Journal of Cutaneous and Aesthetic Surgery
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Year : 2011  |  Volume : 4  |  Issue : 1  |  Page : 70-71
From the Literature in Vitiligo Surgery

Venkat Charmalaya - Centre for Advanced Dermatology, Bangalore, Karnataka, India

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Date of Web Publication9-Apr-2011

How to cite this article:
Anitha B. From the Literature in Vitiligo Surgery. J Cutan Aesthet Surg 2011;4:70-1

How to cite this URL:
Anitha B. From the Literature in Vitiligo Surgery. J Cutan Aesthet Surg [serial online] 2011 [cited 2021 Aug 5];4:70-1. Available from:

Multimodal Single-step Vitiligo Surgery: A Novel Approach

Pahwa M, Gupta S, Khunger N

Dermatol Surg 2010;36:1627-31.

Patients of vitiligo, who do not show adequate response to medical therapy, need surgical management, provided the disease is stable. In this article, the authors have tried to incorporate different techniques of vitiligo surgery in a single session to maximise the advantages of each method and to obtain faster results by combining different methods in the same patient by Multimodal Single-step Vitiligo Surgery (MMSSVS).

Two young female patients with stable vitiligo were treated with a combination of suction blister grafting (SBG), predominantly over facial lesions; split-thickness grafting, predominantly over the limbs and covered areas; and smash grafting (SG), predominantly over the neck and dorsa of feet. The total body surface area of the lesions was approximately 7 to 8% in one patient and 4 to 5% in the other. The SGs were put on neck, presternal region, dorsum of hands (after dermabrasion) and some were co-transplanted with the SBGs on the eyelids, cheeks and neck. Dressing was done at both donor and recipient sites. After 1 week, all the dressings were removed. Patients were advised to use topical PUVA sol during daytime and apply tacrolimus 0.1% ointment at night. Patients were followed up regularly for approximately 10 months. Both the patients showed around 90% repigmentation of all the patches. None of the patients revealed any complication.

In conclusion, MMSSVS is a safe and effective method for the treatment of multiple vitiligo patches at different sites in a single session with faster results, saving time and money, especially in resource-poor settings. However, the disadvantage of this technique is perhaps the higher postoperative pain because of multiple sites being operated on in one session.

Rapid Formation of Suction Blister Through Intradermal Injection of Local Anaesthetics in Epidermal Graft for Vitiligo

Kim T, Roh HJ, Kim JY, Noh S, Oh SH

Dermatol Surg 2010;36:1642-3.

Suction blister epidermal grafting is a useful surgical treatment for stable, recalcitrant vitiligo. Although it is a less-painful and less-scarring method, the procedure is time consuming and causes pain due to negative pressure. In this case report, the authors have tried to demonstrate that intradermal injection of local anaesthetic can reduce the time of blister formation and pain.

A 24-year-old male patient with stable vitiligo was selected for this treatment. Perioral area was selected as recipient site and thigh as the donor area. To compare blister formation with and without local anaesthetic injection, intradermal injection of 1% lidocaine was done at four lesions of the eight planned areas. Vacuum pressure of 200 to 300 mm of Hg using 10 ml sterilised disposable syringes was applied to the donor sites. One hour later, definite blisters were formed at the injection sites. At non-injected sites, it took approximately 2 hours to form definite blisters. Epidermal grafting was done into the perioral areas after dermabrasion. The overall size of the blisters at the two sites was not different, although the time taken to generate a suction blister without lidocaine injection was twice as long as at the injected sites. After 3 weeks, pigmentation of the recipient sites using blisters made with and without injection on the donor sites was not different.

The authors postulate that intradermal injection of local anaesthesia beneath epidermis might increase pressure in dermis through fluid collection, maintaining more negative pressure than the value of pressure in vacuum suction. In addition, injected fluid might induce loosening of cell-to-cell and cell-to-matrix adhesions in dermis and dermoepidermal junction through greater negative pressure. But it is not clear whether lidocaine has any role in rapid blister formation. However, well-formed pigmentation in both epidermal grafts using blisters made with and without injection on donor showed that lidocaine did not affect the result of epidermal graft and survival of melanocytes.

In conclusion, intradermal injection of local anaesthetic into the donor site can reduce the time to create blisters and be free from pain in suction blister grafting.

Use of a Wood's Lamp as an Ultraviolet Light Source to Improve the Speed and Quality of Suction Blister Harvesting

Kaliyadan F, Venkitakrishnan S, Manoj J

Indian J Dermatol Venereol Leprol 2010;76:429-30.

