surgical management of vitiligo

1. SURGICAL MANAGEMENT OF
VITILIGO
DR. SHWETA KHUSHALANI
RESIDENT, DVL

2. INTRODUCTION
 Vitiligo
 m/c depigmentary disorder
 1-2%population worldwide
 Affects all races
 Multiple depigmented macules and patches with
leukotrichia
 Cosmetic and psychological devastating effects
 Indication for surgical management
 Fail to respond to medical therapies
OR
 Respond to therapy with incomplete repigmentation

3.  PRINCIPLE
 Introduce melanocyte into the lesional skin, which then
establish and function as epidermal melanin units

4. INDICATIONS
 Stabile vitiligo
 Leukoderma (post burn, chemical)
 Piebaldism

5. Stability of vitiligo
 Duration
 History of extension of lesions absent for 1 year
 Morphology
 Stable : well defined border, +/- spotty pigmentation
 Unstable : ill-defined border
 Koebners phenomenon absent for 1 year
 Minigrafting test (positive)

6. VIDA scoring
 Evaluation of activity of vitiligo
Duration Scoring
In past 6 weeks : +4
3months : +3
6 months : +2
1 year : +1
Stable for at least I year : 0
Stable for 1 year with
Spont. Repigmentation : -1
 Score 0/-1, stable vitiligo

7. Test grafting
 Placing 6-8 puch grafts over vitiligo lesions
 observe for 12 weeks
 Results :
Unequivocal repigmenation beyond 1mm from the
border
POSITIVE
STABLE

8.  Cellular stability
 Markers (CD8, CD450, FOXP3) assessment
 Higher percentage of CD8 cells is assocociated wth
failure of melanocyte transplanttaion

9. Other factors
 Age of patient
 Young patient respond better
 Children-future course can variable, chances of failure of
surgery

10. CONTRAINDICATION
 Active /unstable vitiligo
 Unrealistic expectations of patient
 Keloidal tendency

11. PREOPERATIVE WORKUP
 Complete detailed history
 Physical examination – systemic and cutaneous
 Investigations : CBC, BT, CT, blood sugar
 Detailed Consent
 Photographic documentation

12. SURGICAL MODALITIES
TISSUE GRAFTS CELLULAR GRAFTS
• Suction blister
grafting
• Minipunch grafting
• Thin split thickness
grafting
• Ultra thin skin grafting
(UTSG)
• Mesh grafting
• Flip –top pigment
transplantation
• Transplantation of
hair follicles
• Micropigmentation
• Excision/ closure
• Dermabrasion,
chemabrasion
• Lasers and light
therapy sysytem
NON GRAFTING
TECHNIQUES
• Autologous
noncultured
epidermal cell
suspension
• Noncultered
Extracted Follicle
Outer Root Sheath
Suspension
• Autologous
cultured pure
melanocyte
transplantation

13. Introduction :
A technique of taking thin, miniature auto skin punch grafts from normal
pigmented donor site and individually grafting them in appropriate punched
out chambers at recipient stable vitiligo site
PRINCIPLE:
Donor dominance : a portion of dermis in the graft tends to have an
influence over the epidermis morphogenesis and differentiation
MINIATURE PUNCH GRAFTING

14. EQUIPMENTS
• Skin punches (1mm,1.5mm)
• Small Jeweller's or graft holding
forceps
• Small curved tip scissors
• Sterile petridish

15. Procedure
Donor site –
Sites:
1. lateral aspect of thighs
2. gluteal region
Surgical preparation
• LA -1% lignocaine
• Punch impressions are made very close to each other so that a
maximum number of grafts can be taken from a small area.

