The aim of surgical treatments in vitiligo disease is to remove the diminishing and/or disappearing melanocytes from the patient and put them on the diseased areas with surgical techniques and to provide coloration again. These treatments are applications made for aesthetic or camouflage purposes rather than a radical treatment applied 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 easiest of the surgical formulas in vitiligo; It is the removal of the diseased area with easy surgical formulas. Its biggest advantage is that it does not require a special instrument and laboratory. The disadvantage of this technique is that it can be performed on body areas with small vitiligo dimensions and low risk of 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 easy as the surgical excision system. Its advantage is high clinical success after the 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 separation and reproduction of the epidermis and melanocytes from the skin taken from the patient and the body area without the disease, and transferring the same patient to the vitiligo area. It is a special method. It requires a special laboratory, group 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 are to be taken, melanocytes are cultured and multiplied, so that it is applied.
Who Can Apply the Surgical Formula 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 most accurate results in surgical treatments are obtained from segmental, that is, focal vitiligo type. Successful results are also obtained in nonsegmental and diffuse vitiligo.
2. In vitiligo, the color of the hairs in the diseased areas is extremely valuable. “Leukotrichia”, that is, the whitening of the hair, is valuable in the pre-treatment evaluation. Bleaching of the hairs in the disease area
shows that the melanocytes are greatly reduced. In these patients, surgical applications can be considered as the first treatment option.
3. Repigmentation (return of color to normal) in vitiligo areas after previous treatments or without treatment supports that adequate response will be received from surgical applications.
4. Stability of vitiligo disease; Surgical treatments are much more successful in stable vitiligo. Although there is no complete consensus regarding the definition of stable vitiligo, the fact that the patients do not develop new vitiligo lesions during the 1-year period, and that the existing vitiligo lesions do not grow, shows that the disease is stable.
Comparing patient photographs taken in previous years is extremely valuable in understanding the stability of the disease.
The vitiligo stability score has been used since 1999. This is called VIDA. In surgical applications, the most accurate results are obtained with 0 and -1 VIDA scores.
6. The patient should not have Köbnerization (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 most appropriate results in surgical treatments are obtained in the neck and anterior chest wall. The response of vitiligo to surgical procedures is weaker on joints (such as on the knuckles), eyelids, lips, genitals, and folds.
9. The patient’s motivation is extremely valuable.
10. Patient’s age; Although there is no direct connection, the treatment harmony in children is not good.
11. Small Punch Graft (MPG) is applied if it is not sure whether the patient will get appropriate results before surgical applications. The results of this test application have sufficient probable positive meaning.
What is Mini Punch Graft (MPG) and how is it done?
For this, a small number of punch skin grafts 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 normal skin of the patient. These are transplanted into the patient’s vitiligo area just like that. 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 appropriate, but subsequent processes may not be successful. Depigmented plaques may develop around the test area while the results are being obtained.
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 color intensification (postinflammatory hyperpigmentation) after wound remodeling is a negative criterion before the treatment of many skin diseases. However, its existence may support that better results will be obtained in vitilgo surgery treatments.
* Hepatitis C and HIV carrier
What are the surgical treatments in vitiligo?
Surgical treatments in vitiligo;
1. Methods of grafting (patching) with autologous (taken from the patient) tissue and cells;
2. Other surgical procedures without grafting; Although autologous tissue and cell grafts have good results in vitiligo treatment, tissue grafts are preferred more because they are easy to apply and 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 the thickness of the intake.
* 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, which is not diseased, 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 size of the vitiligo area. Sometimes, if the vitiligo area is large, the area of the graft taken with a formula called Mesh graft expander can be expanded. In this way, 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 wound conformation, and the color completely 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 graft to be patched and held. The epidermis and the upper layers of the dermis are removed from vitiligo diseased skin. For this, methods such as dermabrasion and Fractional CO 2 laser are used. The success rate is up to 95%.
Excimer laser and 308nm@MEI system are used 2-4 weeks after this grafting method has been applied. This provides a faster and more successful response to treatment.
What is Bule Epidermal Graft created with negative pressure and how is it applied?
It resembles skin germs 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. If water collects on the skin surface, bullae form. 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 graft to be patched and held. Epidermis and superficial dermis layers are removed from vitiligo diseased skin. For this, systems 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 spilled, but repigmentation areas develop under them.
The chances of success are lower by 25-65%. Compared to thin-thickness germs, the application time is less preferred when the 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 way, 1-1.2 mm diameter grafts are taken with instruments called “punch” from the hip, back of the ear and inner part of the upper arm 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 in the middle of 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 in the middle of 60-90%.
While the results are maximum on the face and in length, the application distress and results are weaker in large and large vitiligos, palms, lips and eyelids.
Scars may remain in the donor area. 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 ordinary transplantation, 9 repigmentation increases over 9 mm after Excimer laser and 308 nm@MEI.
2 . HFG(hair follicle grafts); It is similar to a hair transplant. It has been used especially in vitiligo areas with hairs. Like 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 smooth out faster and without problems (with better aesthetic results without color irregularities).
The ultra-thin skin grafts taken are divided into sections smaller than 1 mm2. These cuts are called “Mikroskin Graft”. Special scissors were used to make these small modules. However, in recent years, an instrument called “Mincer” has been used instead of scissors. This divides the graft into smaller cuts 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.
With this aim;
* 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 with this target.
In this way, 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 donor area and vitiligo area dimensions are exactly 1:1, this system 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. About 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 cuts as in the microskin graft. Flap is removed with a dermatome at a depth of 4-5 mm without ablation in the vitiligo area. These modules are placed under this flap. Smoothing is faster.
What are skin cell grafts and how are they applied?
These are the procedures that require a special laboratory and instrument. Their costs are quite high. However, the aesthetic results of success are much higher.
Cell grafts; Two formulas are used.
1. Cultured epidermal cell graft suspensions; divided into 2 in this formula.
* Cultured pure melanocyte grafts (CM); The melanocytes are separated from the grafts taken from the ordinary 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 system is similar to melanocyte cultures. However, in the sample taken from the skin here, melanocytes are not separated. 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. 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 close to 100% response is received at the end of 3 months. This method gives suitable results especially in widespread vitiligo. The prepared suspension can be used in large areas. It can treat an area of vitiligo 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
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. It is often found in dermal mononuclear cells intracellularly in the middle of collagen fibers outside the cell.
Paints are available in the form of pigment-containing pastes. Colors are obtained alone or by mixing them. It is diluted by placing 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 non-beautiful 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 received for any treatment used in these. Piebaldism is a genetic disease. 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. Precedent macules for vitiligo. 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 transitive NAME. Again, there is a problem with the migration of melanocytes to the skin.
4 types are known. The patient has piebaldisime-like macules, but there is no forelock.
Post-burn leucoderma (skin color reduction)
Post-laser leucoderma; after epilation lasers and other medical lasers
Chemical element leucoderma Phenol- and hydroquinone derivatives
leucoderma on the lips and face after herpes
leucoderma after DLE
Idiopathic guttate hypomelanosis