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Amit G. Pandya, MD

Punch Grafting: A Simple and Effective Treatment for Focal areas of Vitiligo

Amit G. Pandya, MD

Wednesday, January 14, 2009

The use of small autologous minigrafts of skin for vitiligo has been described for over 30 years.1 This treatment has stood the test of time, even after the publication of studies comparing it to other surgical treatments for vitiligo.2-5 Although other surgical techniques, such as epidermal blister grafting, split-thickness skin grafting and autologous epidermal suspension grafts, have been used successfully in vitiligo, these techniques are more time intensive, expensive and require greater experience and skill to perform. Punch grafting is simple, relatively quick, and easy to perform by any dermatologist skilled at obtaining punch biopsies. Despite these advantages, punch grafting is not performed very frequently in many countries. This review will summarize the efficacy, technique and side effects of punch grafting in order to improve the comfort level of physicians who may be considering this form of therapy.

Vitiligo is a common disease, affecting 0.5 to 1% of the world's population. The majority of patients have generalized bilaterally symmetric lesions, for which phototherapy is usually the treatment of choice. Patients with segmental and focal vitiligo, however, are often resistant to phototherapy. Because of the localized, stable nature of this form of vitiligo, these patients are especially responsive to surgical treatment modalities. Punch grafting is effective in the majority of such patients.

In one of the first studies with punch grafting, Falabella achieved 90-100% repigmentation in 13 of 17 (76%) patients with localized vitiligo.6 He employed a minigraft test to determine which patients had the potential of responding to punch grafting prior to performing the procedure. Others have achieved success in generalized vitiligo using punch grafts. Boersma et al. reported 80-99% repigmentation in 14 of 36 (36%) lesions and 50-80% repigmentation in an additional 10 lesions (28%) in patients with stable generalized vitiligo.7 A review of nine patient series by Njoo et al. encompassing 258 patients with all types of vitiligo reported >75% repigmentation in 68% of patients treated with minigrafting.2 Another study of 1,000 patients by Malakar and Dhar reported 90-100% repigmentation in 75% of patients.8 A total of 80% of these patients had localized disease. Multiple studies have reported good repigmentation rates using minigrafting, particularly for localized disease. Of course, with any surgical procedure, attention to correct technique is essential in order to produce optimal results.

For unknown reasons, some patients who receive an autologous minigrafts do not show any spread of pigmentation from the graft, in fact, some demonstrate destruction or sloughing of the graft when the site is observed over 1-2 months. For this reason, the minigraft test has been recommended by several authors in order to exclude patients with less likelihood to respond to minigrafting.6,7 The minigraft test is performed by placing 2-4 grafts in a vitiliginous macule and then observing the area for pigment spread over 2-3 months. Patients who do not have pigment spread of at least 1 mm beyond the grafts have a negative test and should not receive further minigrafting.  

Larger grafts cause cobblestoning, whereas smaller grafts may not produce enough pigmentation to be of much use. Therefore, 1.25-1.5 mm grafts have most commonly been used for minigrafting. The use of jeweler's forceps and magnification helps to perform this delicate procedure. The procedure I use is as follows:

