Vitiligo Surgeries

A PPT on vitiligo surgeries, both grafting & non-grafting techniques.

1. INTRODUCTION Vitiligo - common acquired depigmenting disorder HPE - Absence of melanocytes in epidermis Medical & physical therapies for treatment Surgery for resistant areas Objective - produce cosmetically acceptable repigmentation Principle - introduce melanocytes into the lesional skin

2. VITILIGO SURGERIES Choice depends on: Type of vitiligo Extent Site of lesions Availability of equipment Expertise of surgeon

3. TISSUE GRAFTS CELLULAR GRAFTS Minipunch graft (full thickness) Non-cultured cell suspensions – epidermal and ORS follicular Suction blister graft Cultured epidermal / melanocyte cell suspension Thin split thickness graft - Hair follicle grafts - GRAFTING TECHNIQUES

4. Micropigmentation (tattooing) Excision & closure Dermabrasion (therapeutic wounding) NON-GRAFTING TECHNIQUES

5. CRITERIA FOR PATIENT SELECTION Stable vitiligo No new patches Non-expanding patch Absent koebnerization

6. CRITERIA FOR PATIENT SELECTION (contd.) Test grafting

7. CRITERIA FOR PATIENT SELECTION (contd.) Preferrable Younger patients Face, trunk and proximal extremities

8. CONTRAINDICATIONS Unrealistic expectations Unstable vitiligo Bleeding diathesis Severe liver disease

9. PRE-OP INVESTIGATIONS Routine investigations Hemoglobin Blood counts Bleeding and clotting time ECG in elderly

10. CHOICE OF SURGERY TYPE OF LESION TYPE OF SURGERY Small irregular areas Acral areas, palms, soles Minipunch grafting Small areas, face, Lips, eye lids, genitals Suction blister grafting Large areas, abdomen, legs Eyelids, areola, nipple, genitals Thin split thickness skin grafting All areas Autologous noncultured epidermal cell suspension All areas Cultured melanocyte grafting

11. MINIPUNCH GRAFT

12. COMPLICATIONS

13. MINIPUNCH GRAFT SUCTION BLISTER GRAFTING Ultrathin split thickness skin grafts of pure epidermis Indicated for small areas, face, lips, eye lids, genitals.

14. DONOR SITE

15. HARVESTING OF GRAFT Periphery of the blister is cut with a curved iris scissors. One edge of a sterile glass slide, smeared with an antibiotic ointment, is kept near the blister. With forceps, the graft is lifted gently and everted on the glass slide, with the dermal side facing upwards. Fine gauze or acetate sheets are alternative graft carriers .

16. RECEPIENT SITE

17. With sterile moist gauze, the graft is pressed firmly to remove any serous collection underneath graft. Then pressure dressing is done with double layer framycetin tulle, moist gauze, followed sterile gauze and elastocrepe bandage. Donor area is dressed with dry sterile pads. The part is immobilized if necessary and is given a course of antibiotics and anti-inflammatory drugs for 5–7 days.

18. THIN SPLIT THICKNESS GRAFT Most commonly practiced and also the most successful Simple and cost effective procedure Covers large areas in a single sitting Thickness of the graft ranges from 0.1 mm to 0.7 mm Large areas, abdomen, legs, eyelids, areola, nipple, genitals

19. DONOR SITE

20. RECEPIENT SITE

21. First dressing change is done preferably after 24 hours, to check for formation of any seroma or hematoma Dressing is subsequently changed after 1 week by which time the graft is usually taken up and healing is complete. Donor site dressing is also changed after 1 week.

22. ADVANTAGES & DISADVANTAGES Pigmentation is uniform and cobblestoning , which is common with minigrafting , does not occur. Difficult areas such as the eyelids, inner canthus of eyes, areola, nipples, and genitals are easier to treat. Color and texture matching can take time. When large areas need to be covered, limitation of the donor site is a disadvantage.

23. NON-CULTURED EPIDERMAL CELL SUSPENSION Transplantation of noncultured melanocytes/ keratinocytes suspension has the advantage that cell culture is not needed. Skin harvesting from the donor area, cell separation and application of melanocytes can all be undertaken in a single 3 hour procedure.

24. NON-CULTURED FOLLICULAR ORS SUSPENSION Repigmentation in depigmented lesions of vitiligo often starts around the follicles. The bulge area of the human hair follicle is found to be a niche of epidermal and melanocyte stem cells. Inactive melanocytes in the ORS of the hair follicle divide, proliferate and mature during the process of repigmentation They can potentially be harvested and cultivated for therapeutic purposes in vitiligo.

25. DMEM - 4 mM L-glutamine, 4500 mg/L glucose, 1 mM sodium pyruvate, and 1500 mg/L sodium bicarbonate

26. ADVANTAGES Advantage over intact hair follicle transplant – Minimal risk of scarring Good cosmetic acceptability on non‐hair‐ bearing skin as hair follicles are not transplanted Larger patches of vitiligo can be covered

27. ADVANTAGES Advantage over non-cultured epidermal suspension – Donor site is hidden in the hairy scalp (no need large split‐thickness skin grafts from the buttocks or thighs) Donor site does not require postoperative dressing Follicular cell suspension may contain a higher concentration of melanocytes and melanocyte stem cells compared to epidermal cell suspension

28. DISADVANTAGES FUE procedure is time‐consuming and requires skills Cell separation and the preparation of suspension is also slightly more difficult and time‐consuming Costly

29. CULTURED MELANOCYTE TRANSPLANTATION Cultured melanocytes have a donor to recipient area of around 1:100 and hence a very small donor graft is adequate to cover a very large area. Donor skin has variously been obtained using biopsy (punch biopsy/split thickness skin graft/full thickness skin grafts) or suction/ cryoinduced blisters.

30. Several methods have been used to prepare the recipient site including dermabrasion, suction/ cryoinduced blisters, or lasers ( Er:YAG or CO2). Relatively new technique – no standardization

31. AUTOLOGOUS NONCULTURED EPIDERMAL CELL SUSPENSION ADVANTAGES DISADVANTAGES Larger areas can be treated at a single session with small donor skin Laboratory facilities are required Repigmentation is uniform Pigmentation takes up to 2–3 months Expensive technique Needs special training

32. CULTURED MELANOCYTE GRAFTING ADVANTAGES DISADVANTAGES The melanocytes can be expanded up to 100 times by culture methods; hence large areas can be treated in a single session Expensive technique requiring a fully equipped tissue culture laboratory with experienced staff Long term safety of culture media and carcinogenic potential need further evaluation Still experimental

33. Micropigmentation (tattooing) Excision & closure Dermabrasion (therapeutic wounding) NON-GRAFTING TECHNIQUES

34. REFERENCES ACSI Textbook of Cutaneous and Aesthetic Surgery Vitiligo - Medical and Surgical Treatment (Wiley Blackwell, 2018) Mysore, V., & Salim, T. (2009). Cellular grafts in management of leucoderma . Indian journal of dermatology, 54(2), 142–149.