16. Recipient site-
 Test grafting of recipient area
 Surgical preparation
 LA (1% lignocaine with or without adrenaline infileration)
 Recipient chambers, close to border of lesion, 5-10mm apart
 Lift the edge and cut through mid dermis
 Grafts placed directly from donor to recipient area
 Hemostasis achieved by pressing a saline-soaked gauze piece
 Dressing in 3 layers –
 Jelonet ( paraffin embedded non adherent sterile gauze)
 Sterile pads
 Bio-occlusive biopore

17.  Donor area dressing
 Surgipad
 Bio-occlusive Micropore
 Immobilise if necessary.
 Post-operative
 Open dressing after 24 hours, to check for dislodgements of grafts
 Dressing finally removed after 4-7 days
 Phototherapy (PUVA/NB-UVB) every fortnightly for 2months, then
monthly, till complete pigmentation achieved

18. 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

19. Advantages Disadvantages
• Easiest, fastest, and
least expensive
method
• Can be performed
anywhere, on any site
(except angle of the
mouth)
• highest rate of adverse
effects
• Not suitable for larger
lesions as the pigment
achieved is usually not
uniform
• Phototherapy is always
necessary

20.  Introduction :
Thin split thickness skin grafts are harvested from the pigmented donor
area and transplanted at the recipient sites as continuous sheets of
tissue grafts.
 PRINCIPLE OF GRAFT UPTAKE
1. Graft uptake and adherence
2. Inosculation and graft revascularisation
3. Contracture
1.
SPLIT THICKNESS SKIN GRAFTS

21. • EQUIPMENTS
• Dermabrader – mechanical/ electrical
• Skin grafting equipment
• Straight artery forceps with razor blade
• Humpy’s skin gratfing knife
• Padget’s or Davol’s dermatome
• Graft spreading rods or spatula
• Non traumatising forceps
• Surgical glue (N- butyl 2-cyanoacrylate)
• Others : iris scissors, sterile petridish.

22. Procedure
DONOR SITE
Sites :
•Anterolateral aspect of thigh
•Gluteal area
•Arms
•Abdomen
1. Surgical preparation of site
2. Field block Anaesthesia
3. Donor site made taut by stretching
4. Graft harvested from donor site by Humpy’s knife/ razor blade with straight artery
forceps at 10-150 to obtain a thin, translucent uniform graft.
5. Put in sterile petri dish
6. Dressing- semiocclusive dressing heals fastest

23.  RECEPIENT SITE
1. Surgical preparation
2. Infilterative Anaesthesia with 1% lignocaine.
3. Dermabrade up to marked area till pinpoint bleeding appears
4. Achieve haemostasis, cover area with moist saline gauze
5. Place graft on abraded area with dermal side downwards
6. Spread graft using spatula, 3-5 mm beyond marked area
7. Fix graft with glue: N- Butyl 2- Cyanoacrylate
8. Wound dressing with adhesive dressing ( tegaderm) with immobilisation

24. POST OPERATIVE
1. Antibiotics for a week
2. Analgesics
3. Immobilisation if required
FOLLOWUP
• Dressing opened after 24 hrs, check for hematoma/ seroma
• Seroma if present is drained
• Wound redressed
• 2nd dressing removed after 10- 12 days

25. COMPLICATIONS
 Milia formation
 Scarring if graft is too thick
 Tire patch or stuck-on appearance
 perigraft halo
 Hyperpigmentation of the graft/Cosmetic mismatch

26. Advantages
1. Highest success rate
2. Large area can be
treated in one session
3. Rapid and uniform
repigmentation
4. Less time consuming
5. Difficult areas like
eyelids, areola, inner
canthus of the eyes ,
nipple can be treated
Disadvantages
1. Size of donor skin
should be 10-25% more
than recipient area
2. Risk over
hyperpigmentation on
exposed area
3. Scarring of donor area if
thicker grafts taken

27.  A technique when the pigmented epidermis is
harvested from the donor site by using suction to
raise a blister which is then transferred to vitiliginous
area
 PRINCIPLE- Cleavage between basal cells& basal
lamina (DEJ)
SUCTION BLISTER EPIDERMAL GRAFTING

