses
For holding larger size needles.
For performing sutures involving larger areas like trunk, limbs, etc.
Remarks
The transverse groove helps in achieving a good perpendicular grip of the needle.
Ryder Needle Holder
zoom view
Description
Smaller size needle holder with long shanks.
Tips are thinner with cross-serrations.
Uses
For holding smaller size needles—4.0 and 5.0 suture needles.
For performing sutures involving delicate skin like face, earlobe, periorbital area, etc.
Remarks
The thin short blades help to provide better grip to small sized needles.
Castroviejo's Needle Holder
zoom view
Description
Small size needle holder with spring action.
Very thin tips for fine work.
Uses
For holding smaller size needles—4.0 and 5.0 suture needles.
For performing sutures involving delicate skin like periorbital area.
Used in delicate cosmetic surgeries.
Remarks
The thin short blades help to provide better grip to small sized needles.
8
 
Skin Hooks and Retractors
Skin hooks are a commonly used equipment in dermatology where the use of a forceps is better avoided. It can reduce undue damage to skin edges as they are less traumatic. Skin hooks are available with one, two or multiple teeth.
A retractor is used to actively separate the edges of a surgical incision or to hold back underlying organs/structures (e.g. blood vessels, nerves, deeper cysts, etc.), so as to avoid accidental injury to them.
Guthrie Skin Hook
zoom view
Description
Small skin hook with two, three or four prongs.
The tip is flattened.
The prongs may be sharp or blunt.
Uses
To retract skin while performing deep procedures like nerve biopsy, tendon repair, etc.
Remarks
Skin hooks are useful in avoiding use of forceps on delicate tissue which is more traumatic than the hooks.
Joseph's Double Skin Hook
zoom view
Description
Small skin hook with two prongs.
The tip is “U” shaped. The tip is not flattened when compared to Freer skin hook.
Uses
To retract skin while performing deep procedures like nerve biopsy, tendon repair, etc.
Provides better field of vision when compared to Freer skin hook.
Remarks
Skin hooks are useful in avoiding use of forceps on delicate tissue which is more traumatic than the hooks.
Another hook with similar structure but a different curvature angulation is the Cottle's hook.
Frazier Skin Hook
zoom view
Description
Small skin hook with single prong.
Also called Frazier Dura hook.
Uses
To hold tongue, lips and cheeks away from the surgical area.
Remarks
Provide better visualization and easy accessibility of the surgical site.
Senn Retractor
zoom view
Description
Handheld, double-ended retractor used to retract primarily surface tissue.
It has one angled, blunt end and, at the opposite end, facing the opposite direction has a three prong, rake tip. The prongs may be sharp or blunt.
Uses
Retract skin in deep procedures like nerve biopsy and tendon surgeries.
Remarks
Provide better visualization and easy accessibility of the surgical site.
Haber Spreader
zoom view
Description
A set of straight handles connected to a set of curved front arms, and culminating in a set of jaws with four sharp staggered prongs.
Uses
It is used separate a superficial incision along a natural tissue dissection plane.
9
 
Other General Instruments
Curette
Description
Sharpened scrapping instrument.
Loop shaped cutting edge at both edges.
Uses
Curettage of various benign and malignant cutaneous growth.
Remarks
Different types are in use.
Fox Dermal curette
zoom view
Piffard Dermal curette
zoom view
Rein Round curette
zoom view
Volkmann Double Ended Scoop
zoom view
Description
A modification of curette.
Stout handle with spoon shaped extension at the ends.
Extensions maybe round or oval with sharp edges.
Uses
Scooping abscess cavities.
Nail surgeries.
Corn enucleation.
Ulcer debridement.
Application of pellet in cell based vitiligo surgeries.
Maneksha's Manual Dermabrader
zoom view
Description
It has a handle with thumb rest and a rectangular plate at the distal end.
The plate has horizontal and vertical sharp teeth.
Various sizes of 3 to 25 mm are available.
Uses
Recipient area preparation in STSG, SBEG, and NCES.
Dermabrasion of acne scars.
Tattoo removal.
Debridement of wound/ulcer.
Comedone Extractor
zoom view
Description
Central handle with two perforated cups at the ends.
Uses
Expression of comedones.
Remarks
Used keeping the convexity of the cup held against the comedones.
For example, Saalfield comedone extractor, Schaumberg comedone extractor.
Chalazion Clamp
zoom view
Description
It has a forceps-like handle with one distal tip with a flat solid oval plate and another distal tip with a ring-like aperture.
The shaft has a thumbscrew.
Uses
Oral mucosal biopsy.
Deroofing of mucocele.
Minor salivary gland biopsy.
Ear lobe repair.
Scrotal surgery.
Nasal lesions on ala nasi.
Remarks
Various types are available. For example, Braid chalazion clamp, Desmarres Chalazion clamp, Weis Chalazion clamp, etc.
 
