2. Introduction
• It is a commonly acquired depigmentary disorder characterized by
depigmented macules with leukotrichia and histologically by absence
or near absence of functional melanocytes in the affected area.
• Surgical methods become important in cases where medical therapy
fails to cause repigmentation.
3. Choice of surgical treatment depends on the
following
1. Type of vitiligo- It can be done for all types especially those that do
not respond to medical therapy provided the disease is stable.
2. Extent of vitiligo- Segmental vitiligo, Non segmental vitiligo
involving <30% BSA(Immunologically stable).
3. Site of the lesion- Acral lesions do not respond well to surgical
interventions. Lesions involving lips and eyelids, extra precision
should be exercised due to cosmetic and anatomical importance of
these sites.
4. • 4. Stability-
a. Duration of stability- No new lesions, no progression to existing
lesions and absence of koebner phenomenon during past 1 year
b. Lesion versus disease stability- Lesion stability is more important
than disease stability
c. Cellular stability- Higher percentage of cytotoxic CD8+ T-Cell count
in the lesion skin is associated with failure of melanocyte
transplantation.
5. 5. Test for stability
A. Test grafting or mini graft test-
-Place 6-8 test punch graft(1-1.2 mm) within a vitiligo lesion
- Dressing is removed after 2 weeks and is followed by exposure to
sun light for 15 min daily/NB-UVB for a period of 3 months.
- Test site visualized under wood’s lamp to assess for pigmentation
spread.
- The patient is deemed fit for surgical intervention if there is a
unequivocal pigment spread 1 mm beyond the margin of the
implanted grafts
6. B. Vitiligo disease activity score(VIDA)- A low VIDA score(less than or
equal to zero) indicates less activity hence a patient is considerd fit
for vitiligo surgery.
7. Basic principle of surgical treatment
• To achieve cosmetically acceptable repigmentation of the vitiliginous
area by transplantation of autologous melanocytes from unaffected
pigmented skin or hair follicle of the lesional skin.
• It cannot stop the progression of the disease and is indicated for
resistant, stable vitiligo that does not show adequate response to
medical therapy.
8. Contraindications
• Unstable disease
• Active infection at recipient or donor site
• Active heroes simplex infection when operating on lips and perioral
area
• Bleeding disorder
• Keloidal or hypertrophic scar tendency
• Unrealistic expectations
10. Miniature punch grafting
Principle- Transfer of circular pieces or punches of skin tissues from
the donor area into similar shaped pits made on recipient’s
skin.
Instruments- 1.0-1.5 mm punches, graft-holding or jeweler’s forceps,
curved scissors, petri dish, saline soaks and dry-
sterilized gauze pieces, antibiotic coated dressing and
pressure dressing.
11. Procedure-
• Infiltration of the recipient area with 1% or 2% lignocaine
solution both in the subcutaneous and intradermal planes.
• Once adequate anesthesia obtained,1-1.5 mm diameter
punches or chambers are made either manually or with
motorized punches scored up to reticular dermis, first along
the outer border of the recipient area 5-10 mm apart.
• After treating the outer border, similar punch holes are
created throughout the recipient area in such manner that
the individual punches are located 5-10 mm from another
one.
12. • Then similar sized punch graft using 1-1.5 mm punches from the
donor area after infiltrating with a local anesthetic solution.
• The chosen donor site usually the gluteal area, thighs, upper arm or
retroauricular area.
• Grafts placed directly to the recipient chamber one by one.
• Care is taken that the grafts are not crushed or placed upside down.
• The recipient skin then covered with nonadherent antibiotic coated
sterilized gauze, followed by saline-soaked gauze pieces and a
pressure dressing.
• The dressing is removed on the 7th or 8th day of the procedure after
which the recipient skin can be trated with PUVAsol, topical steroids
or even NB-UVB.
