Updates on Surgical Management of Vitiligo

Marwa Abdallah

Professor of Dermatology, Venereolgy & Andrology, Ain Shams University,

Founder & Board Member, Cutis “The Skin Clinic”

Cairo, Egypt

No conflict of interests to declare

Surgical management of vitiligo sets in when segmental and non-segmental vitiligo become stable for at least one year.

Treatment entails the transfer of autologous melanocytes to an area, which did not repigment with medical treatment and/or phototherapy.

Generally, there are two main types of grafting techniques; tissue grafts and cellular suspension grafts. Both epidermis and hair follicles are good sources for both techniques.

Melanocytes can migrate out of the grafts into the recipient area. Therefore, one of the main aims in grafting is to increase the donor-recipient ratio, so that a small piece of pigmented skin can cover a much larger vitiligo area.

Many modifications have been added to the techniques regarding donor and recipient areas preparation, as well as suspension media and dressing types.

Tissue grafts include the use of:

• Punch grafts (1-2 mm), modifications added the use of motorized harvested 0.5 mm grafts put in any direction, and weekly transverse needling. The use of silicone sheets, or harvesting the cobble stones decreases cobble-stoning, a main adverse effect of punch grafting
• Hair follicle unit extraction (FUE) are helpful in vitiligo of hairy areas.
• Split thickness skin grafts with their different modifications like; ultrathin grafts, meek micrografts, minced tissue grafts (micrografts), the latter two offer greater surface coverage.
• Suction blister grafts have had many changes to hasten the procedure and improve their outcome including the use of heat and special gadgets to harvest small-sized grafts that are able to cover a larger vitiligo area.

Cellular suspension grafts:

Suspension grafts of melanocytes, keratinocytes and possibly fibroblasts offer a good recipient coverage and good color match. The cumbersome cultured melanocyte suspensions are sparingly used nowadays.

Suspension grafts have seen lots of variations including:

• Using different melanocyte concentrations, omitting incubators (use patient’s axilla or room temperature), using different dressings (collagen sheets, roof of suction blisters etc) and suspension media (saline, Ringer, PRP) and others.
• Omitting the use of trypsin and using dermabrader to get the cells (Jodhpur technique and its modifications).
• Hair follicle-derived suspension after trypsinization (FUE or hair plucking).
• Combination of epidermal and follicular suspension grafts.

Recipient area preparation for suspension has seen lots of reformations from the use of sandpaper and salicylic/lactic acid-assisted dermabrasion to the use of vertical needling/stamping and fractional CO2 laser.

Finally, treatment of difficult areas like ears, nipples, lips, fingers and genitals have shown success with new ideas.

All recent amendments had the aim to reach an easier, better, cosmetically acceptable, patient-friendly outcome.