How to Optimize Wound Closure in Thin Skin.

Cutaneous surgery often is performed in areas of extremely thin skin. Traditionally, wound closure in thin skin is complicated because the skin tears easily and wound breakdown can occur. Consequently, healing becomes a challenge. Our group of dermatologic surgeons has developed a novel effective technique that minimizes these problems, which we present step by step.

Subcision in acne scarring: A review of clinical trials.

Post-acne scarring is the most common permanent consequence of acne vulgaris. Subcision is an intervention in which a needle or blunt cannula is inserted under the scar and moved back and forth to cut fibrotic strands and form new connective tissue, thereby elevating the atrophic scars. In this study, we reviewed the efficacy and adverse effects of different subcision techniques alone or in combination with other modalities to manage acne scars. The terms (subcision), (subcision AND acne scar), and (subcision AND scar) were searched in PubMed and Google Scholar. We included all available reports on clinical trials written in English and published before June 2022. A total of 16 relevant articles were identified after reviewing the abstracts and full texts. Four articles compared blunt cannula-based subcision as a modified technique with needle-based subcision as a conventional method, while the others investigated the combination of subcision with other modalities. According to our findings, subcision is a safe and effective method for treating atrophic acne scars. Needle-based subcision and cannula-based subcision offer comparable efficacy, with the latter causing fewer side effects and inducing greater patient satisfaction. Combining subcision with the application of autologous tissues (platelet gel) or artificial materials (hyaluronic acid gels and threads) as fillers can improve outcomes and prevent the re-depressing of scars, as can its combination with frequent suctioning. Combinations with microneedling or fractionated microneedle radiofrequency have also been safe and effective. We conclude that modifications of the subcision procedure lessen its side effects, and combination therapies improve its efficacy.

Surgical outcome of modified Karydakis flap and modified Limberg flab in the management of sacroccygeal pilonidal disease: a comparative study

Introduction: Sacrococcygeal pilonidal disease (SPD) is a chronic suppurative condition of the sacrococcygeal region causing chronic sinus tract or cyst. It is an acquired complex disease more common in young adult males, causing considerable morbidity and long periods of interruption in work or education. From simple conservative techniques to complex flap reconstruction, many debatable treatment options are offered; however clear dynamics toward the widespread use of minimally invasive methods and off-midline flap reconstruction are suggested in all guidelines, which recommend the Karydakis and Limberg flap modification. The plethora of literature compares procedures for identification of a single best treatment approach, which has proven to be difficult. The surgical outcome of both techniques is compared in the present study. Objective: To compare the surgical outcomes of the modified Karydakis flap (MKF) versus the modified Limberg flap (MLF) in SPD. Materials and Methods: The present study was conducted at the general surgery department on SPD patients who were ≥18 years old. A total of 67 participants were included after obtaining the informed consent, with group A comprising 33 patients undergoing the MLF procedure and group B comprising 34 patients undergoing the MKF procedure. Results: The mean patient age was 28.85 (range, 18-44) years old. For the MKF and MLF methods, the average operating duration was 32.5 (range, 25-40) and 54.5 (range, 45-65) minutes, respectively. The MKF approach was found to significantly improve pain score, mean sitting painless time, return to normal activity, wound healing time, and patient satisfaction. Conclusion: Comparative outcomes were seen between both MKF and MLF; however, our findings show that MKF is a more favourable method than MLF with superior outcomes. (AU)

Consideraciones prácticas sobre incisiones/extirpaciones óptimas en cirugía dermatológica con énfasis en la orientación de las incisiones y la cirugía del melanoma cutáneo primario / Practical Considerations About Optimal Skin Incisions/Excisions in Dermatologic Surgery with Emphasis on Incisions Orientation and Primary Cutaneous Melanoma Surgery

La cirugía dermatológica tiene 2objetivos principales: 1) asegurar la radicalidad quirúrgica, y 2) obtener unos resultados estéticos y funcionales óptimos. Se tienen que considerar estos 2paradigmas y su jerarquía cuando se realizan intervenciones quirúrgicas en la piel. Incluso la intervención más sencilla, el huso, presenta algunas características que deberían ser conocidas para obtener dichos objetivos. Una de estas características es la orientación de la incisión. La orientación óptima de las incisiones es todavía materia de debate, especialmente porque no hay estudios que comparen los resultados según la dirección de la incisión. Sin embargo, algunas observaciones anatómicas, clínicas e histológicas podrían indicar por qué cortar la piel con una orientación es mejor que otra. Conocer la teoría detrás de las incisiones/extirpaciones cutáneas se vuelve imprescindible cuando hay que enfrentarse a la cirugía del melanoma cutáneo primario. Especialmente si se sospecha que la lesión melanocítica es un melanoma invasivo y se requerirá una biopsia del ganglio centinela (AU)

