Punch Grafting Research Articles

Digital image analysis vs. clinical assessment to evaluate repigmentation after punch grafting in vitiligo

Repigmentation as a treatment outcome in vitiligo is not assessed in a standard way, making results of clinical trials hard to compare. Different types of repigmentation assessments after punch grafting have not been compared so far. To compare assessments of repigmentation by a digital image analysis system (DIAS) with those of clinical observers and patients after punch grafting for vitiligo. One vitiligo patch was selected in each patient (n = 21). This patch was treated with the punch grafting technique. The grade of repigmentation (%) after 3 months was assessed by: (i) DIAS; (ii) 3 clinical observers ; and (iii) the patient, scoring the grade of repigmentation on photographs. Physicians and patients also evaluated the global result on a 7-point scale. There was an almost perfect agreement between the three clinical observers and the DIAS (ICC 0.83). As expected, variation was found between the clinical observers. Patients' scores showed a moderate agreement with the DIAS (ICC 0.49) and a poor agreement with the physicians (ICC 0.28). Overall, the patients were more satisfied with the results than the physicians. Whereas the results of the digital and clinical assessments were comparable, patients' ratings diverged. The DIAS can overcome the inevitable differences between observers, which are intrinsic to a visual grading method, and is advisable for clinical trials on vitiligo to objectively assess repigmentation in limited lesions.

Graft Vasculopathy in Clinical Hand Transplantation

Allogeneic hand transplantation is now a clinical reality. While results have been encouraging, acute rejection rates are higher than in their solid-organ counterparts. In contrast, chronic rejections, as defined by vasculopathy and/or fibrosis and atrophy of skin and other tissues, as well as antibody mediated rejection, have not been reported in a compliant hand transplant recipient. Monitoring vascularized composite allograft (VCA) hand recipients for rejection has routinely involved punch skin biopsies, vascular imaging and graft appearance. Our program, which has transplanted a total of 6 hand recipients, has experience which challenges these precepts. We present evidence that the vessels, both arteries and veins may also be a primary target of rejection in the hand. Two of our recipients developed severe intimal hyperplasia and vasculopathy early post-transplant. An analysis of events and our four other patients has shown that the standard techniques used for surveillance of rejection (i.e. punch skin biopsies, DSA and conventional vascular imaging studies) are inadequate for detecting the early stages of vasculopathy. In response, we have initiated studies using ultrasound biomicroscopy (UBM) to evaluate the vessel wall thickness. These findings suggest that vasculopathy should be a focus of frequent monitoring in VCA of the hand.

Advanced Treatment Modalities for Vitiligo

Vitiligo is an acquired multifocal and polygenic dyschromia that affects 1% to 3% of the world and presents as multiple depigmented macules and patches. Traditionally, the treatment of vitiligo has focused on pharmacologic interventions, but nearly half of all treated patients fail to respond successfully. Several advanced techniques exist that can aid dermatologists in treating vitiligo in patients who do not respond favorably to traditional pharmacologic treatments. These advanced interventions include the use of the 308-nm excimer laser, total body depigmentation therapy with monobenzyl ether of hydroquinone, microdermabrasion, micropigmentation, khellin-UVA therapy, and surgical management using miniature punch grafting, suction blister grafting, and epidermal cultures. This article reviews the current literature on these advanced treatment modalities for vitiligo and provides a practical guide for application of these techniques. Our ability to treat vitiligo may be imperfect, but through appropriate patient selection and careful application of one or more of these advanced therapies, successful treatment of vitiligo, even in patients refractory to treatment, can be achieved.

Efficacy of suction blister epidermal graft without phototherapy for locally stable and resistant vitiligo

Introduction:Surgical methods for treatment of vitiligo include punch grafts, blister grafts, follicular grafts and cultured melanocyte grafts. The aim of this study was to determine the efficacy of suction blister grafts for treatment of vitiligo, without the use of phototherapy.Materials and Methods:This clinical trial study was conducted on 10 patients with vitiligo that was resistant to usual treatments and with limited involvement in the affected sites. We used cryotherapy and a manual suction device for blistering at the recipient and donor sites, respectively. The blister was separated and fixed with sutures and a dressing to the recipient site. Repigmentation of lesions was evaluated monthly for 6 months after treatment. Repigmentation rates higher than 90%, between 71%–90%, from 51%–70%, and less than 50% were graded as complete, good, moderate, and poor, respectively.Results:Ten patients (five females with a mean age of 23.2±3.96 years and five males with a mean age of 30.60±4.15 years) were enrolled in the study. Reponses to treatment after a 6-month follow-up were ‘complete,’ ‘good,’ and ‘moderate’ in 7 (70%), 1 (10%), and 2 (20%) patients, respectively.Conclusion:With this technique, patients with restricted sites of involvement, that did not respond to the usual treatments showed very good repigmentation without any additional phototherapy over a 6-month follow-up; moreover, there were no side effects such as scarring.

