A 27 years old young healthy male reported to the skin OPD with complaints of white patches over his arms and thighs since 8 months. On examination the spots were flat white spots & were numerous and distributed over the arms and legs most of them measuring less than a cm in diameter. the spots were quite subtle almost playing hide and seek looking prominent at sometime and then not so obvious at other times It didn’t fit in clinically with the most common skin issues of similar look ie fungus, allergy, sun sensitivity etc. Routine blood tests Complete blood counts , liver , kidney function tests, thyroid , blood sugars were within normal limits and gave no further insight whatsoever The patient had visited couple of doctors who just like us couldn’t really come to a final diagnosis and he was treated as a case of fungus, allergy white patches with no improvement at all; the case was turning to be most eluding yet teasing,it was like the spots were taunting us having a secret laugh at our ignorance. With nothing more to offer to the patient we admitted to the patient yes even though we are supposed to be specialists we had no clue as to what we were dealing with and we thought let us sleep over this and rake our brains at a later date

Skin Laser Centre
image 1

Thankfully the patient was patient and persistent, and he had more trust in our abilities to help him than what we had frankly and were all about to throw our hands in the air when we noticed that his arms appeared slightly red kinda flushed. So we had a new clue and we started to prod deeper into that and the patient revealed that the redness is very much there on and off but it doesn’t bother him like pain or itch so he choose not to discuss that We then started a cross reference transient redness, flushing we dug into our books and online research ( Dr Google ) threw up a picture akin to our patients condition and we had the diagnosis it was BIER spots, a rare entity but nevertheless reported and published.

So this is how it goes when the patient raises his hands as shown in image 1 they disappear and when the patient puts his arms down the blood gushes down, the flush increase and the white spots reappear magically shining like stars in a dark moonless night (image 2).

In the image 3 we can see both the arms the right is red and beefy and left pale as it had been just raised for a few seconds a moment ago which had emptied the veins ; the contrast is startling and was staring in our face  Like a kid who has been give a free access to a video game parlor we were grinning and asking the patient to raise one arm and then the other and get them down and so on, even he was mesmerized to see the changes in his body happening with a bit of help from gravity The white patches would crop up the moment his arms were hanging

Skin Laser Centre
image 2 & 3

down in the dependent position and disappear in a jiffy the moment he raised them and even though I’m considered a specialist in treating vitiligo ( White Patches ) I swear I have never seen any white patch getting cured at this speed. Medical literature dispels the mystery behind this phenomenon as abnormal Vascular response to venous hypertension and tissue hypoxia so if u see that’s what was happening But the thrill of making this rare diagnosis was a eureka moment for me and my colleague Dr Nupur, the sweet pleasure of arriving at a diagnosis was just divine . We literally patted each other on the back Good job and after a long slog in the OPD we raised a toast ( with tea In thermacol glasses) and exclaimed Elementary Dr Watson Elementary I know some of u must be wondering why I’m so excited to sit down and write a article about this simple condition but it’s something u really go to experience yourself , and in the end it’s the small pleasures that really count in this beautiful journey of life, for these are the drops that become the ocean, and is it not that the entire ocean is in the drop……

― Dr Paul

Suction Blister Grafting

Suction blister grafting (SBG) is a procedure wherein epidermis is harvested from the donor site ie the thigh in the form of suction blister and then transferred to the dermabraded vitiliginous area(White Patches ). The graft acquires the characteristics of the recipient site, thus leading to a better color and texture matching and overall excellent cosmetic result.

Suction blister grafting (SBG) is a procedure wherein epidermis is harvested from the donor site ie the thigh in the form of suction blister and then transferred to the dermabraded vitiliginous area(White Patches). The graft acquires the characteristics of the recipient site, thus leading to a better color and texture matching and overall excellent cosmetic result.

