The aim of surgical treatments in vitiligo disease is to remove the diminishing and/or disappearing melanocytes from the patient and surgically put them on the diseased areas and ensure recoloration. These treatments are applications made for aesthetic or camouflage purposes rather than a radical treatment for the disease. Surgical treatments are used alone or in combination with other treatments in vitiligo.
3 methods are used in surgical applications
1. Surgical excision method; The first and simplest of the surgical methods in vitiligo; It is the removal of the diseased area with simple surgical methods. Its biggest advantage is that it does not require a special instrument and laboratory. The disadvantage of this method is that it can be performed on body areas with small vitiligo dimensions and low risk of leaving visible scars after the surgical procedure.
2. Applications made with skin tissue grafts (patches); In vitiligo, it is the transfer of skin tissue, including melanocytes, taken from the patient himself and the body area without the disease, to the vitiligo area. It is not as simple as the surgical excision method. Its advantage is high clinical success after application. Requires special instrument. The disadvantage is that the application can be applied to small areas of vitiligo.
3. Applications with skin cell grafts; In vitiligo, it is the transfer of the same patient to the vitiligo area by separating and multiplying the epidermis and melanocytes from the skin taken from the patient himself and the body area without the disease. It is a special method. It requires a special laboratory, team and instrument. However, it is the biggest advantage that the patient can apply to large vitiligo plaques in one session. Even if the patient’s normal skin from which melanocytes will be taken is less, melanocytes are cultured and multiplied, so it is applied.
Who Can Be Applied to the Surgical Method in Vitiligo?
The criteria used in patient selection before surgical treatment are as follows;
Surgical treatments are not the first treatment option in vitiligo. Surgical treatment can be performed when there is no response to other previously applied treatments.
1. The type of vitiligo should be prevented. The best results in surgical treatments are obtained from segmental vitiligo type. Successful results are also obtained in nonsegmental and diffuse vitiligo.
2. The color of the hairs in the diseased areas is extremely important in vitiligo. “Leukotrichia”, that is, the whitening of the hair, is important in the pre-treatment evaluation. Bleaching of the hair in the disease area
shows that the melanocytes are greatly reduced. Surgery can be considered as the first treatment option in these patients.
3. Repigmentation (return of color to normal) in vitiligo areas after previous treatments or without treatment supports that a good response will be obtained from surgical applications.
4. Stability of vitiligo disease; Surgical treatments are much more successful in stable vitiligo. Although there is no complete consensus on the definition of stable vitiligo, the fact that patients do not develop new vitiligo lesions for a period of 1 year and that the existing vitiligo lesions do not grow indicates that the disease is stable.
Comparison of patient photographs taken in previous years is extremely important in understanding the stability of the disease.
The vitiligo stability score has been used since 1999. This is called VIDA. The best results in surgical applications are obtained with 0 and -1 VIDA scores.
6. The patient should not have Koebnerization (Köbnerization is the presence of new vitiligo plaques after traumas such as falling on the intact skin, surgery, incision, even itching, etc.).
7. The width of the diseased area to be treated; The smaller the area to be treated, the higher the chance of success.
8. Locations of lesions in the body in vitiligo; The best results in surgical treatments are obtained in the neck and anterior chest wall. The response of vitiligo to surgical methods is weaker on the joints (such as on the hand knuckles), eyelids, lips, genital organs, folds.
9. Patient motivation is extremely important.
10. Patient’s age; Although there is no direct relationship, treatment compliance in children is not good.
11. Mini Punch Graft (MPG) is applied if it is not sure whether the patient will get good results before the surgical applications. The results of this test application have sufficient possible positive significance.
What is Mini Punch Graft (MPG) and how is it done?
For this, a small number of punch skin germs are applied to a small area of the patient with vitiligo. After 1.5-2 months, according to the response, the main surgical treatment is started.
4-6 tissue grafts with 1-1.2 mm diameter are taken from the patient’s normal skin. These are planted in the vitiligo area of the same patient. Treatment areas are covered with sterile dressing for 1 week and 10 days. 10 minutes of sunbathing per day is recommended for the treated vitiligo area. After 3 months of follow-up, the response is checked. A repigmentation of 1 mm or more than 1 mm around the graft means positive.