Instruments for Specific Procedures
 
Vitiligo Surgery
The following transplantation procedures are employed for hypopigmentation disorders.
 
Tissue Grafts
  • Thin and ultra-thin split-thickness skin grafts (STSG)
  • Suction blister epidermal grafts (SBEG)10
  • Mini-punch grafts (MPG)
  • Hair follicular grafts (HFG)
 
Cellular Grafts
  • Noncultured epidermal cell suspension (NCES)
  • Cultured “pure” melanocytes (CM)
  • Cultured epithelial grafts (CE)
Apart from the general instruments, various special instruments are also required to perform many of these procedures.
Razor Blade Holder
zoom view
Description
Stainless steel holder which can fit in standard razor blades.
The blade is fixed by thumbscrew.
Uses
To obtain split thickness skin grafts from the donor site.
Remarks
Ideal for harvesting small grafts.
Both the sides of the blade are exposed and can be used conveniently.
Silver Knife
zoom view
Description
Stainless steel knife which can fit regular razor blades.
It has screws for adjusting the thickness of the graft to be harvested.
Uses
To obtain split thickness skin grafts from the donor site.
Remarks
Ideal for harvesting small intricate grafts from areas which would not be accessible with the larger standard knives, such as the ear, dorsa of the hands or scalp.
Humby Knife
zoom view
Description
A long knife (12 inch long) with disposable blade (6¼ inch long).
It has a handle and a plate where the blade is attached.
The design of the plate is slightly different in different modifications of the knife available.
These knives have an in-built adjustable guard which can limit the maximal thickness of the graft harvested.
A thumbscrew is used to adjust the thickness of the graft.
Uses
To obtain split thickness skin grafts from the donor site.
Remarks
Watson modification is the most commonly used modification of Humby knife.
Braithwaite modification
(1955 Fenton Braithwaite)
zoom view
First modification of Humby knife which can be sterilized without dismantling.
The guard oscillates and rotates when the knife is used.
Thickness of the graft harvested can vary because of the “play” of the guard.11
Watson modification
(1960 John Watson)
zoom view
Modified Braithwaite design with a fine, smooth guard with no movement.
The guard passes eccentrically through the bushes at both ends enabling control of thickness of graft with adjustment of a single knob.
It eliminates “play” of the guard but can cause considerable “drag” on the skin as the guard is fixed.
Cobbett modification
(1968 J Cobbett)
zoom view
Another modified Braithwaite design with oscillating guard to eliminate “drag”.
The guard is fixed to a “D” shaped hole to avoid rolling up of the graft harvested on to the guard.
Powered Dermatomes
Description
These are mechanical dermatomes which use either compressed air/water, DC current or AC current.
Different types are available.
Uses
To obtain split thickness skin grafts from the donor site.
Rapidly remove long strips of skin.
Remarks
Operation is simple.
Procedure can be performed with least number of assistants.
Brown's dermatome
zoom view
Zimmer dermatome
First mechanical dermatome to be introduced.
Works with compressed air/water.
zoom view
Both electric operated and nitrogen gas propelled versions are available.12
Davol Dermatome
zoom view
Cordless, battery operated dermatome.
Ideal for harvesting small grafts.
Padgett Dermatome
zoom view
AC current operated dermatome.
 
Nail Surgery
Nail Splitter
zoom view
Description
Also referred to as English anvil pattern nail splitter.
Has sharp triangular shaped anvil opposed by a sharp and flat edge at the distal end and double spring at the handle.
Uses
To cut longitudinal strip of nail plate in partial nail avulsion.
Remarks
The nail plate is split from the distal to the proximal end.
Nail Spatula
zoom view
Description
Rod shaped/ flattened equipment with flat edges.
The tip of the flat edges may be modified into different shapes.
Uses
Proximal and lateral nail fold separation in nail avulsion, nail matrix biopsy, etc.
Remarks
Spatula is inserted between the proximal/lateral nail fold and nail plate and gently separated by lateral movements.
Freer Septum Elevator
zoom view
Description
Rod shaped equipment with thin curved blades.
Uses
To loosen distal nail plate from hyponychium, proximal nail fold and lateral nail folds.
13
 
