Vitiligo sx1

1. SURGICAL MANAGEMENT OF VITILIGO DR. SHWETA KHUSHALANI RESIDENT, DVL

2. INTRODUCTION  Vitiligo  m/c depigmentary disorder  1-2%population worldwide  Affects all races  Multiple depigmented macules and patches with leukotrichia  Cosmetic and psychological devastating effects  Indication for surgical management  Fail to respond to medical therapies OR  Respond to therapy with incomplete repigmentation

3.  PRINCIPLE  Introduce melanocyte into the lesional skin, which then establish and function as epidermal melanin units

4. INDICATIONS  Stabile vitiligo  Leukoderma (post burn, chemical)  Piebaldism

5. Stability of vitiligo  Duration  History of extension of lesions absent for 1 year  Morphology  Stable : well defined border, +/- spotty pigmentation  Unstable : ill-defined border  Koebners phenomenon absent for 1 year  Minigrafting test (positive)

6. VIDA scoring  Evaluation of activity of vitiligo Duration Scoring In past 6 weeks : +4 3months : +3 6 months : +2 1 year : +1 Stable for at least I year : 0 Stable for 1 year with Spont. Repigmentation : -1  Score 0/-1, stable vitiligo

7. Test grafting  Placing 6-8 puch grafts over vitiligo lesions  observe for 12 weeks  Results : Unequivocal repigmenation beyond 1mm from the border POSITIVE STABLE

8.  Cellular stability  Markers (CD8, CD450, FOXP3) assessment  Higher percentage of CD8 cells is assocociated wth failure of melanocyte transplanttaion

9. Other factors  Age of patient  Young patient respond better  Children-future course can variable, chances of failure of surgery

10. CONTRAINDICATION  Active /unstable vitiligo  Unrealistic expectations of patient  Keloidal tendency

11. PREOPERATIVE WORKUP  Complete detailed history  Physical examination – systemic and cutaneous  Investigations : CBC, BT, CT, blood sugar  Detailed Consent  Photographic documentation

12. SURGICAL MODALITIES TISSUE GRAFTS CELLULAR GRAFTS • Suction blister grafting • Minipunch grafting • Thin split thickness grafting • Ultra thin skin grafting (UTSG) • Mesh grafting • Flip –top pigment transplantation • Transplantation of hair follicles • Micropigmentation • Excision/ closure • Dermabrasion, chemabrasion • Lasers and light therapy sysytem NON GRAFTING TECHNIQUES • Autologous noncultured epidermal cell suspension • Noncultered Extracted Follicle Outer Root Sheath Suspension • Autologous cultured pure melanocyte transplantation

13. Introduction : A technique of taking thin, miniature auto skin punch grafts from normal pigmented donor site and individually grafting them in appropriate punched out chambers at recipient stable vitiligo site PRINCIPLE: Donor dominance : a portion of dermis in the graft tends to have an influence over the epidermis morphogenesis and differentiation MINIATURE PUNCH GRAFTING

14. EQUIPMENTS • Skin punches (1mm,1.5mm) • Small Jeweller's or graft holding forceps • Small curved tip scissors • Sterile petridish

15. Procedure Donor site – Sites: 1. lateral aspect of thighs 2. gluteal region Surgical preparation • LA -1% lignocaine • Punch impressions are made very close to each other so that a maximum number of grafts can be taken from a small area.

16. Recipient site-  Test grafting of recipient area  Surgical preparation  LA (1% lignocaine with or without adrenaline infileration)  Recipient chambers, close to border of lesion, 5-10mm apart  Lift the edge and cut through mid dermis  Grafts placed directly from donor to recipient area  Hemostasis achieved by pressing a saline-soaked gauze piece  Dressing in 3 layers –  Jelonet ( paraffin embedded non adherent sterile gauze)  Sterile pads  Bio-occlusive biopore

17.  Donor area dressing  Surgipad  Bio-occlusive Micropore  Immobilise if necessary.  Post-operative  Open dressing after 24 hours, to check for dislodgements of grafts  Dressing finally removed after 4-7 days  Phototherapy (PUVA/NB-UVB) every fortnightly for 2months, then monthly, till complete pigmentation achieved

18. Complications Recipient site  Cobble stoning  Polka dot  Variegated appearance and color mismatch  Static graft (no pigment spread)  Depigmentation of graft  Perigraft halo  Graft dislodgement / rejection  Hypertrophic scar and Keloid formation Donor site • Keloid • Hypertrophic scar • Superficial scar • Depigmentation / spread of disease

