Letters
This case highlights the multiplicity of the cyst, late presentation of the patient and surgical ease of excision.
Neeraj K Dewanda, Manojit Midya Department of General Surgery, Government Medical College and Associated Group of Hospitals, Kota, Rajasthan, India E-mail: [email protected]
REFERENCES 1. a
2. 3.
4. b
Figure 3: (a) 20× (H&E): The section show the stratified squamous epithelium lining. The lumen is filled with acellular eosinophilic keratinous material (b) 40× (H&E): The higher magnification show the lack of granular layer
Treatment is excision biopsy,[1] which can be easily done under LA. It is the personal experience of the author that TCs are rather easy to excise than the other cysts on the scalp because of the easy plane of cleavage between the cyst wall and surrounding structures. Thomas et al.[1] have also reported that excision can be done with smaller incisions because of the more firm nature of the cyst facilitating easy enucleation.
5.
Thomas VD, Swanson NA, Lee KK. Benign epithelial tumors, hamartomas and hyperplasias. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, editors. Fitzpatrick’s Dermatology in General Medicine, 7th ed. New York,: McGraw-Hill Companies; 2008. p. 1054-67. Adya KA, Inamadar AC, Palit A. Multiple firm mobile swellings over the scalp. Int J Trichology 2012;4:98-9. Seidenari S, Pellacani G, Nasti S, Tomasi A, Pastorino L, Ghiorzo P, et al. Hereditary trichilemmal cysts: A proposal for the assessment of diagnostic clinical criteria. Clin Genet 2013;84:65-9. Greenbaum Adam R, Chan Christopher LH. Skin and subcutaneous tissue. In: Williams Norman S, Bulstrode Christopher JK, Ronan OP, editors. Bailey and Love’s Short Practice of Surgery. 25th ed. London: Hodder Arnold; 2008. p. 593-622. Thomas VD, Snavely NR, Lee KK, Swanson NA. Benign epithelial tumors, hamartomas, and hyperplasias. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K, editors. Fitzpatrick’s Dermatology in General Medicine. 8th ed. New York: McGraw-Hill; 2012. p. 1334. Access this article online
Quick Response Code: Website: www.jcasonline.com
DOI: 10.4103/0974-2077.129994
A comment on A Study of Donor Area in Follicular Unit Hair Transplantation Sir, Nirmal et al. published a study of donor area in follicular unit transplantation.[1] A study of donor area in follicular unit hair transplantation. It is a good thing that studies be carried out to further improve the outcome in surgical hair restoration. Strip Follicular unit hair transplantation (FUHT) scar is definitely an area of concern for the patient and the doctor. However, for a study of the sort detailed above, there are a few things to keep in mind: a. Studies like this should be submitted with high quality
68
pictorial proof. For 30 patients being followed up, picture proof of all of them should be submitted along with graft details and the Norwood level of the patient. b. Ideally, such studies should feature the different type of donor closure on different part of the same patient. This will reduce bias that may occur due to the patient’s personal healing character. (e.g. Some patients have a barely visible scar even when no trichophytic closure is performed.) c. Patient’s satisfaction has to be pre-determined on both counts: Donor area healing. •
Journal of Cutaneous and Aesthetic Surgery - Jan-Mar 2014, Volume 7, Issue 1
Letters
•
Cosmetically pleasing result in the bald recipient area.
If we take too narrow a donor strip, grafts obtained would be reduced and the patient may not feel satisfied with the outcome in the recipient area, especially, if he has extensive hair loss. Filling the strip scar at a later date with grafts extracted from scalp/body by Follicular unit extraction (FUE) would be a better alternative in my opinion.[2] That way the physician can maximise the grafts harvested and later, if the strip scar bothers the patient, he can get it filled with hair. An additional benefit of this approach is that the grafts can be transplanted at the desired angle and direction. Whereas in trichophytic closure, hair direction in strip scar is usually an issue. Grafts can be extracted from the beard or robust body donor areas for this purpose.[1]
Arvind Poswal Dr. A's Clinic, Chittaranjan Park, New Delhi- 110019, India. E-mail: [email protected]
REFERENCES 1. 2.
Nirmal B, Somiah S, Sacchidanand SA. A study of donor area in follicular unit hair transplantation. J Cutan Aesth Surg 2013;6:210-3. Poswal A. Use of body and beard donor hair in surgical treatment of androgenic alopecia. Indian J Plast Surg 2013;46:117-20.
