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| EDITORIAL |
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| Year : 2016 | Volume
: 3
| Issue : 2 | Page : 61-62 |
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Evolution of vitiligo surgery
Sanjeev V Mulekar MD
National Center for Vitiligo and Psoriasis, Riyadh, Saudi Arabia
| Date of Web Publication | 27-Dec-2016 |
Correspondence Address:
Dr. Sanjeev V Mulekar
National Center for Vitiligo and Psoriasis, Post Box 300320, Riyadh 11372, Saudi Arabia
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2349-5847.196292
How to cite this article:
Mulekar SV. Evolution of vitiligo surgery. Pigment Int 2016;3:61-2 |
Vitiligo is a destructive disease of possible autoimmune pathogenesis, which is characterized by the disappearance of melanocytes by an unknown mechanism. Its natural course is unpredictable with periods of progression and remission. The aim of medical therapies is to prevent destruction of melanocytes and stimulate residual melanocytes. In the absence of medical treatment that can prevent destruction of melanocytes for a prolonged period without side effects and inability of stimulating melanocyte multiplication and migration in the absence of its reservoir, surgical therapies remain the only option to replace missing melanocytes. Normally, pigmented tissue (tissue grafting) was the obvious choice.
| Skin Grafting | |  |
Vitiligo patches were treated with Thiersch’s skin graft by Behl, who reported excellent repigmentation in 70% of the 107 patients. Scarring and infection were the most common side effects.[1] Usually, surgeons prefer this method; moreover, this method appears to produce the highest success rate.[2] Milia were observed most commonly, followed by shrinkage of margins, color mismatch, thick margins, etc.
| Suction Blister Grafting | | |
Other sources such as epidermis obtained by suction blisters were explored to cover achromic areas to avoid scarring of donor site.[3] It takes about 2 h to induce blisters. A few modifications, such as intradermal injections of normal saline, application of heat, increase of negative pressure by 100 mmHg at the time of appearance of small vesicles, and choosing donor sites over major trochanter, have been suggested to reduce blister induction time.[4]
| Punch or Minigrafting | | |
Falabella used full thickness biopsy specimens as a source of melanocytes to treat leukoderma and segmental vitiligo, described as autologous minigrafting.[5] Obtaining grafts 0.5 mm larger in diameter than the recipient pits,[6] trimming of excess adipose tissue from the bottom of grafts,[7] using 1 or 1.2 mm grafts,[8] and making perforation holes approximately 1 mm deeper in thickness of grafts[9] are helpful to reduce or eliminate cobble-stoning effect, which is most common with this procedure.
These tissue-grafting methods were effective, easy, and inexpensive, and hence are being widely practiced by dermatologists, especially in South Asia. However, it was realized that it was difficult to treat certain anatomic locations such as glans penis, joints, and eyelids due to practical issues to immobilize these sites, and larger areas required multiple sessions. In addition, these techniques were time consuming and were associated with scarring and cobble stone effect.[2] In spite of several modifications, large areas, time required to complete one session, and sites that are difficult to treat remain the major concerns.
| Cellular Grafting | | |
A paradigm shift in surgical methodology was brought in by Prof. Lerner when he reported successful repigmentation in one patient of piebaldism treated with cultured melanocyte transplantation.[10] However, carcinogenic potential of tetradecanoylphorbol-13-acetate and phorbol esters, which were used in culture media, was a concern. Soon, cultured techniques were modified and melanocytes were cultured without the use of carcinogenic factors.[11] Cocultures of melanocytes and keratinocytes and cultured epidermis with melanocytes were used successfully to treat vitiligo lesions.[8],[12]
These techniques had a potential to treat larger areas, without adverse effects associated with tissue grafting methods, but were expensive, and required special laboratories and two visits of 3 weeks apart, thus making it time consuming. To reduce the cost and time duration, Gauthier attempted autologous grafting of depigmented lesions with noncultured melanocyte suspension.[13] Still, it was a 2-day procedure and involved preparation of donor and recipient sites by blister formation, which was painful and unpredictable. The noncultured technique was simpler but was not significantly cheaper because it required special laboratory for cell processing. This procedure was a departure from previous established ones, as it used separated cell suspension as a source of melanocytes compared to tissue source. Various modifications have made noncultured cellular transplantation easier, cheaper, and more effective. Olsson and Juhlin prepared recipient area with dermabrasion with donor:recipient ratio of 1:10,[14] van Geel et al. added hyaluronic acid to increase the viscosity of suspension,[15] and Mulekar et al. established the procedure in one room with cell separation performed on a clean bench, eliminated the use of trypsin inhibitor, and used sodium lactate as vehicle in cell suspension.[16],[17]On the basis of complicity of the technique, intensity of the training and cost of the noncultured melanocyte#8211;keratinocyte transplantation procedure are more demanding than tissue grafting techniques but less demanding than cultured cellular transplantation technique. It is a daycare procedure, can treat large areas from smaller donor skin, gives much better color matching, does not require immobilization and postoperative phototherapy, and has much less incidence of adverse effects. Thus, it occupies a place in between tissue grafting and cultured methods. However, there are a few lacunae in this procedure, especially unexpected failure to repigment completely or partially, and color mismatch in a few cases. Relationship of response to total area treated in one session, dilution of suspension, appropriate vehicle to prepare cell suspension, and effect of anesthesia on repigmentation need further exploration.
