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Analysis of Grafting Techniques

Procedure: In this technique a split-thickness skin area graft is gathered from the donor site, either thigh or buttocks. It really is then meshed either by hand or within an Ampligreffe or any other suitable meshing equipment. [40, 41] Meshing of the graft causes an expansion in its size to 4 or 6 times its original one. The meshed graft is then applied on the dermabraded recipient skin and bandaged as in any other form of tissues grafting. The primary advantage of this system would be that the graft can care for a vitiligo lesion that is 4-6 times that of its original size. On top of that meshing allows the graft to be applied on areas over joint parts and other areas with difficult contours.

This approach is increasingly being practiced in India and it is a simple, cost- effective technique with good plastic results.

Principle: In this system of vitiligo, grafting the split-thickness or ultra-thin skin area graft is lower or smashed into very small pieces and put on the dermabraded recipient skin. [42, 43]

The donor: recipient ration is roughly 1:10.

Procedure: A split-thickness or ultra-thin skin area graft is first taken from the donor area preferably thigh or buttocks. It really is then smashed/lower into thin parts. The slicing process is sustained till the graft is converted into a uniform mesh or paste. This mesh is then blended with either hyaluronic acid or antibiotic ointments which is then spread equally over the dermabraded recipient area as in virtually any other form of tissue grafting. [42] The recipient area is then protected with a collagen dressing which dressing is removed after 7-8 days and nights. The advantage of this technique is that a relatively greater area can be included in a small size graft. The email address details are almost comparable to those achieved with non-culture epidermal cell suspension system (NCES) technique. On top of that, no expensive reagents or lab support is necessary such as NCES method. Some difficult to take care of areas like the hairy skin area, the joints and bony prominences can be treated with this technique. The drawback is that it's difficult to propagate the grafted tissue evenly to the recipient area.

Figures 34. 7 and 34. 8 shows great results with smash graft on joint parts.

Three main cellular grafting techniques are described on the globe literature. These are non-culture epidermal cell suspension strategy, cultured melanocyte transplant and non-culture follicular suspension technique

Synonyms: non culture melanocyte transplant, non-culture melanocyte-keratinocyte cell transplant (NCCT), basal cell suspension system technique.

Principle: The different cellular components of a STSG are segregated and a suspension system is well prepared out of these cellular components. The suspension system has epidermal keratinocytes and melanocytes' this is applied on to a dermabraded receiver area. The donor: recipient ration is 1:10.

In this mobile grafting procedure a split-thickness epidermis graft is gathered from the right donor area and this is cured with 5 ml of Trypsin-EDTA solution for about 45-60 minutes in an incubator at 37C. This step separates the skin cells of the epidermis from the actual dermis. The next thing is the neutralization of Trypsin which is achieved either by using 2 ml of 0. 5% trypsin inhibitor solution or washing the graft with DMEM or any other ideal medium consistently. The cured graft is then taken in a petridish with the epidermal aspect downwards and the dermal skin cells are teased from the graft with forceps. The overlying dermal tissues is discarded and the solution with the mobile element is centrifuged for approximately 10 minutes at the end which the skin cells pellet have emerged suspended at the bottom of the centrifuge tube and the epidermal portions are floating at the top, which is discarded. The cell pellet is then mixed with a about 0. 8 ml of Dulbecco's Revised Eagle's Medium (DMEM) medium (also called M2 melanocyte medium) and the suspension thus obtained is used in a 1 ml tuberculin syringe. After the recipient bed is established, the cell suspension system is distributed thinly and consistently with a spatula on to the dermabraded recipient epidermis after eliminating needle. The area is then outfitted with collagen dressingto hold the transplanted cells and the dressings are removed after 1 week. As an alternative to the DMEM medium, patient's own serum or hyaluronic acid can be used as it boosts the viscosity of the mobile suspension. [53]

This technique requires expensive lab equipment and is usually applied only at research centres.

Principle: It replenishes melanocytes selectively by building a melanocyte rich suspension. The donor: recipient ration can be as high as 1:100

Procedure: The epidermis goes through trypsinization and the melanocytes and keratinocytes are dissociated. The melanocytes are further seeded in a melanocyte medium made up of progress factors and cultured over 15 to thirty days. The cultured melanocytes (free suspension system or epidermal bed linens) are then transplanted to dermabraded recipient epidermis.