Dermatologic surgery has 2main objectives: 1) to guarantee surgical radicality; and 2) to achieve optimal aesthetic and functional results. These 2paradigms and their hierarchy must be considered when performing surgical procedures on the skin. Even the easiest intervention, the elliptical excision, presents some features that should be known to achieve such goals. One of these features is the incision orientation. The optimal incisions orientation is still matter of debate, especially because studies that compare the outcomes of performing incisions in different directions are lacking. However, some anatomical, clinical, and histological observations may point out why incising the skin in one orientation is better than another. Knowing the theory behind skin incisions/excisions become of outmost importance when dealing with primary cutaneous melanoma surgery. Especially if the melanocytic lesion is suspected to be an invasive melanoma and a sentinel lymph node biopsy will be required (AU)

Acne scar treatment using combination therapy: Subcision and human autologous fibroblast injection.

BACKGROUND: Acne scar treatment is a problem for both the dermatologist and the dermatologic surgeon. Many therapies have been advanced to improve acne scars over the past years. Nevertheless, they were often related to adverse side effects like hyperpigmentation. These combination therapy using subcision and autologous fibroblast injection can provide a better technique for the acne scar treatment. MATERIAL AND METHODS: In this study, we describe nine patients with the age of 25 to 48 and rolling acne scars (moderate to severe) that were treated with combination therapy using subcision (cannula, 18 gauge) and autologous fibroblast injection. Finally, before and 6 months after the final injection, the patients' biometric characteristics were evaluated by Visioface 1000D and Mexameter and a skin ultrasound imaging system. RESULTS: The results show a significant improvement in the acne scars in the patients. The Visioface results showed that the size and number of skin pores and spots were reduced after combination therapy. Also, the results of skin ultrasonography exhibited denser skin layers both in the epidermis and dermis. CONCLUSION: In summary, the combination therapy of autologous fibroblast injection and subcision can be considered as a new alternative, safe, and useful method for acne scar treatment.

Triple steps acne scar revision technique: A new combination therapeutic modality for atrophic acne scars.

BACKGROUND: Atrophic acne scarring is an unfortunate, permanent complication of acne vulgaris, associated with significant psychological distress. OBJECTIVE: A new complementary treatment of atrophic acne scars using subcision and injection of hybrid cooperative complexes of high and low molecular weight hyaluronan (hybrid H-HA/L-HA). METHODS: This study included eighty-two patients divided into two groups with predominantly atrophic acne scarring. Group 1 received subcision with saline injection, while group 2 received triple steps acne scar revision technique (TSASRT). After topical anesthesia, the procedure of combining subcision and hybrid H-HA/L-HA technique was done in which the first step started using subcision technique done to release fibrous cords at the dermal or deep dermal, subcutaneous plane using Nokor needles-18 g. The second step is to inject the scar's atrophic dermal component with a 29 g needle, applying an average amount of hybrid H-HA/L-HA (0.02-0.1 mL) to the dermal component. The third step was to fill the subcisied space with hybrid H-HA/L-HA (0.02-0.1 mL) using a 25 g cannula. RESULTS: Clinical improvement was achieved in both groups. There were statistically significant improvements in the TSASRT versus subcision (p ≤ 0.05) in acne scar severity index and qualitative scarring grading system. CONCLUSION: The triple step acne scar revision technique appears to be a safe and effective way to treat atrophic acne scars on the face.

Achieving stomal continence with an ileal pouch and a percutaneous implant.

In this study, a soft-tissue-anchored, percutaneous port used as a mechanical continence-preserving valve in reservoir ileo- and urostomies was functionally and morphologically evaluated in eight dogs. During follow-up, the skin failed to attach to the implant, but the intestine inside the stoma port appeared to be attached to the mesh. After reaching adequate reservoir volume, the urostomies were rendered continent by attaching a lid to the implant. The experiments were ended at different time intervals due to implant-related adverse events. In only one case did the histological evaluation reveal integration at both the implant-intestine and implant-skin interfaces, with a low degree of inflammation and the absence of bacterial colonisation. In the remaining cases, integration was not obtained and instead mucosal downgrowth and biofilm formation were observed. The skin-implant junction was characterised by the absence of direct contact between the epidermis and the implant. Varying degrees of epidermal downgrowth, granulation tissue formation, inflammatory cell infiltration and bacterial growth and biofilm formation were prominent findings. In contrast, the subcutaneously located anchor part of the titanium port was well integrated and encapsulated by fibrous tissue. These results demonstrate the opportunity to achieve integration between a soft-tissue-anchored titanium port, skin and intestine. However, predictable long-term function could not be achieved in these animal models due to implant- and non-implant-related adverse events. Unless barriers at both the implant-skin and implant-intestine junctions are created, epidermal and mucosal downward migration and biofilm formation will jeopardise implant performance.

