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   Abstract
   Introduction
   Material and Methods
   Results
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STUDIES
Year : 1992  |  Volume : 58  |  Issue : 5  |  Page : 310-314

Autologous miniature punch skin grafting in stable vitiligo



Correspondence Address:
S S Savant


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  Abstract 

Autologous split thickness miniature punch skin grafting is one of the surgical modes of treatment of stable vitiligo. Out of 87 different sites, of stable vitiligo, occurring in 62 cases, (32 focal, 22 segmental and 8 generalised) 75 sites showed total repigmentation with excellent cosmetic colour match. Out of the 62 cases, 46 cases who were treated postsurgically with PUVA therapy repigmented within 2 ˝ to 3 months, 10 cases, who received no treatment postsurgically repigmented by 3 ˝ to 6 months. In addition 6 cases in whom no treatment was given postsurgically had to be given PUVA therapy 3 months after surgery as there was poor repigmentation. The complications seen were graft rejection due to improper immobilization in 6 cases, graft rejection due to secondary infection in 1, contact allergic dermatitis to framycetin in 3, and reactivation of vitiligo in 2. Side effects seen were cobblestoning in 32, sinking pits in 12, variegated appearance in 4, and superficial scarring at donor site in all 62 cases.


Keywords: Vitiligo, miniature punch grafting


How to cite this article:
Savant S S. Autologous miniature punch skin grafting in stable vitiligo. Indian J Dermatol Venereol Leprol 1992;58:310-4

How to cite this URL:
Savant S S. Autologous miniature punch skin grafting in stable vitiligo. Indian J Dermatol Venereol Leprol [serial online] 1992 [cited 2019 Oct 21];58:310-4. Available from: http://www.ijdvl.com/text.asp?1992/58/5/310/3834



  Introduction Top


There are many cases of vitiligo who either fail to respond or only partially respond to the medical line of treatment indicating that melanocyte reservoir [1] is no more available for repigmentation in these areas. Stable vitiligo is a term coined for such cases where, in addition, the disease is inactive and no new patch has developed in past 2 years. These cases of stable vitiligo are treated by surgical methods like tattooing, [2] organ cultured foetal skin allografts, [3] or autologous skin grafting. Autologous skin grafting can be done in various ways such as epidermal culture grafting, [4] pure melanocyte culture grafting, [1],[5] epidermal grafting by suction blister technique, [6,[7] thin Thiersch's split skin grafting, [8] or thin split skin miniature punch grafting. [9],[10] The last method consists of taking miniature thin split thickness (epidermis and part of upper dermis) punch grafts of sizes varying from 1 to 3 mm in diameter from donor site, grafting them in appropriate punched out areas spaced 2 to 5 mm apart at the recipient site and further securing them by firm pressure. The method was first advocated by Falabella to treat small to medium sized localised patches of focal and segmental vitiligo. 9, " In this study this method was modified with the use of indigenously manufactured minimized round body skin biopsy punches.


  Material and Methods Top


Sixty two patients (17 men, 45 women; age range 19-35 years) participated in this study.

Thirty two of them had focal vitiligo, 22 had segmental vitiligo, and 8 had partially arrested generalised vitiligo. Totally 87 different sites were treated as follows: extremities 26, trunk 19, lips 14, face 13, tips of fingers 12 and 1 each on glans penis, beard area and eyebrow area. All of them had received PUVA therapy with or without corticosteroids, placental extracts, chloroquine etc in the past for a period varying from 2 to 7 years. The disease had been stable for past 2 years. Their BCG scars or old scars were examined for keloidal tendency. If the skin overlying the vitiligo patch was rough and atrophic it was treated with local steroid or emollient cream before surgery. Main instruments used were skin biopsy punches of sizes 1, 1. 5, 2, 2.5 and 3 mm diameter. They were specially designed and manufactured by a local surgical instrument manufacturing company in Bombay.

Donor site selected was either gluteal region (48 cases) or extensor surface of the thigh (14 cases) which had not been affected by vitiligo in the past or present. After surgical preparation and isolation, local anaesthesia was given with 1% xylocaine intradermally to an area of 2 sq. inches at the donor site. Multiple thin punch grafts using skin biopsy punch were obtained by going upto the depth of upper dermis and then freeing the graft from the base by cutting tangentially with double curved ' S' shaped scissors as close to the epidermis as possible. These grafts were then transferred to a sterile bowl containing normal saline. Adequate pressure to bring about haemostasis was given and donor site was left covered with sterile gauze. The grafts were handled with nontraumatizing forceps. Commonly used sizes of skin biopsy punches at the donor site were 1.5, 2 and 2.5 mm. Total number of grafts harvested varied from 4 to 55 in number with an average of 20 to 25 at one sitting.

