vitiligo surgery white patches dermatologist residency

1. Vitiligo Surgery – Part 2
- Dr Mariya Kharodawala
Resident doctor - 2

2. Surgical
treatment
of vitiligo
Autologous grafting
techniques
Tissue grafts
Mini punch grafting
Split thickness
grafts
Suction blisters
Hair follicle grafts
Cellular
grafts
Non cultured
Cultured
Non grafting techniques/
therapeutic wounding
Laser ,
Micropigmentation
etc

3. Autologous Non Cultured melanocyte keratinocyte
transplantation ( epidermal suspension-NCES)
• Indication :
• Stable vitiligo
• Secondary leucoderma due to burns / chemical injury
• Contraindication :
• Active vitiligo
• Keloidal tendency

4. • Procedure :
1) Shaving the recipient and donor area
Donor area = 1/5th to 1/10th of recipient area
2) Donor area :-
Site – thigh or gluteal region
Preparation of site by painting and draping and marking of site
3) Infiltration of 1% xylocaine – deep dermal and
subcutaneous to achieve a flat surface

5. • 4) adjust the cutting edge of
knife to take thin graft
use either Watson modification of
Humby knife or a blade mounted
on the straight artery forceps
5) Hold the cutting blade parallel
to the skin and move the knife
tangentially to obtain 0.2-0.3mm
translucent split thickness graft of
desired length.
- Skin should be stretched tightly
by the assistant

6. • 6) transfer the grafts to the petri dish A
containing 10 to 12ml of W/v 0.25% trypsin
and 0.2% EDTA solution
• Place the grafts with dermal side down and
epidermal side up so as to soak them in the
solution
• 7) achieve hemostasis by pressure and
dress the donor site with povidone iodine /
framycetin gauze pads

7. • Preparation of cell suspension:
• Put the petri dish A containing grafts in the
incubator at 37 C for 45 to 90 minutes
• Take a new petri dish B and add to it trypsin
inhibitor and dulbelcos modified eagle media
• Transfer the constituents from petri dish A to
petri dish B. Discard Petri dish A and its left
over contents.
• Separate the epidermis from the dermis with
the help of forceps

8. • Transfer the separated dermal pieces to test tube
A containing 5ml of DMEM/F12 media, leaving
behind epidermal sheets in Petri dish B
• Scrape the dermal surface (basal layer containing
keratinocyte and melanocytes) for the epidermal
sheet .
• Leave the scraped dermal contents in the petri
dish B and transfer the remains to the test tube A
• Lastly transfer all the contents of the Petri dish B
to the fresh test tube B [ trypsin inhibitors, DMEM,
basal layers]
• Mix the contents of test tube A (dermal pieces)
either by putting in VORTEX or by rotating rapidly
between two palms.
• Discard the floating dermal pieces and transfer the
solution to test tube B
• Centrifuge the test tubes B at 1200 rpm for 6
minutes

9. Discard the supernatant and keep the
dark brownish pellet, at the bottom of
the tubes.
Resuspend the pellet in DMEM to
make the total suspension of 1ml
Preparation of viscous suspension/
paste
Add 1ml of 1% hyaluronic acid to the
test tube to make the suspension
Aspirate the suspension in the
tuberculin syringe

10. • Recipient site: vitiligenous area
1. Clean the site and apply EMLA / infiltrate with 1% xylocaine
2. Dermabrade the site upto dermo epidermal junction with a diamond fraise.
Ideal level is when the pin point bleeding spots appear. Cover the denuded area
with normal saline solution after achieving hemostastis
3. Apply the cell suspension aspirated with 1ml tuberculin syringe evenly on the
denuded area and spread with spatula
4. Cover the part with dry collagen dressing , sofratulle and roller bandage
pressure dressing.
patient is advised to restrict the movements post operatively for 10 days .

12. • Post op care:
1. Continue oral antibiotics and anti inflammatory drugs for 10 – 14
days
2. Dressing changed after one week. Removed after 14 days
3. Alternate day sun exposure / photo therapy for accelerating the
repigmentation

13. • Area appears bright pink immediately on removal of dressing.
• Earliest post op pigmentation are seen after 3 weeks. Complete
pigmentation within 3 to 6 months.
• Donor area heals without scarring
• Complication :
Secondary infection , occasional scarring, milia, koebnerisation

14. • Advantages :
1. 10 fold area can be treated at once . Average is 300 cm2
2. Excellent cosmetic results
3. Safe and simple OPD procedure
4. Multiple areas can be treated simultaneously
Disadvantages:
1. Setup required : incubators, dermabraders, culture medias.

