Dermatosurgery
Digital Lecture Series : Chapter 27
Dr. Venkataram Mysore
Director, Venkat Charmalaya Centre for Advanced
Dermatology and Postgraduate Training, Bengaluru
Contributors : Dr. Sindhu Potla, Dr. Subodh D. Jane,
Dr. Madhulika Mhatre, Dr. Gayatri N. Khatri, Dr. Vani Yepuri,
Dr. Vijayalakshmi S. P., Dr. Namitha Chathra
CONTENTS
 Introduction
 Nail surgery
 Electrosurgery
 Vitiligo surgery
 Radiofrequency
 Hair Restoration surgery
 Cryosurgery
 Liposuction
 Chemical cautery
 MCQs
 Local Anaesthesia
 Photo Quiz
 Excision and Suture
 Acne surgery
Dermatosurgery
 Dermatosurgery has made major advances in the last two decades.
 Major contributions have been made by dermatologists to these field.
 Generally these are done under local anaesthesia.
 These include basic surgeries such as electrosurgery, acne surgery,
and advanced surgeries such as vitiligo surgery, hair transplantation
and liposuction.
Electrosurgery
 The term “electrosurgery” is a general term to describe the different
procedures employing electrically generated heat.
Methods of Tissue Destruction :
 The heat production results in tissue destruction by enzyme
deactivation, RNA and DNA destruction, cell wall damage, protein
coagulation, and steaming of water content (dehydration or cell
explosion).
Types of Electrosurgery :
 Electrofulguration
 Electrodessication
 Electrocoagulation
Electrofulguration :
 Charring of superficial tissue is caused by sparks from the electrode
without actually touching the tissue.
 The tissue destruction is rapid with cell dehydration and necrosis.
Electrodesiccation :
 It involves touching the lesion with the electrode. The current intensity
is marginally higher than in fulguration.
 The tissue destruction is deeper, superficial mummification and
necrosis of cells occurs after initial dehydration.
Electrocoagulation :
 The lesion may or may not be touched depending upon the depth of tissue
destruction required.
 Deep necrosis and coagulation occurs with a hyalinized appearance. Thrombosis
of midsized vessels (1–2 mm) also occurs.
Electrosection :
 Used to cut a tissue rather than produce only destruction.
 The advantage is simultaneous hemostasis due to vessel coagulation.
Paradoxically, this is also the drawback, since greater tissue destruction and
subsequent delayed wound healing occurs due to poor vascularity.
Electroepilation :
 Destruction of the hair follicle using an electric current.
 Truly permanent method of hair removal.
Indications and Contra-indications
Indications :
 Benign : Warts, acrochordons, dermatosis papulosa nigra, seborrheic
keratoses, freckles, lentigines, mucosal and sebaceous cysts, spider
angioma, cherry angioma, pyogenic granuloma, syringomas,
trichoepitheliomas, xanthelasma, nevus sebaceus, etc.
 Premalignant : Actinic keratoses and Bowen’s disease.
 Malignant : Small basal cell carcinomas and squamous cell
carcinomas.
Contra-indications :
 Keloidal tendency, local infection, and cardiac disorders (especially if
the patient is on a pacemaker), petit mal epilepsy.
Radiofrequency
 Uses radio waves at a frequency of
3.8 mHz.
 Superior to electrosurgery as it has
a coagulation mode, causes less
heating and therefore less
scarring.
 Used to treat a number of benign
growths and some malignant
growths.
 Also used in aesthetic indications
such as blepharoplasty and
resurfacing.
Cryotherapy
 Cryosurgery is that branch of
therapeutics that makes use of local
freezing for the controlled destruction
or removal of living tissues.
Cryogens and their effective temperatures
 Saltice –20°C
 Carbon dioxide slush –20°C
 Fluorocarbons (Freon) –30°C
 Carbon dioxide snow –79°C
 Nitrous oxide –75°C
 Liquid nitrogen –20°C (swab) or –196°C
(spray/probe)
Mechanisms of Action (Cryonecrosis)
 Ice formation : Extracellular ice damages the cell membranes and
intracellular damages the mitochondria and endoplasmic reticulum.
 Osmolarity changes : Extracellular ice causes decrease in extracellular
water and a resulting increase in the solute concentrations causing
cell membrane disruption.
 Thermal shock.
 Denaturation of lipoprotein complexes.
 Vascular changes : Ischemic necrosis starts around the vessels as a
result of microthrombi within the capillaries and arterioles.
