|Year : 1997 | Volume
| Issue : 5 | Page : 296-300
Punch grafting in vitiligo : Refinements and case selection
Source of Support: None, Conflict of Interest: None
Autogolous split thickness punch grafting is being increasingly used as an effective technique in the management of refractory vitiligo by dermatosurgeons as an office procedure. Refinements in the technique of punch grafting has been described with special attention to the junctional areas and graft interspaces. Based on the experience of 55 cases treated with this technique careful selection of patients and recipient sites has been suggested.
Keywords: Vitiligo, Punchgraft, Dermatosurgery
|How to cite this article:|
. Punch grafting in vitiligo : Refinements and case selection. Indian J Dermatol Venereol Leprol 1997;63:296-300
Complete disappearance of pigmentary cells in the basal layer of dermis and perifollicular epidermis often renders medical therapy ineffective in long standing cases of vitiligo. Such refractory lesions especially in the exposed parts of the body are then treated by one of the various surgical techniques available, viz. tattooing, excision and primary suture, epidermal grafting [2,3] Thiersch's grafting, dermabrasion and skin grafting, cultured skin grafting, melanocyte transfer, cultured foetal skin grafting and autologous miniature punch grafting. [8,9]
Autologous punch grafting is being increasingly used by dermatosurgeons to treat refractory vitiligo lesions as it is inexpensive and can be easily learned and performed as an office procedure. Its indiscriminate use, however, has left many patients unsatisfied after multiple sittings with partially treated lesions difficult to correct by other surgical techniques and cosmetically unacceptable donor site.
I present here my experience of 55 cases of vitiligo treated by autologous punch grafting with special reference to the refinements of the technique and case selection.
| Patients and Methods|| |
Fifty-five patients with focal and segmcntal, vitiligo were selected for punch grafting. All the patients had localized stable vkiligo that had been present for the periods varying from 1 to 19 years, however, most of the patients had achromic lesions for 2-7 years. Majority of the patients were between 10-30 years of age, 76 percent of them being females (80 percent unmarried). All patients had been treated previously with systemic methoxalen plus sunlight exposure with no or transient response.
Old scars of the patients were examined for keloidal and achromic predilection. Informed consent was taken. Operations were performed as day procedure in routine operation theatre. Selected vitiligo site was surgically prepared and draped. Xyiocain 1 percent with 1:2,00,000 adrenalin was injected intradermally to anaesthetize the area. Sharp hair grafting punches of 2.5 - 3.0 mm size were used to punch out the skin with superficial dermis from the recipient site.
First, the skin was punched out at the junction of normal and achromic skin at 5 mm intervals. The second inner row was spaced at 5 mm to 7.5 mm, in such a way that punches in the second (and subsequent rows) were not in the line of the radial towards the central puch, rather they were placed in the interspaces. Few recipient area were selected and an effort was made to complete it in one sitting in patients with many achromic patches, rather than placing a few grafts and placing further grafts in the interspaces in the next sitting after observing the response. As many as 150 punch grafts were done at one sitting in larger patches.
Donor areas selected were upper and lower outer quadrants of the gluteal region (47 cases) and medial, anterior or lateral aspects of thigh (8cases). The donor area was surgically prepared and draped. Xyiocain 1 percent with 1: 200,000 adrenalin was used for local anaesthesia. With skin streched, punches were made with sharp hair grafting punch (0.5 mm larger in diameter than that used in the recipient area). The punched out skin was held in Adson's nontraumatizing forceps and cut in the superficial dermis by sharp curved scissors and were kept in isotonic saline. The grafts were harvested 1-3 mm apart. The donor site was covered with framycetine tulle and a sterile absorbant adhesive dressing was applied.
The punched out regions of recipient site was cleaned with isotonic saline. The punch grafts were placed in the recipient areas and compressed with saline soaked gauze. The gauze was carefully removed. The grafts were covered with framycetine tulle cut to conform the surface. An extra dab of framycetine cream was applied to make the tulle adhere to the surface. A layer of dry gauze was then applied over it and maintained in place by several tapes of micropore. A layer of cotton was then applied over it and bandaged. The dressing was carefully removed after 7 days and reapplied for another 7 days. The patient was then allowed to clean the area and apply ointment at home. Systemic methoxsalen therapy with sunlight exposure was started and continued for 3-6 months. Donor site dressing was removed on 14th day. The cases were followed fortnightly for first 3 months, every month for next 6 months and every 3 months thereafter. The patients have been followed for a period varying from 6 months to 3 years.
| Results|| |
Out of 55 cases (92 lesions), 36 showed complete response, with vitiligo area being completely covered with pigment expanding from grafts and did not require second sitting for the same area. Eight patients showed good response but required second sitting after 4½ months and showed good response at the end of one year. Eleven patients showed poor results requiring 3 or more sittings. Excision and Thiersch grafting were done in 3 of these patients who did not show spread of pigment from the grafts.