This is a novel mobile graft technique by using the hair follicle outer root sheath cell for transplant. Plastic results obtained with this process are almost similar to those seen with NCES approach.

Principle: That is another mobile grafting approach wherein the melanocytes within the hair follicles are used in repigmenting immune vitiligo. The outside main sheath of the head of hair follicle is a wealthy way to obtain inactive melanocyte. Theseinactive melanocytes function as stem cells and therefore can be gathered and used in vitiligo.

Procedure: The procedure is almost comparable to NCES strategy but here extracted hair roots are used rather than a split-thickness epidermis graft. The hair roots can be extracted by the follicular product removal (FUE) method. The locks follicle is decontaminated by cleaning with antibiotics. Enzymatic dissociation of ORS is performed by addition of trypsin and incubated at 37 C. Mechanical disruption of the ORS is performed by vortexing and the ORS cells are segregated from the scalp shaft with a cell strainer. The dissociated skin cells are reviewed microscopically for viability and the cell suspension system can be transplanted onto the well prepared recipient site. This system is in a nascent level, however it shows good repigmentation much like NCES.

The medical techniques reviewed above have various advantages and disadvantages. (Table 34. 3) [50, 58]

Table 34. 3: Advantages and Disadvantages of grafting techniques

Surgical Techniques

Advantages

Disadvantages

MPG

  1. Easiest of all the grafting methods.
  2. Performed on difficult to take care of sites like the finger tips and feet, areolae or hands and bottoms.
  3. Lesions with geographic edges can be managed
  4. Perigraft halo that remains after split-thickness grafting or smash can be supervised with minigrafting. 23
  1. Adverse effects include cobble-stoning, polka dot appearance, perigraft halo and color mismatch. [17, 21]
  2. The method is not suitable for cosmetically important areas like the facial skin.

STSG

1. Split-thickness epidermis grafting gets the highest success rate among all the techniques of muscle as well as mobile grafting. 24, 25

2. A comparatively large area can be cured in as one session.

3. The grafted areas achieve an instant repigmentation after the procedure

  1. The size of the donor graft required is equal to or higher than the area of the recipient area to be treated.
  2. Taking a slender graft of even thickness with reduced dermal tissue requires a great deal of experience and training.
  3. Thicker grafts can lead to skin damage both at the donor and recipient sites.
  4. Milia formation, car tire patch or stuck-on appearance, plastic mismatch of pigmentation, perigraft halo of depigmentation, hyperpigmentation of the graft can be seen especially in dark skinned individuals. [ 27, 28]

UTSG

  1. The cosmetic impact achieved is excellent
  2. There is not any scarring at the donor site and repeated grafts can be studied from a single donor site on multiple occasions.
  3. There is no milia formation and no chances of skin damage at the recipient site.
  1. Perigraft halo and hyperpigmentation in dark individuals common
  2. Good medical skills and skills needed
  3. Large donor area required

SBG

  1. The cosmetic final result achieved is usually excellent as only the epidermis is grafted without any underlying dermal cells.
  2. Difficult areas like the lips, the areolae can be grafted satisfactorily with this kind of grafting. 34, 35
  1. The time used for the blisters to form is too long and becomes really inconvenient for the patient.
  2. Time taken up to perform the task is also accordingly longer.
  3. Patients usually complain of pain after the blister is created on the donor area.
  4. If blister does not form, one may have to change to other techniques

Smash

  1. Relatively larger area can be covered by a small size graft ( 1:10 donor receiver ratio)
  2. no expensive reagents or laboratory support is required
  3. Can be utilized on hairy areas or joints
  1. Difficult to spread the grafted tissue evenly on to the receiver area.
  2. Perigraft halo and hyperpigmentation in dark individuals common

NCES

  1. Relatively bigger area can be treated within a procedure and with a much smaller size of donor graft. [ 44-52] ( 1: 10 donor receiver ratio)
  2. In addition, the repigmentation achieved complements the recipient pores and skin closely leading to a better cosmetic result.
  1. Expensive
  2. Storage facilities for reagents/ incubator needed
  3. Time consuming
  4. Involves a learning curve for the operating doctor. 49

CMT

  1. A large area can be cured in one procedure (1:100 donor recipient ratio)
  1. Expensive lab support and set-up required.
  2. The cost is high
  3. There is a risk of mutagenicity, especially with use of culture mass media, such as tetradecanoylphorbol acetate (TPA).