 Cryoimmunomodulation : low temperatures can induce effective
immune recognition of the remaining viral or tumor cells.
Indications and Contra- indications
Indications :
 Warts, molluscum contagiosum, cystic acne, acne scars, keloid,
granuloma pyogenicum, skin tags, seborrheic keratosis, and mucoid
cyst, leukoplakia, Bowen’s disease, erythroplasia of Queyrat, and
actinic keratosis, basal cell carcinoma, basal cell nevus.
Contraindications :
 Agammaglobulinemia, cold intolerance and cold urticaria,
cryoglobulinemia, cryofibrinogenemia, Raynaud’s disease, pyoderma
gangrenosum, multiple myeloma, concurrent treatment with
immunosuppressives, and patients on renal dialysis.
Methods of application :
 Dipstick technique, Spray technique, Cryoprobe technique, Cryoroller
technique, Cone spray technique.
Advantages :
 Outpatient procedure.
 Patients of all ages can be treated, even those at poor risk for surgery and
general anaesthesia.
 Multiple tumors can be treated at the same time.
 Complications are rare and cosmetic results are excellent.
 Lesions on sites with poor skin mobility that are difficult to excise can be
treated.
Disadvantages :
 Postoperative edema
 Pigmentary changes
Chemical Cautery
 The process of cauterization is carried out by using heat, cold or
chemicals. When chemical agents are used to carry out this process it
is called chemical cautery.
Commonly used chemical agents :
 Trichloroacetic acid
 Phenol
 Podophyllin
 KOH
 Salicylic acid
 AgNO3
 Formalin
Local Anaesthesia
 Analgesia restricted to particular area or field of interest without
causing any impairment of consciousness and cognizance.
 Most of the dermatosurgery procedure are performed under local
anaesthesia.
Mechanism :
 Local anaesthetic agent (LAA) inhibits nerve conduction by blocking
the sodium channels.
 Adrenaline can be added to improve the efficacy and duration of
action of LAA.
 Vasoconstriction at the site of LAA administration leads to delayed
local clearance and increase in duration of local anaesthesia.
(Adrenaline, 1:2,00,000).
Classification and Mode of administration
 Classified based on chemical structure
• Ester (-COO-)
• Amide (-NH-)
 Esters : Cocaine, Procaine, Chloroprocaine, Benzocaine & Tetracaine.
 Amides : Lignocaine, Prilocaine, Bupivacaine, Mepivacaine and
Ropivacaine.
(Amides contains 2 ‘I’ in the name).
Mode of administration :
 Topical anaesthesia
 Infiltration anaesthesia
 Tumescent anaesthesia
 Nerve block
Topical Anaesthesia
 Method of application of LAA over skin or mucosa to cause
anaesthesia.
 Eutectic mixture of local anaesthetics (EMLA)
• Prilocaine 2.5% + Lidocaine 2.5%
• Lidocaine 7% + Tetracaine 7%
 Superficial skin procedures - shave biopsy, skin grafting and laser
procedures.
 Maximal safe dose for 70 kg adult - 300 mg for lidocaine and 50 mg
for tetracaine.
Infiltration Anaesthesia
 LAA is injected directly into the tissue of interest without considering
the course of the nerve supplying it.
 Lignocaine is the most commonly used LAA.
 Safe limit of lignocaine
• 4.5 mg/ kg without adrenaline
• 7 mg/kg with adrenaline
 Adding adrenaline decreases blood loss, reduces the toxicity and
increases the duration of action.
Modifications (Infiltration Anaesthesia)
 Ring block :
LAA is infiltrated all around the area of interest but not into it.
 Field block :
LAA is injected subcutaneously to anaesthetise area distal to the site
of injection. larger areas can be anaesthetised with lesser quantity of
LAA.
 Regional block:
Infiltration of LAA around a nerve or nerve plexus of hands, foot,
fingers, toes and face.
Tumescent Anaesthesia (TA)
 Newer method of local anaesthesia, used in several dermatosurgical
procedures, particularly liposuction.
 LAA + Adrenaline + Saline mixture is used.
 Safe upper limit of lidocaine administration is 55 mg/kg body weight.
 In TA, rate of absorption of is slow, hence leads to smaller peak
values and lesser toxicity.
 0.05–0.1% lignocaine and 1:100,000 –1.5:100,000 adrenaline are
used.