Vitiligo patches over hairy areas where the hair are still pigmented response to medical treatments i.e. oral immunosuppressive (systemic steroids / azathioprine /methotrexate), Phototherapy (UVA, NB UVB or PUVA sol) or topical immunomodulators (Steroids, calcineurinin inhibitors5, Vitamin D derivatives)

However the acral areas, vitiligo patches with leukotrichia, i.e. areas having an absence of functional melanocytes will not respond to medical treatments and for such patients with stable disease, grafting is the only option. It is imperative that the disease is stable for a period of minimum one year before any Vitiligo Treatment is attempted.

The various surgical modalities available are Tissue grafting: Mini punch grafting, ultra thin split thickness grafting, blister grafting, hair follicle grafts, smash grafts, Cellular Grafting: Cultured and non cultured autologous cell suspensions and procedures where melanocytes are not being replaced i.e. tattooing,, excision and closure, dermabrasion or chemabrasion

The focus of this chapter is on technique of suction blister grafting in vitiligo

Suction blister grafting (SBG) is a procedure wherein epidermis is harvested from the donor site in the form of suction blister and then transferred to the dermabraded vitiliginous area.

In split skin thickness grafting and punch grafting, no matter how skilled the surgeon is, in most cases there will be a dermal component in the harvested skin, hence the graft retains some donor site characteristics thus resulting in textural and color mismatch.

In suction blister grafting, the negative suction applied on the skin leads to a cleavage between the basal cells and the basal lamina of the basement membrane zone and the blisters thus raised contains only the epidermis. The graft acquires the characteristics of the recipient site, thus leading to a better color and texture matching and overall better cosmetic result.

Graft site

The donor site can be the flexor aspect of the arm, forearm, abdomen, and the anterolateral aspect of the thigh or leg. It is ideal to take from the thigh as there can be pigmentary changes which can take time to settle.

Pre graftical medication
All patients are given a single dose of antibiotic (cephalexin), ranitidine, analgesic (brufin), and anxiolytic (diazepam) at least one hour before the grafting.

Donor site preparation
The site is shaved then surgically prepared with Betadine , spirit After surgically disinfecting the area a field block is given with a combination of 2% xylocaine, bupivacaine, and sterile water for injection (1:1:1 ratio ), Xylocaine gives immediate anesthesia and bupivacaine has a prolonged action which makes the entire procedure relatively painless.

Raising of blisters
Blisters are raised using 20 ml or 10 ml syringes. Depending on the amount of area to be covered the number and size of syringes is decided. The piston of the syringe is discarded and then IV tube is used to connect the syringe to the suction machine. At 300mmHg suction clamps are applied on the IV tubing using artery forceps or sponge holders. It takes on an average 1.5 to 2.5 hours for the development of blisters.

Deroofing the blister
Once the blisters are formed, the roofs of the blisters are cut with an iris scissors. The roofs are inverted onto a glass slide so that the dermal side faces upwards. The graft is teased out and spread to its maximum size, any blood or dermis is gently removed and it is kept moist with normal saline. Care should be taken the grafts edges are not curled and it is handled carefully because if the graft gets curled up we cannot make out the sides i.e. epidermis and dermis cannot be differentiated since the graft is so thin and transparent The donor site is cleaned and dressed with paraffin dressings, gauze, pad, micropore.

Blister dissection
All the blisters are taken on glass slides and then are cut into smaller grafts using a 23 no surgical blade. The number and size of these grafts will correspond approximately to the recipient site.

Using smaller grafts helps in placing the grafts more accurately to the recipient area and prevents wastage of the graft.

Preparation of recipient site
The vitiligo area is surgically cleaned using spirit and povidone iodine and then anesthetized using plain lignocaine 1%. The area can be dermabraded using motorized dermabrader, Erbium YAG Laser, or a CO2 laser till pinpoint bleeding spots are seen which denotes the papillary dermis level. The dermabrded area is then covered with saline soaked gauzes which helps in maintaining heamostasis and keeps the wounded bed moist.