Controversies: Is FUE a repair technique or small case technique rather than a first option for MPB?

1. Russell Knudsen, MBBS (drknudsen{at}hair-surgeon.com) 1. Sydney, Australia </br>![][1]</img> FUE = micro-punch grafting. It is undoubtedly a superior technique to traditional punch grafting and has been greeted by many patients and some physicians with enthusiasm. It has had 10 years

Characterization of Clinical Response in Patients with Vitiligo Undergoing Autologous Epidermal Punch Grafting

Punch grafting is a well-established treatment for vitiligo, but predictive factors for outcomes are not well established. To determine the characteristics of responses to punch grafting performed in patients with vitiligo. Retrospective, single-center chart review. Response rates were assessed using photographs taken before and after grafting using a 1.5-mm punch instrument. Effectiveness of repigmentation was assessed using the following scale: worse, no improvement, 0% to 25% improvement, 25% to 50% improvement, 50% to 75% improvement, and 75% to 100% improvement. Repigmentation rates were correlated with patient demographics. Thirty-seven charts were reviewed, from which data were available from 30 patients. The total number grafts was 606 in 44 transplanted areas; 87% (530/606) of the transplants survived, and 26 of the 30 (87%) patients achieved some degree of repigmentation. Patients younger than 20 achieved the greatest average improvement in repigmentation (mean 61%), whereas those aged 60 and older showed the least improvement (mean 38%). Punch grafting of the neck and trunk achieved the greatest repigmentation, with 65% and 63% average improvement, respectively. Acral sites and skin overlying joints improved the least. Punch grafting is successful in most patients with vitiligo, with an 87% graft survival rate, but the rates of repigmentation vary depending on clinical characteristics.

A modified, improved, easy and fast technique for split-thickness skin grafting

Large nonhealing ulcers and wounds frequently pose a great therapeutic challenge to clinicians and often require skin grafting. Various skin grafting methods are available to cover large skin defects that fail to epithelize. These methods include the use of small pinch grafts, full-thickness punch grafts, large-sized full-thickness grafts and split-thickness grafts. Large-sized full-thickness and split-thickness skin grafting requires expertise to produce cosmetically acceptable results and prevent cobblestoning, unlike small pinch and full-thickness punch grafts. To describe a modified technique of split-thickness skin grafting that can be considerably faster than alternative methods. We describe a method for split-thickness skin grafting using tumescent anaesthesia at the donor site and an electrodermatome and a polyurethane membrane without sutures at the site of the skin defect. Since 1997, we have practised a modified, improved, quick and easy split-thickness skin grafting method to cover large skin defects at the extremities. Complete healing is usually achieved 4-6 weeks after the split-thickness skin transplantation, and long-term results are aesthetically successful. We provide a sophisticated modified split-thickness skin graft procedure that has been practised for many years and provides cosmetically acceptable results while saving time.

A randomized comparison of excimer laser versus narrow‐band ultraviolet B phototherapy after punch grafting in stable vitiligo patients

Background Ultraviolet radiation following punch grafting may stimulate the migration of melanocytes from the grafts into the vitiliginous skin, thereby increasing the rate of repigmentation. We compared the effects of the 308-nm xenon chloride excimer laser (EL) vs. narrow-band ultraviolet B (NB-UVB) after punch grafting in patients with vitiligo. Objectives The aims of this study were to evaluate (i) repigmentation (%); (ii) treatment satisfaction; and (iii) patient preferences for EL vs. NB-UVB therapy after punch grafting in vitiligo. Methods Fourteen patients were treated with the punch-grafting technique on two symmetrical vitiligo patches. Starting 1 week after the punch grafting, the vitiligo patches were treated twice a week during 3 months, with EL on one side and with NB-UVB on the other side. Repigmentation (%) was measured by a digital image analysis system. Patients' satisfaction and preference for treatment were also assessed. Results Whereas both treatment modalities induced repigmentation, no statistically significant difference was found in grade of repigmentation after 3 months. With EL, 71.4% lower cumulative dose was reached. Patients were significantly more satisfied with NB-UVB and preferred it over EL. Conclusions The choice between EL and NB-UVB cannot solely be based on repigmentation, but rather on other factors, such as patients' preferences. However, given the lower UV dose of EL, we recommend its use in vulnerable populations, such as in small children and patients with sun-damaged skin with a history of long-term UVB treatment.

