Macgyver Jobs in Dermatology

Review DOI: 10.6003/jtad.19131r2

MacGyver Jobs in Dermatology

Ümit Türsen,* MD

Address: *Mersin University, School of Medicine, Department of Dermatology, Mersin E-mail: [email protected] Corresponding Author: Dr. Ümit Türsen. Mersin University, School of Medicine, Department of Dermatology, Mersin.

Published: J Turk Acad Dermatol 2019; 13 (1): 19131r2. This article is available from: http://www.jtad.org/2019/1/jtad191314r2.pdf Keywords: MacGyver, Dermatology, Aesthetic, Dermatosurgery

Abstract

Background: Hair loss is a common clinical presentation in any medical clinic. Telogen effluvium is considered among the most prevalent causes of hair loss particularly in female patients. Telogen effluvium may associate with significant psychosocial comorbidities and the medical treatment may be challenging. In this article we will review the recent literatures about epidemiology, etiopathogenesis, clinical presentation and management of telogen effluvium.

Method: An electronic literature search was performed using the PubMed and Google Scholar to identify relevant articles published between 1993 and 2017. Search keywords included “telogen effluvium” and “hair loss”. We included studies published in English. Editorials, brief notes, conference proceedings, and letters to editors were excluded.

Introduction garbage bags and bamboo. Most importantly, he's the only guy who ever looked cool in a The Oxford Dictionaries state that to “MacGy- mullet and is probably the only guy who ver” is to make or repair (an object) in an im- could get away with it now [1,2]. In dermato- provised or inventive way, making use of logy, we can solve different problems in a whatever items are at hand. Origin comes creative, resourceful, typically “jury-rigged” from Angus MacGyver, the lead character in fashion as Macgyverism (Table 1). the television series MacGyver (1985–1992), who often made or repaired objects in an im- MacGyver Jobs with Skin Biopsy Punches provised way. Main character of show by the same name. Full name Angus Macgyver. Part Punch instrument is a circular hollow blade secret agent for government and phoenix fo- attached to a pencil-like handle ranging in undation, part handyman, part mad scien- size from 0.5 mm to 10 mm available as a dis- tist, part community service volunteer. He posable, reusable, and automated instru- might refuse to use guns, but nobody could ment. Punch biopsy is an apparently simple ever call him a pussy. Macgyver can battle procedure include the relative easiness to Soviet supersoldiers and serve soup at a ho- perform, minimal complications, and provi- meless shelter all in one episode. Macgyver sion of a full-thickness sample. The skin was the epitome of 1980s era optimism. punch is an instrument which is used almost Beats the commies, fixes the environment, exclusively by dermatologists. The skin bi- cures aids, and can make a helicopter out of opsy is a relatively simple, but essential pro-

Page 1 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf cedure in the management of skin disorders. is preferred over shave biopsy. Punch biopsy Properly performed, it may confirm a diagno- has some disadvantages. First, its small size sis, remove cosmetically unacceptable lesi- and variable depth lead to difficulty in histo- ons, and provide definitive treatment for a pathologic interpretation in conditions invol- number of skin conditions. Variants of hand ving adipose tissue such as morphea and held punches are characterised by metallic panniculitis. Because of that, a modification punches with tapering or cylindrical tip; me- called the double-trephine punch biopsy tallic handle with attachable tips; disposable, technique was proposed. Second, the shea- plastic handle punches; available in sizes ring effect of the punch may cause loss of the from 0.5 to 10 mm in diameter. Power punc- blister roof. In such cases, a topical refrige- hes, here the shaft of the punch is mounted rant such as ethyl chloride spray can be used onto a hand machine with adjustable rotatio- to freeze the blister in place when a punch bi- nal speed varying from 2000 to 10,000 rpm. opsy is taken [4,5]. It is available in various sizes of 0.5-1.3 mm. Modified diagnostic punch surgery: Punch It is a circular hollow blade attached to a pen- biopsy is an apparently simple procedure, but cil-like handle ranging in size from 1 to 8 mm. it has some pitfalls. Being aware of the pitfalls It is available as a disposable, reusable, and and ways to work around them helps in subs- automated instrument. Disposable punches tantially improving the outcome of this diag- have the advantages of being presterilized, nostic procedure. Most important is choosing readily available, always sharp, and requiring the most representative lesion for the biopsy, no maintenance. Reusable steel punches are which will yield a better diagnostic outcome. more expensive, require sterilization between Always take a fully evolved, untreated lesion procedures, get dull with repeated use, and and avoid excoriated or ulcerated lesions un- must be maintained by proper, skilled shar- less there is no option. Avoid taking a biopsy pening [3,4]. over bony prominences or pressure-bearing Uses of Punches Can Be Classified İnto areas as a sparse, nonspecific, lymphocytic Three Categories infiltrate present over frictional sites can complicate its interpretation. Punch surgery A-Diagnostic purposes: Skin biopsy for di- does have certain risks, including possible agnosis of dermatological diseases. Punch bi- disturbance of deeper underlying structures opsies are simple to perform, have few such as nerves and arteries. Therefore, physi- complications, and if small, can heal without cians must be familiar with the underlying suturing. For non-facial lesions, a 4-mm anatomy and the danger zones. Punch sur- punch is sufficient; however, in granuloma- gery in critical areas such as the digits or the tous conditions or conditions with atypical eyelid overlying the globe are generally to be features, biopsies of 5 mm or more are prefe- avoided. Caution should also be exercised rable[3]. over areas where there is little soft tissue between skin and bone because the punch can Basic punch: Punch surgery tray should in- cut through the underlying bone [4]. clude alcohol pads, local anesthetic, a punch instrument of the desired size, forceps, scis- Split-punch biopsy technique: This techni- sors and gauze. After preparation of the site, que is used to obtain two tissue samples for the fingers of the nondominant hand are used different studies from one punch biopsy. The to stretch the skin perpendicular to the direc- split-punch biopsy technique is used to ob- tion of relaxed skin tension lines to produce tain two tissue samples for different studies an oval defect that is easier to close. The from one punch biopsy. It is done by advan- punch is withdrawn, and the specimen is ret- cing the punch just into the papillary dermis. rieved by piercing it with the needle from the This is followed by using a no. 11 blade held syringe used for anesthesia or by handling it nearly perpendicular to the skin surface; the with the forceps. If needed, scissors can be specimen is bisected to the subcutis. Then used to transect the subcutaneous tissue at the punch is reintroduced and advanced to its deepest portion. The advantages of punch the subcutis. On removal of the punch, the biopsy include the relative easiness to per- bisected specimen is held in place only by a form, minimal complications, and provision bit of subcutaneous tissue, which must be of a full-thickness sample; because of that, it undercut to complete the procedure, resul-

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Table 1. MacGyver Jobs in Dermatology

Diagnostic Punches Basic punch, modified diagnostic punch, splti-punch, double-trephine punch, string-of-beads biopsy technique, the pendulum (scoop) biopsy, nail biopsy, fine-needle aspiration, diagnosis of eyelid tumors, improving histologic examination of the tumor margin Therapeutic Punches Punch excision of acne keloidalis nuchae, moles, corn, tatoo, scrotal calcinosis, pathologic bone, glomus tumor of nail, enhance wound healing, extrusion of epidermal inclusion cyst, hidrocystomas, pilomatricoma, pilar sheath cyst, and pseudocyst of auricle, chondrodermatitis nodularis helicis, subungal haematoma, periungual exision refractory paronychia, molluscum contagiosum, wart, pyogenic granulomas etc, punch debridement of HS

Cosmetic uses of Punches Punch grefting in vitiligo, punch excision of nevus and acne scars, small lipoma excision, for liposuction to make holes to insert cannulas, in earlobe repair (piercing earlobes), follicular unit extraction method by using micropunches for alopecia Adding hyaluronidase to local anesthesia For minimizing loss of surface contour and enhanced ease in undermining and dissection through subcutaneous tissue planes Preoperative application of topical brimonidine 0.33% gel Decreases blood loss and the need for cauterization

Combination of ligation and timolol before surgical excision Increases the chances of success, prevents PG from enlar- of pyogenic granuloma ging and reduces tumor size, resolve PG, obviating the need for surgery Cutaneous vibrators To relieve pain associated with a variety of dermatology procedures including injections and laser treatments Purse-string suture To repair small, circular wounds easily after excision of skin lesions Round excision A better alternative to conventional fusiform or shave excision of benign, dome-shaped or papular nevi of the face

Extra-fine insulin syringe To evacuation of subungula hematoma 27-gauge needle To remove epidermal cysts 2 needle for intralesional steroid injection For adequate delivery of drug and prevent the rupture of the cyst Needle-assisted electro-coagulation of nasal telangiectasia To puncture skin and vessel without an electric current, with minimal epidermal and surrounding dermal tissue damage TCA and CO2 Laser combination for Nasal Telangiectasia A simple, effective, and inexpensive method

Presuturing A simple, inexpensive and effective method for large skin lesions A standard dissecting forceps and perone lasik forcep An effective extraction technique for eruptive vellus hair cysts, steatocystoma multiplex, comedone, closed macroco- medones, molluscum Freer dissector For the removal of trichilemmal cysts Subcutaneous Curettage Combined with Trimming Through A Minimally Invasive Procedure for Axillary Osmidrosis a Small Incision Using 2 hairdryers To reduction in the time required for suction blister formation Intralesional normal saline injections To treat corticosteroid lipoatrophy successfully Focused cold therapy For the reduction of hyperdynamic forehead wrinkles Fractionated cryotherapy, intralesional cryotherapy, cryoa- To treat keloids, SCC, BCC and postherpetic neuralgia nalgesia Topical nitric oxide Cutaneous leishmaniasis Subsicion-suction method To treat atrophic acne scars Discarded human skin, excised keloid scar, human cada- As Model to Teach Surgical Techniques and Laser treatment vers, live pigs, latex glove, rubberized synthetic skin models, pigs’ feet, ox tongue, hot dog, tomatoes, burned oranges, cantaloupes, bananas, pillowcase baby Refrigerator magnet For controlling surgical sharps Micro-Drilling To do micro nail penetration of topical terbinafine solution

Disposable 5-mL syringe with anticoagulant dextrose solu- To create PRP with high platelet-derived growth factor as tion A and prostaglandin E1 economically1-80

Page 3 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf ting in a clean, bisected tissue split. This is visualized and a procoagulant, such as technique can be used to avoid taking two bi- Monsel's solution or Drysol may be applied opsies or splitting a single specimen, which for hemostasis [4]. might distort or crush the tissue [3]. Nail biopsy: 2 to 3 mm punch biopsy is ade- Double-trephine punch biopsy: This tech- quate for nail plate, nail bed, and nail matrix nique is used to obtain tissue samples for di- in most instances. For a biopsy of the nail agnosis of dermatoses that affect the subcu bed, a two-punch method may be used. In taneous tissue. A 6 to 8 mm punch is inser- this technique, a larger size punch is used to ted to obtain the initial sample. A 6 to 8 mm remove the overlying nail plate and then a punch tool is inserted to the hilt of the ins- smaller punch is used to sample the bed. trument to obtain the initial sample. Once Dermatologists have traditionally taken the the superficial core is removed, a 4 mm nail matrix tissue by exposing the nail matrix punch is subsequently used within the cen- after incising the proximal nail fold. Although ter of the 8 mm defect to obtain the subcu- this has offered much more histopathological taneous tissue [4,6]. information to dermatologists and shown a high success rate in achieving a diagnosis, it String-of-beads biopsy technique: Diag- has many disadvantages. First, the method nostic challenges often require a significant is a complex one which needs expert skills of amount of tissue for a complete evaluation, the operator because it needs several steps which is done either by 6 to 8 mm punch bi- until exposure of the nail matrix, so called opsy or incisional biopsy followed by dividing cul-de-sac. Second, because of the anesthe- the tissue sample into several pieces for mul- sia which needs much amount of local anest- tiple studies. These methods are time consu- hetic, the patients surely suffer from harsh ming, with associated risks of crush artifact pain during injection. Third, the traditional on the specimen and a possible sharps in- nail matrix biopsy leads to decrease in the jury to the physician. The string-of-beads bi- size of the nail plate, eventually. Therefore, opsy technique is done by performing sm the patient may undergo cosmetic problems. aller, adjacent 4 mm punch biopsies in a Finally, a long period of wound healing is ne- row, and the individual biopsy defects may cessary and a postoperative scar may result. be closed in a linear or multiple O-to-Z/W Hence, some authors introduced a simple design with nonabsorbable sutures placed but informative method for patients with nail using the simple interrupted suture techni- matrix disorders. After achieving local anest- que. This method obviates the need for dis- hesia that does not need lots of anesthetic as section of tissue in pieces [3]. compared to the conventional method, they The pendulum or scoop biopsy: The poten- performed two 2-mm punch biopsies on the tial disadvantage of shaving a flat lesion or proximal nail fold for taking proximal nail plaque is the inability to achieve a suffici- matrix tissue. Considering the individual dif- ently deep or representative sample. The ference of the location of the nail matrix, they scoop ensures that adequate tissue sampling chosed two different punch biopsy sites from is achieved, thus making a histopathologic the proximal nail fold. The 2-mm punch was diagnosis readily available. The scoop also advanced down to the nail matrix until the results in a smooth biopsy edge which re- physician got the feeling of touching bone. sults in less trauma and more rapid healing Then, they punched through the nail plate of without scar. The scoop has the additional lunula to the underlying tissue using a 2- benefit of providing enough depth so as to mm punch to obtain the distal nail matrix. make prognostication more accurate in cases Without suturing, a simple dressing with to- of suspected malignancy. Observing stan- pical antibiotics was needed for three to five dard surgical techniques, the lesion is clean- days. The advantages of their technique are: sed and locally anesthetized. Counter it is less painful, has a rapid healing time, traction is applied with the nondominant there is almost no risk of scarring and morp- hand, and the biopsy-pen is inserted into the hological change. They adapted this simple skin in a pendulous manner. The punch tool technique for 18 patients which yielded the scoops the skin like a pendulum. Once the satisfactory results without exposing nail tissue is removed, the subcutaneous tissue matrix. As a result they found that 17 out of

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18 nail specimens contained the nail matrix. streak in the nail plate; suspicion of skin can- Almost histological findings were consistent cer, either melanoma or nonmelanoma; and with clinical diagnoses. The method especially space-occupying lesions, either benign or ma- benefited to classify twenty-nail dys trophy lignant tumors. Biopsy of the nail matrix is into several histological types. It showed a re- not to be taken lightly because of the real pos- latively high success rate in achieving a diag- sibility of scarring, a permanent nail split, or nosis, considering that 2-mm specimens are other longitudinal dystrophy. The patient prone to crush injury during handling and should be fully aware of these potential con- are hard to interpret. However, matrix tissue sequences [3]. was sometimes missing in tissue specimens Saw-toothed power punch for effortless because of its fragility and size. Thus they nail biopsy: A nail biopsy is an important di- were developing an advanced technique to re- agnostic procedure for many nail diseases induce the loss of tissue. Another limitation was volving the nail bed and the nail matrix. The that it was not suitable to be applied to a ma- 3 methods commonly used for nailbed biop- lignancy such as acral lentiginous melanoma sies include excision biopsy, longitudinal bi- because blind technique may not capture the opsy, and punch biopsy using skin biopsy atypical area of the lesion, correctly. In gene- punches. The punch method is the least in- ral, malignant lesions may be clinically dis- vasive method and conserves tissue, there- tinguish from other benign lesions by using fore, is more popular. A nail plate consists of other devices such as dermoscopy, clinicians a densely packed tough keratinized tissue; can choose more invasive and conventional therefore, skin biopsy punches are unsuitable technique to the doubtful cases. Therefore, and often require excessive physical force lea- this less invasive tec hnique could be widely ding to damage to the biopsy specimen and applicable to various benign nail disorders es- the surrounding tissue. Furthermore, it is dif- pecially involving the nail matrix, like twenty- ficult to insert a punch to the desired depth nail dystrophy and median nail dystrophy, in one attempt because of the resistance pro- and it can provide histopathologic informa- duced by the tough nail plate. To overcome tion of whole nail tissues. The dorsal portion this, a 2-punch method has been proposed. of the proximal nail fold, ventral part of the In this method, a larger punch is used to re- proximal nail fold, and the proximal nail mat- move the nail plate and then a smaller punch rix were sequentially shown in the specimen is used to take the nail bed or matrix biopsy. from the proximal nail fold. The specimen In such biopsies, the absence of the attached from the lunula shows the distal nail matrix nail plate leads to loss of orientation of the bi- just beneath the nail plate3,4. Since early opsy specimen. All these factors sometimes 2009, they had got useful histopathologic fin- lead to inconclusive histology reports. If the dings from patients with various nail disor- nail plate is thick, such as in patients with ders through this technique. So far, no pincer nails, obtaining a nail bed or nail mat- complications concerning the procedure have rix biopsy specimen requires removal of the occurred and the physicians and the patients complete nail plate first; this causes undue are all satisfied. In summary, the proximal trauma and delayed healing. To overcome nail fold-lunula double punch technique is these problems, the authors introduce use of both, a physician- and patient-friendly diag- saw-toothed motorized punches of 3 mm or nostic tool. This enables the ph ysician to more in diameter for obtaining a nail biopsy. take nail biopsies more easily and to detect The dimensions of these punches have been more histopathologic findings of inflammatory made to fit in the hand piece of the micromo- nail disorders in the future. There are many tor dermabrader machine, which is usually types of nail unit biopsy, including biopsy of available in dermatology operating rooms. the nail matrix, which is done by retraction of These motorized saw-toothed punches penet- the proximal nail fold; then a punch is intro- rate even the toughest of the nail plates at duced through the newly formed nail plate ex- 2000 to 3000 rotations per minute without tending down to the periosteum of the excessive manual force and easily reach to the terminal phalanx. In most ins tances, the level of the periosteum. The specimen so ob- plate will be avulsed first and the proximal tained has an attached nail plate so that tis- fold retracted for complete visualization. Indi- sue orientation is not lost. Moreover, the nail cations for nail biopsy include a pigmented plate removal is not needed for nail bed or