19. Advantages Disadvantages • Easiest, fastest, and least expensive method • Can be performed anywhere, on any site (except angle of the mouth) • highest rate of adverse effects • Not suitable for larger lesions as the pigment achieved is usually not uniform • Phototherapy is always necessary

20.  Introduction : Thin split thickness skin grafts are harvested from the pigmented donor area and transplanted at the recipient sites as continuous sheets of tissue grafts.  PRINCIPLE OF GRAFT UPTAKE 1. Graft uptake and adherence 2. Inosculation and graft revascularisation 3. Contracture 1. SPLIT THICKNESS SKIN GRAFTS

21. • EQUIPMENTS • Dermabrader – mechanical/ electrical • Skin grafting equipment • Straight artery forceps with razor blade • Humpy’s skin gratfing knife • Padget’s or Davol’s dermatome • Graft spreading rods or spatula • Non traumatising forceps • Surgical glue (N- butyl 2-cyanoacrylate) • Others : iris scissors, sterile petridish.

22. Procedure DONOR SITE Sites : •Anterolateral aspect of thigh •Gluteal area •Arms •Abdomen 1. Surgical preparation of site 2. Field block Anaesthesia 3. Donor site made taut by stretching 4. Graft harvested from donor site by Humpy’s knife/ razor blade with straight artery forceps at 10-150 to obtain a thin, translucent uniform graft. 5. Put in sterile petri dish 6. Dressing- semiocclusive dressing heals fastest

23.  RECEPIENT SITE 1. Surgical preparation 2. Infilterative Anaesthesia with 1% lignocaine. 3. Dermabrade up to marked area till pinpoint bleeding appears 4. Achieve haemostasis, cover area with moist saline gauze 5. Place graft on abraded area with dermal side downwards 6. Spread graft using spatula, 3-5 mm beyond marked area 7. Fix graft with glue: N- Butyl 2- Cyanoacrylate 8. Wound dressing with adhesive dressing ( tegaderm) with immobilisation

24. POST OPERATIVE 1. Antibiotics for a week 2. Analgesics 3. Immobilisation if required FOLLOWUP • Dressing opened after 24 hrs, check for hematoma/ seroma • Seroma if present is drained • Wound redressed • 2nd dressing removed after 10- 12 days

25. COMPLICATIONS  Milia formation  Scarring if graft is too thick  Tire patch or stuck-on appearance  perigraft halo  Hyperpigmentation of the graft/Cosmetic mismatch

26. Advantages 1. Highest success rate 2. Large area can be treated in one session 3. Rapid and uniform repigmentation 4. Less time consuming 5. Difficult areas like eyelids, areola, inner canthus of the eyes , nipple can be treated Disadvantages 1. Size of donor skin should be 10-25% more than recipient area 2. Risk over hyperpigmentation on exposed area 3. Scarring of donor area if thicker grafts taken

27.  A technique when the pigmented epidermis is harvested from the donor site by using suction to raise a blister which is then transferred to vitiliginous area  PRINCIPLE- Cleavage between basal cells& basal lamina (DEJ) SUCTION BLISTER EPIDERMAL GRAFTING

28. Equipment • Sterile disposable syringes (10/20cc & 50cc) • 3 way connector and poly vinyl tubing • Petroleum jelly • 0.9% NaCl solution, 10 % povidone idodine & spirit swabs • Dermabrader –manaul or electrical • Iris forceps • Jeweller’s forceps • Graft spreading rods/spatula • Sterile glass slides • Surgical glue ( N – butyl 2 cyanoacrylate) • Dressing materials

29. PROCEDURE DONOR SITE •Sites- Flexor aspect of forearm, medial aspect of upper arm Lateral aspect of thigh • Surgical preparation of donor site • Topical anaesthesia • Blister is raised using syringe or suction pump with cups • Base of syringe is applied over donor site • 3 way connector is attached • Assembly line- PV tubing,3 way connector,manometer,50cc syringe or suction pump • Suction to create –ve pressure (-200 to -500mmHg) contd.

