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Surgery and Cosmetics

Camile L. Hexsel, MD

Melanocyte Transplantation: Different Techniques can be used for Vitiligo and Other Dermatologic Conditions

Camile Hexsel

Thursday, November 08, 2012

There are multiple techniques available for melanocyte transplantation. These techniques are outpatient surgical procedures, mainly developed for the treatment of vitiligo. Indications include stable vitiligo for at least 2 years and negative history of recent koebnerization, keloids, and hypertrophic scars.

On the other hand, most physicians forget that melanocyte transplantation can also be used for treatment of other hypochromic and achromic conditions, such as idiopathic guttate hypomelanosis, particularly large lesions >5 mm diameter, superficial achromic scars, and hypopigmentation from other causes. However, scars with significant skin atrophy or intense fibrosis of the dermis are not good candidates, as grafting will not correct the color alterations caused by the intense dermic fibrosis.

Faster and more complete repigmentation can be achieved by combining surgical therapies with phototherapy to stimulate melanocyte migration.

Figure 1. Melanocyte transplantation

Hexsel

Autologous minigrafting

Comprises the removal of 1-1.2 mm punches of skin from pigmented autologous donor sites and the transplantation to depigmented or hypopigmented acceptor sites. Similar punch grafts are previously extracted from the recipient area prior to transplantation of the pigmented grafts.1 It is the easiest, fastest and least expensive method; however, there is a high rate of side effects, including scar formation at the donor site and cobblestoning.2

Given the small size of grafts, this technique is particularly useful for treating small lesions, such as areas of localized or segmental vitiligo, given the limited amount of skin.

Autologous suction blister grafting

The total epidermal graft is the thinnest skin graft for melanocyte transplantation. Epidermal blisters induced by negative pressure with a suction device on pigmented donor sites are subsequently transferred to denuded depigmented or hypopigmeted lesions.1,2

The advantage of this graft is lack of scar formation, and the possibility of treating larger areas than the autologous punch minigrafting. Furthermore, it can be done relatively quickly and inexpensively in the office, and it does not require specialized skills. Side effects observed with autologous suction blister grafting include mainly the possibility of hyperpigmentation at the donor site, which can be more significant with this technique than minigrafting and split-thickness grafting.2 This technique should be considered in patients with small- to medium-sized depigmented or hypopigmented lesions that don't have contra-indications for the procedure.

Limitations are related to the thickness of this graft, the limited amount of melanocytes that can be transferred, and the absence of hair follicles in this type of graft. This thin and usually small graft is unable to hide the yellowish aspect of fibrotic scars or change the total extension of the atrophic skin of some scars, when used to treat hypopigmented scars.

Studies have evaluated autologous suction blister grafting in vitiligo treatment. Li et al.3 reported complete repigmentation in 227 patients (20.6%), and excellent repigmentation (>50%) in 568 (51.6%), with an overall success rate of 72.3%. Ko and Chen4 described excellent treatment outcomes for 32 patients (80%), and good outcomes for four patients (10%). Hong et al.5 also reported repigmentation of 50% or more in 83.3% of children, 95% of adolescents, and 84% of adults studied. The mean extent of repigmentation in children, adolescents and adults was 80.7%, 78.9%, and 76.6%, respectively.

Technique for the procedure includes the following steps:

  1. Select the donor area, ideally an area that can be hidden by clothing.
  2. Cleanse the skin with 70% isopropyl alcohol or other antiseptic method of your preference.
  3. Apply the suction device of your preference on the skin.
  4. After the blisters develop on the donor site, the donor areas should be abraded or ablated with the method of your preference at a superficial level, immediately before the donor epidermis is collected.
  5. Collect the blisters after removing the fluid content from them.
  6. Cut the borders of the blisters with an iris scissor.
  7. Position micropore dressing tape or other bandage of your preference over the blisters, keeping the donor skin attached to the micropore dressing tape.
  8. Position the total epidermal graft in the host's previously abraded area, and protect it with other dressings.
  9. Remove dressings 1 week later.
  10. Phototherapy after the procedure is recommended to increase the success.

Split-thickness grafting

Consists of transplantation of a thin split-thickness skin graft harvested from the autologous pigmented donor site to denuded depigmented or hypopigmented lesions.1,2 Scar formation, partial loss of grafts, and milia formation are common side effects of split-thickness grafts.2 

A systematic review of the techniques described above for the treatment of vitiligo showed that maximal repigmentation occurred with split-thickness grafting and autologous suction blister grafting when compared with minigrafting.2

Transplantation of non-cultured epidermal suspensions

Consists of injecting an epidermal suspension with melanocytes and keratinocytes from pigmented donor skin formerly prepared by trypsinization, into denuded, depigmented or hypopigmented recipient sites.1

This is the technique of choice for the treatment of large, depigmented or hypopigmented lesions with relatively small donor areas.1,2 Major disadvantages are cost and the required infra-structure and technical skills, and thus patients should be referred to surgeons who are comfortable with this technique, which can be rare in many countries.

