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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 107-114

Efficacy of autologous melanocytic transplantation by flip-top technique in patients of stable vitiligo


1 Ex-Junior Resident, Department of Dermatology, Venereology and Leprosy, Government Medical College, Amritsar; Assistant Professor, Department of Dermatology, Venereology and Leprosy, Sri Guru Ramdas Institute of Medical Sciences and Research, Vallah, Amritsar, India
2 Professor Emeritus, Department of Dermatology, Venereology and Leprosy, Government Medical College, Amritsar, India

Date of Submission14-Mar-2020
Date of Decision20-Jul-2020
Date of Acceptance06-Jan-2021
Date of Web Publication12-Aug-2022

Correspondence Address:
Dr. Jyoti Budhwar
138, Smile Enclave, Opposite Vrindawan Gardens, Fatehgarh Churian Road, Amritsar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pigmentinternational.pigmentinternational_

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  Abstract 


Background: Vitiligo is an acquired disorder of depigmentation. Various surgical modalities are recommended for quicker resolution of lesions in stable cases. Aim and objectives: To study the efficacy of flip-top technique of autologous melanocytic transplantation in a series of 30 patients with stable vitiligo. Materials and Methods: Thirty patients with stable vitiligo, not responding to adequate trial of medicines were taken in this prospective study. After doing complete investigations, including coagulogram, they were subjected to Flip-top technique of autologous melanocytic transplantation, then 15 patients were put on PUVASOL and 15 patients were exposed to sunlight alone for 3 months. Digital photographs were taken at every sitting. An analysis was performed using the Wilcoxon signed-rank test and Mann--Whitney tests and grading was done for response. Results: Satisfactory cosmetic results were obtained in all cases with 26 patients achieving more than 25% of repigmentation and only 4 patients achieving less than 50% or above repigmentation. Colour match was good with minimal complications. Conclusion: Flip-top technique of autologous melanocytic transplantation appears to be a promising option for patients with stable recalcitrant vitiligo.

Keywords: flip-top technique, repigmentation, vitiligo


How to cite this article:
Budhwar J, Malhotra S K. Efficacy of autologous melanocytic transplantation by flip-top technique in patients of stable vitiligo. Pigment Int 2022;9:107-14

How to cite this URL:
Budhwar J, Malhotra S K. Efficacy of autologous melanocytic transplantation by flip-top technique in patients of stable vitiligo. Pigment Int [serial online] 2022 [cited 2022 Sep 28];9:107-14. Available from: https://www.pigmentinternational.com/text.asp?2022/9/2/107/353667




  Introduction Top


Vitiligo is a pigmentary disorder characterized by areas of depigmented skin resulting from loss of functioning epidermal melanocytes and sometimes hair follicle melanocytes.[1] It affects between 1% and 2% of the general population without any racial, sexual, or regional differences in prevalence.[2] Although vitiligo is not a lifethreatening disease, the psychosocial impact of the disease is devastating, particularly in darker skin. Onset may occur at any age, but the incidence usually peaks in the second and third decades of life.[3] Vitiligo has been classified into two clinical subtypes, segmental and nonsegmental vitiligo. The presence of both forms in a single individual is termed as mixed vitiligo, and a single patch of vitiligo that has not evolved into either subtype for 1 to 2 years is called focal vitiligo.[4] Both medical and surgical therapeutic approaches can be used effectively in the management of vitiligo. The surgical methods are recommended for lesions that are stable and refractory to medical therapies.[5] There are several methods of melanocytic transplantation, such as suction blister grafting,[6] split-thickness skin grafting (STSG),[7] mini grafting (punch grafting),[8] follicular grafting,[9] cultured-melanocytic transplantation,[10] and noncultured-melanocytic transplantation.[11] Surgical techniques are based on the basic principle of restoring melanocytes in recipient vitiliginous sites, obtained from pigmented donor skin. Flip-top technique of autologous melanocytic transplantation is a modification of STSG is an easy and simple technique requiring a simple laboratory setup.


