Surgical management is a safe and effective treatment modality for select patients with vitiligo. Many techniques of vitiligo surgery exist, each with unique advantages and disadvantages. Preoperative screening for appropriate candidates, selection of surgical technique, and postoperative management are all key elements in enabling patients to achieve maximal repigmentation.
Key points
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Vitiligo is a disorder characterized by the development of depigmented macules and patches that can be treated with surgical intervention.
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Surgery is a safe and effective treatment option in select candidates with vitiligo.
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Preoperative evaluation, choosing an appropriate surgical technique, and postoperative management are important components in ensuring optimal results.
Introduction
Vitiligo is a disorder of dyspigmentation characterized by the development of depigmented macules and patches over the body. Treatment is essential in patients who have a significantly diminished quality of life as the psychosocial impact of this condition is greater than many other diseases. Topical, oral, light-based, and surgical therapies are often used in combination to achieve optimal results. Vitiligo surgery is an important, but underperformed, treatment of vitiligo that was first reported in 1947 by Haxthausen and colleagues. Since then, surgical techniques have become more sophisticated and varied, with each method having unique advantages and disadvantages. With this article, the authors hope to provide a comprehensive overview of vitiligo surgery, including preoperative, perioperative, and postoperative considerations.
Preoperative Evaluation
Patient selection
The selection of suitable candidates for surgical intervention is key, as not all patients will benefit from a surgical approach ( Table 1 ). Usually, surgery is performed after failure of medical management for several different types of leukoderma, including vitiligo, piebaldism, halo nevi, physical and chemical leukodermas, and nevus depigmentosus. The difference among the variable responses to therapy seems to be based on the immunology of patients. Patients with stable disease or a nonimmune basis to their depigmentation usually have a better response to surgical intervention.
| Positive prognostic indicators | Negative prognostic indicators |
| Leukoderma treatable with surgery | Koebnerization |
| Segmental/focal vitiligo > generalized vitiligo | New or growing lesions within the past 6 mo |
| Stable disease | Distal fingertip or perioral involvement |
| Lesions on face/neck > trunk > extremities | Lesions over bony prominences and distal extremities |
| Keloidal tendencies | |
| Additional screening questions | |
| |
| |
| |
When evaluating patients with vitiligo for surgery, a detailed history needs to be obtained. First, the clinical subtype of vitiligo should be determined. Vitiligo is described as segmental and nonsegmental, with generalized vitiligo being the most common variant of nonsegmental vitiligo. Segmental vitiligo is unilateral, stable, and poorly responsive to medical management, whereas generalized vitiligo is bilateral and symmetric, with a waxing and waning course. Patients with segmental or focal vitiligo have an extremely favorable response to vitiligo surgery, and it is a first-line option in this population. In contrast, treatment of other subtypes with surgery is often less successful and should only be used when medical management has failed and patients have stable disease.
Disease stability is another parameter that must be evaluated before surgery and is defined by the lack of new or growing lesions within a given time frame, usually between 6 months to 2 years. Several methods can be used to assess stability, such as patient report, serial photography, and validated scoring systems. These methods of evaluation include a lack of change in the Vitiligo Area Scoring Index (VASI), Vitiligo European Task Force Assessment (VETF), and a low Vitiligo Disease Activity Score (VIDA). The VIDA is a scoring method that assesses disease stability in patients who have discontinued treatment of vitiligo for at least 6 months. In cases whereby stability or treatment outcome is uncertain, performing a test spot with a single punch graft in the center of a stable, depigmented lesion to assess the degree of repigmentation is useful. Koebnerization, which involves depigmentation at sites of previous trauma, is an indicator of unstable disease. Future methods for assessing disease stability include reflectance confocal microscopy, total antioxidant status, antimelanocyte antibody levels, and measurement of serum catecholamines and their metabolites. Measurement of other cellular markers, such as interleukin 17, chemokine (C-X-C motif) ligand (CXCL) 9 and 10, and mircoRNA, may also play a role in determining disease stability.