In addition to the grafting techniques, several other methods also have been used including tattooing, excision with most important closure and restorative wounding.

Tattooing: In tattooing, man-made pigments are launched in to the depigmented lesions for long term camouflage. This can be finished with a hand held pin vise or a power device.

Excision with key closure: The depigmented areas are removed and the wound is sutured; this system pays to for small vitiligo lesions.

Therapeutic wounding: Wounding of the lesions stimulate the melanocytes from the periphery of the lesion as well as from the hair roots which migrates and re-pigments the lesion. Various modalities which are used for restorative wounding include dermabrasion, laser ablation, cryosurgery, needling, and local software of phenol or trichloroacetic acid. [59]

Besides the specialized aspects of various strategies (detailed in the earlier section), the other important functional aspects include:

  • Choice of approach (Which process should be performed, where and just why?)
  • General pre and post-operative things to consider,
  • Role of phototherapy,
  • Complications and their management.

The choice of technique will depend on the dermatosurgeons' skills, experience and the availability of facilities in the dermatosurgery create. However, the factors which are believed while planning for a vitiligo surgery also determine the choice of surgical technique employed. Predicated on these factors, an algorithmic method of choosing a proper surgical strategy in steady vitiligo can be progressed. (Illustration 34. 3

In situations of pediatric segmental vitiligo, NCES would work. It can be followed by phototherapy for faster results. Tissues grafting techniques are usually not recommended anticipated to constraints of immobility in this populace subset. In adult, inhabitants both muscle grafting and mobile techniques may be employed based on the website and total section of depigmentation.

Segmental and focal vitiligo are most amenable to surgical treatment. Amongst the non- segmental type, lesions located on the glabrous skin area are suitable for surgical involvement. The acromucosal types are not often responsive.

The location of the lesion performs an important role in determining the decision of grafting strategy. (Stand 34. 4)

Table 34. 4: Anatomical location and selection of grafting technique

Anatomical Location

Choice of grafting technique

Eyelids

SBG, NCES

Lips

SBG, NCES

Genitals

SBG, NCES, UTSG

Acral/ palms, soles

MPG

Areola

STSG, SBG

Hairy areas

STSG, Smash

Joints

Smash

Small areas (1-4 cm) - All techniques work well in vitiligo involving small areas (1-4 cm) and approach should be chosen predicated on anatomical location and cost to the individual. In cases of large areas, NCES, smash or UTSG is preferred.

The standard pre and post-operative aspects have been defined in Box 34. 6. Specific pre and post-operative procedural aspects have been handled in the information of methods.

Box 34. 6: General pre and post-operative aspects

Pre- operative aspects:

Counselling, Images and Informed consent

Serological investigations: Complete blood vessels count, Blood sugars, Bleeding time, Clotting time, Prothrombin time, screening process for HIV and Hepatitis B

Shaving of donor and recipient area, pre medication ( antibiotics)

Proper marking of the donor and receiver area, assess the approximate size or number of grafts required

Post- operative aspects

Proper dressing/ Immobilization

Antibiotics/ Anti-inflammatory medications

Check receiver site after 1-3 days

Change dressing at donor and recipient site after 8-10 days

Phototherapy to be began after 1-2 weeks depending on response

Topical immunomodulators/ Topical steroids or oral immunosuppressants considered later when there is poor repigmentation or uptake of graft

The role of phototherapy (narrow strap UVB) post vitiligo surgery has been well confirmed with various tissue grafting and cellular techniques. Phototherapy can be started within 1-2 weeks pursuing surgery. Concurrent use of narrow music group UVB exerts a stimulatory and proliferative effect on the grafted melanocytes; thus post- surgery phototherapy enhances and accelerates the repigmentation.

In cases of UVB remedy which is set up after split width skin area grafting, repigmentation may appear inside a fortnight and a better shade match at the receiver site is seen. Repigmentation with cellular techniques has been detected within 3-4 weeks after surgery and can progress till 6 months and this can be increased with phototherapy. Usage of excimer laser in addition has shown great results post punch grafting.

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