2. 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
3. • 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.
4. • 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.
6. 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.
7.
8. • 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.
9. • 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
10. 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 method
High rate of success with very few preventable / manageable side effects
Can be performed anywhere, on any site (except angle of the mouth)
11.
12. 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.
13. • 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
16. • 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
17. • 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
18.
19. • 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
20. 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
21. 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
22. Harvesting a thin split thickness graft freehand
with a sterile razor blade mounted on a
Kocher's forceps
23. • 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
24. 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
28. CELL SEPARATION
• Sample is centrifuged at 2000rpm for 5
minutes
• Precipitant is a combination of keratinocytes
and melanocytes
• Precipitant is resuspended with DMEM/F12
