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2008| January | Volume 74 | Issue 7
August 1, 2008
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Standard guidelines of care for vitiligo surgery
Davinder Parsad, Somesh Gupta
January 2008, 74(7):37-45
Vitiligo surgery is an effective method of treatment for selected, resistant vitiligo patches in patients with vitiligo.
The physician performing vitiligo surgery should have completed postgraduate training in dermatology which included training in vitiligo surgery. If the center for postgraduation does not provide education and training in cutaneous surgery, the training may be obtained at the surgical table (hands-on) under the supervision of an appropriately trained and experienced dermatosurgeon at a center that routinely performs the procedure. Training may also be obtained in dedicated workshops. In addition to the surgical techniques, training should include local anesthesia and emergency resuscitation and care.
Vitiligo surgery can be performed safely in an outpatient day care dermatosurgical facility. The day care theater should be equipped with facilities for monitoring and handling emergencies. A plan for handling emergencies should be in place, with which all nursing staff should be familiar. Vitiligo grafting for extensive areas may need general anesthesia and full operation theater facility in a hospital setting and the presence of an anesthetist is recommended in such cases.
Indications for vitiligo surgery
: Surgery is indicated for stable vitiligo that does not respond to medical treatment. While there is no consensus on definitive parameters for stability, the Task Force suggests the absence of progression of disease for the past one year as a definition of stability. Test grafting may be performed in doubtful cases to detect stability.
Preoperative counseling and Informed consent:
A detailed consent form elaborating the procedure and possible complications should be signed by the patient. The patient should be informed of the nature of the disease and that the determination of stability is only a vague guide. The consent form should specifically state the limitations of the procedure, about the possible future progression of disease and whether more procedures will be needed for proper results. The patient should be provided with adequate opportunity to seek information through brochures and one-to-one discussions. The need for concomitant medical therapy should be emphasized and the patient should understand that proper results take time (a few months to a year).
Preoperative laboratory studies
include hemogram including platelet counts, bleeding and clotting time (or prothrombin and activated partial thromboplastin time), and blood chemistry profile. Screening for antibodies for hepatitis B surface antigen and HIV is recommended depending on individual requirements.
Lignocaine (2%) with or without adrenaline is generally used for anesthesia; infiltration and nerve block anesthesia are adequate in most cases. General anesthesia may be needed in patients with extensive lesions.
Proper postoperative immobilization and care are very important to obtain satisfactory results.
Standard guidelines of care for acne surgery
January 2008, 74(7):28-36
Acne surgery is the use of various surgical procedures for the treatment of postacne scarring and also, as adjuvant treatment for active acne. Surgery is indicated both in active acne and post-acne scars.
Any Dermatologist can perform most acne surgery techniques as these are usually taught during postgraduation. However, certain techniques such as dermabrasion, laser resurfacing, scar revisions need specific "hands-on" training in appropriate training centers.
Most acne surgery procedures can be performed in a physician's minor procedure room. However, full-face dermabrasion and laser resurfacing need an operation theatre in a hospital setting.
Surgical treatment is only an adjunct to medical therapy, which remains the mainstay of treatment. Comedone extraction is a process of applying simple mechanical pressure with a comedone extractor, to extract the contents of the blocked pilosebaceous follicle. Superficial chemical peel is a process of applying a chemical agent to the skin, so as to cause controlled destruction of the epidermis leading to exfoliation. Glycolic acid, salicylic acid and trichloroacetic acid are commonly used peeling agents for the treatment of active acne and superficial acne scars.
Cryoslush and cryopeel are used for the treatment of nodulocystic acne. Intralesional corticosteroids are indicated for the treatment of nodules, cysts and keloidal acne scars. Nonablative lasers and light therapy using Blue light, non ablative radiofrequency, Nd:YAG laser, IPL (Intense Pulsed Light), PDT (Photodynamic Therapy), pulse dye laser and light and heat energy machines have been used in recent years for the treatment of active inflammatory acne and superficial acne scars. Proper counseling is very important in the treatment of acne scars. Treatment depends on the type of acne scars; a patient may need more than one type of treatment. Subcision is a treatment to break the fibrotic strands that tether the scar to the underlying subcutaneous tissue, and is useful for rolling scars. Punch excision techniques such as punch excision, elevation and replacement are useful for depressed scars such as ice pick and boxcar scars. TCA chemical reconstruction of skin scars (CROSS) (Level C) is useful for ice pick scars. Resurfacing techniques include ablative methods (such as dermabrasion and laser resurfacing), and nonablative methods such as microdermabrasion and nonablative lasers. Ablative methods cause significant postoperative changes in the skin, are associated with significant healing time and should be performed by dermatosurgeons trained and experienced in the procedure. Fillers are useful for depressed scars. Proper case selection is very important in ensuring satisfactory results.
