Punch Skin Graft in Stable Vitiligo: Donor and Recipient Site Changes - A Retrospective Study

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1 Originl Article Print ISSN: Online ISSN: X DOI: /ijss/2017/430 Punch Skin Grft in Stle Vitiligo: Donor nd Recipient Site Chnges - A Retrospective Study Muthukumrn Rjrm 1, Um Selvrj 2, Sudh Algrsmy 3 1 Associte Professor, Deprtment of Dermtology, Government Dhrmpuri Medicl College, Dhrmpuri, Tmil Ndu, Indi., 2 Associte Professor, Deprtment of Dermtology, Government Theni Medicl College, Theni, Tmil Ndu, Indi, 3 Assistnt Professor, Deprtment of Dermtology, Government Theni Medicl College, Theni, Tmil Ndu, Indi Astrct Introduction: Punch skin grft procedure in the tretment of stle vitiligo is simple nd est office procedure. Aim of the Study: The im of the study ws to evlute the donor nd recipient site chnges occurred during the tretment of vitiligo with punch skin grft. Mterils nd Methods: A totl of 25 cses of vitiligo treted with punch skin grft with dt nd photogrphs were collected nd nlyzed retrospectively in the Deprtment of Dermtology, Government Theni Medicl College, Theni. Results: Out of 25 cses of stle vitiligo, 9 were mle nd 16 were femle. Donor site chnges were noted s hypertrophic scrring, depigmenttion, nd hyperpigmenttion. Out of 222 grfts plced, the grft uptke percentge ws 77.8%. The men pigment spred ws 4.8 mm in non-glrous re. Cosmetic improvement ws 100% in mucosl vitiligo. Depigmentry joining line, peri-individul grft hlo (trget-like pigmenttion), colestoning, grft rejection, crowding of grfts, nd rectivtion of vitiligo s recipient site chnges were noted. Repigmenttion of leukotrichi ws noted. Overll cosmetic improvement ws 70%. Conclusion: If the selection of the stle vitiligo cses nd the expertise of the operting surgeon re good, the donor nd recipient site chnges my e reduced to greter extent to yield etter cosmetic result. Key words: Stle vitiligo, Donor site, Recipient site INTRODUCTION Vitiligo is common depigmenting disorder, chrcterized cliniclly y milky white mcules, nd histologiclly y n sence of functionl melnocytes in the ffected re. It cuses severe cosmetic distress, prticulrly in drkly pigmented skins nd is lso ssocited with gret socil stigm. It hs profound psychologicl impct nd gretly ffects the qulity of life. 1 In 1947, Hxthusen trnsplnted thin split thickness skin grfts from norml to vitiliginous skin in three cses, to study the pthogenesis of the disese. 2,3 In 1964, Behl from Indi, ws the first to descrie the surgicl tretment of vitiligo in lrge Access this rticle online Month of Sumission : Month of Peer Review : Month of Acceptnce : Month of Pulishing : series of 107 ptients with thin Thiersch grfts. 4,5 Flell descried the suction lister technique for repigmenttion of vitiligo in 1971, nd lter the miniture punch grfting technique in The sic principle of ll surgicl methods is trnsfer of melnocytes from uninvolved skin into stle leukoderm lesion, where they grow into, nd function s, effective epiderml-melnin units. Donor dominnce principle sttes tht when grft from norml skin is trnsplnted to n ffected site, the trnsposed grfted re mintins its integrity nd chrcteristics, independent of the recipient site. When norml pigmented donor uto punch grft is trnsplnted onto depigmented stle vitiligo re, it domintes, nd the melnocytes in the minigrfts not only continue to produce melnin ut lso migrte into the djcent depigmented epidermis; seen cliniclly s initil perigrft pigmenttion. 