Vitiligo Surgery

Rationale for surgery in vitiligo

Surgery is indicated in vitiligo when medical treatment is unsatisfactory, particularly in skin of non-hairy, mucosal and bony areas, longstanding lesions, lesions with leukotrichia, lesions in elderly patients, and segmental vitiligo. Surgical treatment offers the potential for rapid and complete repigmentation of lesions. Vitiligo is an autoimmune disease and, when active, is a recipient dominant condition. Therefore, the potential for depigmentation of the grafted skin, as well as the donor area, always needs to be considered carefully, before attempting surgery. Hence, surgical treatment is advocated in stationary, stable, and resistant cases, after failure of proper medical management.

Basic principles of surgical treatment

The aim of surgical treatment in vitiligo is complete cosmetically acceptable repigmentation of the vitiliginous areas. Surgery cannot stop the progression of the disease. The basic principle is to transplant autologous melanocytes from unaffected pigmented skin to lesional skin, as efficiently and atraumatically as possible.

Different surgical modalities are available and the choice of surgical treatment depends on the type of vitiligo, extent, and site of lesions, the availability of equipment, and expertise of the treating cutaneous surgeon. Sometimes more than one procedure may be required. In general, the outcome of surgical treatment is good in stable, localized disease and poor in unstable vitiligo, extensive disease, and acral lesions.

Case selection

Patients with stable, localized, or segmental lesions that do not respond to medical treatment are ideal candidates for surgery ( Fig. 44.1 ). Stability in vitiligo is a controversial subject, and there is no consensus regarding the criteria for defining stability. The factors which define stability are the absence of new lesions and absence of spread of existing lesions. A task force of the Indian Association of Dermatologists, Venereologists, and Leprologists, suggested 1 year as an acceptable period to establish stability, with the following definition: “a patient reporting absence of new lesions, absence of progression of existing lesions, and absence of Koebner phenomenon in the previous 1 year.” Spontaneous repigmentation and absence of Koebner's phenomenon are also considered as favorable signs for vitiligo surgery.

Since the period of stability often depends on the history provided by the patient, which may not be entirely reliable, other methods of establishing stability have been proposed, such as test grafting and vitiligo disease activity (VIDA) scoring. The test graft method consists of placing 6–8 punch grafts within a vitiligo lesion and observing over the next 12 weeks. Unequivocal repigmentation occurring beyond 1 mm from the border of the test graft indicates a positive test and therefore is an indicator of stability. It has been seen that even when the minigraft test is positive, the disease itself may be unstable. The test may only confirm the stability of the lesion tested and not necessarily of the disease process in the patient.

VIDA scoring is another method of establishing objective criteria for stable case selection as proposed by Njoo and colleagues. It is a 6-point scale on which the activity of the disease is evaluated by the appearance of new vitiligo lesions or the enlargement of pre-existing lesions gauged during a period ranging from less than 6 weeks to 1 year ( Table 44.1 ). It is suggested that surgery for vitiligo may be performed only in patients with VIDA scores of −1 or 0.

A recent study has proposed that raised CD8 T cell count in the perilesional skin may be indicative of instability and reactivation of disease. A higher percentage of cytotoxic CD8 and CD45RO cells on tissue biopsy immunohistochemistry is associated with failure of melanocyte transplantation and may serve as a useful objective tool in determining stability of vitiligo and in predicting a successful melanocyte transplantation outcome.

There is no uniformly accepted age limit for surgery. However, many limitations exist for performing surgery in children, such as the need for general anesthesia, where risks might outweigh benefits. The progress of the disease is unpredictable and therefore stability is difficult to predict in children; these surgical procedures are generally not performed in children. However, it has been shown that the results of surgery are better in adolescents than in older patients and hence in exceptional cases with severe psychological distress, surgery using an epidermal suspension, which involves the least donor harvesting, may be performed.

Patient counseling and information

Proper and adequate counseling is of paramount importance. The natural disease course, the rationale of the surgery chosen, expected outcome, need for proper immobilization after surgery, possible complications, and the need for concomitant medical therapy and phototherapy should all be clearly explained. It should be emphasized to the patient that surgical treatment only provides a cosmetic pigmentation, but does not control disease activity. After surgery, pigmentation may be incomplete, particularly at the edges. A satisfactory cosmetic outcome and color match with surrounding normal pigmented skin occurs over a period of time and may take up to several months.

Patient assessment and documentation

History-taking should include information about recent lesion activity, and occurrence of lesions at sites of injury ( Box 44.1 ). Patients with a family history of vitiligo may be more prone to recurrences. The patient's general condition should be assessed to rule out immunosuppressive states that may be a risk for delayed healing and infection. Well-defined and hyperpigmented borders of lesions and follicular or marginal repigmentation indicate stable disease ( Fig. 44.1B ), whereas ill-defined borders suggest unstable disease ( Fig. 44.1A ).

Preoperative photography is of vital importance in documenting disease extent.

Preoperative blood counts, coagulation studies, hemoglobin and blood sugar levels, and an electrocardiogram may be obtained.