30.  20 cc syringe with 3 way connector is retained  Single unilocular non haemorrhagic blister (45 mins – 3 hours)  Deroofing the blister  Roof of the blister is cut  Roof is inverted onto a glass slide  Graft is cleaned and spread  Dressing – framycetin tulle with dry gauze

31. RECIPIENT SITE Transfer Of Graft • Surgical preparation of recipient site • Anaesthesia -1%lignocaine • Dermabraded till minute bleeding spots are visible/ CO2 laser can be used • Graft is placed with dermal side in contact with recipient area • Graft are placed next to each other with overlapping of their borders so as not to leave any raw surface uncovered • At the periphery graft edges 1-2 mm beyond the dermabraded wound edge • Surgical glue is applied followed by double layed framycetin tulle, moist gauze, sterile gauze f/b elastocrepe bandage • Immobilize if necessary

32.  Post operative  Antibiotics + anti-inflammatory for 5-7 days  Dressing is removed after 5-7 days  Dressing removed slowly with downward pressure so as to avoid tearing of the graft from its bed

33. COMPLICATIONS Donor site: Hematoma/seroma Infection Recipient site: Graft rejection, graft displacement Perigraft halo Incomplete pigmentation

34. ADVANTAGES • Simple , safe , inexpensive procedure • No scarring at donor site • Faster repigmentation • Good colour match-eyelids, lips, areola • Scar formation, cobble stoning, thick margins, milia are less • OPD procedure DISADVANTAGES • Time consuming • Raising blister is painful • Multiple sittings for large areas • No immediate results • Small grafts yielded at a time in a single session • Risk of failure of blister induction

35. FLIP- TOP PIGMENT TRANSPLANTATION A technique in which graft is placed b/w a flap of epidermis & dermi at recipient site PROCEDURE • A thin split thickness graft is harvested • Graft is kept moist • A similar flap of epidermis is raised at recipient site • One end of epidermis is left in contact • Flap is turned to expose dermal side • Graft is placed in contact with dermis • Flap is put back in position

36.  Cyanoacrylate glue applied  Dressings FOLLOW UP  Dressing is removed after 1 wk  Phototherapy ADVANTAGES  Flap acts as a biological dressing  Excellent results

37. CELLULAR GRAFTS  Transfer of epidermal cells that have been disaggregated from the skin.  TYPES – 1. NCES ( non cultured epidermal suspension) 2. NCE ORS Suspension ( non cultured extracted outer root sheath suspension) 3. Cultured autologous melanocyte transfer

38. ADVANTAGES  Smaller amount of donor tissue is needed  Donor recipient ratio -1:8 -1:150  Post op pain and morbidity less  Immobilization needed is less  More suitable for certain areas like finger tips

39. NON CULTURED EPIDERMAL SUSPENSION • Transplantation of autologous cultured and noncultured melanocytes which involves self suspension without culture

40. Equipments • Trypsin – EDTA solution of 0.25% • Trypsin inhibitor • Dulbecco’s Modified Eagle’s Medium(DMEM) • Aerobic incubator • diamond fraise dermabrader or CO2 laser • Dermatome or suction apparatus • Pasture pipette or calibrated micropipette • Fine pointed forceps • Centrifuged tubes and petridishes • Collagen dressing

41. Procedure  STEP 1 : PREPARATION OF CELL SUSPENSION • STSG harvested under local anaesthesia • graft placed in a petri dish containing 8ml 0.25% trypsin- EDTA solution • Graft soaked completely in the solution, with epidermis facing upwards • Incubated at 37deg C for 50 minutes • Trypsin solution neutralised by adding 5 ml of 0.5% trypsin inhibitor • Separation of epidermis from dermis, dermis discarded • Cells transferred to a test tube and centrifuged for 5 mins to obtain pellet rich in cells

42.  Test tube centrifugated for 6 mins at 1000rpm  Epidermal cells is transferred to suitable medium (DMEM) in a test tube  Supernatant part discarded, bottom part suspended in 1 ml insulin syrinGE  STEP 2 : TRANSPLANTATION  recipient area cleaned f/b local anesthesia with 2 % lignocaine  Recipient area is abraded down to DEJ using diamond fraise dermabrader  Cell suspension is poured over recipient area drop by drop  The area is covered with transparent collagen film f/b dry gauze kept in place with sterile transperent occlusive dressing

43.  Post – operative  complete rest with no vigorous activities  Antibiotics for 5 days  NSAIDs for 3 days  Dressing removed after 1 week  Complete epithelisation takes 6-10 days  Follow up at week 1 and 3 then at 3 month interval  Phototherapy with PUVA can be initiated after 3 weeks  Pigmentation first appears in 3-6 weeks, take 3-6 months for patched to achieve maximum pigmentation

44. Disadvantages • Complex procedure Specific cell culture grade biochemical and media • Well equipped operating room • More expensive • Training required • Time consuming  Smaller amount of donor tissue is needed  Donor recipient ratio -1:8 - 1:150  Excellent texture and colour matching  No stuck on look  Post op pain and morbidity less  More suitable for certain areas like finger tips Advantages