7 When the grft is tken from the donor site, it is plced on the vsculr ed in the recipient re. From this vsculr ed, it derives its lood supply. Initilly, the grft dheres to its new ed with the help of Corresponding Author: Dr. Um Selvrj, 15/1/38A, Arjunillm, Sivnndh Ngr, P.C. Ptty, Theni , Tmil Ndu, Indi. E-mil: drumshriknnn@gmil.com Interntionl Journl of Scientific Study August 2017 Vol 5 Issue 5 232

2 Rjrm, et l.: Donor nd Recipient site chnges in Punch skin grft in stle vitiligo firin. There is diffusion of nutrients through this firous lyer which keeps the grft live. Within 2-3 dys, cpillry linkge occurs with vsculriztion of the grft. The thinner the grft, the denser the cpillry network in the superficil dermis, nd thus erlier is the process of vsculriztion. 8 MATERIALS AND METHODS A retrospective study ws done in 25 cses of stle vitiligo underwent punch skin grft procedure. The cses done y the uthor were collected with cse records nd photogrphs nd results were nlyzed in the point of donor nd recipient site chnges. This study ws done in the Deprtment of Dermtology, Theni Medicl College, Theni, Tmil Ndu. A selection criteri ws followed while selecting the cses for punch skin grft procedure. 1. Stle vitiligo which is sttionry nd without the development of new lesions in the pst 2 yers 2. Ptients in whom the lesions were not improving in spite of long medicl mngement 3. Ptients with no history of Koener s phenomenon in the lesions 4. Ptients who do not hve keloidl tendency nd 5. Ptients with no history of leeding ditheses. The cses which hd undergone the following methodology were selected for the study. Donor site ws selected s extensor spect of thigh or glutel region. Skin punches of 2.5 mm size re rotted till the cutting edge descends to the depth of upper dermis. At donor site, the punches re cut djcent to one nother keeping 1-2 mm of norml skin in etween 5 nd 10 prllel rows. Recipient site ws the stle vitiligo ptches. Skin punches of 2-mm size re rotted till the cutting end descends to the depth of mid-dermis, nd the cuts re spced 5-10 mm wy from ech other. In single session, 5-10 or up to grfts were tken nd ensuring the derml side of the grft down to the recipient site, ll grfts were trnsferred nd with firm pressure snug fit ws chieved. Dressing ws done with doule lyer of Frmycetin Tulle, guge, nd Elstocrepe ndge. At recipient site, follow-up dressing ws done fter 24 h once to rule out the shift of grfts nd next dressing fter 8-10 dys. At donor site, dressing ws removed fter 8-10 dys. Photogrphs were tken prior nd soon fter the procedure with grfts in situ, t the end of 8-10 dys nd periodiclly fter every 15 dys for 2 months nd there fter every 1 month till the end of 1 yer. Chnges in the donor site were noted. In the recipient site, the numer of grfts tken nd rejected, the men pigment spred (MPS), cosmetic improvement nd disfigurement, nd overll cosmetic improvement were noted nd clculted. Cosmetic ssessment ws done in reltion to the ge, sex, type, nd site of vitiligo t the end of 12 months y singlelind oserver. It ws grded s excellent %, good 71-90%, fir 51-70%, nd d with <50% improvement. RESULTS Out of 25 cses of stle vitiligo, 9 were mle nd 16 were femle. Young femles were more in the elow 20 yers ge group. Lowest ge ws 12 yers nd upper limit ws 50 yers (Tle 1). On evluting the types of vitiligo, 15 cses were focl vitiligo, 6 cses were segmentl vitiligo, 2 cses were mucosl vitiligo, nd 2 cses were crofcil type (Tle 2). Donor site chnges were noted s hypertrophic scrring in 21 cses (84%) (Figure 1), depigmenttion of grfts in 1 cse (4%) (Figure 2), nd hyperpigmenttion in 1 cse (4%) (Figure 3) were noted. No scrring ws seen in two ptients (8%) in the ge of 43 yers nd 50 yers (Tle 3). 