Page 5 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf matrix biopsy even in the presence of a very aspirate lesions that are small, ill-defined, fib- thick nail plate, and healing is faster. The rotic, or dermal in location. Consequently, currently available micromotor dermabrader use of the punch might be very helpful in di- hand pieces have very good hand control, so agnosing solid organ tumors that are close to there is a minimal risk of going too deep. They the skin surface, such as lymph nodes, the need to stop when they feel the ‘‘give’’ on re- breast, and the thyroid, especially if the FNA aching the nail bed to avoid trauma to the yielded a nondiagnostic result. In one study, deeper structures [7]. the use of a punch gave a diagnosis in 17 of Window Nail Plate Avulsion: Nail problems 21 breast tumor cases in which FNA was non- limited to a confined portion of the nail bed diagnostic because of scant cellularity[9]. can be accessed using a window plate avul- Diagnosis of Eyelid Tumors: The manage- sion. This technique is helpful when removing ment of eyelid tumors requires histologic di- a localized foreignbody in the nail bed, explo- agnosis, which is usually obtained by biopsy. ring the nail bed for a welldemarcated neo- Although incisional biopsy is consistently re- plasm, evacuating a subungual hematoma, or cognized as the gold standard, a certain deg- draining an acute paronychia. It is performed ree of surgical skill is necessary, and the using a 5mm, 6 mm, or larger punch to drill procedure is time consuming. In a retrospec- through the localized area of nail plate. Then tive analysis of 20 consecutive incisional bi- a no. 11 blade is used to pry open and lift the opsies and 20 consecutive punch biopsies circular porthole window of the nail plate, ex- done by Rice and colleagues, the histology ob- posing the underlying bed. Then a smaller tained by both biopsy methods was compared punch can be used to biopsy the appropriate to that identified at the time of tumor exci- underlying tissue, if necessary. If these win- sion. The accuracy rates were 95 and 85% for dows of nail plate do not require processing incisional and punch biopsy, respectively. for pathology or microbiology, they can be Punch biopsy has the advantage of being a replaced and secured with a single suture or quick technique requiring minimum equip- Steril-Strips. The procedure can be faster if ment. In addition, the operator requires no the punch is heated [8]. specific surgical skills. The biopsy specimen Skin punch as an adjunct to fine-needle as- can easily be taken at the patient’s initial cli- piration: Use of the punch is helpful in diag- nic visit, allowing a more rapid diagnosis and nosing solid organ tumors that are close to facilitating more efficient tumor management the skin surface, such as lymph nodes, the and fewer visits to hospital [10]. breast, and the thyroid, especially if the FNA yielded a non-diagnostic result. Fine-needle Improving Histologic Examination of the aspiration (FNA) is a percutaneous procedure Tumor Margin: Histologic examination of the that uses a fine-gauge needle and a syringe to surgical margins of skin tumors removed by sample fluid from a cyst or remove clusters of standard surgical excision is not alwaysaccu- cells from a solid mass. The advantages of rate. Vertical sections of surgical specimens FNA are that it is a fast, easy method for bi- represent check points of the margin only 7 opsy, the results are rapidly available, it does microns thick. This means that most of the not require stitches, and patients are usually surgical margin is not checked microscopi- able to resume normal activity almost imme- cally, allowing small tumor islands at the diately after the procedure. An important di- margin to remain undetected. To avoid this sadvantage of FNA is that the procedure and be more accurate, a new punch with con- obtains only very small samples of tissue or centric cutting edges separated by 2 mm has cells from the lesion. If the sample is benign been made to obtain a 2 mm strip of tissue fluid, then the procedure is ideal. However, if representing the entire lateral border of the the tissue is solid or if a sample of cloudy, excision. This specimen is easily mounted as suspicious-looking fluid is obtained, the small a flat section for frozen or paraffin processing. number of cells removed by FNA allow only for These sections will be cut to show the entire a cytologic diagnosis. This can be an incom- lateral excision margin to be checked for plete assessment because the cells cannot be tumor. It requires little additional skill on the evaluated in relation to the surrounding tis- part of the surgeon and is easily handled by sue. Moreover, it is difficult to use the FNA to the pathology laboratory [3].

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B-Therapeutic uses: Punch excision of the treatment of recalcitrant corns. Punch inci- mole can be done for therapeutic reasons. A sion is a simple and effective technique for the punch size is chosen that is 0.5 mm larger treatment of small corns on the palms and than the maximum diameter of the mole to soles. Punch incision is a technique perfor- ensure its complete removal. The depth of the med using a circular blade or trephine 2-6 excised tissue should be adequate to include mm in diameter and 1 cm in length, attached all pigmented tissue. The procedure can be to a pencil-like handle. The advantages of this stopped here and the defect sutured or follo- technique versus classical elliptical excision wed by grafting from the postauricular area a are that it facilitates obtaining deeper and skin punch graft that is 0.5 mm larger than narrower tissue, causes less damage to perip- the recipient area to allow contraction of the heral tissue, is associated with more rapid graft and expansion of the recipient socket. healing and less scarring and is simpler and The recipient site is dressed with nonadhe- easier to perform. The authors recommended rent tulle. Alternatively, it can be dressed with the use of a punch tool that is the same size lubricating jelly. If the lesion is large and oval or larger than the corn. Based on the above in shape, it can still be excised with a punch, study it can be concluded that punch incision as described by Warino and Brodell, where a is a simple and effective technique for the tre- punch is held at a 45µ angle with the cutting atment of small corns on the palms and soles edge of the punch touching the skin at one [11]. pole of the lesion. An oval mole is then squee- zed into the opening of the punch as the han- Pinch punch excision of scrotal calcinosis: dle is reoriented perpendicular to the skin, so Scrotal skin is pinched to highlight the sub- that the cutting edge is flush with the skin cutaneous nodules and using appropriate surface; then the punch is rolled and excision size of punch, nodules/cysts are excised. So- is followed by suture closure. The use of metimes scrotal calcinosis requires excision if punch for excision can be performed for other the subcutaneous nodules are symptomatic, conditions, such as Spitz nevi and small tat- draining chalky white material, or causing de- toos [3,4]. formity to the scrotum. This can be done with a pinch-punch excision, using tumescent Punch excision of acne keloidalis nuchae: anesthesia, 1:10,000 epinephrine and 0.1% The punch should extend deep into the sub- lidocaineneutralized with sodium bicarbo- cutaneous tissue so that the entire hair fol- nate. Use of a tumescent anesthetic exerts a licle is excised. After excision is performed, hydrodissecting effect, thereby separating the the wound edges can be injected with 10-40 cysts from surrounding connective tissue and mg/mL of triamcinolone acetonide to reduce the superficial scrotal fascia. Then you can inflammation. Silk sutures may be used to re- pinch scrotal skin to highlight the subcuta- approximate the skin [4]. neous nodules; after that, incise the skin with Punch excision of corn: The hyperkeratotic an appropriate-sized punch. Suture closure tissue surrounding and over the corn area is is not necessary because of the small-sized pared using number 20-24 sterile surgical wounds, the hemostatic effect of the tumes- blade which makes the central core or kernel cent agent, and the contractile nature of the clearly visible. According to the size of the ker- scrotal skin [12]. nel punch with slow gradual rotatory half cir- Pathologic Bone Excision: Osteoid osteoma cular motion is pushed into the tissue. The is a benign skeletal neoplasm of unknown punched out tissue is gradually pulled wit- etiology that is composed of osteoid and hout cutting and pressure bandage is applied. woven bone. The tumor is usually smaller Hard corns are firm, small, dome-shaped pa- than 1.5 cm in diameter. It causes focal bone pules with translucent central cores, which pain at the site of the tumor. The lesion can occur on the palmoplantar region of toes and be completely excised with a skin punch. This hands due to repeated trauma. Medical ma- method has proven to be both minimally in- nagement of hard corns is difficult and some- vasive and effective in the management of pa- times requires surgical excision. Punch tellar osteoid osteoma [3]. incision is a technique which is performed using a circular blade or trephine attached to Punch excision of glomus tumor of nail: A a pencil-like handle. It might serve as an al- window is created in nail plate by using 5-6 ternative method to surgical excision in the mm punch and tumor in nail bed is excised

Page 7 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf by taking a smaller punch incision (3-4 mm) overlying the cyst; then use a 4 mm punch to and sutured [4]. incise the lesion. After that, the contents of the cyst are expressed with lateral pressure Use of the punch to enhance wound hea- [3,4]. ling: The full thickness punch grafts (3 mm) are harvested from the buttocks or thigh. The punch and graft technique in chondro- Punch holes (2-2.5 mm) are made in the floor dermatitis nodularis helicis: A punch bi- of the granulating ulcer 5 mm from each opsy is applied perpendicular to the skin other, and grafts are pushed into these reci- surface and advanced until a deep punch of pient holes. To increase granulation tissue, underlying cartilage is cut. Then the same- the punch is used in nonhealing ulcers and sized punch of a full-thickness skin graft from central ear lobe defects. Nonhealing ulcers the postauricular area donor site is harvested create a great therapeutic challenge to the cli- and fixed in place with 6-0 interrupted sutu- nician. Large ulcers that fail to epithelialize res. Chondrodermatitis nodularis helicis is a with local dressings for 3 to 4 weeks despite painful inflammatory condition that affects healthy granulation tissue are usually taken the helix of the ear. A punch biopsy, of a dia- up for grafting. Moreover, use of skin punch meter similar to that of the lesion, is applied biopsy to provide an autologous full-thickness perpendicular to the skin surface and advan- skin substitute for healing chronic wounds is ced until a deep punch of underlying cartilage reported to have a high success rate. External is cut. Then the same-sized punch of a full- ear defect can be healed with secondary in- thickness skin graft from the postauricular tention if the surrounding intact cartilage has area donor site can be harvested along with its perichondrium. Granulation and reepithe- underlying fat. The graft is fixed in place with lialization will proceed somewhat more slowly 6-0 interrupted sutures, such that the con- than when the perichondrium is intact, but if tour of the helical rim is preserved [13]. the denuded cartilage is more than 10 mm in Subungal haematoma: Hematoma is drained diameter, trephining with 2 mm punches to by making an opening through the nail plate expose the perichondrium and dermis of the with either number 11 blade, electrocautery posterior aspect of the ear may facilitate de- or punch of size 1.5 or 2 mm or larger. Punch velopment of granulation tissue in the wound is preferred as it remains patent after decom- bed and speed healing [3]. pression and allows further drainage without Punch can be used for extrusion of: epider- the opening getting sealed. The procedure mal inclusion cyst, hidrocystomas, pilomatri- was easily undertaken in the accident and coma, pilar sheath cyst, and pseudocyst of emergency treatment room. No infiltration of auricle with a punch hole technique and the local anaesthetic or ring block was required contents of cyst are drained and pressure in our series and none of the adults or child- bandage is applied. Pseudocyst of the auricle ren complained of pain during trephination. is a benign, asymptomatic, noninflammatory All patients had an uneventful outcome at the pseudocyst that contains yellow, viscous fluid 1 week hand clinic follow-up. This technique resembling olive oil. If left untreated, a per- can be easily learnt by junior doctors as well manent deformity may occur. It can be trea- as accident and emergency nursing staff, em- ted by a small, superficial punch incision on ploys a portable, cheap, sterile and easily the lower part of the cyst to allow for open available instrument and also avoids re-accu- drainage, avoiding cartilage injury, until an mulation of the haematoma. Additionally oily viscous fluid is drained from the punch there is no danger of electrical or thermal biopsy opening. Then taped with a pressure burns which may occur with diathermy or bolster as dental roll for 2 weeks, with daily heated needles [14,15]. cleaning and reapplication of the bolster. Ext- Periungual Exision: The excision of inflamed rusion with a punch hole has been used with tissue on chronic, refractory-totreatment pa- good outcome in other cutaneous conditions, ronychia can be done with nail-fold punch bi- such as small, isolated epidermal cysts or opsy as described earlier [4]. hidrocystomas, drainage of infected or inflamed cysts, and epidermal inclusion cysts. Re- Punch is used to remove: molluscum conta- moval of pilar cysts can also be achieved giosum, wart, pyogenic granulomas, etc [4]. using the standard punch incision technique. First, inject 1% lidocaine with epinephrine

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Punch can be held like a pencil or a area are at risk until preventive measures are pen:which can mimic the cutting angle of a effective [16]. standard curette. With alternating flexion and Cosmetic uses extension of the wrist one can use the punch as a curette when curette is not available. Miniature punch grafting in vitiligo: Punch Punch can be used as an alternative to other grafting can be used on many depigmented surgical tools, such as curettage. Curettage diseases, such as vitiligo, chemical leuko- with a punch has the advantages of low cost derma, lichen sclerosus, and postburn leuko- and easy availability, which makes it a good derma. Punch grafting is also used on hair alternative when a curet is not available. It transplant procedures. Refractory and stable can be used for debulking tumor before exci- vitiligo can be treated with surgical replenish- sion, curettage and desiccation, and treatment ofmelanocytes by variousmethods. One ment of benign conditions such as warts, of these methods is punch skin grafting. Punch grafts of 1 to 2 mm may be used to molluscum, or syringomas after light electro- yield better cosmetic results. Sockets are desiccation. The punch has a sharp circular created in the recipient area at a distance of cutting edge similar to that of the disposable 5 to 10 mm, and harvested grafts are placed curet. It can be held like a pencil or a pen, in these sockets. The cosmetic result and which can mimic the cutting angle of a stan- cobblestoning problem depend on the punch dard curet. With alternating flexion and ex- size. The smaller the punch size, the better tension of the wrist, one can use the punch the cosmetic result and the lesser the cobb- as a curet [3]. lestoning. This method consists of taking mi- Punch debridement of hidradenitis suppu- niature punch grafts of sizes varying from 1 rativa: Punch debridement (mini-unroofing) to 3 mm in diameter from donor site, grafting is perfect for the management of early or them in appropriate punched out areas spa- small acute or subacute inflammatory lesi- ced 2 to 5 mm apart at the recipient site and ons, often involving only 1 folliculopiloseba- further securing them by firm pressure. ceous unit (FPSU). This is a simple procedure Punch grafting is used in different parts of the performed in the office, clinic, or emergency world, variable success for the surgical treat- room setting. Use a 5- to 8-mm circular dis- ment of vitiligo. Flip-top transplantation (FTT) posable biopsy punch. Center the excision is a relatively new procedure for the treatment over the acutely inflamed FPSU nodule, in- of vitiligo and has been tried in many patients clude a small amount of surrounding tissue, with various skin types. In a study done by Falabella and colleagues, 59.1% of patients and ensure that a deep specimen is obtained showed excellent repigmentation with Mini by using a firm twisting action. Remove the Punch Grafting (MPG). In an Indian study plug, submit for histology, and obtain bacte- done by Pasricha and colleagues, 75.2% of rial cultures if purulent. Aggressive debride- patients showed excellent repigmentation ment involves digital pressure to remove with MPG. Similarily Savant and colleagues, purulent elements and then curettage and/or in their study of MPG in stable vitiligo, found simple grattage (scrubbing) with gauze wrap- that 91.9% of patients had excellent repig- ped around a cotton swab. The specimen will mentation, and 8.0% did not show repigmen- contain the fractured FPSU with its associa- tation with MPG. In a study done by Malakar ted sebaceous glands and more importantly, and colleagues, 74.5% of patients showed ex- the ‘‘bulge’’ area of the pilar unit of the FPSU cellent repigmentation with MPG, and 10.6% that contains the stem cells, which are hypot- did not show repigmentation. In the study hesized to be responsible for growth of the done by McGovern and colleagues on FTT, IPGM and the sinus tracts. For hemostasis, 75% of patients showed excellent repigmen- ferric chloride 3.8 molal (37.5%) is applied tation. The authors felt that high graft uptake with a cotton swab, and the excess is wiped rate in FTT was due to the flap that covers the away. A thick layer of petrolatum is applied underlying graft, which works as a biological directly to the wound, held in place with a dressing and retains the graft in place. The gauze pad or simple bandage. No drain is reasons for nonsurvival of punch grafts could used. Healing is by secondary intention. Pain be excessive exudation of serum, thicker der- relief and healing are swift. Recurrences do miş that may favor infection, or inadvertent not occur, but additional FPSUs in the treated crushing during handling. The reason could

Page 9 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf be that grafts used in FTT are superficial, un- recipient site may result in two effects: redu- like the grafts used in MPG, so there is less cing the radius by 1 mm may decrease mela- exudation of serum under the graft and grea- nocyte and pigment spread and because ter possibility of survival of the graft. Flap punch grafts are definitely thicker than thin necrosis could also induce infection, reducing shaved grafts. Furthermore, retraction of a 3- the chance of graft survival. In this study, mm recipient site during healing may force a maximum pigment spread with FTT was 8.1 4-mm graft upward, enhancing cobblestoning mm in the head and neck area, and minimum in spite of an apparent appropriate recipient pigment spread was 1.2 mm, also in the head site at the moment of grafting. Variegated ap- and neck area. In MPG, maximum pigment pearance is mainly seen with FTT because of spread was 4.5 mm in head and neck area, inability to regulate depth while attempting to and minimum pigment spread was 2.8 mm, obtain ultrathin grafts. Hyperpigmentation is on the trunk. The differences in pigment seen with both techniques, but this is regar- spread between the two techniques were sta- ded as a temporary phenomenon that decrea- tistically significant. In a study conducted by ses spontaneously over time. The cost of a Savant and colleagues, maximum pigment razor blade, the main surgical instrument spread was 5 to 10 mm, in the head and neck used in FTT, is 1.0 Indi,an Rupee (US$0.02), area, with MPG, whereas McGovern and col- versus 80 to 90 Indian Rupee (US$1.79–2.01) leagues found maximum pigment spread to for the punches used in MPG. So FTT is more be 6 to 8 mm, in the head and neck area, with economical. Although this difference in cost FTT. The greater pigment spread with FTT is is large, in practical terms, both are inexpen- because of preservation of follicular reservoirs sive, and for repigmentation purposes, it is and melanocytes in depigmented lesion be- more important to avoid cobblestoning or cause we do not remove skin from recipient hyperpigmentation and to achieve approp- site, whereas in punch grafting we remove riate repigmentation than to worry about skin and thus melanocytes reservoir from re- such small costs. FTT was equally effective as cipient site. Nevertheless, more surgical der- PG for treating stable vitiligo. In FTT, the graft mal manipulation may result in more uptake rate was higher, there was greater pig- scarring, cobblestoning, infection, and other ment spread, and the cost of the procedure complications. When minigrafts or epidermal was lower than with PG [17]. grafts or epidermal suspensions are used, fewer side effects will also occur. An excellent Smashed skin grafting or smash grafting: outcome means not only a high repigmenta- A number of new therapeutic options for viti- tion rate, but minimizing unsightly side ef- ligo have become available over the last defects also is equally or even more important. cade or so both on the medical as well as In the study done by Malakar and colleagues, surgical side. One among them is the smas- onset of repigmentation ranged from 15 to 20 hed skin grafting or simply smash grafting, days, and completion of repigmentation was which is a modification of split-thickness graf- seen in 16 to 20 weeks in MPG, whereas in ting. In this method, the graft undergoes the study done by McGovern and colleagues, ‘‘smashing’’ before being applied to the recipi- onset of repigmentation ranged from 15 to 20 ent site. Though a simple and effective proce- days, and completion of repigmentation was dure, very few people are doing the procedure seen in 16 to 20 weeks in FTT. This study either due to lack of awareness or due to lack concluded that treatment variables that affec- of published data. Smashed skin grafting is a ted the development of cobblestoning were simple procedure with fewer side effects, bet- donor and recipient punch sizes; the smaller ter outcome, and high patient satisfaction or, the donor and recipient punch sizes, the in simple words, it can be considered as an lower the incidence of cobblestoning. Fongers alternative to various conventional surgical and colleagues also advised smaller punch modalities like punch grafting and mela- sizes to minimize cobblestoning. Cobblesto- nocyte cell culture methods. Various surgical ning is slightly more common in MPG than modalities for vitiligo available now include FTT, but it was seen in both procedures in autologous suction blister grafting, split- this study. Variegated appearance is mainly thickness grafting, punch grafting, mini- seen with FTT and usually does not occur in punch grafting, single follicular unit grafting, MPG. More cobblestoning is seen in PG, be- smash grafting, cultured epidermal suspensi- cause fitting a 4-mm punch graft into a 3-mm ons, flip-flop pigment transplantation, and