13. Complications-
A. Donor site-
- Hypertrophic scar
- Kobner’s phenomenon with the development of fresh vitiligo lesions
B. Recipient site-
- Cobblestone appearance
- Polka dot appearance
- Depigmentation of the graft
- Perigraft halo
- Others- Graft rejection/Keloidal or hypertrophic scaring/variegated
appearance with a color mismatch at the recipient site.
14.
15.
16.
17. • Advantages-
-Safe and simple technique for patients with stable vitiligo involving only small
areas of skin up to 5% of surface area.
-Considered to be the easiest, fastest, and least expensive
-High rate of success
-Very few preventable or manageable side effects
-Motorized punches allow harvesting more grafts without exerting pressure.
-The procedure can be performed on difficult to treat areas such as on fingertips,
toes, areolae and palms and sole
18. • Disadvantages-
-Incidence of adverse effects is highest.
-Not suitable for large areas as the pigmentation achived is usually not
uniform.
19. Suction blister grafting
Principle-
• The differentiation and development of epidermal cells are regulated
by the dermis.
• It follow the concept of donor dominance. That is, the portion of the
dermis in the graft tends to have an influence over the epidermal
morphogenesis and differentiation.
• In suction blister grafting the cleavage in suction blister takes place
between the base of the basal cell and basal lamina of the basement
mambrane.
20. Instruments-
• syringes (10ml, 20ml and 50ml), 3-way canula and polyvinyl tubing,
petrollium jelly, a dermabrader,1% xylocaine vial or topical anesthetic
cream, 10% povidine-iodine, spirit swab, sterile glass slides, iris
scissors, jeweller’s forceps, graft spreading rods and spatula, sterile
glass slides, surgical glue (N-butyl 2-cyanoacrylate), surgical dressing
material.
21. • Procedure-
1. Preparation to the donor site-
- Site for suction blister formation is inner thigh, medial aspect of
forearm, arm, abdomen, buttocks and anterolateral aspect of thigh.
2. Suction application and blister induction-
- Blister may be raised using syringes or suction pump and suction cups
or a negative pressure cutaneous suction chamber.
- Most commonly used method for blister formation is by using
syringes. In this with the help of suction -300 to -400 mmhg negative
pressure is achieved.
-Suction blister induction usually takes 2-3 hrs.
-A single, unilocular, nonhemorrhagic blister is the best result.
22.
23.
24. Several factors can affect suction blister induction time(SBIT)
I. Diameter of the suction syringe or cup
II. Site of suction blistering
III. Age and gender of the patient
IV. Gradient of negative pressure
V. Temperature of the suction area
VI. Pathological variation
VII. Intradermal injection of saline or anesthetic solution
VIII.Pretreatment with phototherapy or photochemotherapy.
25. 3. Deroofing the blister-
- Once the blister well-formed, the roofs of the blister are gentaly cut
using iris scissors.
- The roofs are inverted into a glass slide such that the dermal side are
faces upward.
4. Transfer of graft-
- The vitiliginous area is dermabraded using a manual or monitorized
dermabrasion using diamond burr till multiple pinpoint bleeding
spots are visible.
- The suction blister grafts are then placed such that the dermal side of
the graft is now in contact with the dermabraded area.
- At the periphery, the graft edges should extend 1-2mm beyond the
dermabraded wound edge. By firm pressure excudate underneath the
graft is removed and surgical glue is applied along the free and
overlapped edges of the graft.
26.
27. • Modifiction in resipient site prepration
-Liquied nitrogen freezing, suction blistering, co2 laser dermabrasion and
Er:YAG laser dermabrasion have been also used.
• Follow up
-The dressing over the recipient site is left on for 8 days.
-The patient may be started on NB-UVB, PUVA or PUVAsol after 2 weeks.
28.
29. Complications-
I. Donor site-
-Pain during blister formation and harvesting
-Koebner’s phenomenon
II. Recipient site
-Hyperpigmentation and incomplete pigmentation
-Perigraft halo
-Infections, hematoma, ecchymosis, wrinkling, displacement of
graft, graft rejection