222 were grfts nd were grfted in 15 sites. In focl vitiligo, out of 84 grfts plced, 79 grfts were tken (97%) nd 5 rejected. In segmentl vitiligo, out of 117 grfts plced, 90 (77%) grfts were tken while 27 rejected. In mucosl vitiligo, out of 6 grfts plced, 5 (83%) grfts were tken nd 1 grft rejected. In crofcil Tle 1: Age nd sex distriution Age group (yer) Mle Femle Mle Femle Mle Femle Mle Femle Focl Segmentl Mucosl 1 1 Acrofcil 1 1 Totl Tle 2: Type of vitiligo Type of vitiligo Numer of cses Focl 15 Segmentl 6 Mucosl 2 Acrofcil 2 Totl 25 Tle 3: Donor site chnges (n=25) Donor site chnges Age group (yers) Numer of cses Totl (%) Hypertrophic scrring < Depigmenttion Hyperpigmenttion No scrring 43 nd Interntionl Journl of Scientific Study August 2017 Vol 5 Issue 5

3 Rjrm, et l.: Donor nd Recipient site chnges in Punch skin grft in stle vitiligo vitiligo, out of 15 grfts plced, 8 (54%) grfts were tken nd 7 rejected. Averge grft uptke percentge ws 77.8% (Tle 4). The pigment spred in mm ws clculted from the grfts plced in 15 sites. In non-glrous (hiry skin), 9 mm spred ws seen in one sclp cse (Figure 4), forehed (1 cse), nose (2 cses), cheek (3 cses), nd mndiulr re (1 cse) (Figure 5) showed 4.5 mm spred s n verge. Upper interscpulr nd ck (2 cses) showed 3-mm spred. In prsternl re, 7 mm (1 cse) (Figure 6), lumr 3 mm (2 cses), leg hiry re 3 mm (1 cse) spred Figure 4: Pigment spred of 9 mm in sclp Figure 1: Hypertrophic scrring t donor site Figure 5: Pigment spred of 4.5 mm in mndiulr re, colestoning, perigrft hlo Figure 2: Depigmenttion t donor site Figure 3: Hyperpigmenttion t donor site Figure 6: Pigment spred of 7 mm in prsternl re, cole stoning, perigrft hlo Interntionl Journl of Scientific Study August 2017 Vol 5 Issue 5 234

4 Rjrm, et l.: Donor nd Recipient site chnges in Punch skin grft in stle vitiligo Tle 4: Recipient site: Numer of grfts tken nd rejected (n=222) Type of vitiligo Totl numer of grfts plced Grfts tken Grfts rejected Grfts tken (%) Focl Segmentl Mucosl Acrofcil Averge grft uptke 77.8% were noted with MPS of 4.8 mm in non-glrous re. Two mucosl re cses showed 3-mm pigment spred s n verge. In Glorous skin, the pigment spred ws noted s 2.5mm in 2 cses of dorsum of hnd,2mm in 2 cses of finger,4mm in 2 cses of leg-medil mlleolus nd 3mm in 1 cse of foot.pigmenttion of grfts lone ws noted in one cse of leg.the verge MPS ws clculted s 2-3mm(Tle 5) In recipient re, cosmetic disfigurement ws noted s depigmentry or hypopigmentry joining line 7 /perigrft hlo 9-11 in 9 cses (36%) (Figures 5 nd 6), colestoning in 7 cses (28%) (Figures 5 nd 6), grft rejection in 1 cse (Figure 7), crowding of grfts in 2 cses (8%) (Figure 8), sttic grft with no pigment spred in 1 cse (4%) (Figure 9), rectivtion of vitiligo in two cses (8%) (Figures 10 nd 11), nd trget-like pigmenttion 12 (hlo round individul grfts) in two cses (Figures 11 nd 12) were noted. In Figure 11, the cse developed pigment dilution nd