  1. I choose highly motivated patients who have maximized repigmentation with topical therapy or phototherapy and who have not had advancement of their disease in the last 6 months. Keloid and hypertrophic scar formers are excluded. Patients should agree to receive phototherapy for at least 4 months after grafting.
  2. After informed consent, the recipient sites are marked, about 8-10 mm apart, and anesthetized. While some patients will only have about 5 mm of pigment spread beyond the graft, others, especially those with darker skin, may have up to 12 mm of pigment spread.9 The minigrafts test helps in determining the spacing of subsequent grafts. 
  3. The donor site is chosen from skin in the boxer short distribution, most commonly the buttocks, hips or inguinal region. A rectangular area is marked off and anesthetized.
  4. After preparing the skin with surgical scrub, the recipient defects are created with a 1.5 mm disposable punch instrument, which is inserted down to the subcutaneous fat. The plugs of skin are removed and discarded.
  5. The grafts are obtained by using the same 1.5 mm punch instrument which is inserted to mid reticular dermis. The grafts are gently raised and cut at the level of the dermis with a pair of sharp, fine scissors. It is important not to include any deeper tissue in the grafts so that they can easily be inserted in the recipient defects. The donor grafts are obtained in linear rows, in close approximation to one another, so that scarring is limited to only one area. 
  6. The grafts are then inserted in the recipient defects and gently pushed into place by tapping on the top with closed forceps.
  7. A skin adhesive, such as Mastisol, is applied on either side of the graft, after which a thin sterile tape, such as Steri-Strips, is applied to hold the graft down. I do not apply the volatile adhesive to the grafts themselves, as this tends to destroy them. Some use petrolatum soaked gauze or transparent adhesive on the grafts post-operatively.
  8. Non-adhesive gauze and a flexible wrap-like dressing is then applied to the surgical site.
  9. The patient is instructed not to get the area wet for a week and to keep the wrap on as much as possible during that time. The Steri-Strips fall off on their own in 5-7 days. Areas of increased mobility need to have good compression with a bandage in order to prevent loss of the grafts.
  10. Phototherapy can be restarted one week after grafting. 

The above procedure is simple to perform and usually yields good results. Complications include cobblestone appearance of the grafts and small, milia-like scars. Both of these improve with time. Cobblestoning is the appearance of papules at the sites of the grafts themselves. This can be minimized by using grafts that are thinner that the recipient defect, as described above. Infections are rare. Hyperpigmentation may appear at the site of the grafts and surrounding skin, but this usually subsides as the macules grow and coalesce with one another. The donor sites heal well with local wound care. Small depressed scars usually remain afterwards.

Phototherapy is often given post operatively, which helps the spread of pigmentation post-operatively.9 Maximum spread of pigment is seen by 4 months and maximum color match by 6 months after grafting.8 Additional grafting is usually done after several months in intervening and adjacent areas which have not repigmented. Patients usually tolerate the procedure well. Older children, who are able to tolerate local anesthesia, can be treated as well.

In summary, punch minigrafting for vitiligo is an easy-to-perform, effective therapy for localized, stable vitiligo. While other surgical modalities, such as blister and split-thickness grafts, may be more effective, the ease with which punch minigrafting can be performed and its low cost make it an attractive choice for dermatologists worldwide. Until a cure for vitiligo can be found, surgical procedures will remain important in the therapeutic armamentarium for this disease.

References

  1. Falabella R. Repigmentation of leukoderma by minigrafts of normally pigmented, autologous skin. J Dermatol Surg Oncol.  1978;4:916-919.
  2. Njoo MD, Westerhof W, Bos JD, Bossuyt MM. A systematic review of autologous transplantation methods in vitiligo. Arch Dermatol. 1998;134:1543-1549.
  3. Gupta S, Jain VK, Saraswat PK, Gupta S. Suction blister epidermal grafting versus punch skin grafting in recalcitrant and stable vitiligo. Dermatol Surg. 1999;25:955-958.
  4. van Geel N, Ongenae K, Naeyaert J-M. Surgical techniques for vitiligo: A review. Dermatology. 2001;202:162-166.
  5. Babu A, Thappa DM, Jaisankar TJ. Punch grafting versus suction blister epidermal grafting in the treatment of stable lip vitiligo. Dermatol Surg. 2007;34:1-13.
  6. Falabella R. Treatment of localized vitiligo by autologous minigrafting. Arch Dermatol. 1988; 124:1649-1655.
  7. Boersma BR, Westerhof W, Bos JD. Repigmentation in vitiligo vulgaris by autologous minigrafting: Results in nineteen patients. J Am Acad Dermatol. 1995;33:990-995.
  8. Malakar S, Dhar S. Treatment of stable and recalcitrant vitiligo by autologous miniature punch grafting: A prospective study of 1,000 patients. Dermatology. 1999;198:133-139.
  9. Lahiri K, Malakar S, Sarma N, Banerjee U. Repigmentation of vitiligo with punch grafting and narrow-band UV-B (311 nm)- a prospective study. Int J Dermatol. 2006;45:649-655.
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