15. • Modifications of the procedure:
- Use of CO2 laser for dermabrasion
- Use of patients own serum instead of hyaluronic acid to increase the
viscosity of suspension
- Omission of use of DMEM and trypsin inhibitors
• Apart from vitiligo NCES used in:
- Piebaldism
- Nevus depigmentosus

16. Autologous cultured melanocyte transplantation
• Aim : replace melanocyte that are missing in achromic areas with
melanocyte obtained from a normally pigmented donor site.
• Cultured cells are useful in all anatomical areas including troublesome
location such as hairy areas, or those with excessive movements like
joints, eyelids and corners of ones mouth.
• However, repeated mechanical traumas promote melanocytic
destruction.
• When vitiligo is associated with hypothyroidism it is less likely to
respond to transplantation procedure.

17. Types of cultured skin grafts
CEA- K &M as sheets / cell suspension
CEA – M as suspension/ scaffolds
CE allograft - fetal skin/donors/ cadaver
Composite graft- CEA + allodermis / CEA + synthetic
dermis

18. Autologous cultured melanocyte
transplantation
Two stage
technique
Stage 1 – donor
site
Harvesting the
graft
Transport to lab Preparation of
grafts
Stage 2 –
recipient site
Placement of
grafts

19. Procedure :
• Stage 1
Donor area : medial aspect of thigh or buttock
1. Preparation of site and 2% lignocaine infiltration
2. split thickness skin grafts upto deep dermis harvested by 6mm
biopsy punch
3. hemostatis achieved and wound dressed
Transport of grafts to specialized tissue culture laboratory in the media
containing antifungals and antibiotics.

20. • Processing of grafts in tissue culture laboratory (TCL):
• TCL – tissue engineering dept of Reliance life Science
Name of technique : Rheinwald Green Technique
1. Incubation of specimen in dispase solution
2. Trimming of epidermis with scissor
3. Epidermal cells released in trypsin EDTA sol
Ution to obtain single cell suspension containing
melanocytes
4. Then it is suspended in melanocyte media

21. •Melanocyte media :
Dulbelco modification of Eagle’s medium:
Amino acids
L- glutaminase
fetal bovine serum
Cholera toxin
Hydrocortisone
Murine fibroblasts
For obtaining pure culture of melanocytes, melanocyte promoters and
keratinocyte inhibitors are added .
Promoters: TPA – tetra deconyl phorbol acetate , isobutyl methyl xanthine,
placental extracts and fibroblast growth factors
Inhibitors : high pH 7.2 of fibroblast, addition of cholera toxin

22. • Duration of melanocyte culture : 4 to 6 weeks
• RELIDERM grafts : prepared by seeding
cultured cells 1-2 x 104 / cm2 on polylactic acid
films / amniotic membrane
• This grafts are transported in the media
enriched with CO2

23. Stage 2
• Preparation of recipient site: cleaning,
marking and infiltration by LA
• Area is dermabraded till pin point
bleeding
• Reliderm graft is lifted and placed om
dermabraded area
• Dressing of site
• Restriction of movement for 2 – 3 days
• Dressing removed after 8-10 days
• Daily exposure to sunlight for 15
minutes
• Uniform pigmentation is achieved
within 3 months

24. • Advantages :
1. large areas can be treated (however areas more than 500cm2 are
not suitable)
2. Excellent cosmetic results
3. Single TCL can supply many centres
Disadvantages:
1. TCLs are needed
2. expensive
3. Two stage procedure
https://youtu.be/UEWFrcETYdQ

25. Informed consent form

26. Hair follicle grafting : FUT, FUE and BHT
• Single hair transplant to repigment vitiligo patches was introduced in 1998
• Principle : a pool of undifferentiated melanocyte stem cells in the hair can
replenish the pool of differentiated melanocytes.
• These stem cells are maintained in the niche micro environment in the “bulge”
area where arrector pili muscle attaches with the hair
• Stable vitiligo & vitiligo patch having leucotrichia : main indication
• Leucotrichial hair can be removed by thermolysis before transplanting hairs on
vitiligo patch
• There are many techniques and modifications for the following procedure.