Access this article online Quick Response Code: Website: www.jcasonline.com
DOI: 10.4103/0974-2077.129997
Practice Pearl: Using ‘Namazi Solution’ for Decreasing the Formation of Bruises in Liposuction Sir, I read with interest the editorial entitled ‘Liposuction and the cutaneous surgeon’ published in the July–September 2013 issue of the journal.[1] In this article, the authors elaborate on the benefits of tumescent solution, including the decreased bruising and haematoma formation due to the compression on blood vessels by the large volume of the solution and the vasoconstrictive effect of the epinephrine. However, despite using tumescent solution, bruising still represents one of the most common complications of liposuction,[2] being very distressing to the patients and limiting some of their social activities such as swimming. In 2007, I suggested the use of a new tumescent solution, made by adding one ampoule of tranexamic acid (500 mg/5 ml) to it, for decreasing the blood loss at the recipient site of hair transplantation.[3] Hereby, I would like to suggest the use of this solution for liposuction as well, in order to decrease the rate and amount of bruises. Tranexamic acid is a synthetic derivative of lysine that exerts its anti-fibrinolytic effect through the reversible blockade of lysine-binding sites on plasminogen molecules. Tranexamic acid is useful in a wide range of haemorrhagic conditions. It reduces post-operative
blood loss in a number of surgeries, such as cardiac surgery with cardiopulmonary bypass, orthotopic liver transplantation and transurethral prostatic surgery, without increasing the risk of thrombosis.[3] In a very recent retrospective study, tranexamic acid use in bilateral total knee arthroplasty was associated with a significant reduction in peri-operative serum haemoglobin drop, without any venous thromboembolic events reported.[4] Interestingly, the early administration of tranexamic acid to bleeding trauma patients reduces all-cause mortality without increasing the risk of vascular occlusive events. Indeed, the risks of arterial thrombosis and myocardial infarction appear to be reduced with this agent. Trauma and surgery are known to generate a systemic inflammatory response, characterised by systemic activation of fibrinolysis, coagulation, complement, platelets and oxidative pathways. This inflammation is associated with increased risk of thrombosis. It is speculated that tranexamic acid can exert antithrombotic effects through blocking the inflammatory and prothrombotic effects of plasmin.[5] The usual evaluated intravenous doses of tranexamic acid, for example in orthopaedic surgery, range between 10 and 20 mg/kg or a fixed dose of 1-2 g.[6] Pharmacokinetic studies are needed to demonstrate
Journal of Cutaneous and Aesthetic Surgery - Jan-Mar 2014, Volume 7, Issue 1
69
Copyright of Journal of Cutaneous & Aesthetic Surgery is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
This case highlights the multiplicity of the cyst, late presentation of the patient and surgical ease of excision.
Neeraj K Dewanda, Manojit Midya Department of General Surgery, Government Medical College and Associated Group of Hospitals, Kota, Rajasthan, India E-mail: [email protected]
REFERENCES 1. a
2. 3.
4. b
Figure 3: (a) 20× (H&E): The section show the stratified squamous epithelium lining. The lumen is filled with acellular eosinophilic keratinous material (b) 40× (H&E): The higher magnification show the lack of granular layer
Treatment is excision biopsy,[1] which can be easily done under LA. It is the personal experience of the author that TCs are rather easy to excise than the other cysts on the scalp because of the easy plane of cleavage between the cyst wall and surrounding structures. Thomas et al.[1] have also reported that excision can be done with smaller incisions because of the more firm nature of the cyst facilitating easy enucleation.
5.
Thomas VD, Swanson NA, Lee KK. Benign epithelial tumors, hamartomas and hyperplasias. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, editors. Fitzpatrick’s Dermatology in General Medicine, 7th ed. New York,: McGraw-Hill Companies; 2008. p. 1054-67. Adya KA, Inamadar AC, Palit A. Multiple firm mobile swellings over the scalp. Int J Trichology 2012;4:98-9. Seidenari S, Pellacani G, Nasti S, Tomasi A, Pastorino L, Ghiorzo P, et al. Hereditary trichilemmal cysts: A proposal for the assessment of diagnostic clinical criteria. Clin Genet 2013;84:65-9. Greenbaum Adam R, Chan Christopher LH. Skin and subcutaneous tissue. In: Williams Norman S, Bulstrode Christopher JK, Ronan OP, editors. Bailey and Love’s Short Practice of Surgery. 25th ed. London: Hodder Arnold; 2008. p. 593-622. Thomas VD, Snavely NR, Lee KK, Swanson NA. Benign epithelial tumors, hamartomas, and hyperplasias. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K, editors. Fitzpatrick’s Dermatology in General Medicine. 8th ed. New York: McGraw-Hill; 2012. p. 1334. Access this article online
Quick Response Code: Website: www.jcasonline.com
DOI: 10.4103/0974-2077.129994
A comment on A Study of Donor Area in Follicular Unit Hair Transplantation Sir, Nirmal et al. published a study of donor area in follicular unit transplantation.[1] A study of donor area in follicular unit hair transplantation. It is a good thing that studies be carried out to further improve the outcome in surgical hair restoration. Strip Follicular unit hair transplantation (FUHT) scar is definitely an area of concern for the patient and the doctor. However, for a study of the sort detailed above, there are a few things to keep in mind: a. Studies like this should be submitted with high quality
68
pictorial proof. For 30 patients being followed up, picture proof of all of them should be submitted along with graft details and the Norwood level of the patient. b. Ideally, such studies should feature the different type of donor closure on different part of the same patient. This will reduce bias that may occur due to the patient’s personal healing character. (e.g. Some patients have a barely visible scar even when no trichophytic closure is performed.) c. Patient’s satisfaction has to be pre-determined on both counts: Donor area healing. •
Journal of Cutaneous and Aesthetic Surgery - Jan-Mar 2014, Volume 7, Issue 1
Letters
•
Cosmetically pleasing result in the bald recipient area.