Transfer of Graft
The dissected grafts are transferred to the deepithealized vitilgo site using glass slide after transferring the grafts it’s important to again spread out the grafts esp. the edges, cyanoacrylate glue can be applied along the margins of the grafts to immobilize it. After the graft has been placed it is covered with paraffin dressing, dry guaze, pad, micropore In case of blister grafting of lips stay sutures are given with 3-0 or 4-0 prolene and a tie over dressing is given.

Postoperative Care
The patient is asked to lie down for 30 mins after the grafting to ensure good adherence of the graft. Patient is given a short course of antibiotic and analgesic for 5 days and advised to keep the area immobile. The dressing over the recipient and donor site is left on for 7 days. If the lip is operated patient is asked to a liquid diet with a straw, while doing the eyelids it’s a good idea to shut the eye to prevent too much movement which can displace the grafts.

Removal of dressing
Dressings are removed at Day 7, it’s important that the dressings are removed carefully so as to avoid dislodging the grafted skin. After removal the guaze and pad it’s advisable to soak the paraffin dressing with normal saline so that the dried blood and scabs are loosened and dressing comes out easily. The grafts usually fall off in most cases or in some cases they are taken up.

Repigmentation starts between one to 3 months post op; if the pigmentation is inadequate or there are some achromic islands, phototherapy or topical steroids can be started to hasten up the pigmentation.

It is time consuming and the raising of blisters is painful. Sometimes inadequate blisters or small blisters are formed. For all practical purpose only small areas can be managed with this technique Improper handling may lead graft tears or the epidermal side being grafted, thus failure to pigment. Hyper pigmentation, incomplete pigmentation, perigraft halo are few of the complications.

In a systemic review13 blister grafting was compared with mini grafting,split-thickness grafting, and grafting of cultured melanocytes, in this review the highest mean success was found with split-thickness grafting(87%), & grafting of epidermal blisters(87%), and it was better than minigrafting (68%) and grafting of noncultured epidermal suspensions(31%).Minigrafting had the highest rates of adverse effects.

Another study14 comparing punch grafting and blister grafting over the lip showed comparable repigmentation but reported better colour match with punch grafting . In the recipient site, cobblestone appearance was the predominant complication in punch grafting and hyperpigmentation and thickening of grafts were common in suction blister grafting.

Blister grafing is a safe, easy, and inexpensive method, with very good success rates. Repigmentation is faster and the color and texture match is better than punch grafting, ultra thin skin grafting and tattooing.

Surgical management of acral vitiligo

Vitiligo patches (White Patches ) are the most difficult variety of vitiligo to manage The primary reason behind failure of treatment in these areas is the absence of viable melanocytes in the skin and the absence of hair follicles ,the second reason behind failure to achieve repigmentation in these areas is that there is disease activity

Vitiligo patches (White Patches) are the most difficult variety of vitiligo to manage The primary reason behind failure of treatment in these areas is the absence of viable melanocytes in the skin and the absence of hair follicles ,the second reason behind failure to achieve repigmentation in these areas is that there is disease activity.

The primary reason behind the failure is the absence of viable melanocytes in the skin and the absence of hair follicles as is now evident that the repigmentation in generalized vitiligo following medical therapies is perifollicular (If the hair on the depigmented patches are still pigmented) or it is marginal repigmentation i.e. melanin production from the viable active melanocytes present in the margin of the vitiligo patch.

The second reason behind failure to achieve repigmentation in these areas is that there is disease activity. Even though most of the patches seem to be stablein a case if generalized vitiligo the acral lesions show a very slow but definite spread in many cases and hence this leads to higher rates of surgical failure in these cases

The third reason for failure is that acral areas are more difficult to operate. The reason of difficulty being two fold i.e. difficult to dermabrade the acral areas and difficulty in immobilizing the grafted area i.e. in retaining the transplanted tissue grafts (Punches, Ultrathin skin grafts ), cellulargrafts (cultured and non cultured autologous cell suspensions). Hence if adequate depths are not achieved while deepitheliazing the recipient area and area is not adequately immobilized the cell/ graft uptakes will be poor and hence result in partial or poor repigmentaion