 10 mEq of sodium bicarbonate is added to 1 liter of solution to
prevent stinging (due to acidic pH).
Nerve Blocks
 Simple procedures that, can be carried in an outpatient setup.
 Small quantities of LAA anaesthetize large areas.
 Good knowledge of anatomy is required to prevent complications like
intravascular injection or nerve laceration.
 Used in full face dermabrasion, vitiligo surgery on hands and feet,
partial or total nail avulsion and hair transplantation.
Complications of local anaesthesia
 Syncope
Secondary to vasovagal attack
 Hypersensitivity Reactions
Skin testing is required
 Methemoglobinemia
Intravenous administration methylene blue is the treatment.
 Cardiovascular Toxicity
• Ventricular arrhythmias and myocardial depression.
• Rarely caused by commonly used LAA.
• Mostly caused by Bupivacaine.
 Others : Bruising and Myonecrosis
Excision
 The elliptical excision is the mainstay of dermatosurgery.
 Steps :
• Proper planning of ellipse
• Clear excision with dissection of lesion
• Undermining of defect
• Achieving hemostasis.
 Good understanding of anatomy, wound healing, lesion biology and
RSTL’s is important.
Types of Excisions
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Simple excision without suture (small lesions).
Elliptical excision with suture (mod-large lesions).
Excision with grafting or rotation flap (large malignant lesions).
Punch excision (with or without suture).
Planning of Ellipse
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Length: Width ratio - 3:1
Angle at tips : 30 degrees
Parallel to RSTL
Long axis of lesion parallel to long
axis of excision.
 Malignant lesion : larger margin
Tips in Excision
 Hold scalpel handle perpendicular
 Incise perpendicular through dermis to subcut tissue
 Pass blade parallel to hair follicle to avoid resection
Avoid cross hatching
Tips in Excision
Avoid boat shaped incisions
Ensure uniform depth of tissue removal,
to avoid pseudo-dog ears.
Suturing
The ideal suture should be sterile, easy to handle, have high tensile
strength, favorable absorption profile and uniform diameter and size.
 Types :
• Absorbable and Non absorbable
• Natural or Synthetic
• Braided or Monofilament
• Antibacterial Sutures
 Absorbable : Catgut, chromic, catgut, vicryl and dexon.
 Non absorbable : Silk, prolene, nylon and Dacron.
Tips in suturing
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Regarding the knot strength, generally four throws are given
Knot should not be placed in incision lines
Knots should be small and the ends cut short (2-3 mm)
Suture should not be tied too tightly as tissue necrosis may occur.
Proper undermining of wound to prevent dog-ears post suturing
Avoid high wound tension as it may lead to hypertrophic scarring
Sutures should be removed in 7 to 10 days
Characteristics of commonly used suture materials
Filament type
Nylon
Polypropylene
Polyester
Polyglactin Gut
Chromic Gut
Fast Gut
Mono
Mono
Multi
Multi
Mono
Mono
Mono
NA
NA
NA
60-90 d
10-40 d*
15-60 d*
3-5 d
Black
Blue
White
White
Tan
Tan
Tan
Time
required for
absorption
Color
Common Use
General
General
More
Advantages
secure
knots
Strength
Tendon
Buried
Used in
Dissolves
tendons
slowly
Children’s
skin
Dissolves
* In the mouth, plain gut absorbs in 3 to 5 days and chromic gut in 7 to 10 days
Tongue
Dissolves
more slowly
Children’s
face
Dissolves
more
quickly
Choice of suture according to area
Techniques
Suturing technique
 Simple interrupted :
Uncomplicated wounds
 Vertical Mattress :
Causes approximation with minimal tension - used for wounds where
tension is expected.
 Horizontal Mattress :
Provides added strength in fascial closure.
 Continuous Suture :
Provides rapid closure.
 Subcuticular Sutures :
Ideal for linear cosmetic closure.
Acne Surgery
 Acne scars are classified as
atrophic (rolling, ice pick,
boxcar scars) and hypertrophic.
 Treatment has to be tailored as
per the type of scar.
Fibrotic bands
Surgical Approaches
 Microneedling
 Subcision
 Punch techniques
•
Punch excision
•
Punch floatation
•
Punch replacement grafting
 CROSS (Chemical Reconstruction Of Skin Scars)
 Dermal grafting
 Dermabrasion
 Scar revision techniques (Z, M and Y plasty)
Microneedling
 Principle : Tiny micro-injuries in the upper dermis trigger the wound
healing cascade including numerous growth factors which leads to a
increased production of dermal collagen and elastin by the
fibroblasts thus causing tissue remodelling.
