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STUDIES
Year : 2005  |  Volume : 50  |  Issue : 4  |  Page : 196-199
Autologous miniature punch grafting in stable vitiligo


Department of Dermatology, Command Hospital (AF) Bangalore, India

Correspondence Address:
R Rajagopal
5 Air Force Hospital, C/o 99 APO
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Autologous miniature punch grafting with certain modifications was taken up in 54 sites in 30 patients with stable vitiligo for 6 months or more. The modifications were: (a) use of same sized disposable punches for both donor and recipient areas except over convex body surfaces, (b) use of Castraviejo's scissors for harvesting donor grafts, (c) use of medial side of thigh as donor site and (d) not removing the primary dressing of the recipient site till 8 postoperaive day. The patients were given systemic PUVASOL after the procedure for a period of three months and mean pigment spread was noted at each site. Results showed that the extent of repigmentation varied among the recipient sites, the maximum being over upper eyelids, axillae and umbilicus. The modifications in the standard procedure were found to produce less complications, like cobblestoning, graft rejection.


Keywords: Vitiligo, Punch grafting, Modifications


How to cite this article:
Rajagopal R, Murthy P S, Kar P K, Vijendran P. Autologous miniature punch grafting in stable vitiligo. Indian J Dermatol 2005;50:196-9

How to cite this URL:
Rajagopal R, Murthy P S, Kar P K, Vijendran P. Autologous miniature punch grafting in stable vitiligo. Indian J Dermatol [serial online] 2005 [cited 2020 Oct 28];50:196-9. Available from: https://www.e-ijd.org/text.asp?2005/50/4/196/19743



   Introduction Top


Despite modern advances in medical science and in the social attitude of people, vitiligo on exposed sites continues to embarrass the victim, resulting in considerable mental agony. In the recent past, a number of surgical methods has evolved to treat stable cases of vitiligo. Miniature punch grafting is one of the favored methods of surgical treatment.

An experience of thirty cases at a service hospital is presented wherein a few practical modifications in the standard procedure for miniature punch grafting have been found useful.


   Materials and methods Top


The study group comprised of thirty patients of stable vitiligo (showing no increase in size of lesions or appearance of new lesions over a period of at least six months) presenting to skin OPD of Command Hospital (Air Force), Bangalore, over a period of two years from June 2000 to June 2002. Patients with actively spreading vitiligo, vitiligo less than six months duration, those with keloidal tendencies were excluded from the study. The included subjects were treated with systemic psoralen therepy (PUVASOL) for at least 3 months but each failed to show significant repigmentation. Initially, test grafts were done in each cases.

Autologous miniature punch grafting was done as laid out in the standard procedure[1] except for the following modifications:

(a) Same size disposable punches were used for both the donor and the recipient areas.It was 1.5 mm disposable punch for the eyelid region and 2 mm punch was used to cover small sized lesions of size 3 cm diameter or less, 2.5 mm punch was used for lesions larger than 3 cm up to 5 cm and 3 mm punches for those greater than 5 cm. Donor area punches were 0.5 mm larger than recipient area punches only in selected cases where the recipient area was over an anatomical convexity, like hip, shoulder or elbow, where the chamber size assumes a larger size than the punch due to skin tension.

(b) Castraviejo's scissors were used instead of the standard 'S' shaped scissors for harvesting grafts from the donor area.

(c) No extra graft was taken from the donor site area, other than those required to fill the recipient chambers.

(d) Medial area of the thigh was used as donor site except in case of facial lesions where postauricular area was used. Gluteal region and lateral aspect of the thigh were not used as donor sites.

(e) Postoperatively, firm dressing with double layered sofratulle, gauze and elastocrepe was done for the recipient areas. Mobility was restricted for two days, by admitting the patient if necessary. Dressing for recipient area was not disturbed for eight consecutive days. The dressing was repeated after 8 days by a light dressing and plaster for another 8 days following which the patient was exhibited PUVASOL therapy for 3 months and mean pigment spread (MPS) was assessed. Patients were followed up for mean pigment spread in mm from date of graft up to 3 months.


   Results Top


Among the study population, 19 (63.3%) were male and 11(36.6%) were female. The youngest patient was 7 year and oldest 53 year. Twenty six (86.6%) had focal vitiligo, 2 (6.6%) had segmental and 2 (6.6%) had acrofacial vitiligo. A total of 54 sites in thirty patients were grafted. Six (20%) patients belonged to skin type III, 22 (73.3%) to skin type IV, and 02 (6.7%) patients to skin type V. Upper chest (11) and shin (11) constituted the most common recipient sites (22.9%) [Table - 1].