Acne Scar Treatment with Subcision Using a 20-G Cataract Blade

The treatment of acne scarring is complex and often involves multiple modalities. Some of the different options for managing scarring are chemical peels, laser resurfacing, photorejuvenation, mini punch grafts, and dermabrasion. Subcision, a nonoperative technique for managing depressed scars by percutaneously releasing scar bands within the dermis and subcutaneous tissue, was introduced in 1995. A needle is used to release the fibrous septa within the scar, resulting in the formation of new connective tissue underneath the scar.

Versatile Punch Surgery

Punch instrument is a circular blade that can be used for many diagnostic and therapeutic purposes in different medical and surgical specialties. Punch surgery (or biopsy) is achieved by using this versatile punch blade under local anesthesia. Basic punch surgery is quick and easy to learn. Complications such as bleeding and infection are minimal. Diagnostic punch surgery can obtain a part of or whole skin lesion for histologic examination. In addition to the skin, nail and mucous membrane tissue can be obtained by punch biopsy. Interestingly, punch biopsy can be used as an adjunctive to fine-needle aspiration to establish the diagnosis of tumors of solid organ such as the breast. Diagnostic punch surgery can be modified to overcome certain problems. The split-punch technique helps avoid crushing the tissue punch when trying to divide it for different examinations. The double-trephine punch facilitates obtaining subcutaneous tissue without the need for full elliptical excision. The string-of-beads technique obviates the need for dissection of tissue into pieces. In other nondermatology and dermatology conditions, such as nerve pathology, arteriosclerosis, melanoma mapping, and eyelid tumors, the diagnosis can be enhanced with the use of punch surgery.Therapeutic punch surgery can be used for excision of unwanted lesions such as nevi, as well as pathologic bone and cartilage tissues. Punch grafting is used in vitiligo surgery and hair transplantion. Punch evacuative surgery can help in the evacuation of unwanted tissue or materials such as lipoma, subungual hematoma, scrotal calcinosis, pseudocyst of the auricle, pilar cyst, and others.Reconstructive punch surgery includes correction of ear lobe defects and acne scars. Enhancement of wound healing can be achieved by use of the punch; therefore, it can help nonhealing ulcers.

Surgical management of vitiligo

Vitiligo is a common condition characterized by hypopigmented and/or depigmented spots on the skin, affecting approximately 1–2% of the world population. Until approximately 30 years ago, it was exclusively treated by medical therapies. The most commonly used medical therapies include topical steroids, calcineurin inhibitors and phototherapy. Lesions on the face and neck respond the best to medical therapies, followed by lesions on the proximal extremities and trunk, while those distributed over acral parts of extremities and nonhairy areas, such as the wrist, feet and male genitals, respond poorly. Surgical methods complement medical therapies by providing melanocytes to these refractory lesions, and are indicated for unilateral segmental and clinically stable bilateral vitiligo, refractory to medical treatment. Tissue-grafting methods include minigrafting or punch grafting, epidermal grafting and split thickness grafting. These methods use full-thickness punch grafts, roof of epidermal blisters and shave biopsy samples, respectively, as the source of melanocytes. Cellular grafting includes noncultured and cultured melanocytes/keratinocytes suspensions obtained from trypsinizing the shaved skin biopsy sample as a source of melanocytes. Recent advances over the years have enabled dermatologists to treat extensive areas located on any anatomic site in a single operative session by surgical intervention. The purpose of this review is to describe the selection criteria for the surgical treatment, their utility and limitations in the various types of vitiligo.