Page 10 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf autologous melanocyte culture grafting. Some either suction blister grafting or splitthick- of these procedures have been combined with ness grafting. Smashed skin grafting is a va- phototherapy to achieve optimal results. One riant of the split-thickness graft with a slight major issue with surgical therapy is compli- modification. In this method, the split-thick- cations like scarring and incomplete pigmen- ness graft obtained from the donor site un- tation. Though a lot of alternatives, for exam dergoes a process of ‘‘smashing’’ before being ple covering up the lesion with cosmetic ca- applied onto the donor site. Smashing of the mouflage or tattooing the lesion, are available, donor tissue can be performed using a simple they are not longstanding and not suitable for sterile scissor. The amount of graft needed in all areas and many times need expert surge- the case of smashed skin grafting compared ons. Common surgical modality like punch with the conventional split-thickness grafts is grafting is easy to perform and does not re- much less. The amount of donor tissue nee- quire any sophisticated instruments, but it ded is roughly 1/10th the size of the recipient carries a high risk of scarring on the patient area. This technique also gives an excellent in the form of cobblestoning, which is a major color and texture matching after repigmenta- problem for people coming for cosmetic treat- tion, and it has been observed that the inci- ment. Recently, a new technique known as dence of repigmentation with this technique smashed skin grafting or smash grafting is is quite high. Surgical therapy for vitiligo has being popularized in India by certain derma- undergone a lot of advances in the past de- tologists and plastic surgeons and is quite an cade. But the accessibility of the patient to alternative for all the conventional surgeries them has been limited by the high cost of the and is giving results similar to melanocyte cell procedure. Moreover, many of the procedures transfer techniques. The biggest advantage of are complicated and time consuming. Cell this new method is the simplicity of the sur- culture and melanocyte transfer methods gery in itself and the high rate of repigmenta- need sophisticated workplaces unlike smash tion with this method. Even the beginners in grafting, which can be performed in a minor the field of dermatosurgery can perform the operation theatre under local anesthesia. procedure without much difficulty and get a Smashed skin grafting has evolved into a sim- very satisfying result. Though the journal se- ple and effective method for the treatment of arch for smashed skin grafting or smash graf- vitiligo. Advantages of smash grafting over ting yields very few results, some dermatology other surgical modalities can be summarized surgeons in India have reported, in various as follows: Need simple instruments, cost ef- conferences held in our country, a very pro- fective to the patient, minimal residual chan- mising result with this new method. Though ges at the donor and recipient sites, unlike it is very effective, very few people are doing suction blister and thin split-thickness graft this surgery, and especially in poor countries where the graft needs to be applied with the it is sad to know that this new technique has dermal side coming into contact with the re- not been embraced with the same enthusiasm cipient area, smash graft can be applied wit- shown to other methods. This is mainly be- hout any side consideration, easy to master cause of the lack of awareness about the m with training and expertise. A few modificati- ethod among the dermatologists and non- ons have been added to this technique by va- availability of the published data. So far the rious dermatologic surgeons, for example: literature search yielded only two articles Kocher’s forceps can be used for holding the mentioning this technique. Another impor- razor blade, hand dermatome, Humby’s knife tant factor is the advancements made in the or Silver’s knife can be used, instead of vase- melanocyte cell culture method that more line or antibiotic gauze, we can use a thin dermatologists prefer this method over smas- linen that is moistened with normal saline to hed skin grafting. Though cell culture techni- cover the recipient area, collagen sheets are ques are giving good results, the procedure better dressing agents, assuming that the pa- needs costly equipment, its time consuming, tient can afford them, erbium-YAG laser ab- and cost to the patient is very high. Smashed lation for the donor area is also a good skin grafting on the other hand hardly needs alternative for dermabrasion. Large-scale stu- specialized equipment and is cost effective to dies have to be undertaken to fully evaluate the patient. Most comparison studies on graf- smash grafting, including the long-term com- ting techniques in vitiligo have shown that plications, if any. Because smashed skin graf- maximum repigmentation is achieved with ting is a simple procedure, it is necessary that

Page 11 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf it should be popularized as it is a very cost- tern. A thin layer of tacrolimus ointment 0.1% effective method for the patient [18]. was applied during the final pressure strokes. Avoidance of harsh chemical applications, to- Chinese Cupping: A Simple Method to Ob- pical antibiotics, and sunscreens was advised tain Epithelial Grafts for the Management to the patient in the immediate postoperative of Resistant Localized Vitiligo: The intro- period. There was mild discomfort to the pa- duction of surgical techniques provided a tient for 1 to 2 days. This procedure was done major development in the management of re- at an interval of 7 to 10 days for a period of 2 sistant vitiligo and replaced other conventio- to 3 months. Vitiligo Area Scoring Index nal unsuccessful therapies. Most of these (VASI) scoring was done before and after pro- procedures require special devices and expe- cedure. After approximately 7 to 8 sittings of rience that prevent many dermatologists from the procedure over a period of 3 months there utilizing them. The aim of this work is to eva- was 70% to 80% repigmentation without luate the introduction of a new simple tech- scarring. Wood’s lamp examination confirmed nique that can be used in epithelial grafting the results. Dermaroller with tacrolimus is a for recalcitrant patches of vitiligo. Twenty vi- simple, effective, office-based procedure with tiligo patients, nonresponding to classic pho- much less downtime that can be used for pa- totherapy, were candidates in this study. A tients with extensive vitiligo [20]. simple Chinese cupping device was used to induce blisters on the inner aspect of the Punch excision of melanocytic nevus: thighs of the patients and the resulting blister Round excision may be a better alternative to roofs were used for grafting on dermabraded conventional fusiform or shave excision of be- vitiliginous patches. The patients were follo- nign papular or dome-shape nevus (<5 mm) wed up for 1 year. Blister roofs induced by of the face because it leaves an almost imper- Chinese cupping were able to repigment viti- ceptible scar [21]. liginous patches in 80% of the patients with Punch excision techniques in acne scars: admirable coloring match, and the donor areas did not show any cosmetic disfigure- -Punch excision and closure: If the scar is ment at the end of the study. Chinese cup- >3.5 mm in size, it is excised and sutured ping is a simple and easy-to-use method to after undermining. obtain epithelial grafts for vitiligo manage- -Punch incision and elevation: If the depres- ment [19]. sed scar has a normal surface texture, it is in- A simple office-based procedure for pati- cised up to the subcutaneous tissue and ents with extensive vitiligo: The setup re- elevated to the level of the surrounding skin. quired for various grafting techniques for -Punch excision and grafting: Depressed pit- vitiligo is difficult, and specialized reagents ted ice pick scars up to 4 mm in diameter are along with expertise are requisites to perform excised and replaced with an autologous, full- them. The color matching and repigmentation thickness punch graft. may not be uniform in all cases, particularly at the margins. To surpass these drawbacks, There are two types of acne scars; atrophic the authors tried simple microneedling with a deep dermal scars and hyperplastic scars. At- dermaroller device as an inexpensive and rophic scars include icepick, rolling, and box- quick office-based procedure; it can also be car scars. The icepick scars are usually used as transdermal drug delivery modality smaller in diameter and deep with tracts to for large-molecular-weight drugs such as tac- the dermis or subcutaneous tissue. Boxcar rolimus. Microdermaroller-mediated drug de- scars are deep and are often 1.5-4 mm in dia- livery can substantially increase effectiveness meter. They have sharply defined edges with by passing the stratum corneum barrier and steep, almost vertical walls. Soft, rolling scars delivering this drug in adequate concentra- can be circular or linear, are often greater tion to the melanocytes and keratinocytes. than 4 mm in diameter, and have gently slo- The site was anesthetized with topical lido- ped edges that merge with normal-appearing caine cream. A Dermaroller with needle skin. Examples of hyperplastic acne scars are length selected according to skin thickness hypertrophic scars and keloids. Punch biopsy and site of vitiligo was used to cause pin-point is a treatment option for deep dermal scars bleeding by rolling it for 15 to 20 minutes with through different techniques such as punch parallel pressure strokes in a crisscross pat- excision, punch elevation, and punch repla-

Page 12 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf cement grafting. Punch excision, done for separate the lipoma from the surrounding tis- scars less than 3.5 mm, removes a pitted scar sue. Lipomas of subcutaneous fat are among with a straight wall by a punch that is slightly the most common benign neoplasms obser- larger than the scar being addressed. The site ved in humans. Patients often come to their may then be allowed to heal by second inten- dermatologist for evaluation and removal of tion, or sutures may be placed to close the these tumors. Standard treatment commonly wound. This technique is preferred for icepick includes incision with extrication or elliptical scars. A scar requiring a punch larger than excision. Unfortunately, these treatments 3.5 mm is repaired by elliptical excision or often elicit a large scar. Many persons have punch elevation because these larger defects multiple lipomatous lesions. For patients with lead to ‘‘dog ear’’ formation on the face. Punch multiple lipomas or angiolipomas, such con- elevation is similar to punch excision except ventional surgical treatments may be exces- that the scar that is punched out is not dis- sively scarring and cost prohibitive. The carded. It is useful if the scar is 3 mm in dia- common cutaneous punch may regularly be meter or greater with a good color match and applied to remove most lipomas in a variety of straight walls. The tissue cylinder is incised locations. The cutaneous punch is customa- down to the level of the subcutaneous fat. The rily used to perform biopsies. Extended uses scar is allowed to float up until it is the same of the punch previously published include re- level as the surrounding skin. If it does not moval of epithelial cysts, dermabrasion Loo- rise easily, it may be transected free at the punch excision technique for removal of level of the fat. The cylinder of tissue will be acne-induced osteoma cutis, and trephine fixed in place by the patient’s serum and sits punch for diagnosis of panniculitis. Brief as a graft, held in position by some surgical mention of the biopsy punch to remove a va- tape. Punch elevation is a method of treat- riety of lesions including lipomas was repor- ment for boxcar scars. Punch replacement ted earlier, as was instruction on the use of grafting is useful for deep fibrotic scarring. the punch for treatment of lipomas. The li- The scar is excised as with the basic punch poma is identified by palpation and visual excision technique. The scar is discarded and inspection. The area overlying the center of is replaced with a slightly larger full-thickness the tumor is marked with gentian violet. The punch graft, usually from the postauricular area is subsequently anesthetized with 1% li- area. It is critical to allow each anesthetic docaine with epinephrine at the subcuta- wheal to flatten completely to prevent distor- neous level and the incision site. A 4-mm tion of scars. Unless the graft is traumatized, punch is inserted into the marked center of it will usually survive well. Some of the grafts the epidermis overlying the lipoma. The will heal with the same skin surface level and punch should be inserted to the hub of its some will be elevated. Donor holes should be cutting surface. The lipoma is then firmly approximately 0.5 mm larger than the recipi- grasped between the thumb and the other di- ent holes. These seal in 5 to 7 days with a fib- gits. Firm pressure and squeezing are applied rin clot. Dermal graft for atrophic scar, 3-5 at the base of the lipoma in an upward fas- mm punch biopsy up to deep dermis is done hion. The force is directed towards the inci- in covered parts of the body. The epidermis sion site. This will usually result in the part is excised and only dermal part is preser- extrication of the lipoma. Larger tumors may ved. Subcision of the scar is done 1 week require both hands to accomplish this removal. A deeper blunt probe or dissection within prior to the dermal graft. Depending on the the incision site may be required to loosen the size of the atrophic scar, appropriate size of lipoma. Often, small clumps of fatty fibrous dermal graft is inserted to the atrophic scar tissue will appear at the opening just before after making the pockets below the scar with expulsion of the entire tumor. When the fib- 18-G needle. Seal the entry point with Steri- rous capsule of the lipoma appears at the strip [22]. opening, the tumor can often be expressed in Small lipoma excision through narrow hole toto with additional pressure. If the lipoma extrusion technique (NHET): In NHET, a appears fibrosed and is difficult to extricate, small, circular punch defect is created in the then a semidestructive step may be required. skin and then the lipoma is extruded through The 4-mm punch is held in one hand and a the hole by applying lateral pressure. A cur- firm upward grasp of the lipoma is held in the ved hemostat can be inserted in the defect to other. One performs a repetitive up-and-down

Page 13 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf chopping motion with the cutaneous punch is kept in normal saline. Then you proceed within the previous punch incision site to loo- with extrusion of lipoma, as in the NHET, and sen the upper fibrous portions of the lipoma. then the punched-out piece of skin is reposi- The lipoma is then expressed piecemeal thro- tioned to cover the defect and sutured into ugh the punch incision site via firm lateroin- place [23]. ferior pressure. Continued deep pinching and ‘Pot-lid” technique for aesthetic removal of upward pressure in a kneading motion may small lipoma on the face: A 5-mm punch in- be required to remove all of the portions of the serted deep into the center of the lesion to lipoma. Once the lipoma is completely remo- create a circular hole. The punched-out piece ved, exploration of the defect for residual li- of skin kept in normal saline. The lipoma is poma should be performed. This can be extruded with the help of a hemostat and by performed with curved hemostats. The inci- squeezing pressure. After achieving hemosta- sion site usually heals well by either second sis, two absorbable buried subcutaneous su- intention or the placement of 1 to 2 interrupted cutaneous sutures. The postoperative tures are placed to create support for the wound requires care similar to that of any graft. The punched-out piece of skin is then punch biopsy procedure. The incision site will positioned to cover the defect, like a “lid on a generally heal with minimal scarring, especi- pot” and dressed. Patients presenting with an ally in comparison to conventional excision asymptomatic subcutaneous facial lipoma de- scars. Excellent locations for the punch ex- sire its removal in order to restore the contour pulsion of lipomas are the extremities and of the face. The standard treatment for lipoma face. Appropriately, these are areas of greatest is excision, with the size of the incision being cosmetic consequence for any surgical proce- about one-half of that of the tumor itself. The dure. Because it is important to be able to long linear scar resulting from simple excision gain a firm grip under the lipoma, areas of the may fail to improve the appearance of the pa- body with thickened dermis or minimal skin tient. The removal of the lipoma through a pliability are difficult areas for this technique. small incision or a punch hole decreases the Thus removal of lipomas on the torso by this size of the resulting scar, but does not elimi- method is variably successful because of the nate it completely. They improved the aesthe- thickened cutis. Nevertheless, most cases tic outcome of the commonly used technique warrant a trial removal attempt with this for lipoma removal, known as the narrow hole technique. If no success at removal is attai- extrusion technique (NHET), by modification. ned, other conventional surgical methods Four patients (three men and one woman) may be attempted. This technique often re- with small lipomas on the face (three on the quires moderate manual physical effort to forehead and one on the cheek) were selected expel the lipoma, especially in areas of thic- for the procedure. A 5-mm punch was inser- kened integument. However, there are many ted deep into the center of the lesion to create obvious benefits to this removal method. Risk a circular hole. The punched-out piece of skin of hemorrhage and infection may be minimi- was kept in normal saline. The lipoma was zed secondary to the decreased degree of in- extruded with the help of a hemostat and by vasion. In cosmetically sensitive areas, this squeezing pressure. This resulted in the for- technique is an effective and aesthetically mation of a subcutaneous cavity. After achi- pleasing method for removal of single lipomas eving hemostasis, two absorbable buried and tender angiolipomas. It is especially app- subcutaneous sutures were placed to create licable to the patient with multiple lesions, in support for the graft. The punched-out piece that many tumors may be easily removed at of skin was then positioned to cover the de- a single office visit. NHET is widely used. In fect, like a ``lid on a pot'' and dressed. The this technique, the lipoma is removed thro- color and texture match of the graft with the ugh a narrow punch hole done by punch bi- surrounding skin were excellent in three of opsy, and the site is left to heal secondarily or the four patients by the end of 6 months. The one to two interrupted cutaneous sutures are graft, which was depressed in the fourth pa- placed. Modification of the NHET, called the tient, improved through spot dermabrasion. pot-lid technique, aiming to improve the aest- The proposed modification of the NHET for li- hetic outcome, was described recently. After poma removal improves the cosmetic out- doing a punch, the punched-out piece of skin come.