27. • Melanoblast – precursor of melanocytes,
originate from neural crest cells.
• Two forms of melanocytes in the hair follicle:
1. Melanotic : contains pigmentary granules
which react with masson silver nitrate and
dopa
2. Amelanotic : devoid of pigmentary granules
and biochemically inactive
The epidermal and follicular melanocyte are two
distinct population and might be transferred from
one compartment to other when activated

28. • In normal individuals, repigmentation of epidermis from regeneration
of melanocytes in the amelantoic zone of hair follicle as melanocytes
are seldom seen in phase of division in melanotic zones.
• Whenever there is a stimulus induced by vibrapuncture , blistering or
by dermabrasion the melanotic melanocytes of the hair follicle
migrate towards the epidermis.
• On reaching the upper part of the hair follicle, they first become
melanotic then hyperplastic and there after migrate to the epidermis

29. • Technique :
Step 1 : Surgical preparation of donor site .
Mainly occiput.
Elliptical incison of 2-3 cm is kept and a strip graft is harvested.
Step 2: Removed donor scalp is washed with normal saline and cut into segments. Each segment is
divided into many single hairs
Step 3: single hairs are placed into the recipient area with the help of hair transplanter.
In follicular unit extraction, single hair is extracted as opposed to a strip of hairs in transplantation.

30. •Appearance and spread of the pigment:
Usually appears on the vitiligo patch by 4th or 5th week after
single hair grafting.
Although there is delay in pigmentation, the color usually
matches with the surrounding skin.
The diameter of pigment spreading is 5 to 12mm per hair
transplant. Therefore the distance between the hair graft is
minimally 5 and maximally 12mm respectively.
N
https://youtu.be/qSyMMHRu5yI

31. • Advantages :
1. High success rate of repigmentation
2. The grafted hair in recipient patch is relatively spared from a resurgent
autoimmune attack because of immune privilege
3. No risk of vitiligo at the donor site
4. Risk of cobblestoning is quite low
Disadvantages:
1. Cannot be performed on lesions of glabrous skin and mucous membrane
2. Time consuming procedure

32. Lesser known techniques:
• 1) Jodhpur technique
• 2) Eyelash transplantation for eyelash leukotrichia
• 3) Flip top technique
• 4) Ultrasonic abrasion and seed grafts for vitiligo

33. Jodhpur technique

34. Jodhpur technique with keratinocyte
melanocyte cell suspension
• Kacchawa and kalla conceptualized jodhpur technique based on their
observation in performing dermabrasion on acne scarred facial skin
• During the procedure they experienced macroscopic skin particles
formed by rotatory motion of the fraise abrading the skin surface
spatter on their face which they thought could be used as grafting
material with presumption of prospective presence of melanocyte in it .

35. • Technique:
Donor area: anterior/ lateral aspect of thigh.
1) Surgical preparation and local anaesthesia.
2) Stretching of donor area to make it taut.
3) Debulking of epidermis:
Use disc diamond fraise endpiece of dermabrader.
Establish the peripheral border of donor area, by smooth strokes along the marked line.
Roll the fraise all over the donor area 2-3 times
Sequentially discard the uppermost stratum corneum layer of epidermis. Clinically visible
as powdery white particulate discoloration due to entrapment of air and refraction of
light through the separated cells of superficial epidermis.

36. • 4) lubricate the superficially dermabraded area with 2% mupirocin ointment. This
would aid in entrapping the epidermal particles that separate during the subsequent
process of superficial dermabrasion.
• With disc siamonf fraise dermabrade superficially with gentle parallel strokes till there
is disappearance of pigment and appearance of multiple tiny punctate bleeding points
with high field density.
• Just before terminating the dermabrasion, rotate the handpiece clockwise in
sequential manner to blend the mupirocin with abraded paticles to make the paste
• Collect this paste with a spatula or graft spreader and transfer it to dermabraded
recipient site.
• Hemostasis

37. • Recipient area:
• Surgical preparation and local anesthesia
Dermabrade the recipient area with diamond fraise disc till pinpoint bleeding
occurs. Cover the denuded area with gauze pieces moistened with normal saline.
Transfer the paste of epidermal particles obtained from the donor area evenly on
the dermabraded denuded area and spread uniformly all over the surface with
spatula.
Cover the area with collagen dressing it with tegaderm transparent dressing.
Patient is allowed to go after immobilization of 30 minutes.

38. • Post operative course :
Recipient site: brown black dried crusted sheet partially attached and partially
peeled off from the site is seen immediately on removal of dressing that falls off
over next 3-5 days to leave behind an erythematous achromic patch.
Earliest diffuse pigmentation is noticed 4 to 6 weeks post surgery.
Complete uniform pigmentation takes place in 16 to 20 weeks.
Donor site heals by secondary intention with PIH without scarring.
Oral / local steroids , topical tacrolimus to accelerate repigmentation can be
used if pigment spread is sluggish

39. To be continued….
• Ultrasonic abrasion and seed grafts for vitiligo
• Flip flop technique
• Non surgical methods:
• Micropigmentation