When we use the term acral vitiligo we broadly include these sites Fingers, toes, Lips, nipples, peri areola, genitalia, peri-anal Dorsum of the hand and feet Lateral and medial malloelus, knees, elbows

These areas are often clubbed as the Lip tip type of vitiligo or the bony vitiligo or acral vitiligo. Besides being notorious to treat all these areas have these characteristics in common
There are almost no or few hair follicles on these sites
They are difficult to dermabrade e.g. the penis, lips, and vaginal patches
It’sdifficult to immobilize and retain the grafts on these sites e.g. the penis, lips, vaginal patches

These patches show some disease activity

Hence they are all labeled as difficult to treat area

The irony in acral vitiligo is that the difficult areas are also the most visible areas and thus they become the most important areas to be treated

Vitiligo after all is a benign cosmetic disease with malignant psychological issues and it’s the acral areas that are the ones which produce most stress and psychological issues in vitiligo patients

Coming to management of acral vitiligo as has been discussed endless medical treatments are not only futile but dangerous if we actually consider the long durations for which some patients of acral vitiligoare subjected to systemic steroids, immunosuppressive, UV radiations when it is quite evident that these areas are unlikely to repigment unless the melanocytes are replaced.

It is important for the treating dermatologist to understand and acknowledge the fact that beyond a certain limit medical treatment will not work and its best to replace the missing cell i.e.the melanocytes with a surgical procedure which he or she is apt at.

The surgical management of acral vitiligo can be classified as

  • Proceduresin which melanocytes are being replaced i.e. the tissue grafts and the cellular grafts
    Tissue grafting: Mini punch grafting, ultra thin split thickness grafting, blister grafting10, hair follicle grafts, smash grafts

Cellular Grafting: Cultured11 and non cultured autologous cell suspensions

  • Procedures in which melanocytes are not being replaced i.e.tattooing, excision and closure, dermabrasion or chemabrasion

How to choose a surgical modality i.e. which type of procedure is best suited for which area
Vitiligo is a cosmetic disease and this should never be forgotten when surgical procedure is being planned. The end result should be a match as close to the surrounding skin in terms of texture and color matching, there should be no alteration in the functionality or the shape or size of the recipient area

Also in the process of repigmenting the recipient large areas of donor areas should not be disfigured or scarred permanently

If the surgical end point can’t fulfill the above criteria it defeats the whole purpose of surgery

All the above mentioned procedures can produce varying amount of repigmenation but have their own advantages and disadvantages

Tattooing or micro pigmentation is a process in which artificial pigments are introduced into the mid dermis level of the vitiligo lesion. In most cases the final color matching is very poor and barring few areas like the angles of the mouth, this procedure should be avoided in all patients.

The tattooedparticle imparts a bluish tinge in the vitiligo skin and it is difficult to correct with other surgical procedures.

Excision and closure of the vitiligo patch is also a procedure with limited use since it can be carried out only in cases of small patches and it will always end up with a linear suture scar line

Dermabrasion or chemabrasion is a treatment modality which works primarily in the hairy areas as the process of therapeutic wounding stimulates the inactive melanocytes present in the outer root sheath of the hairs. Since most acral areas are non hair bearing area just dermabrasion not followed by grafting procedures will fail to produce results

Mini punch grafting is the simplest vitiligo surgery but invariably produces cobble stone appearance at the recipient and donor site and the target like appearance of the repigmentation is not well accepted by the patients

Suction blister grafting produces good cosmetic results esp. on the lips however it is a time consuming procedure and only small areas can be taken up at one time because of small sized grafts

Ultra thin split thickness grafting can be used for large areas however it is a highly skilled based procedure not all surgeons can harvest ultrathin grafts and the grafts may give a stuck on appearance, hyper pigmentation and hypertrophy, perigraft halo and milia formation are other issues commonly encountered. Also the biggest disadvantage is that large sheets of donor area skin are required which in many cases may produce scarring at the donor site.