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NHET is probably the most widely used tech- the excessive growth of fibroblasts and depo- nique; it is simple and gives a good cosmetic sition of collagen do not occur. Hypo/hyper- outcome. In this technique, the lipoma is repigmentation at the grafted site, if it occurs, moved through a narrow punch hole and the disappears with the passage of time and the site is left to heal or one or two interrupted grafted site becomes almost imperceptible 3±4 cutaneous sutures are placed. This results in months later. The potential complications of a circular scar of healing or a linear scar with the procedure include hematoma formation, tissue protrusion (``dog ear''), respectively. which can be avoided by achieving hemosta- Even though the size of the scar is small, this sis and applying a firm pressure bandage. may not be acceptable when the lipoma is lo- Another potential complication is failure of cated at cosmetically prominent sites. Punch the graft to take hold due to mobility of the excision and grafting has been in use for part or necrosis. In this case, the final out- some time for the management of a variety of come will be no worse than that seen in skin conditions of the face, such as the remo- NHET. In conclusion, the described technique val of moles, small skin cancers, and trauma- has excellent potential for the removal of tic and ice-pick acne scars. The commonly small lipomas located at cosmetically sensi- used donor site for grafts in these conditions tive sites [23]. is the retroauricular area. Although it is a Liposuction: Punch is used to make holes to good match for facial skin, some mismatch in insert cannulas. A micro-adit used in tumes- color, texture, thickness, degree of actinic da- cent liposuction is a small circular hole made mage, and sebaceous quality is expected. This by a tiny skin biopsy punch facilitate and pro- may result in a conspicuous graft. Therefore, mote the drainage of residual blood-tinged they decided to remove the lipoma through a anesthetic solution associated with tumes- narrow punch hole and to place the punched- cent liposuction [24]. out piece of skin back to cover the defect, like a ``lid on a pot.'' This gave us an excellent cos- In earlobe repair: Using a punch biopsy ins- metic result with no conspicuous scar, as it tead of the scalpel blade to excise the partial was a small, full thickness grafting procedure cleft in an elliptical fashion. The opposing in which the donor and recipient sites were margins are sutured together in a straight the same. There were two procedural prob- line. Piercing earlobes is a common practice lems in this technique. First, after the remo- all over the world. Several methods have been val of the lipoma, a dead space was created described for repair of an unwanted lengthe- and no recipient bed was left for the graft. Se- ned earring hole. One of these methods is cond, due to the effect of the elasticity of the using a punch technique that removes the skin, the punchedout piece of skin tended to preexisting hole and then subsequently sutu- shrink and the defect expanded, which resul- ring the newly created nonepithelialized tract ted in a mismatch in the size of the hole and [25]. the graft. This was more pronounced in youn- Tattoo removal: Very tiny tattoos, in parti- ger patients. To overcome these problems, cular remnant of post traumatic tattoos or they placed two buried subcutaneous sutu- first attempts at self-tattooing (traditional res. The lightly tightened sutures reduced the green tattoo on forehead), may be removed by size of the defect to match it with the size of a punch biopsy closed by a single suture [26]. the graft. The sutures also supported the graft and prevented the sinking of the graft into the Follicular unit extraction (FUE) method by dead space. Although the artificially created using micropunches for: Androgenitic alope- support does not fulfill the essential require- cia, eyebrow transplant, eye lash implanta- ments for an ideal recipient bed (i.e. rich vas- tion, vitiligo surgeries for poliosis etc. In FUE, cularity for capillary ingrowth and fibroblasts the extraction of intact follicular unit is de- to support collagen18), the graft survives by pendent on the principle that the area of at- the ``phenomenon of bridging.'' In this pheno- tachment of arrector muscle to the follicular menon, the requirements of a small-sized unit is the tightest zone. Once this is made graft are fulfilled satisfactorily from the walls loose and separated from the surrounding of the defect and the survival of the graft is dermis, the inferior segment can be extracted not jeopardized. Rather, it helps to prevent easily. Because the follicular unit is narrowest elevation of the graft (cobblestone formation) at the surface, one needs to use special mic- a common complication of punch grafting), as ropunches of size 0.6-1.0 mm and therefore

Page 15 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf the resulting scar is too small to be recogni- laryngology, this case report was, to our zed. Uses of the punch to diagnose and treat knowledge, the first describing its use in der- many medical and surgical conditions make matologic surgery. This pilot study by Chen it important to many other specialties beside et al analyzed the use of brimonidine 0.33% dermatology. We can propose a punch tech- gel (1 g) applied topically approximately 15 nique as a novel method for dermatosurgical minutes before beginning MMS in patients ta- treatment of various lesions with curative and king anticoagulant and/or antiplatelet good cosmetic results when compared with agents. The results demonstrated that preo- other existing surgical methods. A simple and perative application of brimonidine decreased an inexpensive skin biopsy punch have vast blood loss and the need for cauterization. The applications in dermatology. It is not only safety of topical brimonidine gel has been stu- used to confirm a diagnosis, but used to re- died for its US Food and Drug Administra- move cosmetically unacceptable lesions, and tione approved indication, rosacea; however, provide definitive treatment for a number of it has yet to be studied for its use as a topical skin conditions. The use of skin biopsy punch hemostatic agent. However, 2 cases of central is not only limited to the field of dermatology nervous system depression with topical bri- but also extended to the other specialties. monidine gel when used for hemostasis have Punch surgery is a simple, readily available, been reported. Both patients experienced re- cheap tool that has many advantages, such versible but serious central nervous system as easiness to perform and no need for gene- depression requiring hospitalization. In these ral anesthesia. Punch surgery also has a low cases, larger quantities (10 g) of brimonidine risk of infection and bleeding and can be done 0.33% gel were used under occlusion in acti- in an outpatient setting. Uses of the punch to vely oozing open surgical wounds on the face. diagnose and treat many medical and surgical Brimonidine should not be used for hemosta- conditions make it important to many other sis in open surgical wounds, particularly in specialties beside dermatology [27]. the head and neck. Although safety outcomes The use of hyaluronidase as an adjunct to were not directly reported by Chen et al, the surgical procedures: Although the use of preoperative topical application of a small hyaluronidase as an adjunct to anesthesia is amount of brimonidine 0.33% gel to the sur- frequently described for plastic surgery and gical site can be reasonably assumed to yield ophthalmologic procedures, its use in derma- exposures and risks similar to those with its tologic surgery has not been well investigated. use in rosacea [29,30]. They reviewed the advantages and disadvan- Tripod vibration anesthesia: Cutaneous vib- tages of using hyaluronidase in dermatologic rators have been introduced to relieve pain procedures. The effect of adding hyaluroni- associated with a variety of dermatology pro- dase to local anesthesia was evaluated in 72 cedures including injections and laser treat- operations performed over a 1-year period. ments. The simple tripod massager described Although the duration of anesthesia was in this report is effective and acceptable to pa- slightly decreased, the addition of hyaluroni- tients for cutaneous injection anesthesia. dase to local anesthesia offers the benefits of Most pain associated with cutaneous proce- minimizing loss of surface contour and en- dures results from injection of the local anest- hanced ease in undermining and dissection hetic. Smith et al. have described vibration through subcutaneous tissue planes. The anesthesia in this journal as an adjunct to onset of anesthesia using hyaluronidase was any injection procedure, eliminating the need immediate and the area of anesthesia appears for local anesthesia for some procedures. The increased over anesthesia without hyaluroni- authors recommend several units including dase. They recommended the adjunct of hya- the Acu Vibe Softouch™, the Hitachi Magic luronidase to local anesthesia as a useful Wand™, and Conair™ double headed massa- advancement in surgical technique [28]. ger. They had used the technique they des- Topical brimonidine for hemostasis: Chen cribe, and found it quite helpful for minim et al evaluated the use of topical brimonidine izing the pain of injections. These rather large for hemostasis during Mohs micrographic massagers can be intimidating to some pati- surgery. Although topical brimonidine had ents. Two of the three vibrators (the Acu Vibe been previously reported as a hemostatic Softouch™ and Hitachi Magic Wand™), have agent in ophthalmologic surgery and oto- electric cords and therefore take a little extra

Page 16 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf time to use. Some of the vibration units reducing the possibility of scar hyperplasia. The commended by Smith et al. are apparently transition of the wounds from circles to points sold for sexual stimulation and may be recog- by this method, in our point of view, is a kind nized as such by some patients. They found of leap geometrically. It is an excellent alter- the inexpensive Homedics Mini Massage-On- native to other reconstructions and a simple The-Go™ massager to be useful for reducing method to close skin defects with minimal the pain of injections. The unit is cordless and scarring, achieving an optimal long-term cos- can be managed by a single operator. They metic and functional outcome [33]. cover each "foot" of the unit with a small sheet Round excision: Round excision may be a of Allrap All Purpose Adhesive Covering as a better alternative to conventional fusiform or barrier for antisepsis. The injection is done shave excision of benign, dome-shaped or pa- within the triangular region formed by the 3 pular nevi of the face. Round or circumferen- feet of the unit. One of the feet should be po- tial excision is carried out just outside the sitioned so that it is proximal to the injection perimeter of the lesion. This technique may site. The unit has a toy-like appearance and be chosen when the region involved overlies may contribute to reduction of anxiety in pe- cartilage (i.e. nasal tip or ear rim) or when the diatric patients. The arch allows placement of best repair orientation or approach is not ap- ice, if desired, followed by injection without parent before the excision. Round excision needing to move the unit. The tripod techni- has been recommended for the excision of que is limited to broad surface areas such as nevi, but as round excision and primary clo- the trunk and proximal extremities. For other sure may cause tissue protrusions or dog- sites such as fingers, two of the feet may be ears, many dermatologists avoid this placed along the finger, one foot proximal to procedure. The possibility of dog-ear forma- the injection site [31,32]. tion is related to skin elasticity as well as the Purse-string suture: Purse-string suture length of the incision. In areas of the body enabled us to repair small, circular wounds such as the face, the skin is quite elastic and easily after excision of skin lesions. It is an ex- easily movable and dog-ear formation is rarely cellent alternative to other reconstructions observed. Although the defects left after remo- and a rapid, simple method to close skin de- val of nevi by this technique are circular, fects with minimal scarring, achieving an ex- stretching the skin perpendicular to the lines cellent long-term cosmetic and functional ofrelaxed skin tension whilst performing the outcome. Round and oval skin lesions, like fa- procedure often results in an elliptical defect. cial pigmented nevi, are common and are tra- These elliptical defects were easy to under- ditionally sutured linearly for closure after mine and close with interrupted sutures or excision, leaving scars longer than the nevi buried and interrupted sutures in combina- themselves, which greatly influences their ap- tion. The use of the round excision technique pearance. The purse-string suture enabled us results in an elliptical defect with a shorter to repair small, circular wounds easily after long axis when compared to that created by excision of skin lesions, especially in the fa- the conventional elliptical excision technique. ciocervical region, and is suitable for people Less skin is excised in the round excision with different skin characteristics. Based on technique (approximately half that removed the principle that tensile force converges to- using a fusiform excision) and therefore a sig- ward a central point when the purse-string nificant amount of skin is preserved. Under- suture is employed after incision of circular mining is usually not necessary and the lesions, tension placed on the suture uni- round defect quickly assumes an oval shape formly advances the skin from the entire pe- which is ready for closure, usually with one riphery of the wound, resulting in a signi or two buried, absorbable sutures and then ficant reduction of the defect size by the grea- two or three superficial sutures. The resulting test extent, making it much easier for cells at wound is shorter than that expected with el- the wound edge to sprawl to repair the wo- liptical excision. As is usual for certain sites unds. Also, because the suture compresses on the face that have a concave surface (e.g. both the larger vessels in the reticular dermiş temple, inner canthus, nose), there is a risk and the smaller vessels in the papillary der- of a surgical scar spreading with time, but, mis, enhanced hemostasis is achieved. So the again, it is usually a much smaller scar than wounds heal in the slightest tensile force, re- would have been accomplished with elliptical

Page 17 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf excision. In our experience, round excision simple trephining for symptomatic relief is re- may be a better alternative to conventional fu- quired for simple subungual hematomas, and siform or shave excision of benign, papular aggressive surgical treatment, as suggested in and dome-shaped nevi of the face, because it previous studies, is unnecessary. Prompt de- leaves an imperceptible scar, gives cosmeti- compression will significantly alleviate pain cally superior results, and requires a smaller and decrease the likelihood of delay in the incision, minimizing tissue trauma [34]. regrowth of the nail plate and secondary dystrophy that might result from pressure on Extra-Fine Insulin Syringe Needle: An Ex- the matrix caused by accumulated blood cellent Instrument for the Evacuation of under the nail and allows nail bed healing. Subungual Hematoma: The most commonly Therefore, evacuation should be done no later used treatment method for subungual hema- than 6 to 12 hours after injury. We used an toma is nail trephining, which has some di- extra-fine, 29-gauge insulin syringe for eva- sadvantages. We introduced a very simple cuation. We drained the blood from the and well-tolerated treatment technique for hyponychium under the nail plate using this this common problem. We used an extra-fine, extra-fine needle. Nails should be trimmed 29-gauge insulin syringe for evacuation. We before the procedure. The toenail is cleaned inserted the needle very close to the nail plate and prepared with alcohol and allowed to dry. tominimize pain. We drained the blood from The area of blood pooling under the nail is vi- the hyponychium under the nail plate using sualized under a good light. The most distal this extra-fine needle. The technique descri- part of the hematoma is selected for evacua- bed herein is very fast and simple, and the tion. If the distal part of the hematoma is on patients tolerate it well. It is particularly suc- one level, the lateral side is preferred for eva- cessful for the treatment of smaller subun- cuation. The patient grasps the affected toe gual hematomas of the second, third, and between index finger and the thumb and fixes fourth toenails, in which the trephining is it. Grasping the toe also gives the patient a harder. For these reasons, we suggest this pressure feeling and reduces the pain, and technique as a practical alternative to the tra- the patient feels more confident. The sterile, ditional nail trephining methods. Trauma to disposable, extra-fine insulin syringe with a the nail and systemic pathology, medication 29-gauge mounted needle is held between the and drug reactions, and aging usually cause thumb and index finger of the dominant subungual hematoma. Hematoma formation hand. It is inserted to hyponychium, parallel occurs because of the disruption of the highly to the nail plate. We keep the needle very vascular nail bed. A sudden, blunt, external close to the nail plate, avoiding contact with force or repeated microtrauma causes blee- the nail bed as much as we can to reduce ding beneath the nail plate. The collection of pain. While slowly progressing to the hema- blood produces intense pain that is caused by toma with a gentle push, we give a back and pressure and a bluish discoloration. The most forward drilling movement to the needle. No common method of treatment has been the sudden movement is necessary. If the patient nail trephining. For decades physicians have feels pain, we stop moving for 3 to 5 seconds used a heated paper clip for this purpose. In and start to progress again closer to the nail addition to a heated paper clip, a heated ne- plate. Once the hematoma is penetrated, the edle, a dental bur, a fine-point scalpel blade, needle is withdrawn. The trapped blood is a drill, a cautery device, and carbon dioxide evacuated rapidly because of the pressure laser have been used for trephining, and nail through the small hole. Total evacuation of avulsion, proximal incision or distal incision the hematoma is achieved with light pressure beneath the nail tip, pressure dressings, and to the nail. The drained blood is removed with observation have been employed in the treat- sterile gauze. If evacuation is incomplete, this ment of subungual hematoma. However, the may be due to a septum between hematomas, throbbing pain is relieved only when the blood and in this case, the procedure is repeated is evacuated. Nail bed lacerations and fractu- from the other side. The drainage is usually res of the distal phalanx require further tre- completed in seconds. The treatment of a sim- atment. However, nail plate removal and nail ple subungual hematoma requires subungual bed exploration are not required for subun- decompression, which is usually achieved by gual hematomas as long as the nail and the creating small holes in the nail plate.3 Howe- nail margin are intact. Regardless of size, only ver, there are several disadvantages of nail

Page 18 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf trephining. A heated paper clip can sear the months, as the attached distal part of the nail blood and plug the hole, and the metal may plate becomes smaller as it grows out. In have to be reheated several times. Drilling the summary, this is a very fast, simple, and well- nail can be quite painful because of the pres- tolerated technique and is particularly suc- sure needed to puncture the nail plate, and a cessful for the treatment of subungual digital nerve block may be required. However, hematomas of the second, third, and fourth draining the blood with an insulin syringe ne- toenails. For these reasons, we suggest this edle from the hyponychium is significantly technique as an alternative to the traditional less painful than one injection of digital nail nail trephining methods [35]. block. It is well tolerated by the patients; the- Eruptive vellus hair cysts: an effective ext- refore, there is no need for anesthesia. Be- raction technique for treatment and diag- cause we insert the needle adjacent to the nail nosis: We treated the lesions by using cautery plate, where the tissue is not viable, it does and a standard dissecting forceps under topi- not cause significant pain. As this tissue is cal anaesthesia. After puncturing the overl- not as hard as the nail plate and does not ying skin in the centre using the sharp-tipped show resistance while progressing the needle, cautery point, we grasped the base of the cyst the procedure is very simple and fast. In ad- using a standard dissecting forceps and we ditional, our technique is very successful in extracted the cysts out. Over 150 cysts were the treatment of smaller hematomas of se- extracted with this technique in two patients. cond, third, and fourth toenails, which have The technique was simple, quick and tolera- very small nails that are hard to trephine. In ted well. No lesion recurrence was observed early cases, as in our patient, the hematomas after 4 months. On histopathological exami- of second, third, and fourth toenails are in a nation, extracted cysts were observed to have very small space with very high pressure; the- cyst walls. In patient 2, the diagnosis was refore, they always appear very obscure at made within minutes by microscopic exami- first. In late cases, they become more wides- nation of the potassium hydroxide preparati- pread because of progression of the blood pe- ons of the extracted material. Our extraction ripherally between nail plate and nail bed technique is a simple and effective treatment because of the pressure. Thus, the late lesi- option for these cysts. It can be regarded as ons appear larger and can be observed easily. curative since the cyst walls were also extrac- However, in late cases, this progression may ted. Microscopic examination of the potas- cause secondary dystrophy if it reaches to the sium hydroxide preparation of the extracted matrix. Therefore, early treatment is very im- cysts suggests that this technique can also be portant. We do not suggest performing this used as a simple diagnostic procedure [36]. evacuation technique with thick syringe needles because they may cause significant A simple open comedone extraction tech- pain, especially if the hematoma is located nique for Favre–Racouchot disease: Favre– proximally. Because the needle is sterile, the Racouchot disease (FRD) is a common disease risk of infection is minimal. It is cosmetically characterized by solar elastosis and large superior to nail trephination because the nail open comedones and cysts. This disorder ma- plate is left intact. We also performed this inly affects elderly Caucasian men who have technique successfully to the older hemato- had a great deal of exposure to the sun. Pati- mas. However, we did not have a chance to ents having FRD continuously develop nume- perform this technique to the patients with rous large open comedones that could cause significant onychogryphosis and in patients a cosmetic problem. We performed a simple with significant subungual keratinaceous and effective extraction technique for these debris as tinea unguium. We have been per- open comedones using a standard dissecting forceps. This technique is well tolerated and forming this technique for 3 years and have no complications were observed. We suggest not observed any complications such as in- this comedone extraction technique as a sim- fection and cosmetic or functional deficits yet. ple alternative treatment for this common According to our experience, even in promptly cosmetic problem [37]. treated cases, once the detachment occurs, the nail plate could not attach to the nail bed The use of the freer dissector for the remo- again. After the evacuation of hematomas, a val of trichilemmal cysts: Trichilemmal nail can be broken or shed in the following cysts are keratin-containing cysts, usually si-

