Vitiligo- Punch grafting

  • Best Results8-12 months
  • Treatment Recovery6-12 days
  • Procedure Time60-120 minutes
  • Skin SpecialistDr Davin Lim
  • Duration of ResultsLong-term
  • Anaesthetic Local
  • Back to Work6 days
  • Cost$$ Medicare

Vitiligo- Punch grafting

Punch grafting is the oldest method of pigment transfer for vitiligo. It was first used over fifty years ago & has been replaced with ultrathin split thickness grafts & novel melanocyte transfer techniques. Punch grafting remains a useful procedure for undertaking test spots in areas of depigmentation.

FactsFacts on punch grafting for vitiligo

  • Punch grafting transfers pigment from one area of skin to another
  • Punches are largely outdated as it leaves visible dots & scars
  • Single punch grafts are useful to test if vitiligo is stable
  • Punch grafting also gives an indication of the speed of re-pigmentation
  • Punches are useful to transfer hair follicles to re-pigment white hair
  • The smaller the punch, the more natural the outcome
  • Despite smaller dermal punches, micrografting gives a superior result

What is punch grafting?

This is the easiest technique to repurpose & transfer pigment cells from one area of skin to another. Punches are cylindrical surgical devices used for biopsies & Follicular unit extraction. It takes less than one second to harvest the donor skin, & a few seconds to transplant it.

What types of punches are used to treat vitiligo?

I use specialized punches that are 1 mm or less. For test spots I use a standard 2-3 mm, depending on the site. Other punches include-

  1. Keyes punch: an oldie but a goodie. Less tissue trauma.
  2. FUE punch: many variations of bevels. These are 0.6 to 1.2 mm punches. I use the Cole variety.
  3. Loo’s punch: thin punch that is bigger than the FUE.

*I do not use punches at present to treat vitiligo. They are useful as test patches to determine stability & rate of pigmentation. Micrografting gives much better results.

Who is a candidate for punch grafting?

Suitable candidates for any vitiligo surgery must have the following criteria-

  • Absolute stability of vitiligo for longer than one year.
  • Age over 17 years old. Vitiligo in childhood is classified as unstable.
  • Absence of trauma associated vitiligo
  • Small areas -especially for punch grafting.
  • Poliosis or lack of hair pigmentation.

What areas of vitiligo can be treated with punch grafting?

This outdated treatment can be used on areas such as the face, neck, trunk, limbs, including the hands & feet. Super thin punches can be used to treat eyelid & lip vitiligo. 

I only use punches in the context of vitiligo as a test patch & or to treat areas of poliosis; absence of pigmentation within hair follicles.

How long does it take to recover from punch grafting?

Recovery depends on the site. Facial areas heal up within 5-7 days. Acral (hands & feet) take 9-14 days. The bigger the punch, the longer it takes for the graft to heal.

Where is the donor site for punch grafting?

Traditionally, the donor sites are the upper thigh or buttock. These areas heal with a stippled hypopigmented pattern (no ideal). For test spots I normally take a small amount of skin from the back of the ear or the front. It heals faster than legs & will not leave a scar.

Are the wounds sutured?

No. For small wounds less than 2 mm, a suture is not required. The recipient site heals up within 5-10 days, whilst the donor site heals up in 7-12 days.

Davin’s Viewpoint on punch grafting for vitiligo

Grafting is one of the oldest surgical procedures for vitiligo, made famous by the brilliant dermatologist Dr Norman Orentreich from New York. Incidentally this dermatologist also invented surgical subcision, as well as hair transplantation & cosmetic injectables. Pure genius.

Fast forward to 2022 & beyond, punch grafting & suction blister grafts are now no longer practices, replaced by technology such as micrografting, ReCell & Renova tissue grafts. I occasionally use punches as test spots only, as they are more convenient for the patient (as compared to the donor harvest of SSG). A well-positioned punch allows me to ascertain take up of the graft & rate of pigment transfer. This is especially useful if one is unsure if vitiligo is progressive & or subject to Koebner. I normally review the graft at 6 to 8 months. Patients are not encouraged to see me before that, as pigment migration is much, much slower than watching grass grow.

Why a test spot in some cases? Because the surgical process of micrografting takes a significant number of resources including time for both patients & my clinical team. Recovery following grafting can take a few weeks. A test spot is not absolute, but in cases that are not clear (stability not diagnosis), it can be useful.

Punches invariably give a cobblestone appearance, hence why they are now replaced with newer techniques of repurposing melanocytes. I can correct old punch grafts, with resurfacing & re-grafting, if this applies to you.

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