28. Equipment
• Sterile disposable syringes (10/20cc & 50cc)
• 3 way connector and poly vinyl tubing
• Petroleum jelly
• 0.9% NaCl solution, 10 % povidone idodine & spirit swabs
• Dermabrader –manaul or electrical
• Iris forceps
• Jeweller’s forceps
• Graft spreading rods/spatula
• Sterile glass slides
• Surgical glue ( N – butyl 2 cyanoacrylate)
• Dressing materials

29. PROCEDURE
DONOR SITE
•Sites-
Flexor aspect of forearm, medial aspect of upper arm
Lateral aspect of thigh
• Surgical preparation of donor site
• Topical anaesthesia
• Blister is raised using syringe or suction pump with cups
• Base of syringe is applied over donor site
• 3 way connector is attached
• Assembly line- PV tubing,3 way connector,manometer,50cc syringe or suction pump
• Suction to create –ve pressure (-200 to -500mmHg)
contd.

30.  20 cc syringe with 3 way
connector is retained
 Single unilocular non
haemorrhagic blister (45 mins
– 3 hours)
 Deroofing the blister
 Roof of the blister is cut
 Roof is inverted onto a
glass slide
 Graft is cleaned and
spread
 Dressing – framycetin
tulle with dry gauze

31. RECIPIENT SITE
Transfer Of Graft
• Surgical preparation of recipient site
• Anaesthesia -1%lignocaine
• Dermabraded till minute bleeding spots are visible/ CO2 laser can be used
• Graft is placed with dermal side in contact with recipient area
• Graft are placed next to each other with overlapping of their borders so as not to leave
any raw surface uncovered
• At the periphery graft edges 1-2 mm beyond the dermabraded wound edge
• Surgical glue is applied followed by double layed framycetin tulle, moist gauze, sterile
gauze f/b elastocrepe bandage
• Immobilize if necessary

32.  Post operative
 Antibiotics + anti-inflammatory for 5-7 days
 Dressing is removed after 5-7 days
 Dressing removed slowly with downward pressure so as
to avoid tearing of the graft from its bed

33. COMPLICATIONS
Donor site: Hematoma/seroma
Infection
Recipient site: Graft rejection, graft displacement
Perigraft halo
Incomplete pigmentation

34. ADVANTAGES
• Simple , safe , inexpensive
procedure
• No scarring at donor site
• Faster repigmentation
• Good colour match-eyelids, lips,
areola
• Scar formation, cobble stoning,
thick margins, milia are less
• OPD procedure
DISADVANTAGES
• Time consuming
• Raising blister is painful
• Multiple sittings for large areas
• No immediate results
• Small grafts yielded at a time in a single
session
• Risk of failure of blister induction

35. FLIP- TOP PIGMENT TRANSPLANTATION
A technique in which graft is placed b/w a flap of epidermis & dermi
at recipient site
PROCEDURE
• A thin split thickness graft is harvested
• Graft is kept moist
• A similar flap of epidermis is raised at recipient site
• One end of epidermis is left in contact
• Flap is turned to expose dermal side
• Graft is placed in contact with dermis
• Flap is put back in position

36.  Cyanoacrylate glue applied
 Dressings
FOLLOW UP
 Dressing is removed after 1 wk
 Phototherapy
ADVANTAGES
 Flap acts as a biological dressing
 Excellent results

37. CELLULAR GRAFTS
 Transfer of epidermal cells that have been
disaggregated from the skin.
 TYPES –
1. NCES ( non cultured epidermal suspension)
2. NCE ORS Suspension ( non cultured extracted
outer root sheath suspension)
3. Cultured autologous melanocyte transfer

38. ADVANTAGES
 Smaller amount of donor tissue is needed
 Donor recipient ratio -1:8 -1:150
 Post op pain and morbidity less
 Immobilization needed is less
 More suitable for certain areas like finger tips

39. NON CULTURED EPIDERMAL
SUSPENSION
• Transplantation of autologous cultured and non-
cultured melanocytes which involves self suspension
without culture