The test result can sometimes develop beyond expectations. For example, the micro-graft test result is good, but subsequent procedures may not be successful. Depigmented plaques may develop in the surrounding area while the results are obtained in the test area.
Who cannot undergo surgical treatments in vitiligo;
* More care should be taken in patients with hypertrophic scar (poor and scarring wound healing) and keloidal structure.
* In patients with a tendency to bleeding or using blood thinners
* The presence of a history of skin discoloration (postinflammatory hyperpigmentation) after wound healing is a negative criterion before the treatment of many skin diseases. However, its presence may support better results in vitilgo surgery treatments.
* Hepatitis C and HIV carrier
What are the surgical treatments in vitiligo?
Surgical treatments in vitiligo;
1. Grafting (patching) methods with autologous (taken from the patient) tissue and cells;
2. Other surgical methods applied without grafting; Although the results of autologous tissue and cell grafts are good in vitiligo treatment, tissue grafts are preferred more because of their simple application and the fact that they do not require very special laboratory conditions and instruments.
What are the tissue grafts used in the surgical treatment of vitiligo and how are they applied?
Tissue grafts are classified as follows according to the method of removal and preparation from the skin and their thickness from the skin;
1. “Split thickness” skin grafts.
2. Negative pressure-formed bulla epidermal grafts
3. Full thickness skin grafts
4. Microskin grafts
5. Flip top grafts
What are split thickness skin grafts and how are they applied?
There are subgroups listed below according to their thickness.
* Split-thickness skin graft-ultra-thin (STSG-UT) (0.08–0.15 mm thick)
* Split-thickness skin graft-thin (STSG-T) (0.2–0.3 mm thick)
* Split-thickness skin graft-medium (STSG-M) (0.3–0.45 mm thick)
* Split-thickness skin graft-thick (STSG-THK) (0.45–0.75 mm thick)
Skin grafts of different thicknesses are taken from the normal skin area without disease with special surgical instruments called dermatomes. This area is called the donor area. The inner parts of the hips, thighs and arms are often preferred for skin grafts.
Frequently, the size of the area to be grafted is 1 to 1 with the vitiligo area size. Sometimes, if the vitiligo area is large, the area of the graft taken by a method called Mesh graft expander can be expanded. With this method, the graft can cover 4 times larger vitiligo area.
After 1-2 weeks in the donor area from which the graft is taken, the normal color of the skin begins to appear with the healing of the wound, and the color returns to normal within 6 months. Sometimes there are no traces other than the development of mild milia.
The vitiligo area is prepared for the patching and holding of the graft. The epidermis and upper layers of the dermis are removed from vitiligo-infected skin. For this, methods such as dermabrasion, Fractional CO 2 laser are used. The chance of success is up to 95%.
Excimer laser and 308nm@MEI system are used 2-4 weeks after this grafting method has been applied. This allows the response to be faster and more successful in treatment.
What is Bule Epidermal Graft created with negative pressure and how is it applied?
It resembles skin gerfts of ultra-thin thickness. Skin grafts are taken from the normal skin area without the use of a dermatome. The inner parts of the hips, thighs and arms are often preferred for skin grafts. In this method, negative suction pressure is applied to the skin with special instruments and the epidermis and dermis of the skin are separated. Blisters form on the skin surface in the form of blisters. For the formation of sucking bullae in normal skin, 200-500 mmHg pressure is applied to the skin for 1-2 hours with special instruments.
Afterwards, the epidermis is excised over these bullae.
This area is closed with sterile dressings for 1 week and 10 days.
The vitiligo area is prepared for the patching and holding of the graft. Epidermis and superficial dermis layers are removed from vitiligo diseased skin. For this, methods such as dermabrasion, Fractional CO 2 laser are used. Epidermis grafts taken from bullae are planted in these areas. These areas are covered with sterile dressings.
2 weeks after the application, the transplanted epidermal structure is poured, but the repigmentation areas develop under them.