If we take too narrow a donor strip, grafts obtained would be reduced and the patient may not feel satisfied with the outcome in the recipient area, especially, if he has extensive hair loss. Filling the strip scar at a later date with grafts extracted from scalp/body by Follicular unit extraction (FUE) would be a better alternative in my opinion.[2] That way the physician can maximise the grafts harvested and later, if the strip scar bothers the patient, he can get it filled with hair. An additional benefit of this approach is that the grafts can be transplanted at the desired angle and direction. Whereas in trichophytic closure, hair direction in strip scar is usually an issue. Grafts can be extracted from the beard or robust body donor areas for this purpose.[1]
Arvind Poswal Dr. A's Clinic, Chittaranjan Park, New Delhi- 110019, India. E-mail: [email protected]
REFERENCES 1. 2.
Nirmal B, Somiah S, Sacchidanand SA. A study of donor area in follicular unit hair transplantation. J Cutan Aesth Surg 2013;6:210-3. Poswal A. Use of body and beard donor hair in surgical treatment of androgenic alopecia. Indian J Plast Surg 2013;46:117-20.
Access this article online Quick Response Code: Website: www.jcasonline.com
DOI: 10.4103/0974-2077.129997
Practice Pearl: Using ‘Namazi Solution’ for Decreasing the Formation of Bruises in Liposuction Sir, I read with interest the editorial entitled ‘Liposuction and the cutaneous surgeon’ published in the July–September 2013 issue of the journal.[1] In this article, the authors elaborate on the benefits of tumescent solution, including the decreased bruising and haematoma formation due to the compression on blood vessels by the large volume of the solution and the vasoconstrictive effect of the epinephrine. However, despite using tumescent solution, bruising still represents one of the most common complications of liposuction,[2] being very distressing to the patients and limiting some of their social activities such as swimming. In 2007, I suggested the use of a new tumescent solution, made by adding one ampoule of tranexamic acid (500 mg/5 ml) to it, for decreasing the blood loss at the recipient site of hair transplantation.[3] Hereby, I would like to suggest the use of this solution for liposuction as well, in order to decrease the rate and amount of bruises. Tranexamic acid is a synthetic derivative of lysine that exerts its anti-fibrinolytic effect through the reversible blockade of lysine-binding sites on plasminogen molecules. Tranexamic acid is useful in a wide range of haemorrhagic conditions. It reduces post-operative
blood loss in a number of surgeries, such as cardiac surgery with cardiopulmonary bypass, orthotopic liver transplantation and transurethral prostatic surgery, without increasing the risk of thrombosis.[3] In a very recent retrospective study, tranexamic acid use in bilateral total knee arthroplasty was associated with a significant reduction in peri-operative serum haemoglobin drop, without any venous thromboembolic events reported.[4] Interestingly, the early administration of tranexamic acid to bleeding trauma patients reduces all-cause mortality without increasing the risk of vascular occlusive events. Indeed, the risks of arterial thrombosis and myocardial infarction appear to be reduced with this agent. Trauma and surgery are known to generate a systemic inflammatory response, characterised by systemic activation of fibrinolysis, coagulation, complement, platelets and oxidative pathways. This inflammation is associated with increased risk of thrombosis. It is speculated that tranexamic acid can exert antithrombotic effects through blocking the inflammatory and prothrombotic effects of plasmin.[5] The usual evaluated intravenous doses of tranexamic acid, for example in orthopaedic surgery, range between 10 and 20 mg/kg or a fixed dose of 1-2 g.[6] Pharmacokinetic studies are needed to demonstrate
Journal of Cutaneous and Aesthetic Surgery - Jan-Mar 2014, Volume 7, Issue 1
69
Copyright of Journal of Cutaneous & Aesthetic Surgery is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