depigmenttion in recipient re nd round the grfts t the end of 5 months of punch grft with ppernce of depigmentry mcules s spots throughout the ody nd with susequent steroid therpy, depigmenttion disppered, nd repigmenttion strted. In Figure 12, perigrft hlo ws noted round individul grfts t the end of 7 months. In 1 cse, pigmenttion of white hir (leukotrichi) in sclp (4%) (Figure 13 nd Tle 6) ws noted. Sinking, polk dot ppernce, 7 nd color mismtching were not seen in our study. Overll cosmetic improvement in recipient site ws noted. On n verge, the cosmetic improvement ws 83% in the ptients in the ge group of yers nd 67% in the group of yers ge nd 17% in the ge group of yers. The cosmetic improvement ws oserved to e 90% in focl, non-glrous forehed cse of 19-yers-old girl (Figure 14 nd ), 100% in mle ptient of 43 yers with lip vitiligo, in mucosl type (Figure 15 nd ), 85% in non-glrous skin, over nose, segmentl vitiligo in 25-yer-old mle (Figure 16 nd ), 85% in segmentl right mndiulr re in 25-yerold womn (Figure 17 nd ), nd 56% in glrous skin (Tle 7). The overll cosmetic improvement chieved ws 70% in this retrospective study using the punch grft procedure. Tle 5: Recipient site: MPS Site of vitiligo Numer of cses MPS (in mm) Non glrous Sclp Forehed Nose Cheek Mndiulr re Upper interscpulr nd ck 2 3 Prsternl re 1 7 Lumr 2 3 Leg 1 3 Mucosl Lip Glrous Dorsum of hnd Fingers 2 2 Leg 1 0 Leg medil mlleolus 2 4 Foot 1 3 MPS: Men pigment spred Tle 6: Recipient site: Cosmetic disfigurement nd improvement (n=25) Recipient site cosmetic chnges Numer of cses (%) Cosmetic disfigurement Depigmentry joining line 9 (36) Grft rejection 7 (28) Rectivtion of vitiligo 1 (4) Colestoning 7 (28) Crowding of grfts 2 (8) Sttic grft (no pigment spred) 1 (4) Trget like pigmenttion 2 (8) Cosmetic improvement Pigmenttion of white hir (leukotrichi) 1 (4) DISCUSSION The chnges tht occur in donor or recipient sites s complictions cn e prevented if proper precutions re tken efore, during, nd fter the grfting procedure. Proper selection of the ptient is the most importnt fctor for chieving good cosmetic result with ny grfting procedure in vitiligo. The recommendtion to e followed is to select ptient with no history of progression of lesions, no new lesions, nd no history of Koener s phenomenon over t lest 1 yer efore the procedure. 13 In recent study on the issue of vitiligo stility, period of 18 months 235 Interntionl Journl of Scientific Study August 2017 Vol 5 Issue 5

5 Rjrm, et l.: Donor nd Recipient site chnges in Punch skin grft in stle vitiligo c Figure 7: Grft rejection Figure 10: (-c) Rectivtion of vitiligo c Figure 8: Crowding of grfts Figure 11: ( nd ) Depigmenttion strted fter 5 months of punch grfting. (c) Rectivtion of vitiligo, trget-like pigmenttion, repigmenttion fter steroid therpy Figure 9: Sttic grft with no pigment spred of stle disese ws shown to e most suitle one for undertking ny grfting procedure.14 Recurrence of vitiligo t the grfted or donor site or ppernce of new lesions my occur in unstle cses or if the disese ecomes rective fter period of stility.10 Scrring t the donor site ws oserved more in ptients in the younger ge group Figure 12: Trget-like pigmenttion - perigrft scrring compred to no scrring in the older ge group proly due to the reduced ctivity of firolsts in the older ge group. Hyperpigmenttion in donor site ws not reported in erlier studies. Depigmenttion ws due to rectivtion Interntionl Journl of Scientific Study August 2017 Vol 5 Issue 5 236