Recipient site was surgically prepared, isolated and anaesthetized locally. Skin biopsy punches 0.5 mm smaller in diameter than the graft sizes were used to punch out the skin upto the depth of mid dermis. This was achieved by lifting the punched out tissue high and cutting as far away from epidermis as possible. Many such areas were punched out at the recipient site spaced 5 to 10 mm apart. Punched out tissues were cut and discarded to leave behind multiple recipient chamber beds. These were then dilated with punch guards 0.5 mm larger in diameter than them and the harvested grafts were then placed individually in them. Edges of the grafts were ironed out and they were then secured by firm pressure with moist gauze till complete haemostasis was achieved. When all the grafts had snugly fitted the area was dressed with double layer of 1 sq. inch framycetin tulle pieces followed by sterile gauze and roller bandage. Additional elastoplast or elastocrepe bandage was used when necessary for the first 12 hours. If the grafted area involved skin overlying a joint then this area was immobilized by splints. At the recipient site dressings were changed once or twice in the first 48 hours. The double layered framycetin tulle pieces were soaked with spirit and were gently lifted off. If any of the grafts were found shifted they were put back in their position and the area was dressed back in a similar way. After 48 hours only one dressing was required either on 3rd or 4th day which was removed by 7th to 10th day. Donor area was dressed with double layer of framycetin tulle pieces followed by gauze pieces. This was removed after 1 week. All the patients were covered with a broad spectrum antibiotic orally for 1 week. Out of the 62 cases, 46 cases were subjected to PUVA therapy from the 10th day for a period of 3 months. Of the remaining 16, 6 re-pigmented poorly and were given PUVA after 3 months, whereas 10 were not given any treatment postsurgically. All the cases were followed every fortnightly for the 1st 3 months, every monthly for the next 3 months, and later every 3 monthly. Like this, 9 cases have been followed for 3 years, 15 for 2 years, 22 for 1 year, and all 62 for a minimum of 6 months.


  Results Top


In all the 62 cases the colour of most of the grafts changed from brown, dark brown, violet, to black with the upper scabs falling off by 10 to 15th day to leave behind pink grafts which later on turned to skin colour by 3 weeks. However this change was not observed in all the grafts, some of which remained skin coloured all throughout. Uniform perigraft melanin pigment was observed by 1 to 1 1/ 2 months. These pigmented islands then gradually increased in size and coalesced together to cover the vitiligo area by 2 1/ 2 to 3 months in 46 patients on postsurgical PUVA therapy and by 3 1/ 2 to 6 months in 10 patients without any postsurgical therapy. In- 6 patients without any postsurgical therapy, the quality, quantity. and rate of pigmentation was poor and therefore PUVA therapy was started after a period of 3 months. In another 1 to 1 1/ 2 months on PUVA therapy. these 6 patients re-pigmented totally. Of the 87 sites grafted all showed excellent cosmetic colour match, most remarkable being those of lips.

Underlying growing hair penetrated the grafts put in the hairy areas of the beard and eyebrow instead of lifting the grafts off as feared. In 15 cases the depigmented hair gradually showed pigmentation to normalcy. The size of re-pigmentary zone around the implanted minigraft was 5 to 10 mm on an average and in very dark coloured individuals the pigment spread upto 15 mm in the surrounding vitiligo area. No histopathological study for melanin or melanocytes was done in any of the cases. Cobblestoning (raised graft surface) was noticed initially at 32 sites, which got rectified in 12 of them in next 6 months. It persisted at 20 sites but with less severity in contour at the end of 1 year. Sinking pits at the site of grafting were observed in 12 cases of grafting at the tips of fingers, where thin grafts were placed in deeper chambers. These sinking pits remained permanently without further correction in the contour. Variegated blotchy appearance in pigment was noted in 4 sites where grafting was done on apparently rough and atrophic vitiligo area. Graft rejection was noted in 7 sites. Of these 6 were due to shifting of grafts (improper immobilization) and 1 was due to secondary infection. In 2 cases, the grafts were taken up and the vitiligo area got re-pigmented but reactivation of vitiligo was noticed in 6 to 8 months. Here a halo of depigmentation appeared around the centrally re-pigmented grafted area. These 2 cases were later put on PUVA therapy with good result in 1 and no response and further local depigmentation in another. Three cases showed contact allergic dermatitis to framycetin tulle dressing. No vitiligo was noted at donor site in any of the 62 cases all of which had healed with superficial scarring.


  Comments Top


Therapy aimed at replenishing melanocyte population in vitiligo byway of miniature autologous punch skin grafting gives best cosmetic results. [9],[10] The pigment spreads uniformly, remains permanently, and matches the colour of the surrounding skin perfectly. [11] One can treat vitiligo of any site and of any size by this method and if required repeated multiple sittings can be carried out. Areas where grafts are rejected and which fail to re-pigment due to non uptake of grafts can be regrafted. Being autologous skin grafting, grafts are retained permanently. The procedure requires use of nonexpansive mini sized skin biopsy punches. Lastly, being an extended simple skin biopsy technique, this procedure requires no special training and can be done in the OPD.

In this study 75 out of 87 sites (86%) repigmented with excellent cosmetic colour match. Complications were seen at only 13 sites. Cobblestoning, observed in 32 cases and sinking pits, observed in 12 cases remain major side effects which can be overcome by cutting away the undersurface of the graft or by making the recipient punched out chamber bed more deeper. However these side effects along with superficial scarring at the donor site still remain the main limitations of this method. To avoid delay in the establishment of vascular contact between the graft and the grafted. adrenaline was not used along with xylocaine locally, in this study.