40. Equipments
• Trypsin – EDTA solution of 0.25%
• Trypsin inhibitor
• Dulbecco’s Modified Eagle’s Medium(DMEM)
• Aerobic incubator
• diamond fraise dermabrader or CO2 laser
• Dermatome or suction apparatus
• Pasture pipette or calibrated micropipette
• Fine pointed forceps
• Centrifuged tubes and petridishes
• Collagen dressing

41. Procedure
 STEP 1 : PREPARATION OF CELL SUSPENSION
• STSG harvested under local anaesthesia
• graft placed in a petri dish containing 8ml 0.25% trypsin- EDTA solution
• Graft soaked completely in the solution, with epidermis facing upwards
• Incubated at 37deg C for 50 minutes
• Trypsin solution neutralised by adding 5 ml of 0.5% trypsin inhibitor
• Separation of epidermis from dermis, dermis discarded
• Cells transferred to a test tube and centrifuged for 5 mins to obtain pellet
rich in cells

42.  Test tube centrifugated for 6 mins at 1000rpm
 Epidermal cells is transferred to suitable medium (DMEM) in a test tube
 Supernatant part discarded, bottom part suspended in 1 ml insulin syrinGE
 STEP 2 : TRANSPLANTATION
 recipient area cleaned f/b local anesthesia with 2 % lignocaine
 Recipient area is abraded down to DEJ using diamond fraise dermabrader
 Cell suspension is poured over recipient area drop by drop
 The area is covered with transparent collagen film f/b dry gauze kept in
place with sterile transperent occlusive dressing

43.  Post – operative
 complete rest with no vigorous activities
 Antibiotics for 5 days
 NSAIDs for 3 days
 Dressing removed after 1 week
 Complete epithelisation takes 6-10 days
 Follow up at week 1 and 3 then at 3 month interval
 Phototherapy with PUVA can be initiated after 3 weeks
 Pigmentation first appears in 3-6 weeks, take 3-6 months for patched to
achieve maximum pigmentation

44. Disadvantages
• Complex procedure
Specific cell culture grade
biochemical and media
• Well equipped operating
room
• More expensive
• Training required
• Time consuming
 Smaller amount of donor
tissue is needed
 Donor recipient ratio -1:8 -
1:150
 Excellent texture and colour
matching
 No stuck on look
 Post op pain and morbidity
less
 More suitable for certain areas
like finger tips
Advantages

45.  The bulge area of the human hair follicle is found to
be niche of melanocytes stem cells, a quiescent cell
population, which acts as melanocytes reservoir.
 The stem cells can migrate into migrate into
epidermis and give rise to differentiating
melanocytes to produce pigmentation.
NON CULTURED EXTRACTED OUTER
ROOT SHEATH SUSPENSION

46. Procedure
 STEP 1 : FOLLICULAR UNIT EXTRACTION
 Donor site : occipital area
 Hair are trimmed to size 1-2mm
 Field block anesthesia given using 2 % lignociane with
adrenaline
 1mm punch of intact hair follicle taken and extracted with
hair follicle holding forceps
 Intact hair follicle collected in normal saline and
transferred to laboratory
 Dressing : mupirocin ointment and sterile cotton pads

47.  STEP 2 : PREPERATION OF CELL SUSPENSION
 Extracted hair follicles washed thrice under phosphate
buffered solution (PBS).
 Incubated in 0.25% trypsin with EDTA solution at 370 C for
30 minutes to prepare a single suspension
 In 15-20 mins cells from ORS start seperating and rest
are gently stroked after incubation to loosen cells
 Add trypsin inhibitor to inhibit for digestion of cells
 A cell suspension created f/b centifugation at 1000rpm for
5 mins
 Cell pellet resuspended in DMEM’s

48.  STEP 3 : TRANSPLANTATION
 Recipient area cleaned f/b local aneasthesia with 2 %
lignocaine
 Dermabrasion of recipient area till 5mm beyond the
margin of vitiliginous area ( to avoid depigmentary halo)
 Suspension is aspirated with pipette and spreaded
evenly over the recipient areaDressing: 5 layered,
collagen sheet, antibiotic containing paraffin gauze,
surgical cotton pad, thin transperent dressing film, elastic
adhesive bandage