Time taken for the blister formation is a major limitation in suction blister grafting. Various methods have been tried to hasten blister formation like cryotherapy, ultraviolet (UV) light, infrared light and injection of local anaesthetic over the donor site. In this study, the authors have aimed to study whether a relatively cheap and handy instrument like a Wood's lamp can be used as a UV source to improve suction blister harvesting.

Eight patients with stable vitiligo were selected for the study. The anterolateral aspect of both thighs was used as donor site. All the blisters were raised using 20 cc syringes with same vacuum pressure (350 mm Hg). In all patients, one of the thighs was exposed to a Wood's lamp for 20 minutes (without the UV tubes touching the skin). The vacuum was released simultaneously at both test and control sites when sufficient number of blisters of an adequate size were produced. Complete blisters were further scored for quality of blisters--based on uniformity and size, arbitrarily from 1 to 3.

Suction blisters were attempted to be raised at 58 sites, 8 sites did not produce any blistering (3 irradiated and 5 non-irradiated sites). Of the rest, complete blisters were formed in 37 sites, of which 24 were from irradiated site, while 13 were from non-irradiated site. It was also observed incidentally that time taken for uniform pigmentation in recipient site was lesser for sites in which the graft was taken from irradiated sites only. These findings suggested that more number of good quality blisters were raised at irradiated sites than non-irradiated sites.

The mechanism of blister tissue formation by UV light has not been clarified precisely. The various changes caused by UV light in skin connective tissue are degeneration of collagen and abnormal elastosis. Both UVB and PUVA increase the levels of gelatinases in human skin, which might have a role in inducing secondary connective tissue damage and blistering. The authors propose that the incidental finding of better pigmentation in their study could be due to immediate pigment darkening induced by UV light.

In conclusion, a Wood's lamp may be a cheap, handy, and effective modality to speed up blister formation as well as to improve the quality of the formed blisters. The major limitation of this study, apart from being a pilot study, is that the authors could not rule out the effect of heat, which all patients had felt when they were exposed to Wood's lamp, which itself might have contributed to improving blister formation.

Simplified Cellular Grafting for Treatment of Vitiligo and Piebaldism: The "6-Well Plate" Technique

Goh B, Chua X, Chong K, Mil M

Dermatol Surg 2010;36:203-7.

Surgical options for repigmenting vitiligo include tissue and cellular grafting. In tissue grafting (punch grafting or suction blister grafting), the size of the donor skin restricts the size of the area to be grafted. In contrast, cellular grafting allows transplantation of vitiliginous areas much larger than the size of the donor skin. However, cellular methods are more complicated and need specialised equipment and training. This article reports the success of the authors in simplifying non-cultured cellular technique through the use of a "6-well plate" in the extraction of epidermal cells from donor skin. This modification reduces cell preparation time, amount of reagents needed and cost.

Four patients with stable, segmental, or focal vitiligo and one patient with piebaldism were selected for the study. Donor skin in ultrathin sections was harvested from gluteal region under local anaesthesia. The ratio of the donor to recipient area was 1 : 5. The specimen was washed in phosphate buffered saline (PBS) and cut into smaller pieces before being incubated in 0.25% trypsin and 0.08% EDTA for 40 minutes at 37 o C. After incubation, the tissue was washed in the first well of a 6-well plate containing soybean trypsin inhibitor. The tissue was subsequently rinsed in PBS in the next three wells before separation of the epidermis from dermis and mechanical dislodgement of epidermal cells in fifth well. The epidermal cells were suspended in PBS and filtered through a micro filter placed on the sixth well, to remove the tissue fragments. Hyaluronic acid was added to the filtrate (epidermal cell suspension) to increase its viscosity into a gel-like paste. The recipient areas were treated with flash-scan CO 2 laser to remove the epidermis. The denuded lesions were treated with the cellular suspension and covered with sterile transparent occlusive dressings.

After six months, vitiligo patients achieved 65 to 92% repigmentation. Piebaldism patient achieved 86% repigmentation. One year after grafting, repigmentation remained same for all patients with good colour matching.

In conclusion, the extraction of epidermal cells from donor skin was simplified using a simple, inexpensive 6-well plate, a micro filter and three reagents: trypsin, trypsin inhibitor and PBS. This method is inexpensive, reduces the cell preparation time and the amount of reagents used. However, further studies involving a larger series of patients and larger leucodermic areas are required to confirm its efficacy.

Correspondence Address:
B Anitha
Venkat Charmalaya - Centre for Advanced Dermatology, Bangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-2077.79204

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