There was an initial stationary phase after punch grafting with no spread of the pigment which lasted l-½months, however, at l-½ months a uniform perigraft pigmentation was observed. [Figure - 1] These pigmented islands gradually increased in size and coalesced within 4 months in good responders [Figure - 2] and 7-½ months in poor responders. Spread of pigment was generally faster in patients between 10-25 years of age and in those with thin, soft and elastic undamaged skin. Spread of pigment was rapid in darkly pigmented patients, compared to the patients with fair complexion. All the 3 patients who showed no response were of fair complexion.
Cobblestoning was noticed in one-third of the lesions [Figure - 2]. They were treated with compression garments and subsided in all but three sites. Variegated pigmentation, however, persisted but improved with time and was noticeable only in 4 out of 20 patients followed upto three years. However, none of the patients complained about it.
Sixty-five percent of patients considered their result excellent, 20% good 5% satisfactory and 10% as unsatisfactory. Twelve patients complained about hypopigmentation and mosaic pattern of their donor area. The donor area was treated with local steroid cream (and pressure garment if required).
All patients showed gradual improvement of the donor area and all the patients who were followed up for 3 years had donor area almost indistinguishable from the surrounding.
| Discussion|| |
Replenishing melanocytes in vitiligo by autologous punch skin grafting has been claimed to give best cosmetic results.[8-10] Patients subjecting themselves to surgical treatment are often frustrated with prolonged course of medical treatment, and are psychologically disturbed, as vitiligo still remains a social taboo in many parts of the world. Such patients remain highly dissatisfied with the streaks of the vitiligo which may remain between the neopigmented islands. Although repiguieiitary zone of 2-15 mm around the graft has been reported, [8, 9, 11] I recommend a modest 5-7.5mm space between the grafts. Present method of grafting aims at preventing residual streaks of achromic skin at the junctional areas and between the grafts (which are difficult to treat later) and covering whole of the lesion in one sitting.
An important question arising with the results obtained in the patients described herein is why they show a range of response varying from none to complete. Various racial, hereditary, local biochemical and immunological factors may play a part in pigment spreading. However, we observed that young dark skinned patients with thin soft and elastic skin show best results. Slow spreads, cobblestoning and variegated pigmentation are common in fair patients and when punch grafting is done on eyelids, malar region, chin and dorsum of hand. Such poor results are difficult to correct later except by excision and grafting. I neither use sealing solution nor apply micropore adhesive tape directly over the grafts.
Till we have clear understanding of the factors controlling and modulating the pigment cell repopulation in vitiligo areas, the technique will render many patients dissatisfied with poor cosmetic results and this useful technique itself will fall in disrepute.
| References|| |
|1.||Haider R M, Pham H N, Breadon J Y, et al. Micropigmentation for the treatment of vitiligo. J Dermatol Surg Oncol 1989;15:1092-1094. |
|2.||Kogo M. Epidermal grafting using the tops of suction blisters in the treatment of vitiligo. Arch Dermatol 1987;89:219-224. |
|3.||Tawade Y V, Gokhale B B, Parakh A P, et al. Autologous graft by suction blister technique in management of vitiligo. Ind J Dermatol Venereol Leprol 1991;57:91-93. |
|4.||Behl P N, Bhatia R K. Treatment of vitiligo with autologous thin Thiersch's grafts. Int J Dermatol 1973;12:329-331. |
|5.||Brysk M M, Newton R C, Rajaraman S, et al. Autologous cultured skin as a treatment for vitiligo (abstract). J Invest Dermatol 1988;90:549. |
|6.||Lerner A B, Halaben R, Kiaus S N, et al. Transplantation of human melanocytes. J Invest Dermatol 1987;89:219-224. |
|7.||Gokhale B B, Twade Y V, Bhartiya P R, et al. Use of organ cultured foetal skin in allografts in treatment of resistant vitiligo. Ind J Dermatol Venereol Leprol 1991;57:272-275. |
|8.||Falabella R. Repigmentation of segmental vitiligo by autologous minigrafting. J Am Acad Dermatol 1983;9:514-521. [PUBMED] [FULLTEXT]|
|9.||Falabella R. Treatment of localized vitiligo by autologous minigrafting. Arch Dermatol 1988;124:1649-1651. [PUBMED] [FULLTEXT]|
|10.||Vilech A, Ziff E. Repression of activators. Nature 1984;312:594-595. |
|11.||Savant SS. Autologous miniature punch skin grafting in stable vitiligo. Ind J Dermatol Venereol Leprol 1992;58:310-314. |
[Figure - 1], [Figure - 2]