- Best Results2-6 months
- Treatment Recovery6-12 days
- Procedure Time60-120 minutes
- Skin SpecialistDr Davin Lim
- Duration of ResultsLong-term
- Back to Work6 days
- Cost$$ Medicare
Surgical micrografting is a new method for treating vitiligo. This treatment is considered for patients who have stable vitiligo that is not responsive to conventional treatments like phototherapy &/or topical medications. Micrografting is suitable for small areas of vitiligo. With correct patient selection, its success rate is over 90%.
FactsFacts on micrografting for vitiligo
- Grafting transfers pigment cells from one area to another
- The donor site is usually on the thigh or arm
- A thin micrograft is harvested from this area
- Grafts are placed on a bed of vitiligo skin
- R-epigmentation starts a few weeks after the transplant
- Full re-pigmentation can take 6 months or longer
- Grafting is limited by surface area, stability of vitiligo & age of the patient
What is surgical micrografting?
This is a new remedy that has been developed over the past decade to transfer pigment cells from one area to another using surgical techniques. Pigment cells from a donor site are transferred to the recipient or vitiligo areas using microsurgical skin grafting.
When is surgical micrografting considered?
Micrografting is an option for vitiligo when –
- Vitiligo is stable for a minimum of 9 months.
- When patients fall narrowband phototherapy & creams.
- In small to medium areas of vitiligo
- In cases of segmental vitiligo
Surgical procedures have a limited area of coverage. Smaller areas of vitiligo on the face, neck & hands do best. Following surgical procedures, you will still require narrowband phototherapy for best outcomes. Topical creams are occasionally used post-surgery.
What areas of vitiligo can be treated with micrografting?
This surgical treatment can be used for treating stable vitiligo on the face & upper limbs- trunk. Micrografting can also be used to treat lower limb vitiligo, however the healing times are much longer compared to face vitiligo. I do not use this technique to treat genital vitiligo or flexural vitiligo (underarms, groin).
What does the donor site mean, & where is it?
The donor site describes the area where I harvest the pigment cells from. This site is located on your thigh or arm. This is known as autologous melanocyte transfer, meaning a live transfer of pigment cells called melanocytes. In contrast, cultured melanocyte transfer means placing live cells in a dish, waiting 4-8 weeks before transferring them to vitiligo areas.
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How do I harvest melanocytes?
My usual practice is free hand split harvesting of pigment cells. Occasionally I use a surgical dermatome. I take the upper layer of skin known as the epidermis (that contains melanocytes) & a very thin layer of dermis. The bottom layer allows the cells to survive the transfer & repopulate.
The donor area is numbered with topical anaesthesia for one hour before the surgery. I harvest between 10-400 square centimetres, depending on the extent of vitiligo.
How do I prepare the areas affected by vitiligo?
The recipient site (areas of vitiligo) needs to be prepared. I use a laser or mechanical dermabrasion. This allows the pigment cells to have a nutrient rich bed to survive. This procedure is painless as we use both numbing cream & local aesthetic.
When will I see pigmentation in the treated areas?
You will see changes within the first 3-5 weeks after melanocyte transfer, however the best results can take up to, & beyond 6 months. Faster pigmentation is seen on the face & neck, whilst larger areas on the trunk may take longer. Re-pigmentation is accelerated with phototherapy.
What does the treated area look like & what to expect?
This will depend on your skin type. Red & somewhat even pigmentation is seen if you have fair skin, Caucasians are examples.
If you have dark skin expect a mix of colours including hyperpigmentation (darker) coupled with a halo of white & red. This is not a side effect, but part of the healing process. It will take more than 6 months to even out. This is normal.
How long will it take for the surgical areas to heal?
Healing depends on factors such as your age, health, the donor site area & location. As a guide-
- Vitiligo areas: takes 1-2 weeks to heal.
- Donor site: takes 2-4 weeks to heal. Longer healing times on the legs compared to the arms.
What should you try before contemplating surgical micrografting?
Everything. Surgical micrografting is one of the last line treatments for vitiligo. You should attempt less invasive non-surgical modalities, including narrowband phototherapy & topical creams. In Australia, Medicare reimburses phototherapy treatment for vitiligo.
Is micrografting a cure for vitiligo?
Yes & no. In most patients with stable vitiligo, melanocyte transfer will give a permanent solution. I cannot predict how your immune system will be in the months to years following micrografting. Surgery only addresses the skin; it does not change your DNA or immune response.
What types of vitiligo are unsuitable for surgical micrografting?
If you have recent onset vitiligo (less than 18 months), you are unsuitable for this procedure. The reason is that I cannot predict if your condition will get worse or has stabilised. I do not perform surgery if you have a history of trauma exacerbated vitiligo, known as Koebner. Google this to understand.
I do not perform micrografting on genital or flexural vitiligo. If you exercise a lot & cannot limit your activities for one week, do not consider this procedure. This procedure is not indicated for childhood vitiligo as this is classed as unstable.
How old must you be for surgery?
17. I do not perform vitiligo surgery on young children & young teenagers. Post-surgical care of the operation sites are imperative for good results. I do not like sedating children for this procedure. Narrowband phototherapy & topicals are far better solutions for kids.
International consensus is that vitiligo in children can be progressive & is classified as unstable (exception is segmental vitiligo).