Standard guidelines for the use of dermal fillers
January 2008, 74(7):23-27
Currently used fillers vary greatly in their sources, efficacy duration and site of deposition; detailed knowledge of these properties is essential for administering them. Indications for fillers include facial lines (wrinkles, folds), lip enhancement, facial deformities, depressed scars, periocular melanoses, sunken eyes, dermatological diseases-angular cheilitis, scleroderma, AIDS lipoatrophy, earlobe plumping, earring ptosis, hand, neck, dιcolletι rejuvenation.
: Any qualified dermatologist may use fillers after receiving adequate training in the field. This may be obtained either during postgraduation or at any workshop dedicated to the subject of fillers. The physicians should have a thorough knowledge of the anatomy of the area designated to receive an injection of fillers and the aesthetic principles involved. They should also have a thorough knowledge of the chemical nature of the material of the filler, its longevity, injection techniques, and any possible side effects.
Fillers can be administered in the dermatologist's minor procedure room.
Preoperative counseling and informed consent:
Detailed counseling with respect to the treatment, desired effects, and longevity of the filler should be discussed with the patient. Patients should be given brochures to study and adequate opportunity to seek information. Detailed consent forms need to be completed by the patients. A consent form should include the type of filler, longevity expected and possible postoperative complications. Preoperative photography should be carried out.
Choice of the filler
depends on the site, type of defect, results needed, and the physician's experience.
Injection technique and volume
depend on the filler and the physician's preference, as outlined in these guidelines.
Standard guidelines of care for chemical peels
January 2008, 74(7):5-12
Chemical peeling is the application of a chemical agent to the skin, which causes controlled destruction of a part of or the entire epidermis, with or without the dermis, leading to exfoliation and removal of superficial lesions, followed by regeneration of new epidermal and dermal tissues.
for chemical peeling include pigmentary disorders, superficial acne scars, ageing skin changes, and benign epidermal growths.
include patients with active bacterial, viral or fungal infection, tendency to keloid formation, facial dermatitis, taking photosensitizing medications and unrealistic expectations.
: The physician performing chemical peeling should have completed postgraduate training in dermatology. The training for chemical peeling may be acquired during post graduation or later at a center that provides education and training in cutaneous surgery or in focused workshops providing such training. The physician should have adequate knowledge of the different peeling agents used, the process of wound healing, the technique as well as the identification and management of complications.
: Chemical peeling can be performed safely in any clinic/outpatient day care dermatosurgical facility.
Preoperative counseling and Informed consent
: A detailed consent form listing details about the procedure and possible complications should be signed by the patient. The consent form should specifically state the limitations of the procedure and should clearly mention if more procedures are needed for proper results. The patient should be provided with adequate opportunity to seek information through brochures, presentations, and personal discussions. The need for postoperative medical therapy should be emphasized.
are considered safe in Indian patients.
Medium depth peels
should be performed with great caution, especially in dark skinned patients.
are not recommended for Indian skin. It is essential to do
of the patient's skin with sunscreens, hydroquinone and tretinoin for 2-4 weeks.
Endpoints in peels:
For glycolic acid peels: The peel is neutralized after a predetermined duration of time (usually three minutes). However, if erythema or epidermolysis occurs, seen as grayish white appearance of the epidermis or as small blisters, the peel must be immediately neutralized with 10-15% sodium bicarbonate solution, regardless of the duration of application of the peel. The end-point is frosting for TCA peels, which are neutralized either with a neutralizing agent or cold water, starting from the eyelids and then the entire face. For salicylic acid peels, the end point is the pseudofrost formed when the salicylic acid crystallizes. Generally, 1-3 coats are applied to get an even frost; it is then washed with water after 3-5 minutes, after the burning has subsided. Jessner's solution is applied in 1-3 coats until even frosting is achieved or erythema is seen. Postoperative care includes sunscreens and moisturizers Peels may be repeated weekly, fortnightly or monthly, depending on the type and depth of the peel.