49.  Post- operative
 Immobilize , Keep area clean and dry, Minimal
manipulation for 7 days
 Systemic antibiotics for 7 days
 Dressing removed at 7th day
 Phototherapy started to induce rapid repigmentation

50.  Advantages
 Follicular melanocytes -
 Follicular melanin have 1:1 to
1:5 ratio with keratinocytes
 Melanocytes are cyclically
active
 Melanocytes have more and
larger dendrites
 Melanosome are larger
 Minimally degraded by hair
cortex
 Relatively less susceptibility
to to immune destruction
Therefore relatively less amount
of donor area required for
transplant
 Disadvantages
 Laborious and tome
consuming
 Needs learning to
correctly extract
complete hair follicle
without transection

51. AUTOLOGOUS CULTURED MELANOCYTE
TRANSPLANTATION
• In vitro cultured melanocytes
• Donor to recipient ratio of >1:10( upto 1:60)
• Major advantage to cryo-preserve melanocytes.

52. Equipments
• Trypsin – EDTA solution of 0.25%
• Trypsin inhibitor
• Dulbecco’s Modified Eagle’s Medium(DMEM)/Nutrient mixture F-12
• Aerobic incubator
• diamond fraise dermabrader or CO2 laser
• Dermatome or suction apparatus
• Pasture pipette or calibrated micropipette
• Fine pointed forceps
• Centrifuged tubes and petridishes
• Collagen dressing

53. Procedure
 Step 1 : Collection Of Sample
 Surgical preperation
 EMLA( eutectic mixture of local anaethesia)
 Biopsy of normal pigmented area
 Graft collected in PBS and transported to laboratory
under ice
 Donor area dressed with sterile non-adherent
chlorhexidine gauze f/b sterile surgical pad f/b transparent
occlusive dressing

54.  Step 2: Processing Of The Graft
 Fat attached to graft is removed
 0.25% Trypsin- EDTA solution added, epidermal side
downwards
 Incubation at 40C overnight
 trypsin inhibitor added
 Trypsin inhiboitor removed f/b adding M2 medium added
with separation of epidermis from dermis and waste
tissue removed
 Centifugation at 1000rpm for 5 mins to obtain a pellet

55.  Pellet resuspended in 5ml M2 melanocyte medium and
transferred to a 75 or 150 cm2 culture flask containing M2
medium
 Maintained at 370 C in a humidified , 95% air, 5% CO2
atmosphere
 Medium changed every 3-4 days n checked for
contamination
 Culture done for 15-20 days

56.  Step 3 : Transplantation
 After removing culture medium from the falsk, trysin – EDTA
solution added, incubated for 5 mins
 Suspension then pipetted out, trypsin neutralised by trypsin
inhibitor
 Trypsin inhibitor pipetted out and suspension centifuged at
1000rpm for 5 mins
 Pellet resuspended in M2 medium
 Transplanted onto dermabraded recipient site
 Dressing: 5 layered, collagen sheet, antibiotic containing
paraffin gauze, surgical cotton pad, thin transperent dressing
film, elastic adhesive bandage

57.  Post- operative
 Immobilize , Keep area clean and dry, Minimal
manipulation for 7 days
 Systemic antibiotics for 7 days
 Dressing removed at 7th day
 Phototherapy started to induce rapid repigmentation

58. Advantage
 Cryopreservation of
melanocytes for future
 DR ratio high
 No. of melanocytes can be
expanded upto 100 times
 Large areas can be treated
with small donor area
Disadvantage
•Expensive
•Lab facilities required
•Still experimental

59. MICROPIGMENTATION
 Involves implanting small particles ( mostly iron oxide pigment into
the middle layer of dermis similar to the tattoo)
 Also known as PERMANENT COSMETICS.
 Useful for cosmetics camouflage of vitiligenous patch specially
involving mucosal & mucocutaneous areas

