Vitiligo Surgery

Surgical management is done in stable vitiligo which is inactive for 6 months to 1 year and either refractory, means not responding to medicines or slow responder to medicines.

There are tissue grafting options and cell transplantation options.

The tissue grafting options, although economical, give rise to colour and texture mismatch that is equally psychosocially bothersome as vitiligo.

The cell transplantation achieves better color and texture match. Any eligible patch on any site with any size can be treated successfully, if selected and treated in right time and right way. Several advanced surgical treatment for vitiligo are available at our clinics. The modifications done by Dr.Holla to achieve all these and successfully treat even difficult to treat areas like, lip, acral areas, eye lids, joints, genital areas, areola and large areas. We have done 5000 procedures so far.

Selection Criteria

Stable Vitiligo

No new patch/No increase in Size/No white patch after trauma/No loosing of already regained pigments since last 6 months to 1 year

Stable Patient

Patient with realistic expectation with dedication and involvement

Non-Cultured Epidermal Suspension Transplantation (NEST)

The cell transplantation method used in our clinic is developed by Dr. Holla over last 11 years of dedicated expertise.  In a stable vitiligo patch, this process gives near complete repigmentation and near normal colour and texture match.  Our procedure uses recombinant re agent which are fit for clinical use. The cell suspension prepared by our process gives higher viable cellular yield compared to other conventional methods. We take ultra-thin skin grafts which are usually 1/10th to 1/3rd the size of the recipient area depending on site of lesion. The donor area consequences like scarring is almost nil. Mostly patients will have transient hyperpigmentation. The cell transplantation depends on ‘recipient dominance’ phenomenon where recipient area will decide the colour and texture match. This cell transplantation method mostly covers ideal requirements of vitiligo surgery like replacement of altered keratinocytes, replenishment of lost melanocytes, immunomodulation, efficient proliferation and migration of cells and minimal detachment of transplanted cells. This is two step/two day procedure. In eligible patient and patch, the ultrathin graft is taken on first day evening. The graft is stored in special temperature with recombinant dissociation agent which slowly and effectively separates cell. Next day, the cell suspension is prepared and recipient area is prepared using the combination of advanced Laser and effective motorized dermabrader. The cell suspension is transplanted over the recipient area using our modified dressing method which not only holds the cells in place but also nourishes them. As mentioned in earlier sections, this method is very effective in difficult areas and larger areas. We have vast experience in treating vitiligo patches on areas like, fingers, hands, feet, joints, lip, eye lid, genital areas, folds like under arm, umbilicus, nipple and areola. We are able to treat even 3000 sq cm area patch in single session with this method. This is unique achievement by our team. Another advantage with this method is pigmentation of white hairs on the white patch by mechanism called ‘retrograde migration of melanocytes

Non-Cultured Follicular Suspension Transplantaion (FoST)

This innovated method of cell transplantation has the advantage of no dependence of skin graft. Around 50 to 100 hair follicles are taken from the back of scalp. Compared to conventional follicular cell suspension method, this method doesn’t involve serial cell separation. This method involves single cell separation. However, this method can not be used for larger areas because of excessive time consumption. This method has higher possibility of stem cell presence and immunomodulation. This is also two steps or two-day procedure.

Combined Cell Suspension Transplantation (FEST)

Follicular and Epidermal suspension transplantation or combined cell suspension transplantation is the brain child of Dr. Holla. He had pioneered this technique to combine the advantages of non-cultured epidermal suspension transplantation and non-cultured follicular cell suspension transplantation.

Artificial Reservoir Technique (ART)
This method of cell transplantation was invented by Dr. Holla in the year of 2014. This process is for the areas which usually got higher failure rates due to cell detachments. Here the patients own skin is used as dressing material to hold the cells for longer time. Cell preparation is done in same method as described earlier. Controlled blister formation is achieved over recipient area using cryo pen or cryo gun. With the modified method, cells are injected  in to these blisters. Artificial reservoirs are created over recipient area. This method is useful to treat patches on lip, genital area and acral vitiligo patches like finger tips. Such method is also used in smaller patches and small resistant patches after initial cell transplantation.

Touch Up Technique

Touch up procedures are needed in cases where some resistant islands of white patches remain after successful cell transplantation. This situation is highly challenging one and needs extreme expertise to overcome the resistant patches. Although process is same as first procedure, one needs to be careful with the cell concentration and dressing methods. Touch up technique is done after 6 months of initial procedure.

Trypsin Vs Recombinant Protease

The conventional procedure uses cell separation reagent that is of animal origin. One should look for the recombinant reagent-based procedure that is safer. We do a modified non-cultured epidermal suspension transplantation using safer alternates. We use recombinant reagent which is safer for clinical use. Comparatively this reagent is costlier than the conventional animal origin. The success with such reagent depend on the expertise and needs special protocol.

Cold Method Vs Warm Method

The conventional cell transplantation is based on warm trypsinization where cell separation is done at body temperature (37 degree) which is faster and harsher. Although this is quicker, it achieves much lesser viable cell yield. This  makes it to “difficult to treat difficult areas” successfully consistently.  Also there are chances of higher cell deaths or cell damages which increases auto transplantation of antigens which might aggravate vitiligo. The cold trypsinization or cold cell separation method on the contrary relies on slow and soft cell separation. This method achieves higher viable cell yield and minimal cell death or damage with resultant advantages.

Authored By : Dr. Anantha Prasad Holla P