Vitiligo Surgeries

Introduction

• Vitiligo, characterized by depigmented macules and patches

• Is a common disorder with a high psychosocial impact, particularly in darker skins

• Surgical methods become important in cases where medical therapy fails to cause repigmentation

• Or in cases of segmental vitiligo where the response to surgery is excellent

• Principle-

Autologous grafting of viable melanocytes from pigmented donor skin to recipient vitiliginous areas

• Various grafting methods have been described including tissue grafts and cellular grafts

•  Stability of the disease is the most important criterion to obtain a successful outcome.

• Lesions on sites such as lips, acral areas,nipples, and genitals are particularly resistant to medical treatment

• Counseling of the patient regarding the outcome is vital before surgery.

• The conventional surgical modalities for vitiligo are miniature punch grafting, suction blister grafting, and thin split thickness skin grafting.

• Recent advances include autologous noncultured epidermal cell suspensions and cultured melanocyte suspensions or sheets.

Grafting techniques

Tissue grafts

• Minipunch grafting• Suction blister grafting• Thin split thicknessgrafting• Hair follicle grafts• Mesh grafts• Flip-top pigment

transplantation

Cellular grafts• Noncultured basal cell

suspensions• Cultured

melanocytes/keratinocyte grafts

Mini Punch Grafting

• After proper assessment of the stability status and routine physical examination and investigations

• An informed consent is taken from the patient• The donor and recipient areas are surgically prepared• The instruments required are 1 mm or 1.5mm

punches, small jeweler's or graft holding forceps, and a small curved tip scissors

• The recipient area is prepared first. • Two percent lignocaine with or without adrenaline is

infiltrated as a local anesthetic.

• To minimize the chance of developing any perigraft halo, the initial recipient chambers are made on or very close to the border of the lesion.

• The punched out chambers are spaced according to the result of test grafting or at a gap of 5-10mm from each other

• The donor area is either the upper lateral portion of the thigh or the gluteal area.

• Punch impressions are made very close to each other so that a maximum number of grafts can be taken from a small area.

• The needle of the syringe or the tip of the scissors used for the proper placement of grafts

• Hemostasis achieved by pressing a saline-soaked gauze piece• Care taken to ensure that the graft edges are not folded and the

tissue not crushed or placed upside down.• The recipient area may be immobilized if necessary• Post-surgically the patients are exposed to PUVA• The patients are followed up fortnightly for the initial two

months and then monthly, until complete repigmentation is achieved

• The entire depigmented and grafted area is expected to be completely repigmenetd within 3-6 months

Complications Recipient site

• Cobble stoning• Polka dot• Variegated appearance and color mismatch• Static graft (no pigment spread)• Depigmentation of graft• Perigraft halo• Graft dislodgement / rejection• Hypertrophic scar and Keloid formation

Donor site

• Keloid• Hypertrophic scar• Superficial scar• Depigmentation /

spread of disease• Contact dermatitis to

adhesive tape

Advantages

Easiest, fastest, and least expensive methodHigh rate of success with very few preventable / manageable side effectsCan be performed anywhere, on any site (except angle of the mouth)

Suction blister grafting

• A technique where the pigmented epidermis is harvested from the donor site by using suction to raise a blister which is then transferred

• cleavage occurs between the basal cells and the basal lamina of the basement membrane zone

• Only the epidermal portion of the donor area is grafted

• leading to a better color match and cosmetic outcome.

• The donor site can be from flexor aspect of the arm or forearm, abdomen, or the anterolateral aspect of the thigh or leg

• Blisters may be raised using syringes or suction pump and suction cups or a negative pressure cutaneous suction chamber system.

• The bases of syringes of sizes 10 ml and 20 ml are coated with vaseline and are applied on the donor site

• Negative pressure of about 150-250 ml created• usually takes 1.5 to 2.5 hours for the development of blisters• A single unilocular non-hemorrhagic blister is the best result

Raising suction blisters by the syringe method

Blisters formed after 2 hours of suction

• The roofs of the blisters are gently cut using iris scissors• The roofs are inverted onto a glass slide such that the

dermal side faces upwards• Cleaned and spread to its maximum size and kept moist

with normal saline• Recipient area can be dermabraded using a manual

dermabrader, motorized dermabrader, microdermabrader or a CO2 laser till minute pinpoint bleeding spots are visible

• A nonadherent dressing is applied

• The dressing over the recipient site is left on for 7 days.

• The patient is advised to keep the area immobile. • Usually, the grafts fall off in 1 to 2 weeks; so

essentially this is a technique of melanocyte transfer• The patient may be started on oral or topical

Psoralen-UVA or PUVASOL from the day of removal of dressing

• Repigmentation usually occurs in 3 month's time

• Complications-are uncommon, although • Hyperpigmentation• Incomplete pigmentation• Perigraft halo• Graft rejection may occur• Advantage-• It is a safe, easy, and inexpensive method, with very good

success rates. • Repigmentation is faster and the color match is very good,

especially over the lips, eyelids and areola

Split Thickness Skin Grafting

• Thin split thickness skin grafts are harvested from the pigmented donor area and transplanted at the recipient sites as continuous sheets of tissue grafts

• Principles- • Graft take adherence• Graft revascularization• Contracture

Technique

• Skin is stretched firmly at one end by an assistant with the flat of the hand or a wooden block and the other end is stretched by the operator

• A thin even split thickness graft is harvested free hand using either a sterile razor blade mounted on a Kochers forceps or a blade holding instrument

• Alternatively, a hand dermatome, Humby's knife or Silvers knife may be used

• The donor skin is kept in a sterile petri dish containing normal saline

Harvesting a thin split thickness graft freehand with a sterile razor blade mounted on a Kocher's forceps

• Recipient area is prepred with diamond fraise with electric motor or manually till pin point bleeding

• The graft is carefully placed over the denuded recipient site, taking utmost care to place the dermal surface facing down

• Immobilization of the graft is most important and is achieved by using surgical adhesive, octyl-2-cyanoacrylate and pressure dressing

• Thin split thickness skin grafting is the most successful technique among all the surgical methods, with a success rate of 78 - 91%

• Disadvantage-hyperpigmentation

Transplantation of Hair Follicles

• Repigmentation in vitiligo occurs from the melanocytes in the hair follicle

• Strip or single unit of hair removed• The hair is transplanted onto the vitiligo patch• The patient is started on phototherapy

NON-CULTURED MELANOCYTE GRAFTING

MKTP: HARVESTING DONOR SKIN

Even pressure is maintained

MKTP: CELL SEPARATION

CELL SEPARATION

• Sample is centrifuged at 2000rpm for 5 minutes

• Precipitant is a combination of keratinocytes and melanocytes

• Precipitant is resuspended with DMEM/F12

MKTP: CELL SUSPENSION

Precipitant is resuspended (typical volume 0.2-0.5ml) with DMEM

MKTP: RECIPIENT SITE

• Recipient site is dermabraded

CELL PLACEMENT

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Before

6 months after