60.  INDICATIONS:
 Urgent pigment correction of the dipigmented patch
 Special sites like angle of mouth where graft retention is poor
 TATTOO PIGMENTS- autoclaved
• White titanium dioxide
• Red cinnabar, mercuric sulphate
• Black iron oxide
• Yellow cadmium sulphate
• Camel yellow iron oxide
• Light brown iron oxide
• Dark brown iron oxide

61. Procedure
 Informed consent
 Cleaning with normal saline
 Followed by tumescent anesthesia with 2% xylocaine
 Sterilized no.10 pony sized sewing needles
 Micropigmentation is done until the color matches the surrounding
skin
 Pressure given to stop bleeding
 Area clean with saline
Immediate side-effects : bleeding, hematoma

62. Advantage Disadvantage
 Help blend the color of vitiligo
to more closely that match
surrounding skin
 Breaks up the texture of vitiligo
skin by softening & flattening
 Blackening due to oxidation
 Photosensitisation
 Bleaching of pigment
 Fading of pigment over period
of time
 Reaction to tattoos

63. SURGICAL REMOVAL
 Followed by primary closure
 Practised in urgency to get rid of lesion
 Most common sites : small patch over the lip &
mucosal area

64. Therapeutic wounding
 Dermabrasion or wounding without subsequent graft procedures
 Suited for hairy areas & induces repigmentation by altering epidermal
cytokines milieu which stimulates active melanocytes in outer root sheath of
hairs
 Modalities
manual or motor dermabrasion
laser ablation by CO2 & Er :YAG laser
cryo surgery
chemical peeling with 88% phenol, TCA 30-50%, 5% 5-FU

65. OVERVIEW
TECHNIQUE ADVANTAGES
 MINIPUNCH
GRAFTING
INDICATION
acral areas
 Scarring
 Cobble stoning
 Results are not
immediate, needs
follow up
phototherapy for 2-3
months
DISADVANTAGES
 Simple, easy,
inexpensive,
OPD
procedure

66. OVERVIEW
TECHNIQUE ADVANTAGES
 SUCTION
BLISTER
GRAFTING
INDICATION
lips, eyelids
 Time consuming
 Yields only small
sized grafts
DISADVANTAGES
 No scarring,
 Good cosmetic
results
 Safe and
inexpensive
 No special
surgical skills
required

67. OVERVIEW
TECHNIQUE ADVANTAGES
 THIN SPLIT
THICKNESS
SKIN
GRAFTING
INDICATION
large areas
 Hyperpigmetation
and hypertrophy is
common
 Needs surgical
skills
 Donor healing may
be delayed.
DISADVANTAGES
 m/c
 Covers large
areas over a
short period
 Pigmentation is
uniform
 Systemic
PUVA not
required
 Difficult
areas(eyelids,
nipples,
areaola, inner
canthus of
eyes) can be
treated

68. OVERVIEW
TECHNIQUE ADVANTAGES
 AUTOLOGOU
S EPIDERMAL
CELL
SUSPENSION
INDICATION
All areas
 Lab facilities
required
 Takes 2-3 months
for complete
repigmentation
 Expensive
 Needs special
training
DISADVANTAGES
 Large areas
can be treated
in a single
session with
small donor
area
 Repigmentatio
n is uniform

69. OVERVIEW
TECHNIQUE ADVANTAGES
 CULTURED
MELANOCYT
E GRAFTING
INDICATION
all areas
 Expensive
 Lab facilities
required
 Still experimental
DISADVANTAGES
 No. of
melanocytes
can be
expanded upto
100 times
 Large areas
can be treated
with small
donor area

70. SUMMARY
AREA METHOD OF CHOICE
 Face
 Lips
Genitals
Eyelids
 Acral area(palms/soles)
 Other areas
 SBEG, NCES
 SBEG, NCES
 PUNCH GRAFTS
 STSG, NCES

71. Thank you.