Though these surgical treatment modalities are a step forward in the management of vitiligo, there is a long way to go to achieve the most satisfactory treatment.
| References | | |
| 1. | Behl PN. Treatment of vitiligo with homologous thin Thiersch’s skin grafts. Curr Med Pract 1964;8:218-21.  |
| 2. | Njoo MD, Westerhof W, Bos D, Bassuyt PM. A systematic review of autologous transplantation methods in vitiligo. Arch Dermatol 1998;134:1543-9. |
| 3. | Falabella R. Epidermal grafting. An original technique and its application in achromic and granulating areas. Arch Dermatol 1971;104:592-600. |
| 4. | Gupta S, Shroff S, Gupta S. Modified technique of suction blistering for epidermal grafting in vitiligo. Int J Dermatol 1999;38:306-9. |
| 5. | Falabella R. Repigmentation of segmental vitiligo by autologous minigrafting. J Am Acad Dermatol 1983;9:514-21. |
| 6. | Savant SS. Autologous miniature punch skin grafting in stable vitiligo. Indian J Dermatol Venereol Leprol 1992;58:310-4.  |
| 7. | Mutalik S, Ginzberg A. Surgical management of stable vitiligo: A review with personal experience. Dermatol Surg 2000;26:248-54. |
| 8. | Falabella R, Barona MI. Update on skin repigmentation therapies in vitiligo. Pigment Cell Melanoma Res 2008;22:42-65. |
| 9. | Boersma BR, Westerhof W, Bos JD. Repigmentation in vitiligo vulgaris by autologous minigrafting: Results in nineteen patients. J Am Acad Dermatol 1995;33:990-5. |
| 10. | Lerner AB, Halaban R, Klaus SN, Moellmann GE. Transplantation of human melanocytes. J Invest Dermatol 1987;89:219-24. |
| 11. | Chen YF, Yang PY, Hu DN, Kuo FS, Hung CS, Hung CM. Treatment of vitiligo by transplantation of cultured pure melanocyte suspension: Analysis of 120 cases. J Am Acad Dermatol 2004;51:68-74. |
| 12. | Falabella R. Surgical approaches for stable vitiligo. Dermatol Surg 2005;31:1277-84. |
| 13. | Gauthier Y, Surleve-Bazeille JE. Autologous grafting with noncultured melanocytes: A simplified method for treatment of depigmented lesions. J Am Acad Dermatol 1992;26:191-4. |
| 14. | Olsson MJ, Juhlin L. Leukoderma treated by transplantation of a basal layer enriched suspension. Br J Dermatol 1998;138:644-8. |
| 15. | van Geel N, Ongenae K, De Mill M, Naeyaert JM. Modified technique of autologous noncultured epidermal cell transplantation for repigmenting vitiligo: A pilot study. Dermatol Surg 2001;27:873-6. |
| 16. | Mulekar SV. Long-term follow-up study of segmental and focal vitiligo treated by autologous, noncultured melanocyte-keratinocyte cell transplantation. Arch Dermatol 2004;140:1211-5. |
| 17. | Mulekar SV, Ghwish B, Al Issa A, Al Eisa A. Treatment of vitiligo lesions by ReCell vs. conventional melanocyte–keratinocyte transplantation: A pilot study. Br J Dermatol 2008;158:45-9. |
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