Dr Shoji Okuda (1886–1962): The great pioneer of punch graft hair transplantation

Dr Shoji Okuda (1886–1962): The great pioneer of punch graft hair transplantation

Contemporary Hair Transplantation

The field of hair transplantation has evolved considerably over the last quarter century. Performed correctly, the cosmetic results of contemporary hair transplantation are virtually undetectable in women and men. Large, pluggy "punch grafts" have been replaced with natural-appearing follicular unit grafts, which maintain their existing anatomy and with proper technique can match the orientation of surrounding hair follicles. To review all of the steps involved in hair transplantation surgery and to provide an overview of medications used in conjunction with transplantation to help prevent hair loss. The authors review key aspects of the consultation, physical examination, selection of appropriate candidates, excision of donor area, hairline design, graft creation and placement, and postoperative instructions. The role of medications such as minoxidil and finasteride in preventing ongoing hair loss is an essential part of the treatment plan. For nonsurgical candidates, other treatments such as wigs, hairpieces, and camouflages are reviewed. Future trends may involve the use of low-level laser light therapy, dutasteride, and cloning of follicles. Patients and physicians alike are pleased with the results of contemporary hair transplantation, and physicians can now recommend the procedure without reservation. The authors have indicated no significant interest with commercial supporters.

Long-term results of 2-mm punch grafting in patients with vitiligo vulgaris and segmental vitiligo: effect of disease activity

Punch grafting is a simple and frequently used technique for the treatment of stable vitiligo, resistant to medical therapy. However, studies reporting long-term results are exceptional. To evaluate the long-term results of 2-mm punch grafting in patients with vitiligo vulgaris and segmental vitiligo. We studied a prospective cohort study involving 61 patients (25 male, 36 female) with vitiligo vulgaris and nine patients (all male) with segmental vitiligo who underwent 2-mm punch grafting more than 3 years ago. The main outcome measure was the degree of repigmentation of a single transplanted lesion as measured with a digital image analysis system with a mean follow-up of 5.2 years. In patients with vitiligo vulgaris, 17 lesions (28%) showed excellent, 14 lesions (23%) showed good, 14 lesions (23%) showed fair and 16 lesions (26%) showed poor repigmentation. In patients with segmental vitiligo, seven of nine lesions (78%) showed excellent repigmentation. A cobblestone-like effect was observed in 19 of 70 patients (27%). Disease activity after punch grafting was reported in 94% of patients with poor repigmentation but in only 18% of patients with excellent repigmentation (chi(2) test, P < 0.0005). Patients who reported disease activity after transplantation had a lower mean repigmentation than those who did not report disease activity (77% vs. 39%, P < 0.05). Two-millimetre punch grafting in vitiligo is an effective surgical procedure with long-lasting effect. To prevent a cobblestone-like effect, we advise the use of smaller grafts (1-1.2 mm). Disease activity after grafting, localization and type of vitiligo, prior ultraviolet B treatment and a Koebnerized donor site influence the long-term outcome of punch grafting and should be taken into account in the selection of patients eligible for this treatment.

Evolution and evaluation of autologous mini punch grafting in vitiligo.

Vitiligo is a result of disrupted epidermal melanization with an undecided etiology and incompletely understood pathogenesis. Various treatment options have resulted in various degrees of success. Various surgical modalities and transplantation techniques have evolved during the last few decades. Of them, miniature punch grafting (PG) has established its place as the easiest, fastest, and least expensive method. Various aspects of this particular procedure have been discussed here. The historical perspective, the instruments, evolution of mini grafting down the ages, and the methodology, advantages, and disadvantages have been discussed. A detailed discussion on the topic along with a review of relevant literature has been provided in this article.

Follicular Unit Transplantation

Follicular unit transplantation (FUT) is the culmination of decades of refinement and evolution of hair transplantation techniques. Hair naturally grows in groups of one to four individual follicles separated by intervening soft tissue. These clumps or groups of hairs are termed FOLLICULAR UNITS. FUT uses microscopic dissection to separate these units for transplantation in a fashion that most closely resembles naturally occurring hair. FUT has grown to become recognized by many prominent hair restoration surgeons as the state-of-the-art method of hair replacement surgery for both male and female pattern alopecia. Although larger punch grafts, scalp flaps, and alopecia reductions may play a role in certain cases, FUT achieves results that are difficult to differentiate from naturally occurring hair. The central attributes of the technique are the provision of natural-appearing hairlines with reasonable density together with low morbidity and minimal "downtime." Nevertheless, the technique is only as effective as the technician, and results are heavily dependent on the forethought of the architect.