6 Rjrm, et l.: Donor nd Recipient site chnges in Punch skin grft in stle vitiligo Tle 7: Assessment of cosmetic improvement in reltion to ge, sex, type, nd site of vitiligo Cosmetic improvement grding (%) Age Sex Type of vitiligo Site of vitiligo >41 M F S F M AF Non glrous Glrous Mucosl lip Excellent (91 100) 100% Good (71 90) 83% 71% 67% 80% 71% 80% Fir (51 70) 67% 57% 56% Bd<50 17% 15% Over ll cosmetic improvement = 70%. S: Segmentl, F: Focl, M: Mucosl, AF: Acrofcil Figure 13: ( nd ) Pigmenttion of leukotrichi in sclp Figure 16: ( nd ) Before nd fter grfting segmentl vitiligo with 85% cosmetic improvement Figure 14: ( nd ) Before nd fter grfting focl, nonglrous vitiligo with 90% cosmetic improvement Figure 17: ( nd ) Before nd fter grfting segmentl vitiligo with of 85% cosmetic improvement Figure 15: ( nd ) Focl vitiligo efore nd fter grfting with 100% cosmetic improvement of or unstility of vitiligo nd ws lso documented y Mjid, 13 Khunger et l. 10 Grft rejection ws 22%, wheres the sme is 10% in the study reported y Ds et l. 15 This cn e voided y mstering the technique nd y providing proper dressing nd septic environment to the movement prone res. MPS in the recipient re correltes with the study conducted y Svnt et l., 7 Lhiri, 9 nd Rjgopl et l. 16 Cosmetic disfigurement in the recipient res such s depigmentry joining line or perigrft hlo noted in our cses could e due to two fctors. First, improper plcement of donor grfts, tht is, fr from the mrgin of the ptch so tht the repigmenttion does not extend till the mrgin. Second, reson could e grfting in cses of unstle/ctive vitiligo. 12 In ctive vitiligo, the utoimmune process consisting of ctivted T-cells is mximum t the mrgin of the lesion. These ctivted CD3+, CD4+, nd CD8+ T cells express the cutneous lymphocyte-ssocited ntigen (HECA-452+) typicl of infiltrting T cells. Hence, the periphery of the vitiligenous ptch fils to repigment. 17 By plcing the grfts, initilly ll long the periphery just out 1-2 mm inside the outer order of the recipient re, the perigrft hlo cn e prevented. Colestoning noted in the other studies 7,9,10,13,16,18 s well my e voided using smller punches of mm size, putting upper surfce of the thinner grft t the level of recipient skin, trimming the under surfce of the thicker grft, using shrp cutting edge instruments, nd voiding trum to the grft nd using silicon sheet dressing. Overcrowding of grfts my e minimized y plcing grfts t lest 5 mm prt from ech other. Trget-like pigmenttion (hlo round individul grfts) noted in Figure 11 ws due to rectivtion of vitiligo, nd the second cse could e due to contrction of elstin fiers during hrvesting of grfts or scrring round individul grfts nd oth the fctors hd een well stted y Bisen et l. 12. Svnt mentions use of donor grfts 0.5 mm lrger thn the recipient ed to compenste for ny grft contrction nd prevent perigrft circulr scrring mm punches which re 0.5 mm lrger thn the recipient site punches used y 237 Interntionl Journl of Scientific Study August 2017 Vol 5 Issue 5

