Punch Grafting: A Simple and Effective Treatment for Focal areas of Vitiligo
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
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
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:
- 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.
- 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.
- 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.
- 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.
- 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.
- The grafts are then inserted in the recipient defects and
gently pushed into place by tapping on the top with closed
- 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
- Non-adhesive gauze and a flexible wrap-like dressing is then
applied to the surgical site.
- 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.
- Phototherapy can be restarted one week after
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.
- Falabella R. Repigmentation of leukoderma by minigrafts of
normally pigmented, autologous skin. J Dermatol Surg
- Njoo MD, Westerhof W, Bos JD, Bossuyt MM. A systematic review
of autologous transplantation methods in vitiligo. Arch
- 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.
- van Geel N, Ongenae K, Naeyaert J-M. Surgical techniques for
vitiligo: A review. Dermatology. 2001;202:162-166.
- 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.
- Falabella R. Treatment of localized vitiligo by autologous
minigrafting. Arch Dermatol. 1988; 124:1649-1655.
- 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.
- Malakar S, Dhar S. Treatment of stable and recalcitrant
vitiligo by autologous miniature punch grafting: A prospective
study of 1,000 patients. Dermatology.
- 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.