Tumescent liposuction: Standard guidelines of care
January 2008, 74(7):54-60
: Tumescent liposuction is a technique for the removal of subcutaneous fat under a special form of local anesthesia called tumescent anesthesia.
: The physician performing liposuction should have completed postgraduate training in dermatology or a surgical specialty and should have had adequate training in dermatosurgery at a center that provides training in cutaneous surgery. In addition, the physician should obtain specific liposuction training or experience at the surgical table ("hands on") under the supervision of an appropriately trained and experienced liposuction surgeon. In addition to the surgical technique, training should include instruction in fluid and electrolyte balance, potential complications of liposuction, tumescent and other forms of anesthesia as well as emergency resuscitation and care.
: Liposuction can be performed safely in an outpatient day care surgical facility, or a hospital operating room. The day care theater should be equipped with facilities for monitoring and handling emergencies. A plan for handling emergencies should be in place with which all nursing staff should be familiar. A physician trained in emergency medical care and acute cardiac emergencies should be available in the premises. It is recommended but not mandatory, that an anesthetist be asked to stand by.
Liposuction is recommended for all localized deposits of fat. Novices should restrict themselves to the abdomen, thighs, buttocks and male breasts. Arms, the medial side of the thigh and the female breast need more experience and are recommended for experienced surgeons. Liposuction may be performed for non-cosmetic indications such as hyperhidrosis of axillae after adequate experience has been acquired, but is not recommended for the treatment of obesity.
: Detailed history is to be taken with respect to any previous disease, drug intake and prior surgical procedures. Liposuction is contraindicated in patients with severe cardiovascular disease, severe coagulation disorders including thrombophilia, and during pregnancy.
should be detailed and should include assessment of general physical health to determine the fitness of the patient for surgery, as well as the examination of specific sites that need liposuction to check for potential problems.
Preoperative Informed consent
: The patient should sign a detailed consent form listing details about the procedure and possible complications. The consent form should specifically state the limitations of the procedure and should mention whether more procedures are needed for proper results. The patient should be provided with adequate opportunity to seek information through brochures, computer presentations, and personal discussions.
Preoperative laboratory studies
to be performed include Hb%, blood counts including platelet counts, bleeding and clotting time (or prothrombin and activated partial thromboplastin time) and blood chemistry profile; ECG is advisable. Liver function tests, and pregnancy test for women of childbearing age are performed as mandated by the individual patient's requirements. Ultrasound examination is recommended in cases of gynecomastia.
: Preoperative antibiotics and non-sedative analgesics such as paracetamol are recommended. The choice of antibiotic and analgesic agents depends on the individual physician's preference and the prevailing local conditions.
Type of anesthetic employed
: Lidocaine is the preferred local anesthetic; its recommended dose is 35-45 mg/kg and doses should not exceed 55 mg/kg wt. The recommended concentration of epinephrine in tumescent solutions is 0.25-1.5 mg/L. The total dosage of epinephrine should be minimized and should not exceed 50 µg/kg.
It is always advisable not to combine liposuction with other procedures to avoid exceeding the recommended dosage of lignocaine. However, such combinations may be attempted if the total required dose of lignocaine does not exceed the maximum dose indicated above. The recommended cannula size for liposuction is not to be larger than 3.5 mm in diameter. The recommended volume of fat removed is in proportion to the fat content and/or size and/or weight of the patient being treated. It is recommended that the volume of fat removed not exceed 5000 mL in a single operative session.Large volume liposuctions or mega-liposuctions are not recommended.
Intraoperative and postoperative monitoring
: Baseline vital signs including blood pressure and heart rate, are recorded pre- and postoperatively. Pulse oximeter monitoring is essential in all cases.
Postoperative antibiotics should be selected by the physician and taken for five days. Postoperative antiinflammatory drugs such as Cox 2 Inhibiters may be given for 5-7 days; specialized compression garments, binders, and tape help to reduce bruising, hematomas, seromas, and pain. Generally, compression is recommended for two weeks although this is variable according to the needs of the individual patient.