7 Rjrm, et l.: Donor nd Recipient site chnges in Punch skin grft in stle vitiligo Lhri et l. lso noticed such trget-like pigmenttion in their studies. However, Rjgopl et l. reported the use of sme size punches with good results. 16,20 Pigmenttion of leukotrichi noted in our study is n dded dvntge of punch grft procedure nd ws lredy reported y Svnt. 7 The cosmetic improvement chieved in our study ws lso recorded y mny uthors. 7,9,10,13,16,18 CONCLUSION Punch skin grft procedure is simple, sfe, inexpensive, nd quickly responding office procedure with high success rte of pigmenttion. If the selection of the stle vitiligo cses nd the expertise of the operting surgeon re good, the donor nd recipient site chnges my e reduced to greter extent to yield etter cosmetic result. REFERENCES 1. Prsd D, Dogr S, Knwr AJ. Qulity of life in ptients with vitiligo. Helth Qul Life Outcomes 2003;1: Flell R. History nd chronology of development of surgicl therpies for vitiligo. In: Gupt S, Olsson MS, Knwr AJ, Ortonne JP, editors. Surgicl Mngement of Vitiligo. 1 st ed. Msschusetts, USA: Blckwell Pulishing; p Svnt SS. Surgicl therpy of vitiligo: Current sttus. Indin J Dermtol Venereol Leprol 2005;71: Behl PN. Tretment of vitiligo with homologous thin Thiersch grfts. Curr Med Prct 1964;8: Flell R. Epiderml grfting. An originl technique nd its ppliction in chromic nd grnulting res. Arch Dermtol 1971;104: Flell R. Repigmenttion of leukoderm y minigrfts of normlly pigmented, utologus skin. J Dermtol Surg Oncol 1978;4: Svnt SS. Miniture punch grfting. In: Svnt SS, Shh RA, Gore D, editors. Text Book nd Atls of Dermtosurgery nd Cosmetology. 1 st ed. Mumi, Indi: ASCAD Pulishers; p Burge S, Ryment R. Free skin grfts. Simple Skin Surgery.1 st ed. Mumi: Blckwell Scientific Pulictions; p Lhiri K. Evolution nd evlution of utologous mini punch grfting in vitiligo. Indin J Dermtol 2009;54: Khunger N, Kthuri SD, Rmesh V. Tissue grfts in vitiligo surgery - Pst, present, nd future. Indin J Dermtol 2009;54: Mjid I, Imrn S. Ultrthin split-thickness skin grfting followed y nrrownd UVB therpy for stle vitiligo: An effective nd cosmeticlly stisfying tretment option. Indin J Dermtol Venereol Leprol 2012;78: Bisen N, Bht RM, Lhri K, Kmil SM. Trget-like Pigmenttion fter minipunch grfting in stle vitiligo. Indin J Dermtol 2014;59: Mjid I. Grfting in vitiligo: How to get etter results nd how to void complictions. J Cutn Aesthet Surg 2013;6: Ro A, Gupt S, Dind AK, Shrm A, Shrm VK, Kumr G, et l. Study of clinicl, iochemicl nd immunologicl fctors determining stility of disese in ptients with generlized vitiligo undergoing melnocyte trnsplnttion. Br J Dermtol 2012;166: Ds SS, Psrich JS. Punch grfting s tretment for residul lesions of vitiligo. Ind J Dermtol Venereol Leprol 1992;58: Rjgopl R, Murthy PS, Kr PK, Vijendr P, Autologous Miniture Punch Grfting in Stle Vitiligo, Indin J Dermtol,2005,50(4), Bdri AM, Todd PM, Grioch JJ, Gudgeon JE, Stewrt DG, Goudie RB. An immunohistologicl study of cutneous lymphocytes in vitiligo. J Pthol 1993;170: Muthukumrn R, Sudh A, Suhshini S, Um S. Autologous miniture punch skin grft procedure in 25 cses of stle vitiligo. Int J Sci Study 2017;4: Svnt SS, Autologous Miniture Punch Grfting in Vitiligo, Indin j Dermtol Venereol Leprol 1992;58: Mlkr S. Punch grfting. In: Pul A, editor. An Approch to Dermtosurgery. 1 st ed. Clcutt: Plsons Drugs Pvt. Ltd.; p How to cite this rticle: Rjrm M, Selvrj U, Algrsmy S. Punch Skin Grft in Stle Vitiligo: Donor nd Recipient Site Chnges - A Retrospective Study. Int J Sci Stud 2017;5(5): Source of Support: Nil, Conflict of Interest: None declred. Interntionl Journl of Scientific Study August 2017 Vol 5 Issue 5 238