Page 19 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf tuated on the scalp. They often show an au- ment was well tolerated by the patient. No tosomal dominant inheritance pattern. Exci- complications developed during or after the sion is the treatment of choice. We describeed procedure. After 14 months follow up no re- a practical surgical technique that eases the currences were observed and the results were removal of these cysts. A 24-year-old woman cosmetically excellent. This modi®ed techni- presented with a 5-year history of cystic lesi- que is very simple and time saving. Its cosme- ons on her scalp, clinically diagnosed as tric- tic and longterm results are successful. We hilemmal cysts. She was treated with the new believe that it must be considered as the tre- technique. After making a small incision atment of choice for steatocystoma multiplex under local anesthesia, a freer dissector (Aes- [40]. culap OL 165 R) was used as a blunt dissec- A Minimally Invasive Procedure for Axil- tor. The freer dissector was inserted through lary Osmidrosis: Subcutaneous Curettage the incision. A blunt dissection was made to Combined with Trimming Through a Small dissect the cyst free from the surrounding Incision: Though minimally invasive proce- dermis and, by using the dissector as a lever, dures often yield excellent esthetic results for gentle pressure was applied to the opposite axillary osmidrosis, the high recurrence rates side to ease the cyst from the dermis. Four of malodor limit its further application. In- cysts were removed with this technique. The complete removal of the apocrine glands treatment was well tolerated by the patient. would lead to recurrence of the axillary brom- No complications developed during or after hidrosis, while excessive resection of the the procedure. This modified technique is apocrine glands firmly attached to the dermis simple and practical. The slight curve at each would easily result in local skin necrosis. The- end of the freer dissector makes it easy to refore, accurate management of the apocrine grasp the cyst and, functioning like forceps, glands is extraordinarily important, particu- the cyst can be eased from the dermis. We be- larly with a limited access. Herein, we would lieve that the use of the freer dissector in the like to introduce an effective and minimally surgical excision of trichilemmal cysts aids invasive procedure combining subcutaneous and speeds up the procedure [38]. curettage and trimming for the treatment of Multiple epidermal inclusion cysts of the axillary osmidrosis. A 5-mm incision was eyelid: a simple technique for removal: marked at the inferior pole of the central axil- More extensive cyst removal with skin exci- lary crease. Subcutaneous undermining was sion followed by skin grafting would have led done clinging to the axillary superficial fascia. to an unsightly end result, as there was no The whole procedure was performed in the donor skin of like consistency available. The following sequence of ‘‘scraping–trimming– 27-gauge needle technique is simple and re- scraping’’ against the undermined skin flap peatable and is associated with little recovery until the remaining hairs were easily pulled time and rapid healing [39]. out. All the wounds healed primarily without significant complications. Out of 300 axillae, A simple surgical technique for the treat- 294 (98 %) showed good to excellent results ment of steatocystoma multiplex: Since for malodor elimination. Scars were invisible steatocystoma multiplex is an uncommon di- in 280 axillae (93.3 %) and slightly visible in sorder, its treatment has not been discussed 18 axillae (6 %). The dermatology life quality in detail in the textbooks and surgical exci- index score decreased significantly after the sion is the most commonly mentioned met- operation. The procedure is an efficacious and hod. We described a very simple surgical minimally invasive method for the treatment technique, which was developed by modifying of axillary osmidrosis. Level of evidence was previous reports. A 29-year-old woman, diag- IV of this article [41]. nosed clinically and histologically as steatocystoma multiplex, was treated with this Faster suction blister formation using 2 modified technique. We punctured the cysts hair dryers: Suction blisters are important under local anesthesia with a sharp-tipped for surgical treatment of vitiligo. One of the cautery point and evacuated the contents by main limitations of suction blisters is the time squeezing the cyst with a fine forceps. Then, required to create them. Several methods the cyst wall was grasped by the forceps and have been described in the literature to shor- the sacs were extracted through small holes. ten the duration needed for the development More than 50 cysts were treated. The treat- of suction blisters. All described methods aim

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to increase the local temperature to facilitate tumor that commonly grows on fingers and blister formation. One recently described met- the orofacial region. While many therapeutic hod is the use of a hair dryer. The time requi- options exist, surgical excision is associated red for blister formation was reduced from with the lowest probability of recurrence. Ho- 120 minutes to 70 minutes. This is still con- wever, surgical excision leaves a linear scar, sidered a long duration and additional met- which can be a cosmetic or functional chal- hods to shorten the duration would be lenge, especially in the digits and orofacial appreciated. Using 2 hair dryers from oppo- area. Immediate surgery is not always feasible site directions would further reduce the du- due to either the patient’s or surgeon’s sche- ration required for blister formation. Two dule, and a delay of the procedure is inevi- suction (5-mL and 3-mL) syringes were used. table. For PGs that cannot be removed The syringe plunger was removed and the immediately, it can be ligated the base with proximal part of the syringe was placed on the 4-0 black silk followed by application with ti- skin. The distal part of the syringe was attac- molol maleate ophthalmic 0.5% solution (2 hed to a 3-way valve. A 10-mL syringe was dropsx4/daily). A previous study showed used to apply suction through the other end that ligation of PG base with suture material of the 3-way valve. A hair dryer operating at leads to necrosis. Recently, timolol, a nonse- low heat was then directed towards the suc- lective b-blocker, was introduced for PG tre- tion area from an; 20-cm distance. At this dis- atment. However, these methods frequently tance, there is mild to no pain associated with fail to involute PG. The combination of liga- the procedure. When using 2 hair dryers from tion and timolol strangulation increases the opposite directions, there is an; 10-minute re- chances of success. This preoperative combi- duction in the time required for blister forma- natorial approach has a few advantages. tion. Some blisters form in a multilocular First, it prevents PG from enlarging and fre- fashion. Applying gentle lateral pressure al- quently reduces the tumor size before the lows formation of a unilocular blister [42,43]. planned surgery. In addition, this procedure Perone LASIK forcep for molluscum: Mol- might completely resolve PG, obviating the luscum contagiosum, a common viral infec- need for surgery. Therefore, the combination tion, is a self resolving condition. However, of ligation and timolol represents an accep- intervention in the form of ablation or curet- table therapeutic strategy for PG before sur- tage is desired in a number of cases. Mollus- gery [45]. cum lesions pose a challenge when they are Successful treatment of lipoatrophy with present around eyelid margins. Patients, as normal saline: Margulies and Morris presen- well as the dermatologists, are apprehensive ted a case of lipoatrophy treated successfully regarding the use of available modalities for with intralesional normal saline injections. the removal of eyelid margin molluscum. Mec- Localized lipodystrophy, or lipoatrophy, pre- hanical treatment modalities and chemical sents as focal loss of subcutaneous fat with treatment modalities might not be advisable variable overlying skin changes and depth de- because of the proximity to the eye. We ca- pending on the cause. Lipoatrophy could re- nuse of the Perone LASIK forcep for easy ext- sult from both oral and local intralesional raction of eyelid margin molluscum. The corticosteroid use, with the buttocks and pro- Perone LASIK forcep is commonly used in ximal extremities being the most commonly LASIK (laser in situ keratomileusis) surgery affected sites with oral use. Minimal literature for holding the corneal flap. This forcep is exists about corticosteroid-induced lipoat- available for purchase through surgical ins- rophy. Localized reactions to injected corti- trument vendors or through online shopping. costeroids are thought to occur in less than This forcep has a circular ring on both tips, 0.5% of cases, which primarily include he- which enables a firmhold on molluscum lesi- morrhage, atrophy, secondary infection, ons. Molluscum can be held between the cir- changes in pigment, hypersensitivity reacti- cular rings and then extracted with gentle ons, and panniculitis. The observed lipoat- pressure. The procedure is painless and the rophy typically begins 2 to 3 months after degree of damage to the skin is less extensive injection and can resolve spontaneously. Here [44]. the authors reported a case of acquired loca- Combination of ligation and timolol before lized lipodystrophy, which results mostly in surgical excision of pyogenic granuloma: cosmetic concerns but has limited treatment Pyogenic granuloma (PG) is a benign vascular options to offer patients. They described the Page 21 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf technique for intralesional saline injections to The alternative treatments mentioned above assist clinicians in use of this treatment. Suc- are expensive and inconvenient, potentially cess of this technique has been previously prohibiting patients from following through described, and their case report confirms this with experimental treatment. On the other previous report but uses different time inter- hand, monthly intralesional bacteriostatic sa- vals between injections. Corticosteroids are line can be a convenient and affordable treat- commonly used intralesionally for hypertrop- ment for lipoatrophy attributed to intrale hic scars, alopecia, and other skin conditions. sional or intra-articular steroids. Their pati- Glucocorticoids suppress leukocytes from ad- ent had improvement in the appearance of hering to endothelial cells, which limits the her skin lesions while undergoing monthly inability of leukocytes to enter the nearby tis- jections and had no significant side effects. sues and decreases inflammation. In addi- There may have been faster improvement if tion, corticosteroids are potent vasocons she had undergone weekly injections as des- trictors, reducing both oxygen delivery to the cribed previously. However, further studies wound and reepithelialization. Collagen synt may help determine if a synergistic effect bet- hesis is also slowed by the steroid’s antimito- ween time and saline injection is possible, tic effects. Decreasing inflammatory molecu- les with intralesional corticosteroid injections further delineating the need for injections on can improve scar pliability, shrink scar size, a monthly versus weekly basis. It is hypothe- and reduce pain. Although steroids such as sized that injecting saline where steroid triamcinolone are efficacious in this scenario, crystals lie would put them back into suspen- side effects can include subcutaneous tissue sion, where the crystals could then be recog- atrophy, capillary dilation, and hypopigmen- nized as foreign bodies and naturally removed tation. Many articles cite known side effects from the body. The pathogenesis of post-in- of the drug. However, it is difficult to find how jection induced localised lipoatrophy remains many patients experience corticosteroid-indu- unclear. Several reports identified the cluster ced lipoatrophy. One study found that lipoat- of differentiation 68(+) macrophages in their rophy was preceded by an injection in 62% of patients’ specimen and suggested that they patients. Histologically, it has been found that played an important role in the development after corticosteroid injections, adipocytes dec- of the lesions. Iftikhar Ahmed postulated that rease in size and number and are surrounded macrophages may be activated through non- by hyaline. The fat cells were noted to resem- immunologic means and was a natural res- ble embryonic fat cells because of prominence ponse of the body to eliminate those injected of vessels, termed involutional fat. Macropha- foreign materials. The post-injection localised ges, some with yellow-gray and mucin-posi- lipoatrophy occurred in various medications tive granules have been found in the area of and seemed to affect women predominantly. interest as well. In some instances, macrop- The exact causes for this gender difference re- hages were shown to engulf adipose tissue, mained speculative. Presumably, there are thereby becoming lipophages. As the micros- hormone-related differences in resistance of copic findings of the substance engulfed by adipose tissue or it is a result from the hete- macrophages disappeared, the lipoatrophy rogeneous receptor status of human adipose faded as well Serial saline injections on a we- tissue. There is no specific treatment for cor- ekly basis are found to completely resolve the ticosteroid injection induced localised involu- cosmetic effect of lipoatrophy within 4 to 8 weeks of the initial saline injection. In one tional lipoatrophy but the majority of the case report, autologous fat injection was used lesions resolve spontaneously within 1–2 to treat atrophy with results noted 6 months years. Shumaker et al. performed localised in- after treatment began. Intralesional poly-L- tralesional normal saline infiltration in four lactic acid acts to induce fibroblast and colla- patients with persistent cutaneous atrophy gen formation, has been used for treatment of following the corticosteroid injection and gai- human immunodeficiency virus associated ned satisfactory results after 5–8 weeks, res- facial lipoatrophy, and was recently reported pectively. Saline is a non-allergenic, inex in a case of corticosteroid-induced lipoat- pensive and readily available material and rophy. Maximal improvement of the lipoat- they suggested the saline was capable of re- rophy was noted in 3 to 5 months. Their suspension and redistribution of poorly so- patient was followed over a 9-month period. luble corticosteroid crystals [46,47,48].

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Cold Therapy: Palmer at al assessed the cli- hods, particularly neurotoxins, the effect is nical safety and effectiveness of focused cold delayed. An immediate effect can be in part therapy (FCT) for the reduction of hyperdyna- due to the effects of a lidocaine block, howe- mic forehead wrinkles. Subjects treated for fo- ver care was taken to inject lidocaine superfi- rehead wrinkles showed significant clinical cially to avoid any interactions with the nerve. improvement with high subject satisfaction The 7-day results for the horizontal forehead and no serious adverse events. Focused cold lines indicate that a small percentage of sub- therapy seems to be an effective, safe nonto- ject (6%) results did not carry over from their xic alternative to popular wrinkle-reducing immediate experience. This percentage of treatments. Second-degree nerve injury invol- subjects was larger for the glabellar region ving Wallerian degeneration of the axon oc- (21%), although this may be because of the curs at temperatures of -20 to -100 ˚C. superficial nerve branch innervating the cor- Treatment in this range results in a reversible rugator muscle where the lidocaine was injec- degeneration of the axon and myelin sheath. ted. The side effects reported were mild, However, the structural elements of the nerve transient, and consistent for a needle-based bundle remain intact; therefore, the axon is treatment, and the reporting rate of 10% for able to regenerate along the previously estab- headaches is lower than 30% for injectable lished path to reinnervate the muscle at a rate neurotoxins for the treatment of hyperdyna- of approximately 1 mm/d. Focused cold the- mic wrinkles. Although the incidence of epi- rapy (FCT) uses the well-established princip- dermal cold injury was somewhat high (22%), les of cryotherapy to induce a second-degree recent device improvements have shown pro- nerve injury, resulting in reduced muscle ac- mise for the reduction or elimination of this tivity. When applied to temporal nerve branc- side effect. It is believed that hyperpigmenta- hes of the facial nerve, the result is temporary tion and dimpling are secondary to epidermal reduction in forehead animation and a corres- cold injury development and will be reduced ponding reduction in hyperdynamic wrinkles. with device improvement. It is estimated that This study demonstrates that the application 25% of patients exploring treatments for of low temperatures to the temporal branches hyperdynamic wrinkle reduction have reser- of the facial nerve results in a temporary in- vations about toxins. The results demonstrate terruption of target muscle function and rela- that FCT is a safe, effective minimally invasive xation of hyperdynamic forehead wrinkles. nonsurgical treatment option for reducing Treatment with FCT resulted in an effective hyperdynamic forehead lines. Focused cold reduction in forehead wrinkles. Less dramatic therapy may appeal to patients who are results occurred for the treatment of glabella averse to the use of toxins and fillers but re- because of the FCT treating 1 (corrugator) of main interested in the reduction of forehead the 3 muscles (corrugator, depressor, and rhytides. This study demonstrates that the procerus) involved in glabellar furrowing. application of FCT to temporal branches of Most subjects (91%) appreciate continuing ef- the facial nerve can induce a temporary nerve fectiveness at 1 month after treatment with injury, leading to reduced muscle contraction the majority noting an improvement in the fo- and a corresponding reduction inhyperdyna- rehead wrinkle after the treatment. The dura- mic forehead wrinkles. Focused cold therapy tion of effect due to treatment with FCT is could fill an, as of yet, unmet clinical need for most comparable with that of neurotoxins. In an effective, safe, and toxin-free alternative for comparison with the duration of effect, 16 to temporary dynamic wrinkle reduction [49]. 32 units of botulinum toxin Type A for forehead wrinkles and 25 units of abobotulinum Fractionated cryotherapy: Cryotherapy is a toxin A for glabellar wrinkles retained its ef- commonly performed procedure in dermato- fect in 40% of the subjects after 12 weeks, alt- logy outpatient departments for destruction hough another study showed that 40% of the of pathologic tissue. It is an easy-to-perform, subjects may retain effects to 180 days after inexpensive, and sutureless technique and the treatment. Given that the nerve regene- carries a minimal risk of infection. However, rates at a rate of approximately 1 mm per day, the procedure is associated with many com- future treatments will be placed at sites furt- plications and sequelae such as blistering, ul- her from the innervation site (2–3 cm) to pro- ceration, necrosis, and permanent or long the effect. Focused cold therapy results longstanding pigmentary alterations. This li- in an immediate effect, whereas in other met- mits its use on cosmetically sensitive sites