45.  The bulge area of the human hair follicle is found to be niche of melanocytes stem cells, a quiescent cell population, which acts as melanocytes reservoir.  The stem cells can migrate into migrate into epidermis and give rise to differentiating melanocytes to produce pigmentation. NON CULTURED EXTRACTED OUTER ROOT SHEATH SUSPENSION

46. Procedure  STEP 1 : FOLLICULAR UNIT EXTRACTION  Donor site : occipital area  Hair are trimmed to size 1-2mm  Field block anesthesia given using 2 % lignociane with adrenaline  1mm punch of intact hair follicle taken and extracted with hair follicle holding forceps  Intact hair follicle collected in normal saline and transferred to laboratory  Dressing : mupirocin ointment and sterile cotton pads

47.  STEP 2 : PREPERATION OF CELL SUSPENSION  Extracted hair follicles washed thrice under phosphate buffered solution (PBS).  Incubated in 0.25% trypsin with EDTA solution at 370 C for 30 minutes to prepare a single suspension  In 15-20 mins cells from ORS start seperating and rest are gently stroked after incubation to loosen cells  Add trypsin inhibitor to inhibit for digestion of cells  A cell suspension created f/b centifugation at 1000rpm for 5 mins  Cell pellet resuspended in DMEM’s

48.  STEP 3 : TRANSPLANTATION  Recipient area cleaned f/b local aneasthesia with 2 % lignocaine  Dermabrasion of recipient area till 5mm beyond the margin of vitiliginous area ( to avoid depigmentary halo)  Suspension is aspirated with pipette and spreaded evenly over the recipient areaDressing: 5 layered, collagen sheet, antibiotic containing paraffin gauze, surgical cotton pad, thin transperent dressing film, elastic adhesive bandage

49.  Post- operative  Immobilize , Keep area clean and dry, Minimal manipulation for 7 days  Systemic antibiotics for 7 days  Dressing removed at 7th day  Phototherapy started to induce rapid repigmentation

50.  Advantages  Follicular melanocytes -  Follicular melanin have 1:1 to 1:5 ratio with keratinocytes  Melanocytes are cyclically active  Melanocytes have more and larger dendrites  Melanosome are larger  Minimally degraded by hair cortex  Relatively less susceptibility to to immune destruction Therefore relatively less amount of donor area required for transplant  Disadvantages  Laborious and tome consuming  Needs learning to correctly extract complete hair follicle without transection

51. AUTOLOGOUS CULTURED MELANOCYTE TRANSPLANTATION • In vitro cultured melanocytes • Donor to recipient ratio of >1:10( upto 1:60) • Major advantage to cryo-preserve melanocytes.

52. Equipments • Trypsin – EDTA solution of 0.25% • Trypsin inhibitor • Dulbecco’s Modified Eagle’s Medium(DMEM)/Nutrient mixture F-12 • Aerobic incubator • diamond fraise dermabrader or CO2 laser • Dermatome or suction apparatus • Pasture pipette or calibrated micropipette • Fine pointed forceps • Centrifuged tubes and petridishes • Collagen dressing

53. Procedure  Step 1 : Collection Of Sample  Surgical preperation  EMLA( eutectic mixture of local anaethesia)  Biopsy of normal pigmented area  Graft collected in PBS and transported to laboratory under ice  Donor area dressed with sterile non-adherent chlorhexidine gauze f/b sterile surgical pad f/b transparent occlusive dressing

54.  Step 2: Processing Of The Graft  Fat attached to graft is removed  0.25% Trypsin- EDTA solution added, epidermal side downwards  Incubation at 40C overnight  trypsin inhibitor added  Trypsin inhiboitor removed f/b adding M2 medium added with separation of epidermis from dermis and waste tissue removed  Centifugation at 1000rpm for 5 mins to obtain a pellet

55.  Pellet resuspended in 5ml M2 melanocyte medium and transferred to a 75 or 150 cm2 culture flask containing M2 medium  Maintained at 370 C in a humidified , 95% air, 5% CO2 atmosphere  Medium changed every 3-4 days n checked for contamination  Culture done for 15-20 days

56.  Step 3 : Transplantation  After removing culture medium from the falsk, trysin – EDTA solution added, incubated for 5 mins  Suspension then pipetted out, trypsin neutralised by trypsin inhibitor  Trypsin inhibitor pipetted out and suspension centifuged at 1000rpm for 5 mins  Pellet resuspended in M2 medium  Transplanted onto dermabraded recipient site  Dressing: 5 layered, collagen sheet, antibiotic containing paraffin gauze, surgical cotton pad, thin transperent dressing film, elastic adhesive bandage