Recipient site location, which refers to the site of the lesion being treated, should be taken into account, as areas with a greater vascular supply and follicular density, such as the head and neck, have a better response to surgery than the extremities. Presentations associated with poor outcomes include the acrofacial variant, which is characterized by perioral and distal fingertip involvement around the nail bed. Areas over joints also respond poorly, possibly because of repeated friction and injury at these locations. Patients must also be screened for keloidal tendencies, significant bleeding issues, blood-borne infections, and additional contraindications to surgery.
Consultation
Preoperative discussion is focused on educating patients about the procedure, screening for candidacy, and obtaining informed consent. General information about vitiligo as well as perioperative and postoperative expectations are discussed. To ensure that no contraindications to surgery or potential allergies to anesthesia exist, past medical history, medications, and drug allergies are reviewed. Risks of the procedure and the measures taken to minimize their occurrence are also explained. These risks include bleeding, infection, scarring, pain, contact dermatitis from dressings, and anesthesia-related arrhythmias or allergy. To ensure that patients have realistic expectations, providers must emphasize that repigmentation and color matching takes several months to years and that surgery is a treatment, not a cure. Although patients may achieve long-term remission, even with focal or segmental vitiligo, there is always the possibility of reactivation of disease that patients should be aware of. Adjuvant treatments, including additional surgeries, may be necessary to achieve maximal repigmentation, especially if the treatment area was too large to complete in a single session or the degree of repigmentation after surgery is unacceptable.
Preoperative Work-up
Preoperative laboratory work includes screening for blood-borne diseases, such as human immunodeficiency virus, hepatitis B, and hepatitis C. This screening is especially important if dermabrasion is being used to prepare the recipient site, as infectious particles can aerosolize. Patients undergoing general anesthesia should have a preoperative evaluation for surgical fitness based on comorbidities and the extent of surgery. This evaluation should be done before any decisions to pursue surgery because of the significant additional cost general anesthesia adds to this procedure. General anesthesia is not commonly performed but is useful in patients who are extremely anxious or have large surface areas being treated. Photographs under appropriate lighting and measurements of the donor and recipient site are obtained before surgery and are critical in tracking progress. Woods lamp photographs are often valuable in patients in whom depigmented areas are not easily visualized, especially in lighter-skinned individuals. This high quality and woods lamp photographs enables a more accurate comparison of preoperative and postoperative photographs in evaluating treatment response.
Introduction
Vitiligo is a disorder of dyspigmentation characterized by the development of depigmented macules and patches over the body. Treatment is essential in patients who have a significantly diminished quality of life as the psychosocial impact of this condition is greater than many other diseases. Topical, oral, light-based, and surgical therapies are often used in combination to achieve optimal results. Vitiligo surgery is an important, but underperformed, treatment of vitiligo that was first reported in 1947 by Haxthausen and colleagues. Since then, surgical techniques have become more sophisticated and varied, with each method having unique advantages and disadvantages. With this article, the authors hope to provide a comprehensive overview of vitiligo surgery, including preoperative, perioperative, and postoperative considerations.
Preoperative Evaluation
Patient selection
The selection of suitable candidates for surgical intervention is key, as not all patients will benefit from a surgical approach ( Table 1 ). Usually, surgery is performed after failure of medical management for several different types of leukoderma, including vitiligo, piebaldism, halo nevi, physical and chemical leukodermas, and nevus depigmentosus. The difference among the variable responses to therapy seems to be based on the immunology of patients. Patients with stable disease or a nonimmune basis to their depigmentation usually have a better response to surgical intervention.
| Positive prognostic indicators | Negative prognostic indicators |
| Leukoderma treatable with surgery | Koebnerization |
| Segmental/focal vitiligo > generalized vitiligo | New or growing lesions within the past 6 mo |
| Stable disease | Distal fingertip or perioral involvement |
| Lesions on face/neck > trunk > extremities | Lesions over bony prominences and distal extremities |
| Keloidal tendencies | |
| Additional screening questions | |
| |
| |
| |
When evaluating patients with vitiligo for surgery, a detailed history needs to be obtained. First, the clinical subtype of vitiligo should be determined. Vitiligo is described as segmental and nonsegmental, with generalized vitiligo being the most common variant of nonsegmental vitiligo. Segmental vitiligo is unilateral, stable, and poorly responsive to medical management, whereas generalized vitiligo is bilateral and symmetric, with a waxing and waning course. Patients with segmental or focal vitiligo have an extremely favorable response to vitiligo surgery, and it is a first-line option in this population. In contrast, treatment of other subtypes with surgery is often less successful and should only be used when medical management has failed and patients have stable disease.