Page 23 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf and for indications like facial rejuvenation, actinic keratoses (HAKs) than cryotherapy particularly in people with pigmented skin. alone at 14 weeks. In this study, the authors Fractionated cryotherapy can reduce the show a benefit of using imiquimod 3.75% im- complication rates and expand its indications mediately after cryotherapy for the treatment in rejuvenation and aesthetics. For this, thin of HAKs. For patients with HAKs, combina- plywood or transparent plastic plates (poor tion treatment of cryotherapy plus imiquimod conductors of heat) have been taken and is superior to cryotherapy alone in reducing created multiple uniform holes using a drill lesion count [51]. machine. The size and distance between holes Intralesional cryosurgery for Keloids: In can be customized depending on the site and 1993, Weshahy described his new technique indication for which fractionated cryosurgery for applying cryosurgery in depth, i.e., intra- is planned. Closely placed larger holes are lesional cryosurgery (ILC), by using Wes- suited for indications for more aggressive hahy’s cryoneedles in order to achieve a cryotherapy such as thick keloids on the higher degree of effectiveness and avoid many chest and shoulders. Templates with closely of the disadvantages of the conventional sur- placed smaller holes and sparsely placed face techniques. Some trials have been pub- smaller holes with alternate rows are suited lished using the ILC for treatment of keloids for less aggressive cryotherapy on cosmeti- and hypertrophic scars. Cryosurgery has cally sensitive sites such as post herpes zoster been successfully used to treat keloids and hypertrophic scars on the face. Sparsely pla- hypertrophic scars. Better results may be ced smaller holes are well-suited for resurfa- explained by the more timewe gave until the cing, like cold slush peels and rejuvenation. ice cylinder formed extended 2 mm outside The plate was firmly placed on the area of the clinical borders of the lesions, and by the skin to be treated and liquid nitrogen was deep insertion of cryoneedles at or immedia- sprayed by the spiral or paint brush method tely under the base of the lesions, targeting over the entire plate. The duration of freezing the blood supply of the lesion, others might is generally longer than that for conventional do the procedure more superficially. The the- continuous freezing. Two to three 30-40 se- rapeutic effects of cryosurgery depend on di- cond freezethaw cycles (after repositioning of rect cell damage and changes in the the template) may be used for thick nonfacial microcirculation provoked by freezing that keloids, and one or two 15-20 second freeze- cause vascular damage and blood stasis wit- thaw cycles may be used for facial scars. This hin the keloid tissue leading to cell anoxia, leads to fractionated freezing and a rapid tha- the keloid is composed mainly of fibrous tis- wing of the frozen tissue resulting from the sue that resists the freezing process. The con- dispersion of thermal energy from intermit- tact and spray techniques are the two mostly tent areas of unfrozen tissue. After treatment, practiced methods for cryosurgery. However, improvement might be seen without pigmen- the depth of freezing attained by these two tary changes. The procedure is much less pa- techniques is not enough to complete the ope- inful as compared with conventional uniform ration in one or two sessions, and can’t reach freezing. Using this technique multiple times the base of the lesion effectively leading to can be safely done in 1 session, and the pro- high rates of recurrence. Surface cryotherapy cedure can be repeated at frequent intervals. also produces an open, oozing wound which For curved surfaces, mouldable plastic mate- is considerably larger than the size of the le- rial can be used. Transparent plastic templa- sion due to the lateral extension of cryodes- tes allow better visualization of the area to be truction that usually takes several weeks to treated under the template. Fractionating has heal. In addition, a certain degree of skin at- the potential to expand the indications for rophy and longer hypopigmentation is also in- cryotherapy in aesthetics and rejuvenation evitable with this approach because of [50]. melanocyte sensitivity to low temperatures. Safety and Efficacy of Imiquimod 3.75% Therefore, this characteristic probably ren- Cream When Used After Cryotherapy in the ders surface cryotherapy in dark-skinned pa- Treatment of Hypertrophic Actinic Kera- tients less than optimal. It destroys the core tose: Cryotherapy plus imiquimod 3.75% of the keloid immediately due to destruction cream resulted in a statistically significant of the cellular element and blood vessels at improvement in the reduction of hypertrophic the base which are more sensitive to the

Page 24 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf cryoprocess than the fibrous core causing its ted by the herpes zoster satisfactorily atte- necrosis, with a minimal limited damage to nuated the herpetic neuralgia in all patients. the superficial tissue and melanocytes. In Before the sixth treatment session, good or contrast, the lethal zone, which is created by excellent improvement was obtained in 94% the contact probe, includes the epidermis, of the study patients. Pain was eliminated melanocytes, upper dermis, and to a lesser with one session in nine patients (19%), and extent, the deeper dermis due to the counte- with two sessions in eight patients (17%). racting heating effect produced by the blood They concluded that this non-freezing techni- vessels so the efficacy is minimal and the rate que is absolutely safe and injury-free, and is of recurrence is high. This technique can very efficient in calming PHN [55]. transfer the maximum intensity of cold di- Is topical nitric oxide and cryotherapy rectly to the base avoiding that counteracting more effective than cryotherapy inthe tre- heating effect of the blood vessels [52]. atment of oldworld cutaneous leishmania- Successful treatment of cutaneous squa- sis? Current systemic treatments for mous cell carcinoma and basal cell carci- cutaneous leishmaniasis (CL) are limited by noma with intralesional cryosurgery: Wide their toxicity, high cost, side effects and the excision or Mohs surgery is the standard tre- emergence of drug resistance. New approac- atment of skin squamous cell carcinoma hes, including topical therapies, are urgently (SCC). Superficial SCC or tumor smaller than nee ded. Nitric oxide (NO) produced by human 1 cm has been treated successfully with open and canine macrophages has long been de- spray cryosurgery. Larger tumor may not be monstrated to be involved in the intracellular as effective because tissue destruction is usu- killing of Leishmania. There is evidence from ally superficial. Intralesional cryosurgery (IC) several experiments that NO is involved in the may provide a deeper and better cell killing ef- microbicidal activity of macrophages against fect in larger tumors. Lee et al investigated the a number of intracellular pathogens including safety and efficacy of treating nodular SCC in Leishmania major, Trypanosoma cruzi and 4 patients with IC. Complete remission was Toxoplasma gondii. However, the cellular and noted in all tumors (100%) in 2 months. No molecular mechanisms whereby NO exerts its recurrence was noted during follow-up. All cytotoxic activity are not yet well described. patients were satisfied with the results. This Recent studies found that apoptotic processes observation suggests that IC could be simple and several targets in organisms may be af- and effective alternative treatment for SCC fected by NO. The leishmanicidal effect of NO patients whose condition is not suitable for or seemed to be the consequence of induction of who refused operation [53]. A single intrale- a programmed cell death-like process. Howe- sional cryosurgery session can also comple- ver, both in vitro and in vivo immunological tely eradicate BCC on the lower extremities in studies indicate that NO radicals within Le- elderly patients. This technique is associated ishmania lesions could reduce the parasite with relatively minor complications, is well to- number. Application of NO donors/inducers lerated, and represents a safe and effective could mediate the leishmanicidal activity of therapeutic modality for BCC of the lower macrophages and may prevent progression of limbs [54]. infectious diseases. Delivery of supplemen- tary NO to target areas where the protective Cryoanalgesia for post-herpetic neuralgia: effects of endogenous NO have been lost is an The existent therapeutic options for post-her- attractive therapeutic option. Topical treat- petic neuralgia (PHN) are varied, albeit not ment for CL, in which the parasites are found sufficiently effective. The aim of this study in the dermis up to a depth of 5 mm or more, was to try a new treatment modality for PHN. is problematic because of the very limited pe- A spray of liquid nitrogen (LN) was used in 47 netration of drugs through the skin. Because patients suffering from PHN as a stimulator NO is so freely diffusible, we reasoned that it of a mechanism not yet completely unders- may be possible to apply an acidified nitrite tood. The LN spray was carefully applied (so cream over the lesions of CL and thereby ge- as not to freeze the skin surface) along the di- nerate enough NO exogenously to kill Leish- seased sensory nerve dermatome, at weekly mania without causing damage to host tissue. sessions lasting for 30 seconds each, with a In one study, 16 Ecuadorean patients were mean of three applications per patient. The treated with a SNAP (NO-donor, S-nitroso-N- area corresponding to the dermatomes affec- acetylpenicillamine) cream administered on

Page 25 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf lesions for 10 days. All lesions were parasito- pain associated with procedures is a frequent logically cured and clinically healed by day complaint and may be a reason that they 30. In another study, a different NO-produ- avoid the treatment for both medical and cos- cing cream was employed to treat 40 Syrian metic dermatology issues. According to infor- patients. Only 11 (28%) of 40 patients showed mation cited by these authors, almost 3 improvement and only five (12%) of 40 were quarters of surgery patients have inadequate cured at 2 months. This study was designed pain control. Although the advent of safe and to determine the clinical responses and effec- effective local anesthetics made much of der- tiveness of NO plus cryotherapy for the treat- matologic surgerymore comfortable, the injec- ment of old world CL. A double-blind, tion of these anesthetics is a source of randomized, placebocontrolled clinical trial discomfort. Clearly, there is ample room for was performed for the evaluation of therapy improvement, and this article suggests moda- with topical nitric oxide 3% and cryotherapy lity that seems to be simple and effective. in 63 Iranian patients with CL in the south of Using the gate theory of pain control, these Iran. Thirty of 36 participants (83.3%) had authors have proposed an “anodyne” device complete improvement in the treatment group made from a few cotton balls, a disposable as did 20 of 27 (74.1%) from the control group glove, and a vibrating massager. Placed on the (p = 0.627). This study could not show any site before injection, it inhibits transmission more effectiveness from combining a 12-week of pain in a manner that minimizes discom- course of treatment with 3% nitric oxide fort. The authors further postulate that this cream and a once-weekly treatment with type of vibratory stimulus can be comforting cryotherapy in comparison with cryotherapy to patients. It is always important for physi- and placebo in patients with CL [56]. cians to try to improve the experiences of the Local anesthesia injection technique for patients. This modification of readily avai- aesthetic removal of dermal nevi: Derma- lable, inexpensive products is 1 potential tologists should be aware of the surgical tech- means of doing so. Given its simplicity and niques that reduce the level of skin distortion minimal risk, it is likely that it will be tried by following biopsy procedures. (1) a dilution of many of our colleagues [58]. lidocaine with bacteriostatic 0.9% sodium A simple and effective treatment for nasal chloride and (2) injection of the solution di- telangiectasia; Needle-assisted electrocoa- rectly into the nevus. The nevus balloons in gulation: Nasal telangiectasia is a common size and shape and becomes tenser resulting phenomenon and can cause significant cos- in a change in the skin level permitting for metic and psychological problems. Although easy shave. Good injection technique of there exist various lasers and chemical treat- anesthesia may represent a simple, but im- ments for nasal telangiectasia, insufficient ef- portant means to improve postoperative cos- fect and side effects such as purpura and metic outcomes. Zaiac et al found good postinflammatory hyperpigmentation are cosmetic result with (1) a dilution of lidocaine common. They used needleassisted electro- with bacteriostatic 0.9% sodium chloride and coagulation as treatment for nasal telangiec- (2) subcutaneous injection of the solution di- tasia with success. Electrocoagulation has rectly into the nevus. Our solution consists of been reported to be safe and effective in here- 3 mL of 1% lidocaine in 30 mL of bacteriosta- ditary hemorrhagic telangiectasia, especially tic 0.9% sodium chloride in a 1:10 ratio, in with epistaxis. The authors used Surgitron® which each mL contained 9 mg of sodium for needle-assisted electrocoagulation. After chloride and 9 mg of benzyl alcohol. Using a 30 minutes of local anesthesia with lido- 30-gauge needle, this solution is directly in- caine/prilocaine cream and applying groun- jected into the nevus. The nevus balloons in ding plate underneath the patient, a 30G size and shape and becomes tenser resulting needle tip was placed in the telangiectatic ves- in a change in the skin level permitting for sel lumen through the skin overlying the ves- easy shave. This technique results in a smo- sel. Then an electric current with a power oth-surfaced area devoid of stitches that heals intensity of 30 W was delivered through it for in an aesthetically pleasing manner [57]. 1 second. With an electric current, the blood A Simple Elastomer-Pad Vibratory Dampe- vessel disappeared, instantly. The same pro- ner to Maximize Pain Control of Injections cedure was repeated along the vessel at about in Patients' Undergoing Dermatological 1 to 2 mm distance between needle punctu- Surgery: For many dermatology patients, res. The total procedure time was approxima- Page 26 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf

tely 10 minutes. There may be a slight stin- technique has several advantages. The tech- ging sensation during the procedure, made nique is simpler and faster with less morbi- tolerable with just the EMLA cream. Conven- dity and an improved cost-benefit ratio tional electrosurgery tips, even the finest one, compared with tissue expanders, which re- cannot easily puncture skin by itself. Using a quires the insertion of a prosthesis. Although needle tip enabled us to puncture skin and for defects localized on the forehead or tem- vessel without an electric current. Then an ple, presuturing can be considered, it should electric current was delivered directly into the be noted that in localizations with less skin vessel lumen. Because the electrical resis- laxity, for example, lesions on the scalp, the tance of blood is much lower than that of epi- presuturing technique is not suitable. In dermis or surrounding dermis, selective these cases, tissue expanders are a good coagulation of the vessel walls with minimal choice for skin expansion. If appropriate re- epidermal and surrounding dermal tissue da- garding defect size and localization, the pre- mage can be achieved. Immediately after the suturing technique can be used before procedure, only needle marks exist, which excision of congenital nevi and benign lesions heal well without dressing. Patients can see and correction of scar tissue. Presuturing the improvement of telangiectasis immedia- enables primary wound closure for defects tely after the procedure. There was no pur- that would normally necessitate staged exci- pura with a minimal risk for sions or reconstruction with a more sophisti- postinflammatory hyperpigmentation. They cated technique, such as local flaps or skin used Surgitron®, but they think this method grafts. It is a reliable, inexpensive technique may be applicable with other bipolar devices. with a low complication rate that provides an A patient with nasal telangiectasia showed excellent cosmetic outcome and is especially dramatic improvement after 1 session. After suitable in an outpatient setting [60]. 4 sessions, almost complete clearance was Ligation of the base of pyogenic granu- obtained and there was no recurrence during loma—An atraumatic, simple, and cost-ef- the 2 years after last treatment [59]. fective procedure: Pyogenic granuloma (PG) Presuturing: A simple technique for exci- is a common, benign, acquired vascular sion of large skin lesions: Excisions of large tumor mostly presenting as a rapidly growing skin lesions, for example, congenital mela- red and sometimes pedunculated papule. nocytic nevi, often require staged excisions or Commonly described treatment options are more sophisticated reconstructive procedu- complete surgical excision, shave excision, or res. A simple and reliable way to reduce the curettage followed by electrodesiccation, vari- number of staged excisions and risk of wound ous forms of laser operation, cryotherapy, or dehiscence is the so-called presuturing tech- injection of sclerosing agents. The authors nique. Under local anesthesia, multiple non- described an atraumatic, simple, fast, and resorbable sutures are placed across the cost-effective alternative treatment option. lesion, pulling the edges and folding the adja- The PG is ligated as closely as possible to its cent skin over the area that is to be excised. base using soft surgical suture material. This The sutures should be placed at least 24 maneuver can be facilitated by lifting the PG hours up to 5 days before excision. The prin- with forceps. The tumor is then ligated with ciple behind this technique is the stretching knots that are as tight as possible and the su- of adjacent skin beyond its inherent extensi- ture material is snipped so short that it will bility to reach sufficient skin laxity. Thus, re- not irritate the surrounding skin. The ligated duction of the number of staged excisions or tumor can be covered by a wound dressing. a complete 1-stage excision of the lesion with The tumor will become necrotic and fall off in a standard primary closure technique can be several days. Patients, parents, or both need achieved. The amount of undermining can be to be advised that bleeding could occur from reduced or even eliminated, maintaining a the nurturing blood vessel. This unusual better vascularity. For the subsequent pri- event can be controlled by self-applied simple mary closure, we suggest the use of pulley compression of the lesion for several minutes. stitches and butterfly sutures with a slowly Only clinically obvious cases of PG should be absorbable material. Although tissue expan- treated by this technique because no histolo- ders are also an long-proven alternative for gic examination will be available. This proce- skin expansion, the described presuturing dure is very simple, fast, and can be

Page 27 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf performed even in small children. No anest- and the breaks in the skin can be secured hesia is required because it is atraumatic. with gauze. This ensures an adequate delivery This smaller lesion can be easily treated, eg, of drug, preventing the rupture of the cyst by laser operation or light electrodesiccation. [63]. A persisting vessel can also cause recurrences Medical Student Preference for Simulation as described after shave excision or curettage Models: The pig foot model is preferred for te- followed by electrodesiccation. It is so simple aching dermatologic surgical skills. These re- and fast that it can be performed in any der- sults re-affirm that the pig foot model is an matologist’s office, and it is less expensive effective, low-cost solution for training. The Il than most alternatives. In case of persistence Duomo Basic – With Tumor is the first appa- or recurrence of the PG, complete excision ratus on the market designed for dermatolo- can still be performed [61]. gic surgery with respect to tissue planes A Simple Technique for Treatment of Nasal (epidermis, dermis, and fat), underlying ana- Telangiectasia Using Trichloroacetic Acid tomy, and simulated tumors with margin in- and CO2 Laser: Nasal telangiectasia is a dicators. This mannequin is anatomically common disfiguring condition and may cause sophisticated and provides a more-robust significant psychological distress. Although training experience for dermatology residents lasers are effective in treating such lesions, than others on the market, but it is expen- there are many disadvantages, such as pur- sive. With it, trainees can perform local anest- pura, scarring, and cost. objective. Twenty hetic administration, nerve blocks, suturing patients with nasal telangiectasia were trea- techniques, punch biopsy, elliptical closure, ted with CO2 laser 2 weeks after modified random axial and interpolation flaps, skin sclerotherapy using 80% TCA. After one tre- grafts, botulinum toxin injections, tumor ex- atment session, all patients had excellent re- cision with realistic margins, and scar revi- sults with more than 75% vessel clearance. sion. The layers simulated are skin, There were mild side effects, such as transi- subcutaneous fat, facial muscles and nerves, ent erythema and fine frosting. After follow- blood vessels, parotid glands and ducts, su- up of 1 year, there were no relapses. They perficial muscular aponeurotic system, nasal concluded that CO2 laser after modified scle- cartilage, skull, and auricular cartilage. The rotherapy using 80% TCA appears to be a cost is more than $1,500 per mannequin. simple, effective, and inexpensive method for Despite its sophistication, the medical stu- the treatment of nasal telangiectasia [62]. dents in the surgical skills laboratory least Intralesional drainage injection of triamci- preferred the Il Duomo mannequin. It scored nolone acetonide for epidermal cyst: Infla- poorly in epidermal and dermal quality be- med but noninfectious epidermal inclusion cause they felt that it did not resemble the feel cysts are often injected with intralesional tri- of human skin. Its highest average scores amcinolone acetonide before surgical exci- came in the underlying anatomy and reusa- sion. This method helps reduce inflammation. bility sections. One disadvantage of the Il However, giving an excessive amount of fluid Duomo simulator for medical students is that during the injection has the potential to rup- the platform is designed to teach moresophis- ture the cyst, further aggravating the inflam- ticated skills such as large lesion excision rat- mation and potentially causing a secondary her than simple surgical skills such as a infection. Hence, it is of utmost importance punch biopsy and suturing. In contrast, a re- that an optimum amount of steroid is injected cent study by Nicholas and colleagues using into the cyst cavity. Two needles can be inser- the Il Duomo mannequin found that derma- ted into the cavity of the cyst. Sudden loss of tology residents rated the Il Duomo platform resistance while inserting the needle indicates for initial training of advanced procedures in that the needle is in the cavity. One needle is dermatologic surgery as very beneficial. The attached to a syringe and used for injecting SynDaver Basic Surgical Pad was chosen to the steroid and the other needle is not attac- represent the nonfoam skin simulator group hed to a syringe and preferably positioned in because its tissue planes, moisture content, the punctum, if present. As the steroid fills up and feel are similar to those of human skin. the entire cyst cavity, the excess steroid overf- Uses for this platform include subcuticular lows into the other needle. This indicates the and subcutaneous suturing, subcutaneous cavity is full. Both needles may be pulled out, injections, fine dissection, and surgical stap-