Perigraft pigmentation was evident from 3rd week of grafting, steadily increasing up to the endpoint of record, i.e., 3 months. Mean pigmentary spread (MPS) varied depending on the site grafted, maximum spread (8 mm) occurring over eyelid, axilla and umbilicus. An MPS of 7 mm was recorded over the upper chest. Bony sites, like ankles, recorded a low MPS of 3 mm. Similar low figures of MPS (2-3 mm) were observed for fingers and toes as well [Table - 1]. Twenty two (73.3%) patients of skin type IV showed 50-90% repigmentation and 2 (6.7%) patients of skin type V showed 90-100% repigmentation at the end of 3 months [Table - 2].

There was no case of graft rejection, graft extrusion, secondary infection of the grafted site or donor site depigmentation. Failure to repigment was noted in one (3.3%) case, junctional lines in 3 (l0%) cases, cobblestoning in one (3.3%) case, hypertrophic scarring in 2 (6.6%) cases (one at recipient and one at donor site), postoperative traumatic uveitis in one (3.3%) case [Table - 3]. Cases with junctional lines were taken up for filler grafts. Post-traumatic uveitis subsided with topical steroid drops and anti-inflammatory drugs.


   Discussion Top


The success of miniature punch grafting depends upon various factors such as:

(a) Proper selection of cases ensuring stability of patch

(b) Good quality instruments

(c) Pre-operative counseling about procedure and realistic expectations

(d) Patient co-operation during the procedure

(e) Surgical skill

(f) Adequate postoperative care including firm dressing and restricted mobility during first two days postoperatively and guarded activity during first week.

During the present study a few interesting aspects have been observed:

(a) Though stable vitiligo has been traditionally defined as patches stable in size and number for two years, it is felt that cases that are stable for a period of 6 months can be taken up for grafting without untoward complications.

(b) Punches of same size for both donor and recipient areas have been found to reduce the incidence of cobblestoning in most areas of the body. Exceptions are recipient areas over body convexities like hip, shoulder, elbows and mammary areas where the chamber assumes a larger diameter due to stretching of the skin. In these areas 0.5 mm larger punch for donor area was found useful.

(c) A maximum of 30 to 35 grafts should be taken up at one session to avoid operative fatigue and error. It also ensures better patient compliance and co-operation for the next session.

(d) Castraviejo's scissors were found more useful in harvesting thin donor grafts than the traditional "S" shaped double curved scissors in the present work. Since Castraviejo's scissors have a shorter and sharper cutting edge than the standard scissors and blades are open in the resting position, better control is achieved while harvesting the grafts.

(e) The accurate circular shape of the donor site grafts was not found critical for graft take as long as the size was not markedly different from that of the recipient chambers and the grafts were properly oriented (dermal side down).

(f) Over soft and mobile parts, like mammary area, it is found necessary to manually fix the recipient site with the other hand or assistant's hand to provide sufficient counter-resistance for making recipient chambers. Over areas like the upper eyelids, it may be necessary to use a metallic eyeshield applied under topical corneal anesthesia to avoid postoperative traumatic uveitis, as happened in one case in the present study.

(g) Medial side of the thigh offers an ideal site for harvesting donor grafts as the skin is not under stretch as over the gluteal region or lateral side of the thigh and does not inconvenience the patient's daily routine in visiting the toilet.

(h) Mean pigmentary spread (MPS) was found to be maximum over the eyelids, axilla, umbilicus and upper chest and low over ankles and fingers and toes as were seen in some other studies.[2]

(i) Skin types IV and V correlated well with good degree of repigmentation in this study as in many others. [3],[4],[5] On the other hand skin type III did not repigment well.

To conclude, a few variations from the usual procedure were found useful in reducing cobblestoning without adversely affecting graft outcome. Miniature punch grafting remains a useful and gratifying procedure in stable focal, segmental and even acrofacial vitiligo both for the patient and the physician.

 
   References Top

1.Savant SS . Miniature punch grafting.In: Savant SS, et al. Shah R, Gore D. eds . Textbook and Atlas of Dermatosurgery and Cosmetology.ASCAD: Mumbai, India, 998;235-9.  Back to cited text no. 1    
2.Lahiri K, Sengupta SR. A regionwise comparative study of the extent of post punch graft surgical repigmentation in cutaneous achromia. Indian J Dermatol Venereol Leprol 1998; 64:4.173-5.   Back to cited text no. 2    
3.Savant SS. Autologous miniature punch grafting in stable vitiligo. Indian J Dermatol Venereol Leprol 1992:58:310-4.  Back to cited text no. 3    
4.Das SS, Pasricha JS. Punch grafting as a treatment for residual lesions of vitiligo. Indian J Dermatol Venereol Leprol 1992;58:328-30.   Back to cited text no. 4    
5.Singh KG, Bajaj AK. Autologous miniature skin punch grafting in vitiligo. Indian J Dermatol Venereol Leprol 1995; 61:77-80.  Back to cited text no. 5    


Tables

[Table - 1], [Table - 2], [Table - 3]



 

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    Abstract
    Introduction
    Materials and me...
    Results
    Discussion
    References
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