Disease stability is another parameter that must be evaluated before surgery and is defined by the lack of new or growing lesions within a given time frame, usually between 6 months to 2 years. Several methods can be used to assess stability, such as patient report, serial photography, and validated scoring systems. These methods of evaluation include a lack of change in the Vitiligo Area Scoring Index (VASI), Vitiligo European Task Force Assessment (VETF), and a low Vitiligo Disease Activity Score (VIDA). The VIDA is a scoring method that assesses disease stability in patients who have discontinued treatment of vitiligo for at least 6 months. In cases whereby stability or treatment outcome is uncertain, performing a test spot with a single punch graft in the center of a stable, depigmented lesion to assess the degree of repigmentation is useful. Koebnerization, which involves depigmentation at sites of previous trauma, is an indicator of unstable disease. Future methods for assessing disease stability include reflectance confocal microscopy, total antioxidant status, antimelanocyte antibody levels, and measurement of serum catecholamines and their metabolites. Measurement of other cellular markers, such as interleukin 17, chemokine (C-X-C motif) ligand (CXCL) 9 and 10, and mircoRNA, may also play a role in determining disease stability.
Recipient site location, which refers to the site of the lesion being treated, should be taken into account, as areas with a greater vascular supply and follicular density, such as the head and neck, have a better response to surgery than the extremities. Presentations associated with poor outcomes include the acrofacial variant, which is characterized by perioral and distal fingertip involvement around the nail bed. Areas over joints also respond poorly, possibly because of repeated friction and injury at these locations. Patients must also be screened for keloidal tendencies, significant bleeding issues, blood-borne infections, and additional contraindications to surgery.
Consultation
Preoperative discussion is focused on educating patients about the procedure, screening for candidacy, and obtaining informed consent. General information about vitiligo as well as perioperative and postoperative expectations are discussed. To ensure that no contraindications to surgery or potential allergies to anesthesia exist, past medical history, medications, and drug allergies are reviewed. Risks of the procedure and the measures taken to minimize their occurrence are also explained. These risks include bleeding, infection, scarring, pain, contact dermatitis from dressings, and anesthesia-related arrhythmias or allergy. To ensure that patients have realistic expectations, providers must emphasize that repigmentation and color matching takes several months to years and that surgery is a treatment, not a cure. Although patients may achieve long-term remission, even with focal or segmental vitiligo, there is always the possibility of reactivation of disease that patients should be aware of. Adjuvant treatments, including additional surgeries, may be necessary to achieve maximal repigmentation, especially if the treatment area was too large to complete in a single session or the degree of repigmentation after surgery is unacceptable.
Preoperative Work-up
Preoperative laboratory work includes screening for blood-borne diseases, such as human immunodeficiency virus, hepatitis B, and hepatitis C. This screening is especially important if dermabrasion is being used to prepare the recipient site, as infectious particles can aerosolize. Patients undergoing general anesthesia should have a preoperative evaluation for surgical fitness based on comorbidities and the extent of surgery. This evaluation should be done before any decisions to pursue surgery because of the significant additional cost general anesthesia adds to this procedure. General anesthesia is not commonly performed but is useful in patients who are extremely anxious or have large surface areas being treated. Photographs under appropriate lighting and measurements of the donor and recipient site are obtained before surgery and are critical in tracking progress. Woods lamp photographs are often valuable in patients in whom depigmented areas are not easily visualized, especially in lighter-skinned individuals. This high quality and woods lamp photographs enables a more accurate comparison of preoperative and postoperative photographs in evaluating treatment response.