  Materials and methods Top


The study was an open, randomized, and prospective study that was conducted over a period of 2 years after taking ethical clearance from the institutional review board. Thirty cases of stable vitiligo were selected at random from the Department of Dermatology, Venereology, and Leprosy of a tertiary care hospital attached to Government Medical College for the present study. These patients were divided into two groups, that is, Group A and Group B. How was randomisation done?

Group A: Fifteen patients with stable vitiligo were subjected to flip-top technique along with PUVASOL therapy for 3 months.

Group B: Fifteen patients with stable vitiligo were subjected to flip-top technique followed by sun exposure alone for 3 months.

Inclusion criteria

The patients selected were the ones who were suffering from a stable form of vitiligo. The disease process was considered stable in these cases if it has not progressed in the form of the appearance of new patches or enlargement of existing patches for at least 12 months preceding the inclusion of the case in the study. Patients selected were emotionally stable and their age was more than 12 years.

Exclusion criteria

Patients of younger age (age less than 12 years) with active disease and infection at the site of transplantation or on any other part of the body, keloidal and bleeding diathesis, positive Kobner’s phenomenon, pregnancy, and lesions over mucosa, palms, and soles were excluded from the study.

Preoperative protocol

After taking informed written consent, baseline investigations included a complete hemogram and coagulogram, HIV, and Hepatitis B and C virus serologies were done and recorded in prestructured proforma. Realistic expectations on part of the patients were emphasized.

Procedure

Preoperatively, both the donor and the recipient site were anesthetized with the application of the eutectic mixture of local anesthetic for about 1 hour. After giving premedication and preparation, donor site was draped and the site was held flat and made taut by stretching. The assistant for the procedure stretched the skin behind the moving knife/razor, whereas the operator stretched the skin in front with the palm of the left hand. By holding the cutting edge of a razor blade with artery forceps parallel to the skin surface, it was advanced to cut tangentially through the upper papillary dermis to obtain a split skin graft of thinnest possible thickness according to the requirement of the recipient area. The main emphasis was given on the thinness of the graft rather than continuity. Sheets of skin grafts were transferred to a  Petri dish More Details containing saline. Hemostasis was achieved by pressure and the donor area was properly bandaged. The donor specimen was then laid on a glass slide made wet with normal saline. The specimen was then divided into approximately 5-mm diameter pieces using a razor blade/scissors avoiding crush injury to the tissue [Figure 1]. The donor site for graft included anterior, lateral, or posterior thigh or the upper arms.
Figure 1 Stages of harvesting of grafts

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An epidermal flap of skin was then raised at the recipient site. A razor blade was used in a similar manner as in harvesting of the donor grafts, except that the superficial skin was incised on three sides and left attached like a hinge on one side. The aim was to elevate the flap right above the dermo-epidermal junction. Any oozing of blood was controlled by direct pressure. The hinge of tissue was lifted like a flip-top. The donor grafts were then placed at a gap of 5 to 6 mm beneath this hinge of skin with the epidermis up so that the dermis of the graft was in contact with the dermis of the recipient site. The hinge was then flipped back into place over the donor skin. The flap at the recipient site was then covered with Fevikwik (Pidilite Industries) on all three sides.[12] After waiting for 1 to 2 minutes for the adhesive to dry, the antiseptic povidone-iodine dressing was given over the recipient site [Figure 2]. The patient was put on antibiotics and anti-inflammatory drugs for 1 week. Antiseptic dressing was changed on the third day and the recipient site was looked for any collection of blood. The dressing was finally removed on the 10th day. Postoperatively, Group A patients were put on oral psoralen (trimethylpsoralen) in the dose of 0.3 to 0.6 mg/kg and advised to expose their operated lesion to sunlight after 2 hours. The treatment was given twice a week on nonconsecutive days. These patients were instructed to expose themselves to the sun between 11 to 12 am for 5 minutes, whereas Group B patients were advised to expose their operated lesion to sunlight between 11 to 12 am for 5 minutes daily. The patients were further followed at 2, 4, 6, 8, and 12 weeks, after removal of final dressing regarding the progress of pigmentation and complications if any.
Figure 2 Steps showing operative procedure at recipient site