 Indication : Boxcar scars and rolling scars.
 Method :
• Topical anaesthetic cream is applied on the affected area for
45min.
• After cleaning the area , the skin is stretched and the dermaroller
instrument is rolled to and fro in 4 directions till pinpoint
bleeding is seen and then the face is washed with water.
• The session is done 4-6 times after an interval of 4-6 weeks.
Microneedling principle
Microneedling instrument
(Dermaroller)
Microneedling technique
Subcision
Indication : Rolling acne scars
Principle :
 Releasing fibrotic bands underlying scars .
 Organization of blood in the induced dermal pocket.
 Connective tissue formation in the area.
Method :
 Anaesthesia given subcutaneously with lignocaine and adrenaline.
 18 gauge Nokor needle is inserted in the periphery of scarred area
just below the dermal subcutaneous junction plane and gently swept
across the site, thus breaking the fibrotic bands.
Subcision principle
18 gauge Nokor needle and Subcision
Punch techniques
 Principle : All punch techniques remove a pitted scar with a small rim
of normal tissue.
Punch excision
 Indications : Ice pick ,deep boxcar scar less than 3.5 mm in dia.
 Method : Done under local anesthesia.
 Scars are excised with a biopsy punch and the skin is sutured.
Punch floatation
 Indications : > 3mm boxcar scar that has no significant colour and
textural abnormalities.
 Method : Punch sized to match the inner diameter of the scar is
selected and punch is performed.
 Plug is elevated and positioned to lie slightly higher than the
surrounding skin and the punch is secured by tissue adhesive.
Punch floatation
Punch replacement grafting
 Principle : Technique is similar to that of a punch floatation, but
replaces the plug with a donor plug instead of elevating the original
defect.
 Donor plug obtained from the postauricular area or inner arm.
 Indications : Deep, irregular pits and tethered boxcar scars with
altered skin texture.
Chemical Reconstruction of Skin Scars (CROSS)
 High strength TCA (trichloroacetic acid) is used focally on the atrophic
scars to induce collagenization.
 Principle : TCA causes precipitation of proteins, coagulative necrosis
of cells in the epidermis, and necrosis of collagen in the papillary to
upper reticular dermis.
 Indications : Ice pick scars .
TCA Cross
Method :
 Skin is stretched and TCA
applied with wooden toothpick
upto bottom of the scar .
 After 10-15 secs frosting can be
seen and then face is washed
with water. (Repeated at 3 week
interval for 3-4 sessions).
Dermal grafting
 Dermal graft is a skin graft from which epidermis and subcutaneous
is removed.
 Principle : Placement of dermal grafts into precise pockets under the
skin after subscision.
 Indications : Rolling scars
 Method : After subcision, dermal graft is placed in the defect.
Dermal grafting
Dermabrasion
 Principle : It involves mechanical removal of layers of skin (restricted
to upper reticular or mid - reticular dermis) by manual or electrical
motorized abraders (diamond and steel brushes) and further
allowing this wound to heal by secondary intention so as to achieve
resurfacing effect.
 Limitations : As it is an invasive procedure involving long healing
time and increased morbidity, it is largely replaced by laser
resurfacing.
Dermabrasion Equipment
Diamond brushes
Dermabrasion machine
Manual dermabrader
Nail Surgery
 Nail surgery requires thorough knowledge of anatomy , physiology
and pathology of nail complex.
 Along with surgery skills, good anesthesia, aseptic precautions and
good light, nail surgery has excellent outcome and gives satisfactory
therapeutic / diagnostic results.
Nail anatomy and blood supply
Anatomy of nail unit
Blood supply of nail
Indications
Diagnostic
 Exploration of the nail bed and the
nail matrix :
Inflammatory dermatoses,
infections, connective tissue
diseases and tumors.
 Performing biopsy :
psoriasis, lichen planus, twenty nail
dystrophy, nail unit tumors, nevi,
melanonychia and pachyonychia
congenita.
Therapeutic
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Ingrown toe nail/onychocryptosis
Chronic onychomycosis
Traumatic nail injuries
Chronic paronychia
Pincer nails
Myxoid cysts
Subungual or periungual verruca
Retronychia
Tumours - glomus tumour,
onychomatricoma
 Miscellaneous - melanoma and non
melanoma cancers, pyogenic
granuloma etc.