57.  Post- operative  Immobilize , Keep area clean and dry, Minimal manipulation for 7 days  Systemic antibiotics for 7 days  Dressing removed at 7th day  Phototherapy started to induce rapid repigmentation

58. Advantage  Cryopreservation of melanocytes for future  DR ratio high  No. of melanocytes can be expanded upto 100 times  Large areas can be treated with small donor area Disadvantage •Expensive •Lab facilities required •Still experimental

59. MICROPIGMENTATION  Involves implanting small particles ( mostly iron oxide pigment into the middle layer of dermis similar to the tattoo)  Also known as PERMANENT COSMETICS.  Useful for cosmetics camouflage of vitiligenous patch specially involving mucosal & mucocutaneous areas

60.  INDICATIONS:  Urgent pigment correction of the dipigmented patch  Special sites like angle of mouth where graft retention is poor  TATTOO PIGMENTS- autoclaved • White titanium dioxide • Red cinnabar, mercuric sulphate • Black iron oxide • Yellow cadmium sulphate • Camel yellow iron oxide • Light brown iron oxide • Dark brown iron oxide

61. Procedure  Informed consent  Cleaning with normal saline  Followed by tumescent anesthesia with 2% xylocaine  Sterilized no.10 pony sized sewing needles  Micropigmentation is done until the color matches the surrounding skin  Pressure given to stop bleeding  Area clean with saline Immediate side-effects : bleeding, hematoma

62. Advantage Disadvantage  Help blend the color of vitiligo to more closely that match surrounding skin  Breaks up the texture of vitiligo skin by softening & flattening  Blackening due to oxidation  Photosensitisation  Bleaching of pigment  Fading of pigment over period of time  Reaction to tattoos

63. SURGICAL REMOVAL  Followed by primary closure  Practised in urgency to get rid of lesion  Most common sites : small patch over the lip & mucosal area

64. Therapeutic wounding  Dermabrasion or wounding without subsequent graft procedures  Suited for hairy areas & induces repigmentation by altering epidermal cytokines milieu which stimulates active melanocytes in outer root sheath of hairs  Modalities manual or motor dermabrasion laser ablation by CO2 & Er :YAG laser cryo surgery chemical peeling with 88% phenol, TCA 30-50%, 5% 5-FU

65. OVERVIEW TECHNIQUE ADVANTAGES  MINIPUNCH GRAFTING INDICATION acral areas  Scarring  Cobble stoning  Results are not immediate, needs follow up phototherapy for 2-3 months DISADVANTAGES  Simple, easy, inexpensive, OPD procedure

66. OVERVIEW TECHNIQUE ADVANTAGES  SUCTION BLISTER GRAFTING INDICATION lips, eyelids  Time consuming  Yields only small sized grafts DISADVANTAGES  No scarring,  Good cosmetic results  Safe and inexpensive  No special surgical skills required

67. OVERVIEW TECHNIQUE ADVANTAGES  THIN SPLIT THICKNESS SKIN GRAFTING INDICATION large areas  Hyperpigmetation and hypertrophy is common  Needs surgical skills  Donor healing may be delayed. DISADVANTAGES  m/c  Covers large areas over a short period  Pigmentation is uniform  Systemic PUVA not required  Difficult areas(eyelids, nipples, areaola, inner canthus of eyes) can be treated

68. OVERVIEW TECHNIQUE ADVANTAGES  AUTOLOGOU S EPIDERMAL CELL SUSPENSION INDICATION All areas  Lab facilities required  Takes 2-3 months for complete repigmentation  Expensive  Needs special training DISADVANTAGES  Large areas can be treated in a single session with small donor area  Repigmentatio n is uniform

69. OVERVIEW TECHNIQUE ADVANTAGES  CULTURED MELANOCYT E GRAFTING INDICATION all areas  Expensive  Lab facilities required  Still experimental DISADVANTAGES  No. of melanocytes can be expanded upto 100 times  Large areas can be treated with small donor area

70. SUMMARY AREA METHOD OF CHOICE  Face  Lips Genitals Eyelids  Acral area(palms/soles)  Other areas  SBEG, NCES  SBEG, NCES  PUNCH GRAFTS  STSG, NCES

71. Thank you.

Vitiligo sx1

Vitiligo sx1

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