Mulekar reported his technique with good results even for large areas affected by vitiligo. These are the steps of the procedure, described by Mulekar:

  1. A shave biopsy skin sample of up to one-tenth the size of the recipient area is incubated.
  2. The cells are mechanically separated by using trypsin EDTA solution.
  3. The material is centrifuged to prepare a suspension.
  4. The cell suspension is applied to the dermabraded, depigmented skin area with a collagen dressing to keep it in place.

In a study of 122 patients with generalized vitiligo, 43 with segmental and 19 with focal vitiligo, 53% of the patients showed excellent repigmentation in the generalized vitiligo group, 84% in the segmental vitiligo group, and 69% in the focal vitiligo group.6 In another study, 84% of the patients with segmental vitiligo had excellent pigmentation, and 73% of the patients with focal vitiligo had excellent pigmentation (95-100% repigmentation). These results were retained until the end of the follow-up period (1 to 5 years).7 In a subsequent study (n=142), 56% of the patients had excellent repigmentation and 11% showed good repigmentation.8 A recent study in the United States of 28 patients treated with this technique followed for 6 months showed that 17% of the patients achieved excellent (95-100%) repigmentation (n=28), 31% of the patients achieved good (65-94%) repigmentation, 10% of the patients achieved fair (25-64%) repigmentation, and 41% of the patients achieved poor (0-24%) repigmentation. The average percent improvement in vitiligo was 45% in this study.9

Transplantation of in vitro cultured autologous epidermis or pure melanocytes

Consists of the transplantation of autologous thin sheets of epidermis or pure melanocytes previously cultured in vitro into denuded depigmented or hypopigmented recipient site.1,2 There is a concern of the tumorigenic risk of culturing techniques because of the presence of tumor promoters in certain culture media combined with the use of post-operative phototherapy.2

Advantages include the possibility of treatment of large depigmented or hypopigmented lesions with relatively small donor areas.1,2 Major disadvantages are cost and the required infra-structure and technical skills, and just like with non-cultured epidermal suspensions, patients should be referred to surgeons who are comfortable with this technique, which is uncommon in many countries.

In general, although many conditions characterized by dyspigmentation, including but not limited to vitiligo, are difficult to treat medically and surgically, it is nice to have different options available to offer patients, depending on the size of the lesions and the amount of involvement. Even though the response rate in studies for both medical and surgical modalities is not perfect, many patients will still prefer treatment and will be happy with any improvement. It is important to keep in mind that many individuals, especially those with dark skin, are very disturbed by these conditions, and many of these individuals come from cultural backgrounds in which the pigmentary disorder can have a tremendous impact on their social and quality of life, and, in some cultures, even can affect their ability to get married, for example.

References

  1. Falabella R. Surgical approaches for stable vitiligo. Dermatol Surg. 2005;31:1277-84.
  2. Njoo MD, Westerhof W, Bos JD, et al. A systematic review of autologous transplantation methods in vitiligo. Arch Dermatol. 1998;134:1543-9.
  3. Li J, Fu WW, Zheng ZZ, et al. Suction blister epidermal grafting using a modified suction method in the treatment of stable vitiligo: a retrospective study. Dermatol Surg. 2011;37:999-1006.
  4. Ko WC, Chen YF. Suction blister epidermal grafts combined with CO2 laser superficial ablation as a good method for treating small-sized vitiligo. Dermatol Surg. 2009;35:601-6.
  5. Hong WS, Hu DN, Qian GP, et al. Treatment of vitiligo in children and adolescents by autologous cultured pure melanocytes transplantation with comparison of efficacy to results in adults. J Eur Acad Dermatol Venereol. 2011;25:538-43.
  6. Mulekar SV. Melanocyte-keratinocyte cell transplantation for stable vitiligo. Int J Dermatol. 2003;42:132-6.
  7. Mulekar SV. Long-term follow-up study of segmental and focal vitiligo treated by autologous, noncultured melanocyte-keratinocyte cell transplantation. Arch Dermatol. 2004;140:1211-5.
  8. Mulekar SV.Long-term follow-up study of 142 patients with vitiligo vulgaris treated by autologous, non-cultured melanocyte-keratinocyte cell transplantation. Int J Dermatol. 2005;44:841-5.
  9. Huggins RH, Henderson MD, Mulekar SV, et al. Melanocyte-keratinocyte transplantation procedure in the treatment of vitiligo: The experience of an academic medical center in the United States. J Am Acad Dermatol. 2012;66:785-93.
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