Contraindications
 Peripheral vascular disease
 Collagen vascular disease
 Uncontrolled diabetes mellitus
 Disorders of hemostasis
 Acute infection or inflammation of the nail unit, including the
surrounding paronychial tissues
Instruments
General instruments
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Binocular magnifier loupe
Delicate adson’s forceps
Castro veijo scissors
Double prong Guthrie retractors
Delicate needle holders
Stevens scissors
Straight mosquito forceps
Curette
Digital tourniquet
Specific instruments
 Nail elevator- freer septum
elevator/dental spatula
 English anvil-action nail splitter
 Nail nipper
Instruments
Instruments include fine curved (Castro Veijo's) scissors, fine curved forceps,
nail spatula, nail splitter, and disposable biopsy punches (3 mm and 4 mm).
Preoperative work up and Anaesthesia
 Proper history and diagnosis
 Clinical examination
 History of drugs that interfere with hemostasis
 Counsel and explain the patient
 Proper photographs and consent mandatory
Anaesthesia
 Distal nail blocks
• Distal digital block(wing block)
• Distal anesthesia through PNF
• Distal anesthesia through hyponychium
 Proximal digital blocks
 Transthecal digital anesthesia
 Regional blocks
Nail surgery Procedures
Nail Surgery Procedures
 Nail plate avulsions - complete/partial
 Nail plate repositioning
 Proximal nail fold reflection
 Nail biopsy
 Matrixectomy
 Nail avulsion is the most common surgical procedure
 Paring the nail plate is the process of taking off pieces of the nail in a
transverse or longitudinal fashion to fully observe an involved area on
the nail bed, performed in subungual or periungual verruca.
Nail avulsion
 Excision of the body of the nail plate from its primary attachments,
the nail bed ventrally and the PNF dorsally.
 The 2 primary methods of nail avulsion are distal avulsion and
proximal avulsion.
 Nail avulsion can be partial or complete
 Indications – onychocryptosis, excision of tumours, for examination of
underlying pathology, preliminary step in nail biopsy, therapeutically
in fungal and bacterial infections, trauma.
Partial nail avulsion
a: nail plate is detached from nail bed
b: cutting of nail plate to be removed
with splitter
c: nail plate removed with sweeping
movements
d: phenolisation to destroy matrix
Biopsies of nail includebiopsy of nail bed, nail plate, nail
matrix, nail fold and nail unit.
Intra-operative
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Bloodless field is mandatory.
For simple avulsions lateral digital pressure suffices.
Commonly digital tourniquet at the base of the finger is used.
Tourniquet should not applied for more than 15 mins at a stretch.
Electrocoagulation should be avoided.
Post-operative care
 Postoperative care is essential for a successful nail avulsion.
 Non-adherent, highly absorbent dressing is ideal.
 The lateral grooves may be studded with either a paraffin gauze or an
antibiotic tulle.
 Dressing is removed after 24 h after soaking in warm water or saline.
 Povidine-iodine solution application may promote the healing
process.
 The operated limb is kept elevated so as to minimize the pain and
swelling.
 Minimal activity is recommended, especially if toenails are avulsed,
for at least 2 weeks.
Complications
Complications are seldom and may result from nail matrix damage
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Pain - most common.
Allergy to anaesthetic
Minor wound discharge
Infection
Hematoma
Nail deformity
Mal-alignment
Nail impaction (distal embedding)
Local spicule growth
Vitiligo surgery
Indications
 Stable vitiligo
• Absence of new lesions
• No extension of old lesions
• Absence of Koebner’s phenomenon
 Refractory lesions
 Secondary leucoderma
 Piebaldism
1 year
Test-grafting : transplantation of few grafts on to the recipient area
before the main surgical procedure. The test grafts are then observed
over some time to see the repigmentation response.
Types of vitiligo surgery
 Therapeutic wounding : to stimulate the melanocytes from the
periphery and hair follicles. e.g. Therapeutic dermabrasion, laser
ablation, cryosurgery, needling, local application of phenol or TCA.
 Grafting techniques : Repopulation of the depleted melanocytes by
various grafts. e.g. Ultra-thin grafts, Suction blister graft, Miniature
punch grafts, Cellular transplants (cultured and non-cultured).
 Tattooing : Uniform implantation of minute, metabolically inert,
pigment granules into the dermis, to create permanent camouflage,
using manual/electrical needles; depth of deposition is 1.5mm, in the
upper & mid dermis.