Dermoscopic evaluation of tranexamic acid versus Vitamin C, with microneedling in the treatment of melasma: a comparative, split-face, single-blinded study.

BACKGROUND: Melasma is a complex pigmentary disorder with challenging management. OBJECTIVES: Evaluation of efficacy of topical tranexamic acid (TXA) versus Vitamin C (Vit C) with microneedling (MN) in melasma therapy. MATERIALS AND METHODS: In 30 females with melasma, after 4 weeks of using Modified Kligman's formula, the right side of the face was treated with MN + TXA and the left with MN + Vit C for five biweekly sessions. Wood's light, dermoscopy, Melasma Area and Severity Index (MASI), MASI malar right and malar left (MASIMR and MASIML), Visual Analogue Score (VAS), and Dermatology Life Quality Index (DLQI) were evaluated at weeks 0, 4, 12, and 16. RESULTS: Both MASIMR and MASIML decreased significantly (p < .001). Both sides exhibited significant diminution in dark fine granules (p-value < .001), homogeneous pigmentation (p-value = .005) and pseudoreticular brown network (p-value = .028). However, telangiectasia significantly improved only on the TXA treated side (p = .002). DLQI improved significantly on both sides (p < .001). In some patients transformation of mixed to dermal melasma was depicted. CONCLUSION: MN followed by Vit C or TXA is successful in melasma management, the latter being advantageous vis-a-vis dermal vascularity and epidermal pigmentation. Dermoscopic evaluation appears crucial in choosing optimum treatment in each patient.

Survey of Dermatologic Procedures in Transgender Adults.

BACKGROUND: Dermatologists have the opportunity to provide medically necessary procedures, including laser hair removal, to transgender patients for gender affirmation. Further research is required to better assess the unique dermatologic needs of this population. OBJECTIVE: To examine the prevalence of dermatologic procedures among transgender people in the context of gender-affirming treatment. METHODS: This cross-sectional study examined survey responses from 696 transgender persons enrolled in the Study of Transition, Outcomes, and Gender cohort. Prevalence of self-reported dermatologic procedures was examined and compared across participant subgroups. RESULTS: Electrolysis was the most commonly reported procedure (32.9%). Transfeminine patients were more likely to use dermatologic procedures compared with transmasculine patients. Only 19 participants (2.8%) reported the use of dermal filler injections. CONCLUSION: Differences in utilization of dermatologic procedures were noted in transgender populations. Motivations, barriers, and optimal timing for gender-affirming dermatologic procedures among transgender persons should be examined in future studies.

Evaluation of bilateral interdigitated Pacman flap for reconstruction of skin defects in different parts of the body.

Restorative surgical repair using different surgical modalities is required on the excision of skin lesions or when treating traumatic lacerations; each modality has advantages and drawbacks. In this article, we evaluate the efficacy of using a bilateral interdigitated Pacman flap to reconstruct circular and oval cutaneous defects on different parts of the body. Fourteen patients with soft tissue defects on different parts of the body underwent reconstruction using a bilateral interdigitated Pacman flap. The design of this flap is similar to that of a conventional bilateral V-Y advancement flap; however, the limbs of the V are drawn as slightly curved convex lines. All patients were followed-up for more than 6 months. All soft tissue defects were reconstructed completely using this technique, and no significant complications were noticed except in one patient who developed partial flap necrosis. However, aesthetic issues remain a limiting factor in using this technique. This flap is a reliable, practical and effective option for closure of circular and oval soft tissue defects, although there are certain limitations when used on the face and in younger patients.

Dermatological surgery: an update on suture materials and techniques. Part 2.

This is the second part of a two-part series summarizing the latest evidence related to suture materials and wound closure techniques in dermatological surgery. We critically appraised evidence focusing on the following consequences of suture choice: scar/cosmesis, pain, patient satisfaction, cost, infection and wound complications. We searched the databases MEDLINE, PubMed and Embase using the keywords 'skin surgery', 'dermatological surgery', 'sutures', 'braided sutures', 'monofilament sutures' and 'antibacterial sutures' to identify relevant English-language articles. This part of the review assesses the evidence for different types of buried sutures, including braided vs. monofilament sutures, longer-absorbing sutures and antibacterial sutures. The majority of trials were noted to be of poor quality, single-centre (thus lacking external validity) and underpowered, which presents challenges in comparing suture techniques in skin surgery. Future large-scale, multicentre, randomized trials are needed, with both surgeon and patient-assessed validated outcomes.