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Percentage of repigmentation achieved was assessed as follows:

% of repigmentation= Y/X × 100

where, X = Area of vitiligo

Y = Area of repigmentation

Extent of repigmentation of the treated area was matched with the surrounding normal skin at the end of 3 months and was graded as follows:
  1. Grade I (Poor): <25% of pigmentation.
  2. Grade II (Fair): 26%–50% of pigmentation.
  3. Grade III (Good): 51%–75% of pigmentation.
  4. Grade IV (Excellent): >75% of pigmentation.


Statistical analysis

Mann-Whitney U tests were used to compare percentage, onset, and completion of repigmentation. The chi-square test was used to compare complications between the two groups. The paired t test was used to assess maximum pigment spread. P < 0.05 was taken as significant.


  Observations and results Top


All the patients completed the study of 12 weeks and were included in the final analysis. Baseline characteristics of the patients were recorded. All cases in our study had a history of prior treatments: corticosteroids (oral or topical), PUVASOL (oral or topical), placentrex gel, topical irritants, levamisole, indigenous, and homeopathic medicines. All patients had not attempted any treatment for 3 months prior to enrolment in the current study. The sociodemographic profile of patients is given in [TABLE 1].
TABLE 1 Socio-demographic observations

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The results of the procedure were noted in the form of the intensity of pigment, perigraft spread of pigment, and the color match with the surrounding skin. At the same time, the texture of skin over the grafted area was matched with that of the surrounding normal skin. In all the thirty cases, repigmentation was observed from the second week onward and continued to increase on subsequent follow-ups. At the end of the study, that is, after 12 weeks, 11 (36.7%) cases achieved Grade III repigmentation, whereas it was Grade I in four (13.33%) cases. Thus, at end of the study, only 11 (36.67%) patients achieved >50% repigmentation [Figure 3] and [Figure 4] and [TABLE 2].
Figure 3 Different stages of repigmentation in Group A

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Figure 4 Different stages of repigmentation in Group B

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TABLE 2 Results at the end of 12 weeks follow-up

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On further analysis, it was observed that Group A patients (With PUVASOL therapy), achieved Grade III, that is, 50% to 75% repigmentation in seven (46.7%) cases, whereas in Group B (with sunlight exposure alone), only four (26.7%) cases showed Grade III repigmentation [TABLE 3] and 4. Although at the end of 12 weeks, there was no case of treatment failure but complications at the recipient site were seen in two cases [Figure 5]. Postoperative PUVASOL was seen to produce better color intensity and spread of pigment, thus hastening the complete response stage.
Figure 5 Complications at recipient site

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TABLE 3 Comparison of repigmentation in Groups A and B after second, fourth, sixth, eighth, and 12th week of follow-up

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  Discussion Top


Vitiligo is a socially, emotionally, and cosmetically disfiguring entity for which the patient is desperate to get a quick response as early as possible. With the advent of various surgical modalities, a ray of hope can be offered to these patients, especially those not responding to medical therapy. Depigmentation in vitiligo is the result of the depletion of melanocytes following their destruction by the underlying disease. In the past decade, various surgical techniques have been developed based on the basic principle of restoring melanocytes on vitiliginous sites from pigmented donor skin to treat stable recalcitrant vitiligo.