 Excision with primary closure : removal of the depigmented areas.
Suction Blister Technique
 Donor site : Application of a prolonged suction at a negative pressure
to produce split at Dermo-Epidermal Junction.
 Blister is cut all along its border, anchoring filaments & coagulum
scraped, split thickness skin grafts containing only epidermis
obtained.
 Recipient site : Transplant epidermal sheet to dermabraded/laser
ablated vitiligenous patch.
 Tulle & dressing, removed 10-12 days.
 Course of graft
• Melanocyte transfer occur by 48-72 hrs
• Grafts either dries or gets macerated
• Complete regimentation after 2-3 months
Miniature punch grafting
 Donor site : Take miniature skin punch grafts of sizes 1.5, 2, 2.5 mm
with cylindrical skin biopsy punches.
 Recipient site : Individually insert donor grafts in the punched out
chambers (same size as donor site) spaced 5 to 10 mm apart.
 Place grafts all along the border and at the same level as adjacent
skin, pressure dressing.
 Pressure dressing (after 24 hrs check if any grafts have shifted) for 8 to
10 days.
 Peri-graft pigmentation starts by 1 month & gradually increases to
cover entire patch in 3 to 6 months.
Test Grafting
Miniature punch grafting
Thin Thiersch’s split thickness skin grafting
 Donor site : Obtain split thickness skin grafts, consisting of epidermis
& part of papillary dermis from thigh/gluteal area/ abdomen.
 Ultra Thin Skin Grafting : contains epidermis & uppermost part of
superficial papillary dermis.
 Recipient site : Dermabrade 2 to 3 mm beyond the border, until
punctate bleeding points appear.
 Lift graft with ring forceps & place it with dermal surface facing
abraded bed
• Extend 3-5 mm beyond edge
 Apply surgical glue along edges followed by pressure dressing which is
removed after 10-12 days.
 Graft taken up by 10 days, merges with surrounding skin by 3 months.
Noncultured Melanocytes-keratinocyte Transplantation
(Autologous melanocyte rich cell suspension technique)
 Thin split thickness skin grafts trypsinized & incubated at 370c for 50
min.
 Add 2 ml of Trypsin inhibitor in PBS to discontinue trypsin action.
 Tease & separate the epidermis from dermis with forceps, cut the
epidermis.
 Add Dulbecco's Modified Eagle's Medium and centrifuge at 2000 rpm
for 10-15 minutes.
 Pellet formed is smeared over dermabraded recepient area, covered
with a collagen dressing for 10 days.
 Pigmentation noticed after 3 wks & blends with surrounding area
after 6 to 8 months.
Noncultured Melanocytes-keratinocyte Transplantation
Before surgery
After surgery
Advantages
Method
 Tattooing
 Thiersch’s split thickness skin
graft
 Miniature punch graft
 Suction blister graft
 Non-cultured epidermal cell
suspension
Advantages
 Instant, inexpensive, no chance of
rejection, repeatable, at any anatomical
site.
 Larger areas, Good cosmetic result,
Immediate results.
 Easy & least expensive, 'difficult-to-treat'
locations.
 Pure epidermal graft; no scarring, Good
repigmentation.
 Ten fold large areas can be treated at one
time, Excellent cosmetic results.
Complications of vitiligo surgery
Method
 Tattooing
 Thiersch’s split thickness skin graft
 Suction blister graft
 Miniature punch graft
Complications
 Leaching, color mismatch, change in
shade over time.
 Graft rejection, stuck-on tyre patch,
perigraft halo, scarring of donor site.
 Ecchymosis, post-inflammatory
hyperpigmentation.
 Cobblestoning, polka dot
appearance, depigmented junctional
zone, graft rejection, scarring of
donor site.
Complications of vitiligo surgery
Method
Complications
 Therapeutic wounding (Phenol)
 Scarring
 Ultra-thin skin grafts
 Skip areas and depigmented junctional
line.
 Milia, scarring, koebnerization.
 Non-cultured epidermal cell
transplantation
Hair transplantation
 Androgenetic alopecia is the
commonest cause for baldness and is
largely treated by hair
transplantation.
 Based on donor dominance - occipital
hair is androgen resistant and hence
regarded as permanent.
 Principle is to extract these hairs and
then implant them in bald area.
 Two steps:
• Donor harvesting
• Recipient insertion
 Done under local anaesthesia.