Skin Biopsy
Punches
Description
Circular blade ranging in size from 1 to 8 mm which is attached to a pencil-like handle.
May be provided with corresponding size plungers.
Uses
Skin biopsy involving delicate areas, cosmetically important areas, etc.
Proximal and distal nail matrix biopsies, nail bed biopsy.
Mini punch grafting in vitiligo surgery.
Remarks
The common punch size used to diagnose most inflammatory skin conditions is the 3.5 or 4 mm punch.
Reusable metallic punches with plungers
zoom view
Disposable punches
zoom view
Disposable punches with stainless steel blades of sizes varying from 1 to 8 mm.
Punches with or without and inbuilt plungers are available.
Disposable elliptical punches
zoom view
Disposable elliptical punches with fixed and moveable blades are available.
Used for better closure of the wound and for better comsetic results especially on the face and exposed parts.
Dermablade/BiopBlade
zoom view
Description
Small, flexible, sterile blade with plastic side grips.
Uses
Shave biopsy.
Remarks
Can also be used for harvesting small STSG in vitiligo surgery.
 
Hair Transplantation
Implanters
zoom view
Description
An attempt to automate and quicken the process of implantation of hair.
Uses
In hair implantation of scalp, eyebrow and other parts of body.
Remarks
In a single move a slit is created and without removing the implanter the graft can be placed.
Choi implanter
(Korea)
zoom view
Originated at the Kyungpook National University (KNU) in Korea
Atlanta implanter (USA)
zoom view
Suited for large or super mega sessions, up to 4000 plus grafts as well as smaller sessions for eye lashes, eye brows, cut scars and corrective surgery procedures with great convenience and speed.14
SAVA Implanter
(India)
zoom view
Conceived by Dr Sajeev Vasa of Ahmedabad, Gujarat.
An inexpensive, high quality disposable implanter.
Minimises the graft trauma, but also reduces the overall cost of the surgery.
Lion Implanter
(Spain)
zoom view
The device uses a clip, which is not found in previously used hair transplanters. This clip reduces the procedural time and makes the replacement of the needle easier.
 
Circumcision Instruments
Plastibell Clamp
zoom view
Description
It is a plastic device designed for circumcising infant males.
Uses
Circumcision.
Remarks
Other popular available clamps include Gomco clamp and the Mogen clamp.
 
Acne Scar Surgeries
Nokor Needle
zoom view
Description
It is a 1.5 inch, 18-gauge needle with a flat pointed end.
Uses
Subcision.
Remarks
For treatment in boxcar acne scars.
 
Sterilization of Instruments
Defined as a process that destroys or eliminates all forms of microbial life including bacterial endospores.
Sterilization Methods
Method
Suitable for
Remarks
Hot air sterilization
Glass instruments, forceps, scissors, scalpels, swabs, dusting powder
1 hour at 160°C
½ hour at 180°C
10 min at 200°C
Steam autoclaving
(Gravity displacement)
Wrapped instruments/utensils
Most widely used method
30 min at 121°C or 15 min at 132°C and drying time of 15–30 min.
Textile packs
30 min at 121°C or 25 min at 132°C and drying time of 15 min.
Steam autoclaving (Dynamic air removal)
Wrapped instruments/utensils
4 min at 132°C and 20–30 min of drying time
Textile packs
4 min at 132°C and 20 min of drying time
Cold sterilization or Chemical sterilization
Sharp metallic instruments
2% Glutaraldehyde, 70% Alcohol, Carbolic acid, Lysol, etc. can be used
Instrument immersed for at least 30 min
Gas sterilization
Glass, Rubber articles
Fumigating OTs, hand pieces of hand machine.
Ethylene dioxide, Formaldehyde used
15
Sterilization of Dermatological Equipment
Skin grafting for vitiligo
Stainless punches
Autoclaving
Disposable punches
Not to be reused
Artery forceps
ETO sterilization
Blades, forceps, scissors
Autoclaving
Hair transplant
Needles, Forceps, Cutting boards, Blades, BP handle, Artery forceps, Adson's forceps, Needle holder
Autoclaving
Plastic blade holders, Plastic bottles for spraying saline
ETO sterilization or prolonged exposure to chemical disinfectant like Glutaraldehyde
Chemical peels
Brushes to apply chemicals on face
ETO sterilization
Laser
Metal spacers, Interchangeable metal hand pieces
Autoclaving
Interchangeable plastic hand pieces, Goggles
ETO sterilization or prolonged exposure to chemical disinfectant like Glutaraldehyde