In the present study, flip-top technique of autologous melanocytic transplantation was done in the treatment of stable vitiligo. All the cases showed resistance to treatment with various medical therapies in the past. Vitiligo lesions can repigment in three ways, that is, perifollicular when predominant repigmentation is follicular, marginal when predominant repigmentation is from the borders of the patches, and diffuse when generalized darkening occurs across the patches of vitiligo.[13]

In our study, lesions in 30 patients were selected and patients were randomized between Group A (PUVASOL) and Group B (sunlight alone). In both the groups, that is, in all of the 30 cases, the start of repigmentation was perimarginal from the grafts placed in all the lesions which later on became diffuse when merged with the pigmentation from the adjacent grafts. Repigmentation started appearing from the second week onward. It was observed after 12 weeks of study, out of 30 patients who were subjected to this procedure of autologous melanocytic transplantation by flip-top technique, 26 (86.67%) patients showed more than 25% of repigmentation. Out of these 26 patients, 11 (42.30%) patients achieved 50% to 75% of repigmentation, whereas 15 (57.69%) patients could achieve repigmentation between 25% and 50% of repigmentation in relation to the color of the surrounding skin. There were four (26.67%) cases in which repigmentation could not reach beyond 25% of surrounding skin color. However, there was no case of treatment failure recorded.

Being a pioneer study, not much has been reported in the literature about the flip-top technique of autologous melanocytic transplantation in the management of vitiligo. McGovern and Leffell[14] performed this technique on more than 40 recipient sites in their seven patients. Recipient sites included were neck, cheek, forearm, and hand. One patient had this procedure performed after obtaining maximal benefits from PUVA therapy, whereas six received only topical corticosteroids for their vitiligo. All of the grafts that survived demonstrated at least 3 mm of pigment spread over a period of 3 months. In a similar study conducted by McGovern, Leffell, and Bolognia,[15] a total of 25 grafts were transplanted during 12 procedures on four patients. Repigmentation was noted in 22 of 25 (88%) grafts in the first three patients, whereas in one patient the grafts were rejected. Pigment spread 2 to 3 mm beyond the graft perimeter was seen in all grafted sites, thus achieving a 100% success rate, without complications. Thus, our results were in concordance with those reported by McGovern et al.[14] in their studies

In flip-top technique that is a modification of split skin thickness grafting, slow but the uniform spread of pigmentation around the grafts is seen, thus chances of variegate pigmentation are less. The flap acts as a natural bandage and chances of infection are almost negligible, thus, improving the outcome of the process. In the present study, although the number of grafts placed were equal in both the groups, a lesser degree of repigmentation in Group B could be explained by the rejection of few grafts at some of the sites of Group B than Group A and stimulating effect of PUVASOL therapy in Group A cases that were more than the sunlight exposure alone given in Group B cases. But at the end of the follow-up period, pigment difference in both the groups was not statistically significant that could be due to the small sample size and a short period of study. Thus, the flip-top technique of autologous melanocytic transplantation is simple, inexpensive, and easy to perform for beginners. The flap acts as a natural barrier and bandage thus, minimizing the chances of infection. Hence, this fact also contributes to improving the outcome of the procedure. The flap can be retained satisfactorily by applying Feviquik as was done in our study. The flap acting as a biological dressing helped in reducing the cost of surgery. Thus, the flip-top technique was found to be a safe, simple, time-saving, less expensive method for achieving uniform repigmentation of medical treatment failure cases of stable vitiligo that eliminates the need for special laboratory facility and equipment. It is also a good method for beginners who are unable to harvest larger continuous uniformly thin sheets of grafts when even small broken pieces of harvested grafts can be utilized for grafting. Although the number of study cases was small and also the follow-up period was short (only 12 weeks), we can still infer from the results that this method can be another promising tool in the armamentarium of the dermatologist to treat resistant cases of vitiligo. As repigmentation is slow to progress and may continue beyond 12 months following the transplantation procedure, it is recommended that a further study comprising a larger number of patients who should be followed up for a longer period (minimum 6 months) should be undertaken to arrive at any final conclusion about the efficacy of this newer safe, simple, and cost-effective surgical modality with which recalcitrant areas of vitiligo can also be treated without any complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Dhar S, Dutta P, Malakar R. Pigmentary Disorders. In Valia RG, Valia A, eds. IADVL Textbook Dermatology. 3rd ed. Mumbai: Bhalani Publishing house 2008. p. 749–58.  Back to cited text no. 1
    