PUVA therapy after the grafting was found to expedite repigmentation, therefore it can be used for the first 3 months after grafting. Such a combination therapy has not been used in earlier studies.

Comparing this method to that of Falabella [9],[10] following improvisations were made. Falabella had used 1:2 mm diameter punch at both recipient and donor sites. In this study a difference of 0.5 mm. diameter between the two sites was kept for better fitting of grafts. Biophysics of contraction of donor grafts and expansion of recipient site have been taken into account to avoid shifting of grafts due to improper fitting and perigraft circular scars at the recipient sites. Also, in this study punch sizes 1, 1.5, 2, 2.5 arid 3 mm were used. This was done to facilitate the appropriate selection of proper size of the punch depending upon the size, shape, and the geographical pattern of vitiligo area. Grafts below 1 mm size would be difficult to retain due to small size and it was noticed that beyond 3 mm size, for proper fitting of grafts, the difference between the two sites should be 0.25 mm. Also the cosmetic blending (merging) of graft with surrounding skin is better with small size and hence punches from 1 to 3 mm size were used in this study. Falabella had spaced the grafts 3 to 5 mm apart and had observed a repigmentary zone of 2 to 5 mm around the implanted minigrafts. [9],[10] In this study grafts were implanted 5 to 10 mm apart and the average repigmentary zone in most of the cases was 5 to 10 mm, being upto 15 mm in a few very dark patients. Racial colour factor and individual hereditary colour factors thus play part in pigment spreading. [11]

Sealing solution [9],[10] was not used in this study to secure the grafts as in Falabella's technique since simple pressure was enough to secure them. Falabella had used micropore adhesive tape directly over the grafts for dressing. In this study double layered framycetin tulle pieces were used since it was nonadherent and easily removable.

Falabella used this method as an adjunct to medical line to treat resistant patches of vitiligo after doing test grafting in a small vitiligo area. He advocated use of this method in those cases of positive test area, [10] irrespective of the fact whether the disease was stable or not. In this study only stable vitiligo patches were treated and no test grafting was done. Falabella achieved a success rate of 100% in 4-cases of segmental vitiligo in one study, [9] and 75% in a group of 22 cases of vitiligo (17 segmental and 5 focal) in another. [10] His suggestion of using autologous minigrafting' as an alternative for resistant patches of focal and segmental vitiligo was confirmed in this study and it was observed that even large areas of stable generalised vitiligo could be treated with multiple sittings by this method. Colour changes seen are not only due to melanin spread from the grafts edges, but also due to melanocyte decolonisation of the epidermis within the achromic skin. [9],[10],[11]

Autologous minigrafting does not modify the clinical course of progressive (unstable) vitiligo and therefore only stable vitiligo patients should be treated by this method.

 
  References Top

1.Suvanprakoran P, Sompong DA, Pongsomboon C, et al. Melanocyte autologous grafting for treatment of leucoderma. J Am Acad Dermatol 1985 ; 13 : 968-74.  Back to cited text no. 1    
2.Halder R M, Pham H N, Breadon J Y, et al. Micropigmentation for the treatment of vitiligo. J Dermatol Surg Oncol 1989 ; 15 : 1092-4.  Back to cited text no. 2    
3.Gokhale BB, Tawade YV, Bharatia P R, et al. Use of organ cultured foetal skin in allografts in treatment of resistant vitiligo. Ind J Dermatol Venereol Leprol 1991 ; 57 : 272-5.  Back to cited text no. 3    
4.Brysk MM, Newton R C, Ralaraman S, et al. Autologous cultured cells as a treatment for vitiligo (abstract). J Invest Dermatol 1988; 90:549.  Back to cited text no. 4    
5.Lerner AB, Halaben R, Klaus SN, et al. Transplantation of human melanocytes. J Invest Dermatol 1987 ; 89 : 219-24.  Back to cited text no. 5    
6.Koga M. Epidermal grafting using the tops of suction blisters in the treatment of vitiligo. Arch Dermatol 1988 ; 124 : 1646-8.  Back to cited text no. 6  [PUBMED]  
7.Tawade YV, Gokhale BB, Parakh AP, et al. Autologous graft by suction blister technique in management of vitiligo. Ind J Dermatol Venereol Leprol 1991 ; 57 : 91-3.  Back to cited text no. 7    
8.Behl PN. Bhatia RK. Treatment of vitiligo with autologous thin Thiersch's grafts. Int J Dermatol 1973 ; 12 : 329-31.  Back to cited text no. 8    
9.Falabella R. Repigmentation of segmental vitiligo by autologous minigrafting. J Am Acad Dermatol 1983 ; 9 : 514-21.  Back to cited text no. 9  [PUBMED]  
10.Falabella R. Treatment of localozed vitiligo by autologous minigrafting. Arch Dermatol 1988 ; 124 : 1649-51.  Back to cited text no. 10  [PUBMED]  
11.Vilech A, Ziff E. Repression of activators. Nature 1984 ; 312 : 594-5.  Back to cited text no. 11    


    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8]

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