Perioperative considerations
Once preoperative evaluation is completed, surgical techniques should be considered. There are several methods for preparing the donor and recipient site as well as a multitude of surgical techniques. Typically, skin is removed from normally pigmented skin at the donor site, which is then either directly transferred or manipulated and transferred to the recipient site. Lesion location, size, and clinic resources should all be taken into account when deciding on a specific method ( Table 2 ).
| Surgical Method Preferred According to Area of Involvement and Site of Vitiligo | |||
|---|---|---|---|
| Preferred Technique | Alternative Technique | ||
| Area | Small | SBG, STSG, FTG | SG, PG |
| Moderate | NCES, STSG, FTG | SG, PG | |
| Large | NCES, CM, CE | SG | |
| Site | Fingers and toes | NCES, PG | SG, PG |
| Palms and soles | PG | ||
| Lips | NCES, SBG | SG, PG | |
| Eyelids | NCES, SBG, STG | SG | |
| Nipple & areola | NCES, SBG | SG, PG | |
| Genitals | NCES, SBG | SG | |
| Eyebrows, scalp | HFG, NCFRS | ||
Site Preparation
Before preparation of the donor or recipient site, these areas must be cleaned and anesthetized. Alcohol, povidone iodine, and chlorhexidine are all options for disinfection and can be used in combination. If lasers are used for recipient site preparation, alcohol cannot be used because of its flammable nature.
Topical, local, and general anesthesias are all options for pain control depending on lesion size and location, patient preference, and resources of the performing facility. Topical formulations, which usually feature different concentrations of lidocaine in combination with prilocaine or tetracaine, can be used under occlusion for the donor site and for select small recipient sites. Injection of 1% to 2% lidocaine using a field block technique to prevent uneven surfaces or a nerve block can be used for more extensive and sensitive areas. If dermabrasion is being used, lidocaine without epinephrine is used to enable visualization of pinpoint bleeding. Weight-based calculation of maximal dose is also important because of the risk of cardiotoxicity with overdose.
Donor Site
Before obtaining a skin graft, hair from the donor site may be removed by shaving, depilation creams, or plucking in order to prevent hairs from interfering with graft manipulation. The main methods of harvesting skin from the donor site include the shave, blister, and punch biopsy approaches. With the shave method, a thin (0.125 mm–0.250 mm) to ultrathin (less than 0.125 mm) skin graft is obtained using either a sterile razor blade held by hemostats, a silver skin grafting knife (E. Murray & Company, Cork, United Kingdom), a Goulian-Weck knife (Edward Weck & Co Inc, Research Triangle Park, NC), or a motorized dermatome ( Fig. 1 ). Appropriate grafts are transparent and float when placed in sterile saline for rinsing. If curling of the graft edges is noted, then the graft is too thick and another sample should be obtained. The straight razor allows maximal operator control of size and depth, but it takes considerable skill to obtain uniform grafts of appropriate thickness. A Goulion blade allows for uniform thickness but does not allow for adjustment of depth like the Silver’s grafting knife. Motorized dermatomes provide uniform grafts quickly without the level of operator skill required for manual blades, but are more costly. A 1.0- to 1.5-mm punch biopsy can be used to harvest tissue but is typically only used for mini-grafting or test spots. Suction blisters are also used to obtain grafts by using suction pressure to create mechanical disruption at the dermoepidermal junction (DEJ), resulting in a purely epidermal blister roof. The easiest method for blister induction is by using a Luer lock disposable syringe with a 3-way stopcock and pulling plunger ( Fig. 2 ). The degree of negative pressure necessary for blister formation varies by age, with younger patients requiring higher pressure. Depending on site and age, blister formation can take between 15 minutes to 3 hours. In order to facilitate more rapid blister formation, heat or injection of sterile normal saline can be used. Scarring and dyspigmentation at the site of blister formation are uncommon.
Related posts:
The Medical Treatment of Vitiligo
Quality of Life, Burden of Disease, Co-morbidities, and Systemic Effects in Vitiligo Patients
Skin Cancer Risk (Nonmelanoma Skin Cancers/Melanoma) in Vitiligo Patients
Phototherapy and Combination Therapies for Vitiligo
Depigmentation Therapies for Vitiligo
Vitiligo Pathogenesis and Emerging Treatments
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