2.
Falabella R. Surgical approaches for stable vitiligo. Dermatol Surg 2005;31:1277–84.  Back to cited text no. 2
    
3.
Bleechen SS, Anstey AV. Disorders of skin colour. In Burns T, Breathnach S, Cox N, Griffiths C eds. Rook’s Textbook of Dermatology. 8th ed. London: Wiley-Blackwell; 2010. p. 58.46–9.  Back to cited text no. 3
    
4.
Ezzedine K, Eleftheriadou V, Whitton M, van Geel N. Vitiligo. Lancet 2015;386:74–84.  Back to cited text no. 4
    
5.
Bahdoran P, Ortonne JP. Classification of surgical therapies for vitiligo. In Gupta S, Olsson JM, Kanwar JA, Ortonne JP, eds. Surgical Management of Vitiligo. 1st ed. Chennai: Blackwell 2007. p. 59–62.  Back to cited text no. 5
    
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Savant SS., Gore D, Atal SR, Sarangi K. Suction blister technique. In Savant SS, Gore D, Atal SR, Sarangi K, eds. Text Book of Dermatosurgery Cosmetology. 2nd ed. Mumbai: ASCAD 2005. p. 351.  Back to cited text no. 6
    
7.
Savant SS. Thin Thiersch’s split thickness grafting. In Savant SS, Gore D, Atal SR, Sarangi K, eds. Text Book of Dermatosurgery Cosmetology. 2nd ed. Mumbai: ASCAD; 2005. p. 345.  Back to cited text no. 7
    
8.
Savant SS. Miniature punch grafting. In Savant SS, Gore D, Atal SR, Sarangi K, eds. Text Book of Dermatosurgery Cosmetology. 2nd ed. Mumbai: ASCAD 2005. p. 359.  Back to cited text no. 8
    
9.
Malakar S, Dhar S. Repigmentation of vitiligo patches by transplantation of hair follicles. Int J Dermatol 1999;38:237–8.  Back to cited text no. 9
    
10.
Lerner AB, Halaben R, Klaus SN, Moellmann GE. Transplantation of human melanocytes. J Invest Dermatol 1987;89:219–24.  Back to cited text no. 10
    
11.
Savant SS. Cultured and noncultured epidermal cell transplantation. In Savant SS, Gore D, Atal SR, Sarangi K, eds. Textbook of Dermatosurgery Cosmetology. 2nd ed. Mumbai: ASCAD; 2005. p. 387–92.  Back to cited text no. 11
    
12.
Khunger N. Cyanoacrylate Adhesive in Split thicknes skin Grafts for Resistant Vitiligo- an experience in 50 cases. Presented at 31 st National Conference of Indian Association of Dermatologist Veneorologist and Leprologist, Kolkatta, Jan 30-Feb 2, 2003, Book of Abstracts page 180.  Back to cited text no. 12
    
13.
Kanwar AJ, Parsad D. Understanding the mechanism of repigmentation in vitiligo. In Gupta S, Olosson JM, Kanwar AJ, Ortonne JP, eds. Surgical Management of Vitiligo. 1st ed. Chennai: Blackwell Publishing Ltd; 2007. p. 14–9  Back to cited text no. 13
    
14.
Mcgovern TW, Bolongia J, Leffel DL. Flip top pigment transplantation. Arch Dermatol 1999;135:1305–7.  Back to cited text no. 14
    
15.
McGovern TW, Leffell DJ. Surgical therapies, part-II: Flip-top transplants in vitiligo. Dermatol Ther 2001;14:15–19.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [TABLE 1], [TABLE 2], [TABLE 3]



 

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