Guidelines on the use of botulinum toxin Type A
January 2008, 74(7):13-22
Botulinum toxin is available as types A and B. These two different forms need different dosages and hence, the physician needs to be familiar with the formulations. A thorough knowledge of the anatomy and physiology of the muscles in the area to be injected is essential.
Indications for botulinum toxin:
Dynamic wrinkles caused by persistent muscular contractions are the main aesthetic indications for the use of Botulinum toxin. These include forehead lines, glabellar lines, crow's feet, bunny lines, perioral wrinkles, and platysmal bands. Non-aesthetic indications include hyperhidrosis of the palms, soles and axillae.
: Any qualified dermatologist may practice the technique after receiving adequate training in the field. This may be obtained either during post-graduation or at any workshops dedicated to this subject.
Botulinum toxin can be administered in the dermatologist's minor procedure room.
Preoperative counseling and informed consent
Detailed counseling with respect to the treatment, desired effects, and longevity of the results should be discussed with the patient. The patient should be given brochures to study and adequate opportunity to seek information. A detailed consent form needs to be completed by the patient. The consent form should include the type of botulinum toxin, longevity expected and possible postoperative complications. Pre- and postoperative photography is recommended.
depends on the area, muscle mass, gender and other factors outlined in these guidelines.
It is recommended
that beginners should focus on the basic indications in the upper third of the face and that they treat the middle and lower parts of the face only after garnering adequate experience.
Standard guidelines of care: Laser and IPL hair reduction
Rajesh M Buddhadev
January 2008, 74(7):68-74
Laser-assisted hair removal, Laser hair removal, Laser and light-assisted hair removal, Laser and light-assisted, long-term hair reduction, IPL photodepilation, LHE photodepilation; all these are acceptable synonyms. Laser (Ruby, Nd Yag, Alexandrite, Diode), intense pulse light, light and heat energy system are the different light-/Laser-based systems used for hair removal; each have its advantages and disadvantages. The word "LONG-TERM HAIR REDUCTION" should be used rather than permanent hair removal. Patient counseling is essential about the need for multiple sessions.
Laser hair removal may be practiced by any dermatologist, who has received adequate background training during postgraduation or later at a centre that provides education and training in Lasers or in focused workshops providing such training. The dermatologist should have adequate knowledge of the machines, the parameters and aftercare. The physician may allow the actual procedure to be performed under his/her direct supervision by a trained nurse assistant/junior doctor. However, the final responsibility for the procedure would lie with the physician.
The procedure may be performed in the physician's minor procedure room. Investigations to rule out any underlying cause for hair growth are important; concurrent drug therapy may be needed. Laser parameters vary with area, type of hair, and the machine used. Full knowledge about the machine and cooling system is important. Future maintenance treatments may be needed.
Hair transplantation: Standard guidelines of care
Narendra Patwardhan, Venkataram Mysore
January 2008, 74(7):46-53
Hair transplantation is a surgical method of hair restoration.
: The physician performing hair transplantation should have completed post graduation training in dermatology; he should have adequate background training in dermatosurgery at a centre that provides education training in cutaneous surgery. In addition, he should obtain specific hair transplantation training or experience at the surgical table(hands on) under the supervision of an appropriately trained and experienced hair transplant surgeon. In addition to the surgical technique, training should include instruction in local anesthesia and emergency resuscitation and care.
: Hair transplantation can be performed safely in an outpatient day case dermatosurgical facility. The day case theatre should be equipped with facilities for monitoring and handling emergencies. A plan for handling emergencies should be in place and all nursing staff should be familiar with the emergency plan. It is preferable, but not mandatory to have a standby anesthetist.
Indication for hair transplantation
is pattern hair loss in males and also in females. In female pattern hair loss, investigations to rule out any underlying cause for hair loss such as anemia and thyroid deficiency should be carried out. Hair transplantation can also be performed in selected cases of scarring alopecia, eyebrows and eye lashes, by experienced surgeons.
Preoperative counseling and informed consent
:Detailed consent form listing details about the procedure and possible complications should be signed by the patient. The consent form should specifically state the limitations of the procedure and if more procedures are needed for proper results, it should be clearly mentioned. Patient should be provided with adequate opportunity to seek information through brochures, computer presentations, and personal discussions. Need for concomitant medical therapy should be emphasized. Patients should understand that proper hair growth can be expected after about 9 months after transplantation.