Hair transplantation
Concept of Follicular unit (FU) :
 1-4 hairs are held together by
arrectores as a unit of hairs.
 Implanting these units is referred to
as follicular unit transplantation
(FUT).
 This method allows dense packing
and gives natural results- and hence is
the gold standard method.
 Two methods of harvesting :
FU strip harvesting.
FU extraction.
FU strip dissection
 A strip 1 cm wide (length depending
on number of grafts) is taken.
 Strip is carefully dissected and
removed.
Strip dissection
 Wound sutured in two layers to
obtain a linear scar.
 It is important to avoid wound
tension to avoid a wide scar.
 Needs experience to ensure thin
scar.
Microscopic dissection
 Microscopic dissection of the strip
is essential to ensure minimum
damage to roots.
 Units are separated by careful
dissection.
Follicular unit extraction
 A small hole is made for
each unit through a punch
up to the level of arrectors.
 This loosens the unit and
the unit is extracted with a
forceps.
 Time-consuming, but
leaves less scar, and heals
faster.
Implantation
Can be done in three ways :
 Making all holes and then placing
grafts one by one.
 Making each hole and then placing
units.
 Using special implanters.
Results
Tumescent liposuction
 Gold Standard for removal of fat
 Large amount of fluid with anaesthetic infiltrated in to fat and then
aspirated through cannula.
 Klein has shown that, in tumescent anaesthesia, much higher doses of
lidocaine, even up to 45-55 mg /kg weight can be administered.
 Liposuction removes resistant fat which can not be removed by
exercise / dieting.
 It is safe, done under local anaesthesia.
Mechanism - How does tumescent liposuction work?
Step 3 Fat after
suction
Fat before
liposuction
Step 1 filling fat with
2-3 L of special
tumescent solution
Step 2 Sucking the fat
through small cannulae
(2-3 mm pipes)
Common areas for liposuction
 In women :
Abdomen, hips, thighs and knees.
 In men :
Flanks, abdomen, breast (Gynaecomastia).
 Other areas :
Chin, arms, neck and face.
Instruments
Suction apparatus
of 1HP power
Cannulae for aspiration and
infiltration
Pressure cuffs
for infiltration
Procedure
 Aspiration is done through
cannula of different sizes.
 To and fro motions of the
cannula; smooth, fan shaped
movements from below to upper
layers.
 Average duration : 1-2 hours
depending on the area.
 Patient goes home with
dressings.
 Patient should come back next
day for removal of dressing.
Power-assisted liposuction
 Power-assisted liposuction uses a
machine which moves the cannula
to and fro and side by side and
efficiently removes fatty tissue.
 Decreases surgeon fatigue, increases
precision, in less time, with less
bruising and a faster healing time.
 It also helps in removing tough fat &
causes skin tightening.
Results
 Results are seen at 6 weeks
 Liposuction removes fat in two ways :
• By sucking it out
• By Damaging it which gets absorbed over 4-6 weeks
 Once removed fat cells are not regained easily, hence after liposuction
the new body’s shape is permanent.
 There is no hanging of skin post surgery. Since skin is elastic, it returns
to its normal state after liposuction.
 Laser and powered machines induce fibrosis and induce some
tightening.
 However, patient needs to maintain the shape by regular exercise.
MCQ’s
Q.1)
A.
B.
C.
D.
Which of the following chemicals are not used for chemical cautery?
Phenol
Acetone
TCA
Formalin
Q.2) A 26 year old lady has primarily ice pick scars. The treatment of
choice is A. Microneedling
B. Grafting
C. TCA CROSS
D. Subcision
MCQ’s
Q.3)
A.
B.
C.
D.
Chemical matricectomy is done by use of the following agent
88% phenol
50% TCA
50% glycolic acid
30%
Q.4)
A.
B.
C.
D.
Eutectic mixture of local anesthetics (EMLA) is an example of
Infiltration anesthesia
Topical anesthesia
Tumescent anesthesia
Nerve block
MCQ’s
Q.5)
A.
B.
C.
D.
Which of the following is the best method to cover larger area
Suction blister grafting
Miniature punch grafting
Tattooing
Non- cultured epidermal cell suspension
Q.6)
A.
B.
C.
D.
Which is the gold standard method of hair transplantation
Punch transplant
Minimicrograft
Follicular unit hair transplant
None of the above
Photo Quiz
What is the type of block given in the picture?
Photo Quiz
Identify the procedure.
Thank You!