Cultured melanocyte grafting is an excellent procedure where melanocytes can be expanded by 100 times with a very small donor area; this process is limited because of the requirement of an elaborate tissue culture lab which makes the process very expensive

Non cultured epidermal cell suspension can be used to treat large areas with small donor area (5- 10 times expansion) the color and texture matching is excellent

with no stuck on appearance, no cobble stoning, it does require training but elaborate culture labs and equipments are not required

Even though most dermatosurgeons will have their favorite techniques the noncultured autologous epidermal cell suspension scores over most techniques

It’s a cellular graft so no texture, shape functionality alterations will occur at the recipient site, no cobblestone look, no milia formation, no stuck on graft look

Since the cells can be expanded 5-10 times a very small donor area is required so no or minimum scarring at the donor site

Immobilization of the recipient area in the acral is easier as there is no tissue graft to hold

Preoperative counselling and Informed consent13

The entire process starts with detailed history of the patient pertaining not only to vitiligo but general health and associated diseases. The patient needs to be properly counselled about the procedure and the pre and post op care

 A detailed consent form elaborating the procedure and possible complications should be signed by the patient. The patient is informed of the nature of the disease. The consent form should specifically state the limitations of the procedure, and the possibility that the NCECS is replacement of functional melanocytes into the vitiligo area which is devoid of melanocytes and the disease can become unstable again in the future and there can be a loss of pigment on other sites as well as operated sites and if the disease shows future progression additional medical line of treatment and or procedures will be needed for proper results. The patient is also counselled that he/she may require additional medical treatments and or phototherapy post op to stimulate pigmentation on the operated patches and that it can take a few months to a year for significant repigmentation and colour match

Preoperative laboratory studies include complete haemogram including platelet counts, bleeding and clotting time (or prothrombin and activated partial thromboplastin time), Thyroid profile, LFT, KFT, serum electrolytes, Chest X ray PA view, ECG in adults. Screening for antibodies for hepatitis B, C and HIV is recommended.


Small areas can be managed under topical and or local anesthesia in an OT as a day care procedure.

If a case is being done under locallignocaine (2%) with or without adrenaline is generally used. Maximum dosage that can be used is 4.5mg/kg (up to 300 mg) and with epinephrine 7 mg/kg (up to 500mg) Larger areas may need regional blocks or IV sedation

Procedure of preparing the autologous melancyte cell suspension
The steps involved in this process are

  1. Harvesting a Skin graft from the Thigh
  2. Trypsinization and Cell separation
  3. Dermabrasion of the recipient (vitiligo) site
  4. Transfer and fixing of melanocyte rich cell suspension

    Harvesting of Skin Graft
    The lateral aspect of the gluteal region is selected as the donor area. Care should be taken to ensure that the Donor area had no vitiligo patches. The size of the split-thickness donor skin takenis one-tenth of The recipient area while dealing with large confluent patches. In cases having multiple scattered small patches, larger donor skin is taken – approximately one-fifth of the recipient area. Under aseptic precautions, a very superficial sample is harvested using a shaving blade held in straight Kocher’s forceps. The donor area is dressed with liquid paraffin dressing tulle (Fairlee) and sterile gauze pad.

    Trypsinization and Cell separation technique
    The cell separation was done under aseptic precautions in a laminar flow bench kept in the operation theatre. The skin sample harvested is transferred to a Petri dish containing 5 ml of the 0.2% w/v trypsin solution, epidermal side facing upwards, and incubated for 45 min at 37°C. After 45 min, the action of trypsin is neutralized with trypsin inhibitor (Life Technologies, USA).The epidermis is separated from the dermis and transferred (epidermis) to a test tube containing 2 ml of Dulbecco’s modified Eagle medium: Nutrient Mixture F-12 (DMEMF/12) medium (Life Technologies) and vortex mixed for 15 s.

    The epidermis is further broken into smaller pieces in a Petri dish and washed with the DMEM F/12 medium and finally transferred to a test tube containing the DMEM F/12 medium and centrifuged for 6 min. The supernatant was discarded and the pellet was suspended in a 1-ml insulin syringe The final volume prepared varied from 0.2 to 0.5 ml depending on the size of the area to be treated.