Preoperative laboratory studies
to be performed include Hb%, blood counts including platelet count, bleeding and clotting time (or prothrombin time and activated partial thromboplastin time), blood chemistry profile including sugar.
: Follicular unit hair transplantation is the gold standard method of hair transplantation; it preserves the natural architecture of the hair units and gives natural results. Mini-micro-grafting is a method hair transplantation involving randomly assorted groups of hairs, with out consideration of their natural configuration of follicular units, under loupe or naked eye examination. Mini-grafts consist of 4-5-6 hairs while micro-grafts consist of 1-3 hairs. Punch gives ugly cosmetically unacceptable results and should no longer be used.
: Hair transplantation can be performed in any person with pattern hair loss, with good donor area, in good general health and reasonable expectations. Caution should be exercised in, very young patients whose early alopecia is still evolving, patients with Norwood grade VI or VII with poor density, patients with unrealistic expectations, and patients with significant systemic health problems.
Most patients will need concurrent medical treatment since the process of pattern hair loss is progressive and may affect the remaining hairs.
: Hair transplantation is a team effort. Particularly, performing large sessions, needs a well trained team of trained assistants.
2% lignocaine with adrenaline is generally used for anesthesia; tumescent technique is preferred. Bupivacaine has been used by some authors in view of its prolonged duration of action.
: Strip dissection by single blade is recommended for donor area.
is recommended for dissection of hair units in follicular unit transplantation; mini-micro-grafting does not need microscopic dissection.
: Different techniques and different instruments have been used for recipient site creation ;these depend on the choice of the operating surgeon and have been described in the guidelines.
is important to ensure survival.
: Minimum density of 35-45 units per sq cm is recommended. Results depend on donor characteristics, technique used and individual skills of the surgeon
Standard guidelines of care: CO
laser for removal of benign skin lesions and resurfacing
January 2008, 74(7):61-67
Resurfacing is a treatment to remove acne and chicken pox scars, and changes in the skin due to ageing.
: Both ablative and nonablative lasers are available for use. CO
laser is the gold standard in ablative lasers. Detailed knowledge of the machines is essential.
Indications for CO
Therapeutic indications: Actinic and seborrheic keratosis, warts, moles, skin tags, epidermal and dermal nevi, vitiligo blister and punch grafting, rhinophyma, sebaceous hyperplasia, xanthelasma, syringomas, actinic cheilitis angiofibroma, scar treatment, keloid, skin cancer, neurofibroma and diffuse actinic keratoses. CO
laser is not recommended for the removal of tattoos.
Resurfacing for acne, chicken pox and surgical scars, periorbital and perioral wrinkles, photo ageing changes, facial resurfacing.
Any qualified dermatologist (DVD or MD) may practice CO
laser. The dermatologist should possess postgraduate qualification in dermatology and should have had specific hands-on training in lasers either during postgraduation or later at a facility which routinely performs laser procedures under a competent dermatologist/plastic surgeon, who has experience and training in using lasers. For the use of CO
lasers for benign growths, a full day workshop is adequate. As parameters may vary in different machines, specific training with the available machine at either the manufacturer's facility or at another centre using the machine is recommended.
lasers can be used in the dermatologist's minor procedure room for the above indications. However, when used for full-face resurfacing, the hospital operation theatre or day care facility with immediate access to emergency medical care is essential. Smoke evacuator is mandatory.
Preoperative counseling and Informed consent
Detailed counseling with respect to the treatment, desired effects, possible postoperative complications, should be discussed with the patient. The patient should be provided brochures to study and also given adequate opportunity to seek information. Detailed consent forms need to be completed by the patients. Consent forms should include information on the machine used; possible postoperative course expected and postoperative complications. Preoperative photography should be carried out in all cases of resurfacing.
Choice of the machine and the parameters
depends on the site, type of lesion, result needed, and the physician's experience.
Localized lesions can be treated under eutectic mixture of local anesthesia (EMLA) cream anesthesia or local infiltration anesthesia. Full-face resurfacing can be performed under general anesthesia. Proper
is important to avoid complications.
Guest editor's remarks
January 2008, 74(7):3-3
IADVL dermatosurgery guidelines: Charting uncharted territory
January 2008, 74(7):4-4
Safer practice of dermatosurgery
January 2008, 74(7):75-77
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