Page 28 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf les and adhesives. Layers simulated are epi- teaching basic dermatology surgical skills to dermis, dermis, hypodermis, subcutaneous medical students [64]. fascia, and fat. Unique features of this model Banana: A New Simulation Model to Teach are realistic puncture resistance and compa- Surgical Techniques for Treating Ingrown tibility with electrocautery, laser scalpel, radio Toenails: Ingrown toenails, when recurrent frequency ablation devices, harmonic blades, and painful, are often treated surgically. Sur- monopolar and bipolar devices, gamma kni- gical treatment has traditionally been perfor- ves, ultrasound equipment, computed tomog- med as matricectomy involving sharp excision raphy, and magnetic resonance imaging. This of the matrix; another option is chemical era- product represents the two classes of more- dication of the matrix with phenol, which has typical “bench model” simulators in the stu- become more popular and is more effective at dent skills laboratory. It is more limited than preventing symptomatic recurrence. There the Il Duomo mannequin but represents a are no animal models on which to teach and class of models within reach of many prog- practice these techniques. Surgical models rams’ budgets. Anastakis and colleagues, in can be used to improve depth perception and a study comparing efficacy of different simu- surgical skills. The authors sought to develop lators, found that bench models have training an economical simulation model to teach the capabilities equivalent to that of cadavers and different phases and surgical techniques used emphasized that underlying anatomy is not to treat ingrown toenails to dermatology resi- essential for learning some procedural skills. dents. The authors selected large, ripe bana- Data from the student surveys reveal that the nas without imperfections on the peel to skin pad was the second most preferred of the simulate toes. The banana peel was incised to three groups. It scored poorly in underlying create a nail bed. They used flexible acetate anatomy, because this product group does plates to create the nail plate and matrix. The not recreate underlying anatomy beneath the plates were fixed into the banana’s core, subcutaneous fat. This model’s highest scores slightly oblique to the peel, and were ade- were in movement, pliability, and reusability. quate for delicate manipulation. The plate Students felt that this model moved and felt must be cut larger than the nail bed so that like human skin and survey results demons- it is inserted and fixed. No glue or external fi- trate that this model is a viable option for xation was used. The acetate plate remains basic dermatologic surgical skills laborato- fixed during the peel incision, but because ries. Olson and colleagues recently published there are no ligaments created with the bed, their experience with the use of hydrophilic it is necessary to hold this plate using the foam pads as a suturing model. This inexpen- contralateral hand. They used conventional sive simulation platform suffers from the li- surgical materials to demonstrate and prac- mitation that it does not reproduce tice the techniques. Acetate plates are com- underlying anatomy, although it provides an monly used as document covers. The banana excellent model to practice wound eversion, and acetate plate were adequate to create a demonstrating “step off” deformities created model for the composition of the nail unit. by uneven height of everting dermal sutures, This model allows good representation of the and running subcuticular closure. Medical proportions and anatomic structures involved student preference data from this study de- in surgery for ingrown toenails. Each banana monstrate that the pig foot model is an effec- model was used only once for each technique. tive, low-cost solution for teaching basic They demonstrated to undergraduate stu- dermatologic surgery skills. The major limita- dents and residents the main techniques for tions of the pig foot model is that it is best for surgical treatment of ingrown toenails, such teaching basic procedural skills and is poten- as digital block anesthesia, tourniquet or rub- tially less useful for training of more-sophis- ber band around the toe, classic matricec- ticated dermatologic techniques such as tomy, avulsion of the nail plate. Afterward, flaps, grafts, and curettage. Preference data the residents may practice these procedures. should continue to be collected to fully assess No major difficulties were faced in the process the Il Duomo mannequin and other morecom- of teaching these techniques for surgical tre- plex synthetic lesion simulator platforms, alt- atment of ingrown toenails using this model. hough we found that the tried-and-true pig Simulation is increasingly recognized as an foot platform is still a preferred platform for effective means of team training, the acquisi-

Page 29 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf tion and maintenance of technical and profes- imaginary patient with a red vascular lesion sional skills, and reliable performance asses on which residents can learn firsthand how sment. In addition, a simulated surgical m to properly hold the laser, activate approp- odel encourages active participation and can riate buttons, and aim at the target. With this enhance the retention and transfer of lear- technique, residents are also readily able to ning. Surgical models using fruit have been see the effect of the pulsed dye laser (PDL) on previously reported: tomatoes for shave biop- the target. The drawn and colored in target sies, burned oranges for necrotic ulcer debri- serves well as an imaginary vascular target dement, cantaloupes for sigmoidoscopy tec that allows learners to immediately visualize hniques, and bananas as a training model to the outcome of their PDL treatment. PDL, in refine blade control for Mohs layer removal particular, is an ideal device for application of and skin incisions. In the case of partial avul- this teaching tool since it is the laser that der- sion of the nail plate with chemical matricec- matology residents use most frequently. Pil- tomy, it is possible to discuss the different lowcase Baby can be adapted in various ways protocols. There are protocols using 80% to to practice the use of other lasers on different 88% phenol applied directly to the nail mat- types of targets. For example, we drew and co- rix, including two cycles of 1 minute and lored in a black circular target that could be three cycles of 1 minute, as well as protocols used as a model for a nevus of Ota, tattoo, or using 10% sodium hydroxide for 1 minute other pigmented lesion for practicing quality- and 100% trichloroacetic acid. The pros and switched alexandrite (and other Q-switched) cons of each protocol can also be discussed. lasers. Again, the marker target allows for This simulation model for teaching techni- good visualization of the target, guide light, ques to treat ingrown toenails is easy to use and treatment effect. It is important to note and allows performance and visualization of that this teaching technique is safe and clean. all surgical phases. This model also allows de- To minimize the risk of fire or injury to the velopment of new surgical techniques for trea- underlying pillow or examining table, the pil- ting nail problems [65]. lowcasewas placed on a folded sheet moistened with saline before starting the training Pillowcase Baby: A Laser Teaching Tool for session. The marker pigments do not penet- Dermatology Residents: Pigs’ feet are widely rate through the pillowcase even after nume- used as a teaching tool for suturing and bi- rous passes of the different lasers that opsying and have served as a traditional met- residents practice with. As with actual laser hod to help dermatology residents become treatment sessions, residents should be ins- acquainted with these procedures before per- tructed to check their surroundings and en- forming them on live patients, but there has sure that there is nothing flammable around not been an equivalently effective teaching before treating their Pillowcase Babies. Other modality for lasers. Because dermatologists variables that increase the risk of fire include perform more laser procedures than any an oxygen-rich environment, which is especi- other specialtists, it is important that derma- ally relevant in real-life cases in which inha- tology residents receive proper training in lation anesthesia is used or when the laser laser surgery during their residency, for pati- procedure is performed in the oxygenenriched ent safety and for upholding high standards atmosphere of the operating room. Certain of care as experts of procedural dermatology. types of lasers such as carbon dioxide laser It has been reported that the resident role in and certain types of materials such as polyes- laser procedures varies greatly, raising con- ter also increase the risk of fire, and care cerns about adequate training during resi- must be taken to minimize the risk of fire in dency. Practicing the proper use of a laser accordance with the safety protocol of the in- device before performing the procedure on a dividual institution. In summary, Pillowcase patient is especially important in pediatric Baby can serve as an effective teaching tool dermatology, where patients may be less coo- for dermatology residents during laser proce- perative than their adult counterparts, adding dure training. The teaching session also in- to the technical complexity of the procedure. corporates other aspects of laser surgery, To introduce dermatology residents to lasers, such as wearing proper protective goggles and the authors used a pillowcase on which a dra- setting laser parameters, which further helps wing of a target is made using a red perma- learners become familiar with the overall pro- nent marker. The drawing serves as an cess of laser treatments. Performing laser the-

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rapy on a Pillowcase Baby as their first laser sistant or returned to the surgical tray, pivot case is not only safe, but it is also a fun met- the needle 90 degrees toward the instrument hod for introducing dermatology residents to joint. The needle’s point should be directed to- the exciting field of cutaneous laser surgery ward and touching the needle driver, and the- [66]. reby, disarming the needle. To avoid dulling the needle, the point should not be grasped Short-contact topical tretinoin therapy to by the needle driver. Disarming the loaded ne- stimulate granulation tissue in chronic wounds: The use of retinoids in wound healing edle may reduce the chance of sharps injury is increasing. It has been shown that retinoic during instrument hand off and retrieving acid reverses the inhibitory effects of gluco- instruments from the surgical tray. Ninety- corticoids on wound healing and accelerates nine percent of surgical residents incur at the formation of healthy granulation tissue. least one needlestick injury during their trai- Pretreatment with tretinoin before epidermal ning. The Center for Disease Control and Pre- injury such as chemical peeling and dermab- vention estimates that there are over 1000 rasion has shown accelerated wound healing. needlestick injuries per day. Percutaneous in- Enhanced healing of full-thickness skin wo- juries represent both an infection and conta- unds has also been demonstrated in early mination risk, as well as a major cost: wound healing studies. However, tretinoin follow-up after a single needlestick injury can therapy can be quite irritating. The authors cost up to $3000 even when no infection oc- observed the clinical and histologic effects of curs. Needlestick injuries can occur many topical tretinoin solution 0.05% applied di- times during surgery. The following method rectly to the wound beds of chronic leg ulce- addresses sharps exposure during instru- rations. All were treated with topical tretinoin ment hand-off between the physician and as- solution 0.05% applied directly to the wound sistant, and during the retrieval of from the bed. The tretinoin solution was left in contact surgical tray [68]. with the ulcer bed for a maximum of 10 mi- Simple method for controlling surgical nutes daily and then rinsed with normal sa- sharps: During surgical procedures, control line. Punch biopsy specimens were obtained of sharps is important for both infection con- from the wound beds at baseline and mid the- trol and for minimizing contamination. In rapy. Standard wound care was continued fact, there has recently been a push to in- throughout the study. They founded that as crease the awareness of the risks of sharp in- early as 1 week after treatment with topical juries and development of new devices to tretinoin solution 0.05%, there was increased minimize said risks. In dermatologic surgery, granulation tissue first noted at the wound’s the main culprits for sharp injuries are scal- edge. After 4 weeks of therapy with tretinoin, pels, hooks, and needles. Attempts to mini- there was further stimulation of granulation mize sharps injuries include the use of tissue, new vascular tissue, and new collagen ‘‘neutral zones’’ for hands-free transfer of formation. Short-contact tretinoin therapy sharps, and placement of potentially injuri- can be a novel modality in which to treat ous devices under drapes and into dental chronic ulcers and stimulate the formation of rolls. Although the number of sharp injuries granulation tissue [67]. among health care workers has declined, the A simple means of disarming the “locked number is still not zero. As a result, any de- and loaded” needle: Surgery, in any setting, vice or technique that can help to decrease has several inherent risks not only to the pa- this hazard to health care workers is invalu- tient, but the physician and his assistants as able. As curved needle injury is the most com- well. Safe handling and management of the mon type of sharp injury, and the most sharps to prevent inoculation injuries is one commonly used needle in dermatologic sur- of these risks, in particular: 1) instrument gery, our focus is on decreasing the risk of in- hand-off of the needle and needle driver bet- jury from this type of instrument. The authors ween the physician and his assistants; 2) ret- described a simple device for eliminating the rieval of instruments from the surgical tray. risk of suture needle injury. During packing The authors’ review a simple means of disar- of our surgical trays, they include a thin small ming the needle loaded in the needle driver to section of a refrigerator magnet, similar to reduce sharps injury. Before the needle and those found on, for instance, many notepads needle driver are either handed off to the as- and advertisements for pharmaceuticals. The

Page 31 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf magnet is sterilized along with the entire sur- have an increased propensity for the disease. gical pack before the first use. During the sur- Management of the condition to date has pro- gical procedure, the needle can be placed on ved challenging. Oral systemic agents such as the magnet, which is kept in a corner of the terbinafine and itraconazole have shown good surgical tray. During placement of the needle, mycological cure rates when taken over a the magnet will attract the needle to it, furt- number of months. However, potential side her aiding in placement in the desired loca- effects, drug interactions and reluctance from tion. Furthermore, the magnet will serve to some patients to oral medications remains a hold the needle in place, and allows for easy limitation. Exploring new techniques, the use retrieval with the needle driver when suturing of lasers has been suggested and reported as is initiated. During breaks in suturing, the a less invasive and safer technology to destroy needle is simply replaced onto the magnet, the subungual infection by rapid heating of thus, safely isolating it from the rest of the the infected area. However, results have sug- tray and, thereby, minimizing the risk for ac- gested that it has little evidence to date to cidental injury. Although this technique does support their widespread use in onychomyco- not prevent injury during suturing, it is a sis. Topical treatments, applied directly to the simple and novel approach to minimizing the nail plate, have also been used widely but risk in the surgical tray area. It also serves to consistently have been shown to be less effec- declutter the surgical tray when multiple ne- tive than the systemic drug regimes. The nail edles are used. This is done without the po- plate is naturally a barrier to drug penetra- tentially dangerous method of placing the tion, effectively shielding the subungual area needle into a dental roll, which on occasion so the underlying infection remains protected. can lead to needle-stick injury. These mag- In addition, patients are expected to apply the nets are generally easy to find at little to no medicament to the nail for many months. cost. At the end of the procedure, these mag- Studies of topical medicament usage have nets can be sterilized along with the other shown that compliance decreases the longer surgical instruments in the tray. As a result the treatment continues, which may result in of this simple device, needle-stick injuries can a treatment failure. Measures designed to en- be reduced with no cost to provider and pati- hance topical drug delivery have been trialled ent [69]. with some success. Chemical penetration en- Rapid treatment of subungual onychomy- hancers have been developed and incorpora- cosis using controlled micro nail penetrated into many topical drugs to boost delivery tion and terbinafine solution: Onychomyco of the active ingredient through the nail. sis continues to be a common and intractable Combination therapy has also been shown to problem in adults, often responding poorly to improve overall cure rates. Topically, nail re- drug treatment. Toenails are most frequently duction by mechanical thinning of the nail affected by the infection, particularly the hal- has shown to modestly improve the clinical lux.1 Studies suggest its prevalence to be aro- response to antifungal agents. Recently, rese- und 29% across Europe, showing an increase archers have employed the use of fractional in prevalence with age and in countries with lasers to penetrate the full thickness of nail longer winters. The causative agents are typi- plate to create a porous structure, thus allo- cally the dermatophyte species of fungi which wing the easier passage of any applied anti- spread from plantar skin over many months fungal. Fractional lasers concentrate power to to invade the nails through a distal and late- a very small area, thus reducing the risks of ral subungual route producing the characte- thermal damage to peripheral tissue. This ristic discolouration of the nail plate.4 Over work is ongoing, with potential promise, but many months, complete invasion of the nail the expense of such systems is still prohibi- may lead to total dystrophy. Onychomycosis tive for general podiatric use. In addition, as is often trivialised as a cosmetic condition but with most “hot” lasers, pain appears to be a studies have confirmed its effect on the pati- commonly reported side effect of the treat- ent’s wellbeing and quality of life. Moreover, ment with a risk of damage to the delicate su- the presence of fungus on the foot is a risk bungual tissues. For the last few years there factor for the development of lower limb cel- have been few significant advances in the on- lulitis – a particular risk for patients with pe- going struggle to treat onychomycosis more ripheral vascular disease and diabetes who quickly and effectively. As reported by Podi-