    Derambrasion of the recipient site
    The recipient site is abraded with a dermabrader fitted with a diamond fraise wheel (Delasco) While operating close to the eyelid margins, an Erbium: YAG laser is usedwith a fluence of 1000 mJ, 1–2 passes. The endpoint of ablation is pinpoint bleeding. Haemostasis is achieved and the ablated area is covered with saline-soaked gauze pieces.

    Transplantation technique
    The cell suspension is spread evenly on the dermabraded area and covered with collagen dressing (Collomedica Laboratories) to hold the cells applied This is covered with liquid paraffin and gauze pieces. Patients are instructed to lie still in the same position for at least 1 h to ensure cell fixation and then shifted to a room and further instructed to avoid excessive movements of the treated area for at least 6 h.

    Post-procedure instructions
    All patients are instructed to take complete rest and avoid all vigorous physical activities. Patients are Prescribed oral antibacterial agents for 5 days and nonsteroidal anti-inflammatory drugs (NSAIDs) for 3 days. The dressings are removed after 1 week in most cases. Patients are asked to follow up at weeks 1 and 3, and then at 3-month intervals. Patients were instructed not to scrub the area and postprocedureno medication was prescribed. Patients were permitted to use make-up on the treated area 10 daysafter the removal of dressings.

    Certain Modifications of the procedure for specific acral areaa
    Since acral areas are difficult to operate because of the difficulty of dermabrasion and retaining the cells transferred these techniques can be used to improve the results over specific acral sites

    How I do it!!! Eyes

    • Dermabrasion
    • Use cylindrical burs
    • Stabilize well
    • Use a corneal shield to provide base for DA
    • Immobilization
    • Small areas only collagen leave it open
    • Larger area ( full eyelid) collagen>> paraffin>> guaze>> pad>> close eye for 7 daysHow I do it Finger tips!!!
      • Dermabrade
      • Deeper DA
      • Immobilization
      • Dress each finger individually and then the whole hand

      How I do it Lips!!!

      • Derambrasion
      • Use bigger wheels
      • Put a guaze inside mouth to make the lips taut
      • Use the co2 laser or erbium YAG Laser
        • Immobilization
        • Collagen>> Paraffin>> tie up with 4-0 prolene

        Specific issues with surgery over penis / scrotum

        • The length & girth will keep varying
        • Temperature, anxiety, sleep, all can alter the tumescence of penis
        • Scrotum skin can considerably contract & expand

        How I do it Penis / scrotum

        • Dermabrasion
        • Pear shaped bur
        • Pinch skin around to make it taught
        • Immobilization
        • Collagen pixel
        • Put in a catheter
        • Admit patient
        • Drugs to reduce erectionDiscussion
          The advent of vitilgo surgery has definitely changed the treatment outcomes of vitiligo esp. in the acral and segmental variety; and in vitiligo surgery it is the autologous non cultured cell suspension technique which has totally revolutionized the surgical options and has taken the patient and doctor satisfaction to the highest level.However it’s important that before we subject any patient to any vitiligo surgery we have a detailed discussion regarding the advantages, disadvantages, limitations of the treatmentEach patient should be counseled about the risk of failure, riskof incomplete repigmentaion, colour, texture mismatch, and most of all the risk of recurrence. Vitiligo is an autoimmune disease and it can have its phases of stability and activity, surgical procedures should be taken up only in cases which are at least one year stable and in most patients medical treatment may be need to continued even post surgery to keep the autoimmune process in check.Every patient of vitiligo is an individual and the treatment surgical or medical should be customized or tailor made according to the type, extent, stability of the disease, equal consideration need to be given to the medical condition of the person i.e. age, family history, co morbidities e.g. diabetes, hypertension etc. we should keep a watch out for the potential side effects of the medical treatment i.e. medications, lasers, lights.Hence a holistic approach keeping all these Factors in mind will provide a ray of hope to the cases of vitiligo.

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