Guideline for the diagnosis and management of vitiligo

This detailed and user-friendly guideline for the diagnosis and management of vitiligo in children and adults aims to give high quality clinical advice, based on the best available evidence and expert consensus, taking into account patient choice and clinical expertise. The guideline was devised by a structured process and is intended for use by dermatologists and as a resource for interested parties including patients. Recommendations and levels of evidence have been graded according to the method developed by the Scottish Inter-Collegiate Guidelines Network. Where evidence was lacking, research recommendations were made. The types of vitiligo, process of diagnosis in primary and secondary care, and investigation of vitiligo were assessed. Treatments considered include offering no treatment other than camouflage cosmetics and sunscreens, the use of topical potent or highly potent corticosteroids, of vitamin D analogues, and of topical calcineurin inhibitors, and depigmentation with p-(benzyloxy)phenol. The use of systemic treatment, e.g. corticosteroids, ciclosporin and other immunosuppressive agents was analyzed. Phototherapy was considered, including narrowband ultraviolet B (UVB), psoralen with ultraviolet A (UVA), and khellin with UVA or UVB, along with combinations of topical preparations and various forms of UV. Surgical treatments that were assessed include full-thickness and split skin grafting, mini (punch) grafts, autologous epidermal cell suspensions, and autologous skin equivalents. The effectiveness of cognitive therapy and psychological treatments was considered. Therapeutic algorithms using grades of recommendation and levels of evidence have been produced for children and for adults with vitiligo.

A review of modern surgical hair restoration techniques.

The field of hair restoration has had a chequered history. From the days of punch grafting to the present day techniques of follicular unit hair transplantation, the field has seen a number of new advances. This article reviews these developments.

The Use of CO2Laser in Trichophytic Closure and in Ablation of Skin Irregularities from Pitting or Tenting from Old Punch Grafts

The Use of CO₂Laser in Trichophytic Closure and in Ablation of Skin Irregularities from Pitting or Tenting from Old Punch Grafts

S432: Hair Transplantation and Micrografting for Oral and Maxillofacial Surgeons

Hair transplantation is the most commonly performed cosmetic procedure for facial enhancement. Its efficacy is based on over forty years of study, which began with Dr Norman Orentreich’s original paper on the theory of “Donor Dominance.” In this paper, he noted that grafts taken from hair-bearing areas on the back and sides of the scalp would become: “Donor Dominant” and grow at recipient sites on the front and top of the scalp. These grafts, if properly selected and taken, could then continue to grow hair for the rest of the patient’s life. A complete understanding of male pattern baldness is needed to have a basic overview of which patients are candidates for hair transplantation. There are over seven categories of male pattern baldness in which hair loss is both genetically and hormonally (androgens) controlled. Similarly, areas of the scalp (back and sides) on the same individuals, who have male pattern baldness, have the genetic predisposition to continue growing for life. However, in assessing candidates for transplantation, potential donor areas that exist must be sufficient to cover the balding or thinning areas completely; and, certainty should be evaluated for hair density, in order to achieve the most favorable cosmetic results. The procedure utilized in this discussion will be punch grafting and critical to its success is careful staging of transplantation so that all grafts receive optimum blood supply. Equally important is hairline placement, which is drawn in relationship to the concept of facial thirds. Studies of punch grafting techniques have supported the fact that donor grafts must be taken along the hair shafts to optimize the number of growing hairs in each graft. Hair direction, as well as the selection of proper punch diameter size, is also critical in achieving optimum cosmetic results. Over the past several years, the most refined method of hair transplantation involved the placement of micro and minigrafts, which can be utilized to completely correct areas of alopecia and/or further enhance the frontal hairline. Micrografts contain from one to three hairs, minigrafts from four to eight hairs, which produce a more delicate result, more closely resembling hair growth prior to balding. These grafts are usually taken from a donor strip. Through meticulous microsurgical technique, single hair follicle may also be used. Additional grafts can be placed throughout the transplanted area in order to blend hair and achieve the fullest appearance. This virtually eliminates the “tufted” look often created by individuals unfamiliar with the true art of hair transplant surgery. Lastly the postoperative use of medication, proper bandaging and careful cleansing of each graft in the immediate postoperative phase insures virtually 100% graft survival.