Page 32 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf atry Today in November of 2007, the novel studies of onychomycosis, using controlled idea of drug delivery to the nail using trephi- micro-nail penetration delivered by a U.K. de- nation or “mesoscissioning” was first introdu- vice known as Clearanail. The authors further ced using Pathformer, a handheld device, that hypothesize that a “subungual mass of der- uses a microscopic cutter to penetrate the matophyte hyphae which are not attached to nail plate but not the nail bed. The principal the nail bed or nail plate remain shielded by of this device is based on electrical impe- the overlying nail plate.” This presence of a dance, effectively decreasing the inherent dermatophytoma slows the passage of low- electrical potential of the epidermis, a known tension anti-fungal solution without the ad- insulator. This idea allows drugs to enter the junct of micro-drilling. It is a safe and “stratum corneum-free” nailbed painlessly. A painless, turbo-charged drug-delivery system Phase 1 study conducted at Bringham and to the affected nail and nail bed, via ‘micro- Women’s Hospi tal found the procedure to be pores’. Trephination as a concept, it seems, painless, offering both depth control and a would certainly provide a podiatrist with a mycological cure in a diverse patient popula- very useful and welcome addition to the tool- tion. Of interest, a terbinafine 1% cream was box [70]. applied to the nails, in direct contrast to to- Knot Technique: A New Treatment of In- day’s standard of care with low molecular we- grown Nails: Ingrown nails are a painful ight, hydrophilic solutions widely preferred. A problem that affects all ages, particularly the recent study from Shemer and Gupta AK, in young, and it may become chronic if not trea- Israel presents a noteworthy exception. The ted. A new technique was used to treat pati- work reveals an open comparative study of ents with Stages 2 and 3 ingrown nails in nail drilling by trephine, as an adjunctive tre- whom conservative and surgical methods atment for toenail onychomycosis. Presented were attempted. A total of 30 patients presen- as a parallel three-arm trial the study inves- ting with Stages 2 and 3 ingrown nails to the tigates the effects, outcome and safety of tre- clinic between 2010 and 2012 were included. atment using trephine technology. The study A wedge excision of the upper and lower soft concludes that both groups managed concur- tissues of the nail was performed. The wound rently with trephined holes in the nails had a margins were simply sutured with 2/0 polyp- significantly higher percentage of clear nail ropylene. Approximately 8 to 10 knots were compared with topical terbinafine alone. Inte- tied without cutting the stitches under the restingly, the addition of oral terbinafine pro- nail. These knots were used to push the soft vided no significant advantage with tissue down and to raise the nail. This was comparable out comes. Treatment of fungal achieved by placing a knot under the nail nails with holes plus topical terbinafine pro- after the needle had been passed inside the duces greater improvement in the appearance nail, without cutting the suture before anot- of the toenail and a higher, and significantly her knot was tied above the nail. Therefore, earlier, mycological cure rate. For nail trephi- the ingrown part of the nail was raised. Pati- nation, the Israeli study used an ingenious ents were followed up for 20 months (range, apparatus, an automatic device manufactu- 10–24 months). Relapse was observed in only red by Ex-It Medical Devices Ltd. This is used 1 patient. No infection was observed, and to drill two horizontal lines of holes just pro- none of the patients required additional sur- ximal to the border between the diseased and gery. Stages 2 and 3 ingrown nails can also healthy segment of the nail. Holes are of a 1.8 be safely treated with this technique. This mm diameter, spaced 2mm apart. Grossly, study demonstrated that ingrown nails can be the nail plate consists of a superficially dry successfully treated using a simple surgical compartment and a deeper humid depart- technique with low rates of recurrence [71]. ment. This trephine technology is designed to detect when the drill has reached the more Treatment of ingrown nail with a special humid department. When a pre-defined device composed of shape-memory alloy: humid level is reached the drill aborts, to pro- Ingrown nail is a common nail problem resul- tect against pain and nail bed injury. Nail ting in pain and disability in daily life. Re- trephination is required one time only. After cently, a new treatment modality for an this work, data analysis confirms that no case ingrown nail was reported that used a device of bleeding or pain was reported. It was also composed of shape-memory alloy, K-D. The reported further treatment success in 3 case aim of the present study was to determine the

Page 33 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf efficacy, recurrence rate and complications of bidity and high rates of success. Therefore, K-D. The majority of patients were very satis- partial nail avulsion and BCA matricectomy fied. There were no side-effects in most pati- can be used as an alternative treatment met- ents except loss of nail in one patient. K-D hod for the treatment of ingrowing toenails. has some advantages such as simple applica- Bichloracetic acid is a viable alternative to tion steps, no deformity after the procedure, other modalities in the management of ungius high patient satisfaction and obvious effect incarinatus. Advantages include simplicity, compared to other non-invasive and invasive cost-effectiveness, speed, safety, and effica cy methods [72]. [74]. A Simple, Pain-Free Treatment for Ingrown The effectiveness of matrix cauterization Toenails Complicated with Granulation with trichloroacetic acid in the treatment Tissue: Gulru decided to apply a small appa- of ingrown toenails: Ingrown toenail is an ratus made of 0.4 mm-thick stainless dental often painful clinical condition that usually wire with two hook-like pieces attached to affects the big toe. Chemical matricectomy each side of the nail, which were connected with phenol has a low recurrence rate and by a dental string in the middle. The granula- good cosmetic results. However, it produces tion tissue was cauterized by silver nitrate, extensive tissue destruction that can result in and they were advised to have foot baths with drainage and delayed healing. Alternatives one tablet of 250 mg potassium permanga- such as sodium hydroxide and trichloroacetic nate diluted in 2 L of warm water twice daily, acid (TCA) have therefore come into vogue. A for 10 minutes each time. Patients were called total of 39 patients with 56 ingrown toenail back 1 and 6 months after the cessation of edges underwent chemical matricectomy with the treatment, and none had any complaint 90% TCA after partial nail avulsion. In most with their toenails. Applying a special nail ap- of the patients, adverse effects such as posto- paratus together with silver nitrate and potas- perative pain and drainage were minimal. sium permanganate foot baths may be an One patient who underwent matricectomy inexpensive, easy, and patient-friendly treat- had recurrence in a single nail edge (1.8%) at ment alternative to surgical interventions for 12 months follow‑up. No recurrence was ob- ingrown toenails complicated with granula- served among 38 patients during the mean tion tissue [73]. follow‑up period. This was considered to be statistically significant (P < 0.001). Partial nail The Effectiveness of Matrix Cauterization avulsion followed by TCA matricectomy is a With Bichloracetic Acid in the Treatment safe, simple, and effective method with low of Ingrown Toenails: Partial nail avulsion fol- rates of postoperative morbidity and high lowed by BCA matricectomy is a safe, simple, rates of success [75]. and effective method with low rates of postoperative morbidity and high rates of success. Resin splint as a new conservative treat- Therefore, partial nail avulsion and BCA mat- ment for ingrown toenails: Several conser- ricectomy can be used as an alternative tre- vative as well as surgical methods are used atment method for the treatment of ingrown for the treatment of ingrown toenails until toenails. This is the first study to use BCA for date. The conservative methods are either the treatment of ingrown toenail. In our based on nail splinting or on orthonyxia, but study, side effects such as postoperative pain no methods employing both principles have and drainage were at a minimal level in the been reported thus far. Moreover, surgical majority of the patients. None of the patients methods usually involve postoperative pain, had postoperative infection. The success rate prolonged wound healing and restricted acti- of treatment was found to be 96.6%. One pa- vities of daily living. Therefore, considering tient who underwent matricectomy had re- the need of a simplified, non-invasive method, currence at the 12th month of the follow-up. in this study, we applied a novel splint to treat In this study, 90% BCA matricectomy shows patients with ingrown toenails and estimated treatment success comparable with those of the clinical efficacy as well as rate of recur- phenol, TCA and sodium hydroxide matricec- rence following treatment. The splint is a tomy. Partial nail avulsion followed by BCA plate made of resin that is attached to the la- matricectomy is a safe, simple, and effective teral edge of the nail using a bandage. The method with low rates of postoperative mor- authors studied 61 patients with an average

Page 34 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf application duration of 9.3 months and an and less traumatic than classical gutter tech- average follow-up period of 10 months in all nique. It can be considered an initial treat- patients. All patients experienced pain relief ment for most patients with mild ingrown within a week of splint application and a dec- toenail. However, this conservative method rease in the degree of nail deformity. Moreo- may not be the first choice for cases with soft- ver, follow-up revealed a recurrence rate of tissue overgrowth or extensive granulation 8.2%. Therefore, the authors believe that this tissue. Acrylic treatment with gutter splint new device is an excellent conservative treat- and sculptured nail was found to be vastly ment method for patients with ingrown toe- superior to the other methods described, es- nails [76]. pecially in the ability to firmly affix the gutter Nail-splinting method with flexible plastic splint and sculptured nail for the extended tubes for ingrown toenails: Ingrown toenail period required for treatment. The treatment is a common disorder in the great toe. Many leads to a complete remission with almost treatments have been described for ingrown instant alleviation of pain, with no disfigure- nails. But they have many disadvantages, ment, while allowing for the resumption of such as a prolonged wound-healing period, daily activities. Conservative methods utili- the production of an unsightly nail, or the zing formable acrylics are highly beneficial in restriction of normal activities. The authors the treatment of an ingrowing nail and should performed a modified method of lateral nail be viewed as the first treatment option [78]. manipulation with placement of splints on 6 A New Economic Method for Preparing Pla- patients who gained instant relief from pain telet-rich Plasma: Although platelet-rich and resumed normal activities immediately. plasma (PRP) is nowadays a common method Most patients experienced no recurrence 20 in various medical fields, including cosmetic months after the treatment77. Nazari also en- surgery or dermatology, the expensiveness of countered 32 cases ingrown toenails in this the kit for processing is still a hurdle. A new clinical trial. All of the patients were treated unique economic method for preparing PRP using the plastic nail tube insertion technique was reported. The method consists in a sim- for 7 to 15 days. Patients were examined daily ple modification of a disposable 5-mL syringe for the first 3 days of treatment and were eva- that allows insertion into a common centri- luated 3 and 6 months after treatment. All pa- fuge and positioning of the syringe on the cen- tients were followed up by a single observer. trifuge so the PRP separates next to the tip of Recurrence was seen in only two patients the syringe. Platelet-derived growth factor BB after 6 months of treatment. The low recur- in PRP was measured under anticoagulant rence rate using the nail splinting technique dextrose solution A (ACD-A) or heparin as an- in the treatment of ingrown toenail, as well as ticoagulant and with or without prostaglandin its simple application, shows that this treat- E1 (PGE1) as a platelet aggregation suppres- ment constitutes an effective, non-invasive sant. The new method successfully created method. It appears that this technique can PRP with high platelet-derived growth factor substitute other more invasive surgical met- BB in all conditions, and the highest value hods, particularly in the early stages of this was obtained by using ACD-A and PGE1. The disease [77]. new method is useful, and the use of ACD-A A ConservativeMethod to Gutter Splint In- and PGE1 is the most recommended. The grown Toenails: In conservative approaches whole blood of 60 mL was taken from each for treating ingrown toenails, lifting the nail healthy volunteer. Thirty milliliters was under plate out of the ulcer bed using the gutter existence of ACD-A solution, and the rest 30 technique improves wound healing. There is mL was under heparin. The mixing rate was no need to free the side of the nail plate all the 9:1 in volume. Sixteen pieces of disposable 5- way to the proximalnail fold or matrix. Pus- mL syringes were prepared for the first cen- hing a plastic gutter between the nail edge trifugation with their finger-holders cut by and the ulcer bed is all that is necessary and scissors. Four milliliters of the whole blood usually does not require anesthesia. Cyano- was put into each syringe and centrifuged as acrylate glue offers more security and stability it stands. The rotation speed and time was than suturing or other methods for attaching 3000 rpm × 3 minutes, which was the mini- the gutter. This approach is more effective, mum for separating red blood cells (RBCs) easy to perform, more acceptable to patients, from plasma empirically by KOKUSAN H-19α

Page 35 of 39 (page number not for citation purposes) J Turk Acad Dermatol 2019; 13 (1): 19131r2. http://www.jtad.org/2019/1/jtad19131r2.pdf centrifuge with RF-109 rotor and MA-109K venation treatments, particularly in the mid- buckets. The centrifugal force was calculated face region. Techniques to date have largely with the corrected real radius to be 704g. The relied on multiple injections, fanning techni- syringes were then taken out from the centri- ques and deep placement of product under fuge and arranged on a special handmade muscle or on periosteum. A new technique to holder. A 3-way cock and an extension tube enhance volume in the midface using a single (both are common medical disposables) were injection of cross-linked hyaluronic acid at connected, and the other end of the extension the subdermal level and above the muscle has tube was attached to the syringe after centri- been described. The technique approaches fugation. Eight syringes for the second centri- midface rejuvenation with reference to both fugation were prepared as the same way as the bony skeleton and the medial malar fat the syringes used for the first centrifugation. compartment. After appropriately marking One microgram of PGE1 diluted in 0.05 mL of the skin, the filler is placed using a blunt can- saline was added to each of 4 syringes befo- nula. The treatment achieves satisfactory vo- rehand. The syringe was connected to the 3- lume correction, enhancing the sharp cheek way cock and the plasma was aspirated. The bones and malar fullness typical of an attrac- second centrifugation was performed at 4000 tive adult face. The approach is simple, quick, rpm (1252g) for 15 minutes, which is the fas- and well tolerated by the patient and may re- test speed of the machine and considered to sult in less bruising than deeper techniques. be the realistic time as a daily practice. The The attractive adult midface has clean, sharp supernatant was discarded leaving 0.65 mL cheekbones accentuated by a shadow bene- in each group (namely, ACD-A PGE1+, ACD- ath them formed by a concavity in the cheek A PGE1−, Heparin PGE1+, and Heparin and a smooth transition between different PGE1−), and the sediment was mixed with it areas of the face. With aging, there is a loss using a vortex mixer (Vortex V-1 plus, BIO- of projection in the midface as fullness and SAN). Finally, 0.65 mL of PRP solution was volume reduces. In particular, reduction in prepared from 16 mL of the whole blood in fat over the upper maxilla flattens the malar each group. PRP in each group was divided area. Malar fat has been shown to consist of into 3 pieces of 0.2 mL. Twenty microliters of three separate compartments; medial, middle, 0.5% Triton X in saline was added to 1 of the and lateral temporal cheek fat. A change of 3 and 20 μL of 8.5% calcium glucuronate to volume in the medial compartment in parti- another. Triton-X is a kind of detergent that cular, lateral to the nasolabial fold, has been destroys cell membrane and let α-granules suggested as the main cause of the loss of discharge nonspecifically. Calcium glucuro- midface projection, exaggeration of the naso- nate neutralizes the anticoagulant effect of labial fat compartment and, therefore, loss of ACD-A while it has no effect to heparin. Pla- the smooth transition typical of the youthful telet count of the 4 groups was performed by face. Restoration of facial shape by sculptural using disposable counting chambers. The manipulation of facial soft tissues has been PRP solutions were stored at 22–29°C4 over- deemed the highest priority in midface reju- night for the delivery to a laboratory. PDGF- venation. Volumetric replacement at the mid- BB was measured there using Human face region can restore a more youthful and PDGF-BB immunoassay microplate (R&D fuller facial appearance and may also soften systems). Ten microliters of the specimen was the nasolabial folds by elevating loose skin taken from each whole blood or PRP solution above the folds. This technique approaches after mingling, diluted to 190 mL buffer and midface rejuvenation with reference to both measured. The rest 190 μL of the samples the bony skeleton and the medial malar fat were centrifuged at 10,000 rpm for 10 minu- compartment. Fullness of the malar region tes, and the supernatants were also measu- conveys a youthful appearance and promi- red. This new method is useful and ethical in nent malar eminences are typically conside- clinical practice. The use of ACD-A and PGE1 red aesthetic. The area posterior and superior is recommended for preparing PRP with dense to the crossing of Hinderer’s lines is used to PDGF-BB [79]. indicate the location of the most prominent A single injection technique for midface part of the malar eminence. Newer hyaluronic rejuvenation: The correction of volume loss acid fillers provide an effective option for vo- has become an important part of facial reju- lume enhancement in the midface region. To

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date, these have typically been applied using 5. Kim JE, Ahn HS, Cheon MS, Lee KJ, Cho BK, Park either multiple ‘‘bolus’’ injections or a fanning HJ. Proximal nail fold-lunula double punch technique: A less invasive method for sampling nail technique to place product deeply either in matrix without nail avulsion. Indian J Dermatol the muscle layer or just above the perios- Venereol Leprol 2011; 77: 346-348. PMID: 21508584 teum. This method achieves adequate volume 6. Christenson L, Patterson J, Davis D. Surgical pearl: correction but can result in plump, ‘‘baby use of the cutaneous punch for the removal of face’’ cheeks with little shape. The single in- lipomas. J Am Acad Dermatol. 2000; 42: 675-676. PMID: 10727317 jection technique described enhances the sharp cheek bones and malar fullness typical 7. Gupta S, Jangra RS, Gupta S, Mahendra A, Singla R. Saw-toothed power punch for effortless nail biopsy. J of the attractive adult face. Reference to the Am Acad Dermatol 2016; 75: 109-111. PMID: bony skeleton in injection placement assists 27543233 in achieving this. The limited resistance to 8. Collins SC, Cordova K, Jellinek NJ. Alternatives to movement of the cannula assists to establish complete nail plate avulsion. J Am Acad Dermatol. that the cannula is in the subdermal level and 2008; 59: 619-626. PMID: 18793936 above the muscle. By contrast, vigorous back- 9. Shin HJ, Sneige N, Staerkel GA. Utility of punch biopsy for lesions that are hard to aspirate by ward and forward cannula motion would be conventional fine-needle aspiration.Cancer. 1999;87: needed to penetrate the muscle. Using the 149-154. PMID: 10385446 degree of resistance against the cannula to 10. Rice JC, Zaragoza P, Waheed K, Schofield J, Jones establish cannula position in the midface is CA.Efficacy of incisional vs punch biopsy in the described by Berros and Taieb. Additionally, histological diagnosis of periocular skin tumours. Eye (Lond). 2003;17: 478-481. PMID: 12802346 the overlying tissue can be tented with the cannula tip to ensure the correct injection 11. Güngör Ş, Bahçetepe N, Topal I. Removal of corns by punch incision: A retrospective analysis of 15 depth as recommended by Wu et al. Because patients. Indian J Dermatol Venereol Leprol 2014; the cannula is confined to the subdermal level 80:41-43. PMID: 24448122 and remains above the muscle, the single in- 12. Chang CH, Yang CH, Hong HS. Surgical Pearl: Pinch- jection technique reduces the bruising and punch excisions for scrotal calcinosis. J Am Acad swelling often associated with deeper injecti- Dermatol. 2004; 50: 780-781. PMID: 15097965 ons and reduces the potential for nerve da- 13. Rajan N, Langtry JA. The punch and graft technique: a novel method of surgical treatment for chondrode mage. The latter can mean that the technique rmatitisnodularis helicis. Br J Dermatol. 2007; 157: is more feasible for less experienced injectors, 744-747. PMID: 17672876 for whom deeper cannula techniques are not 14. Kain N, Koshy O. Evacuation of subungual advisable. The injector may draw back the haematomas using punch biopsy. J Plast Reconstr plunger after advancing the cannula to con- Aesthet Surg. 2010; 63: 1932-1933. PMID: 20359972 firm the cannula is not positioned in a blood 15. Khan MA, West E, Tyler M.Two millimetre biopsy vessel. Effective rejuvenation of the midface punch: A painless and practical instrument for evacuation of subungual haematomas in adults and can be achieved using this safe and simple children. J Hand Surg Eur Vol 2011; 36: 615-617. technique. The use of a single injection on PMID: 21724686 each side of the face yields highly satisfying 16. Danby FW, Hazen PG, Boer J. New and traditional results with reduced patient discomfort com- surgical approaches to hidradenitis suppurativa. J pared to currently favored, deeper injection Am Acad Dermatol 2015; 73: S62-65. PMID:264 70619 techniques [80]. 17. Sharma S, Garg VK, Sarkar R, Relhan V. Comparative study of flip-top transplantation and punch grafting in stable vitiligo. Dermatol Surg 2013; References 39: 1376-1384. PMID: 23898910

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