The chance of success is lower by 25-65%. Compared to thin-thickness germs, the application time is less preferred when both clinical results and side effects are compared.
What are full-thickness skin grafts and how are they applied?
There are 2 types of full-thickness skin grafts;
1. MPG(Micro punch grafts); In this method, 1-1.2 mm diameter grafts are taken from the hip, behind the ear and inner part of the upper arm with instruments called “punch” under local anesthesia.
Planting areas are opened with 1 mm punches on the vitiligo diseased area. (There should be a difference of 0.2 mm between the punch diameter used in the donor area and the punch diameter used in the transplant area) Graft transplantation is performed in the vitiligo area at 5-10 mm intervals. The grafted and transplanted area is covered with sterile dressings for 1 week after sowing. In 2-4 weeks, repigmentation begins around the grafts in vitiligo areas, and after 3-6 months, repigmentation is maximum. Success varies between 60-90%.
While the results are maximum on the face and neck, the application is difficult and the results are weaker in large and large vitiligos, on the inside of the hand, lips and eyelids.
Scars may remain in the donor area. On the other hand, in vitiligo graft cultivation areas, the appearance of “cobblestone = cobblestone” appears.
Application of 308 nm@MEI after sowing increases the results further. While the repigmentation around the grafts is measured as 3 mm after normal transplantation, after Excimer laser and 308 nm@MEI, 9 repigmentation increases over 9 mm.
2 . HFG(hair follicle grafts); It is similar to a hair transplant. It has been used especially in vitiligo areas with hairs. Such as eyebrows, eyelashes, scalp and beard area. The posterior part of the scalp and the back of the ear are chosen as the donor area. 2-8 weeks after the application, repigmentation begins around the hair follicle. It spreads by 2-10 mm.
What are microskin skin grafts and how are they applied?
Microskin skin grafts are the most frequently used application in our center.
In this application, ultra-thin grafts of 0.08-0.15 mm thickness are taken from the non-vitiligo skin area of the patient with a special tool called a dermatome.
The inner parts of the hips, thighs and arms are often preferred for skin grafts.
Removing a graft of this thickness allows the donor area to heal faster and without problems (with better aesthetic results without color irregularities).
The ultra-thin skin grafts taken are divided into pieces smaller than 1 mm2. These parts are called “Mikroskin Graft”. Special scissors were used to make these small parts. However, in recent years, an instrument called “Mincer” has been used instead of scissors. This divides the graft into smaller pieces with a diameter of 0.8 mm x 0.8 mm.
The vitiligo area is being prepared for micrograft transplantation. The purpose of this preparation is to lift the skin over vitiligo up to the upper layer of the dermis (ablation) and to make it suitable for the placement of the grafts.
For this purpose;
* Dermabrasion; Mechanical burs or ultrasonic dermabrasion are used.
* Ablation is performed with liquid nitrogen.
* Laser ablation is performed. Erbium YAG or CO2 laser is used. In our center, DEKA Fractional CO2 laser is used for this purpose.
With this method, the donor area / vitiligo area ratio is 1/15, that is, the vitiligo area 15 times the diameter of the donor area can be treated.
Different methods are used to place the micrograft in the vitiligo area.
1. Spatula placement; If the dimensions of the donor area and vitiligo area are the same, that is, 1:1, this method is preferred. After placement, the vitiligo area is covered with special muslin-vaseline compresses and bandages. After 7-10 days, the bandages are opened.
2. Docking with spray nozzles; It is preferred if the donor area is much smaller than the vitiligo area. Like 1:5-1:15. After the vitiligo area is prepared, the micrografts are either sprayed directly on the vitiligo area with special spray apparatus or applied to the vitiligo area by spraying on muslin-vaseline.
What are flip-top skin grafts and how are they applied?
Grafts are taken from the donor area at a depth of 2-4 mm and these grafts are divided into 1-2 mm small pieces as in microskin grafts. Flap is removed with a dermatome at a depth of 4-5 mm without ablation in the vitiligo area. These parts are placed under this flap. Recovery is faster.
What are skin cell grafts and how are they applied?
These are methods that require a special laboratory and instrument. Their costs are quite high. However, the chances of success are much higher than the aesthetic results.