Disclaimer: I do not see vitiligo in children under the age of 7. Cutis Clinic has a few paediatric dermatologists.
What is phototherapy & how does it help re-pigment skin after micrografts?
Phototherapy is a medical procedure designed to wake up pigment cells called melanocytes. After surgical transfer, light therapy stimulates re-pigmentation of vitiligo at a faster rate than without light.
This treatment uses band specific UVB, delivered by a medical device at Clinic Cutis. Treatments take between 30 to 240 seconds to perform. It is painless and bulk billed through Medicare, saving patients over $200 per week.
Can eyelid or lip vitiligo be treated with surgical micrografting?
Yes, but eyelid vitiligo treated with surgery means I suture your upper eyelid closed for one week. This enables the graft to survive.
Lip vitiligo can be treated with ablation & grafting. Healing time of approximately 7 days.
What about the hands, feet, fingers & toes?
Success in these areas ranges from 60-70% on the hands to 20-30% on fingers-toes-feet. Lack of follicular units in these areas means I cannot prepare the graft bed as well. These areas are less perfused (circulation) compared to face-neck.
These areas are more prone to graft scarring compared to facial areas. If I do perform surgery on these areas, you will require a splint for 5-9 days.
What factors govern successful outcomes for micrografting?
It is important to understand that the success of surgical micrografting depends on many factors, including things that I can control & factors that I cannot. Every step of the transfer process is vitally important for pigment cell take up. This includes-
- Patient selection & type of vitiligo
- Harvesting of the graft
- Preparation of micrografting
- Preparation of the recipient site
- Graft transfer
- Correct application of dressings
- Dressing duration
- Post procedure care
- Post grafting stimulation of pigment
- Immune response & other factors
What can you do to increase the chances of success following surgery?
Follow the instructions given by my team. Do not remove your dressings or you will dislodge the graft, meaning your pigment cells would fail to survive.
My nursing staff will give you specific instructions on how to look after the donor & recipient sites. Bathing & exercise restrictions apply, be guided by them.
Can supplementation & diets help?
Dietary supplementation does no harm. A literature review has shown that the following foods & vitamins can help (even if it is placebo).
Vitamins to take include Vitamin B12, folic acid, iron & vitamin D. Vitamin D has the most amount of evidence, & I do prescribe this to most patients as part of a trial when vitiligo stabilises. Another supplement that I add is ginkgo biloba.
Dietary supplementation with antioxidant rich foods such as leafy green vegetables, legumes, seed & fish can improve health, & in rare cases, vitiligo.
What can go wrong with micrografting?
This procedure is classified as skin surgery. It carries the benefits of re-pigmentation at a rate that far exceeds normal creams & phototherapy. It also carries the risks of surgery including-
- Infection at the recipient site or donor site: 2-4% of cases
- Prolonged recovery at both sites: 5-7%
- Failure of graft uptake: less than 5%
- Hypertrophic scar donor site: 5-7%
- Skin colour changes at donor site lasting more than 8 months: 8%
- Scarring at recipient site: less than 3%, higher for areas off the face
- Non-response: variable, higher in Koebner & unstable vitiligo
What is the difference between micrografts vs punch & suction blister grafts?
Micrografting is infinitely smaller than punch & suction blister grafting. Traditionally dermatologists have used dermal punches that transfer full thickness dermis with the overlying epidermis. This gives a cobblestone appearance that looks unnatural.
Suction blister grafting was popular in the 80s’ & 90’s, however, like dermal grafting it gives an unnatural result with patchy pigmentation. Micrografting on the other hand consists of thousands of mini-grafts, hence integration is better.
How can you get an appointment with me?
Book an appointment with me at Clinic Cutis. I do need to examine your vitiligo & take a full history to see if you are a suitable candidate. I cannot do this online, & I do not do e-consults.
A referral from your GP is required, as I am a specialist dermatologist. Reception can guide you through this process.
How much does it cost for surgical micrografting for vitiligo?
Not much in the scheme of things. Australia’s Medicare subsidies most treatments. Surgical procedures start at $1290 to $4390, depending on complexity & surface area.
Phototherapy is bulk billed, saving approximately $7500 per year.
Davin’s viewpoint on micrografts for vitiligo
Surgical treatment of vitiligo has come a long way. Melanocytes can be repurposed from one site to another. These pigment cells are in the base of the epidermis occupying one in 34 cells. They are also located within the follicular units.
Transfer via grafting can be accomplished using punch grafting (easiest to do). This is of historical importance. Dermal punch grafting however can be a super easy way of determining stability & melanocyte migration. A one-millimetre graft can be placed in the middle of a vitiligo patch. It takes less than 20 seconds to perform. Migration of melanocytes within 0.5 mm takes 5 to 8 months. If pigment cells survived it signifies a good prognosis.
Suction blister & traditional SSG grafts offer better tissue integration. The downside, especially for blister grafting is the very slow melanocyte migration between grafts- typically 5 mm apart. It can take 2-3 years to fully repigment. A patchy or stuck on look is universally seen. The answer? ReCell promises to be a great treatment, but in my experience, it is underwhelming.
Micrografting is probably one of the better solutions, short of autologous in vitro melanocyte cell culture. Grafting can treat 10-15X surface area, however for most cases I hover around 5-7X. Results are predictable in over 90% of cases, & like any other surgical procedures for vitiligo, it takes 12 months or more for results to be seen.
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