Cell grafts; 2 methods are used.
1. Cultured epidermal cell graft suspensions; This method is divided into 2 parts.
* Cultured pure melanocyte grafts (CM); The melanocytes are separated from the grafts taken from the normal skin and reproduced in the culture medium. (1000-2000 melanocytes per mm2) These are transferred to the area with vitiligo.
* Cultured epithelial grafts (CE); The method is similar to melanocyte cultures. However, in the skin sample taken here, melanocytes are not differentiated. All of the removed skin is cultured and applied.
2. Epidermal cell graft suspensions without culture (NCES);
The skin taken from the patient’s non-vitiligo area is exposed to special enzymes. These enzymes separate the skin at the epidermis and dermis level. The dermo-epidermal cells are then mechanically scraped off. The cells obtained as a result of this scraping contain epidermal-melanocyte cells. Suspensions are prepared from them. The vitiligo area is prepared for ablation with dermabrasion or CO2 laser. This suspension is applied to these areas. Closed dressing is applied after the application. After 7-10 days, the closed dressing is opened and 3 weeks later, Excimer laser or 308 nm@MEI treatments are started. Repigmentation begins in vitiligo areas within 2-4 weeks, and at the end of 3 months, close to 100% answers are received. This method gives good results especially in common vitiligo. The prepared suspension can be used in large areas. It can treat a vitiligo area 10 times the skin sample taken from the donor area.
Recently, this system is also called “cell spray” application. ReCell is a system that has been used in recent years and prepares the application in 30 minutes. However, these systems are still quite expensive systems.
What are the surgical treatments without using grafts in vitiligo?
These are two.
1. Laser and light treatments;
- excimer laser
- Holmium laser
- 308 nm@MEI narrowband UVB treatments
2. Micropigmentation;
Tattoo is the use of tattoo for camouflage in vitiligo.
It is the placement of pigment-containing particles (nonallergenic, stable in tissue) with a diameter of 6 microns into the dermis.
Pigment particles remain inside or outside the cell. Extracellularly, it is often found between collagen fibers and intracellularly in dermal mononuclear cells.
Paints are available in the form of pigment-containing pastes. Colors are obtained alone or by mixing them. It is diluted by adding 1-2 drops of 80% alcohol or water into the pastes. It can be dripped in glycerin.
It is highly preferred in mucosal and mucocutaneous lesions.
What are the side effects of surgical applications in the treatment of vitiligo?
It is divided into 2.
1. Side effects in the field of vitiligo;
- * Hypopigmentation at the edge of the application area
- * Delayed hyperpigmentation
- * milia
- * Inclusion skin cysts
- * Acromic fissure
- * Thickening at the edges
- * Stuck image
- * Cobblestone; It is mostly observed in Punch grafts.
- * Contact dermatitis
- * Infection
- * Scar development
- * Cosmetic not good image
1. In the donor area;
- superficial scar
- * Hypopigmentation
- * Hyperpigmentation
- * Kobner development
- * Infection
What are the other uses of surgical treatments other than vitiligo?
Piebaldism; It can be mistaken for partial albinism or vitiligo. However, no response can be obtained from any treatment used in these. Piebaldism is a genetic disease inherited from AD. It is observed in 1 in 14000 births. Men and women are equal. Migration of melanocytes to the skin during embryonic development is a problem. Vitiligo-like macules. 90% with forelock on the forehead, bilateral on the anterior aspect of the trunk, feet and mid-arms. There is a hyperpigmented border around the macules and hyperpigmented islets are present within the macules
Waardenburg’s syndrome; One in 42 000 births with AD transit. Again, there is a problem in the migration of melanocytes to the skin.
4 types are known. The patient has macules similar to piebaldis, but no forelock.
Post-burn leucoderma (skin color reduction)
Post-laser leucoderma; after hair removal lasers and other medical lasers
Chemical substance leucoderma Phenol- and hydroquinone derivatives
leucoderma on the lips and face after herpes
piebaldism
leucoderma after DLE
halo nevus
Nevus depigmentosus
Idiopathic guttate hypomelanosis
