|CLINICAL, DIAGNOSTIC AND THERAPEUTIC PEARLS
|Year : 2019 | Volume
| Issue : 2 | Page : 151-153
Simple but effective blister-forming trick in suction blister technique
Sandeep Mahapatra1, Rohit Kumar Sharma1, Rani James2, Kaushik D Deb2
1 Derma Solutions Clinic, Bangalore, Karnataka, India
2 DiponEd BioIntelligece, Bangalore, Karnataka, India
|Date of Web Publication||15-Jul-2019|
Kaushik D Deb
DiponEd BioIntelligence Bengaluru - 560 099, Karnataka
Source of Support: None, Conflict of Interest: None
Vitiligo is a common skin disorder of our country. Many of the patients are refractory to medical treatment. Dermato-Surgery is very rewarding in these cases. Thus proper selection of technique will play a major role in achieving good therapeutic and end cosmetic results. Suction blister technique is convenient and cost effective, less time consuming, pure epidermal graft, excellent colour match, pigment spread from the graft to surrounding area- upto 46% and maximum pigmentation within 3-4 months happens without any scar. Suction Blister Technique: The in vivo separation of epidermis from rest of the skin by production of a suction blister using 50 ml syringe as a vacuum creating device instead of the expensive and cumbersome vacuum devices as the time taken for the blister formation is the same. The advantage in this method we needn't inject intradermal saline into the blisters as blisters formed are appropriate and chances of improper blisters are very rare.
Keywords: Blister formation, suction blister technique, syringe, vitiligo, vaccum
|How to cite this article:|
Mahapatra S, Sharma RK, James R, Deb KD. Simple but effective blister-forming trick in suction blister technique. Clin Dermatol Rev 2019;3:151-3
|How to cite this URL:|
Mahapatra S, Sharma RK, James R, Deb KD. Simple but effective blister-forming trick in suction blister technique. Clin Dermatol Rev [serial online] 2019 [cited 2020 Jul 7];3:151-3. Available from: http://www.cdriadvlkn.org/text.asp?2019/3/2/151/262772
| Introduction|| |
Vitiligo is an acquired skin disorder characterized by patchy depigmentation of the skin. Vitiligo affects approximately 0.5%–2% of the population worldwide, and the prevalence appears to be equal between men and women. The prevalence of vitiligo is often said to range from 0.09% to 8%, especially in India. Vitiligo occurs on the skin in different parts of the body and sometimes also on the mucous membranes. A number of therapeutic options for regimentation are available. Psoralen and ultraviolet A (UVA) treatment is the most important treatment for generalized vitiligo that affects >10%–20% of the cutaneous surface. For localized vitiligo, topical corticosteroids or calcineurin inhibitors are the most valuable treatments. Depending on the type, extent, and duration of vitiligo, conventional medical therapies such as topical and systemic corticosteroids, topical immunomodulators, and phototherapy are not always successful, and repigmentation is often incomplete.
Surgical techniques have also been introduced for stable, segmental, and unresponsive vitiligo. A number of dermatosurgery techniques are available to promote repigmentation of vitiligo in adults and children, such as mini or punch grafts, split-thickness skin grafts, cultured epidermal sheets, cultured melanocyte suspensions, follicular grafts, and suction blister grafts.,,,, Among these methods, the highest success rates have been achieved with split-thickness skin grafts and epidermal blister grafts.
Epidermal blister grafting involves the formation of epidermal blisters by application of a negative pressure to the normally pigmented skin. After blister formation, the depigmented epithelium is removed and the roofs of the pigmented donor blisters are transplanted to the denuded lesional areas. Suction blister technique (SBT) is convenient and cost-effective, less time-consuming, pure epidermal graft, and excellent color match; pigment spread from the graft to surrounding area up to 46%; and maximum pigmentation within 3–4 months happens without any scar.
| Materials and Methods|| |
The study was conducted on ten patients with vitiligo that was resistant to usual treatments and with limited involvement in the affected sites. They were admitted to the dermatology ward of the Derma Solutions, Marathahalli. Patients excluded from the study included those with unstable disease. All patients were advised to discontinue previous treatments at least 1 month before the grafting procedure to minimize any possible drug effects.
On the day of surgery, a donor site usually front or lateral aspect of thigh was infiltrated with xylocaine. The piston of 10c.c. syringe is removed and instead of 3 way connector [Figure 1]a, we have used an assembly line consisting of polyvinyl tubing (IV Line). The tube is cut at both ends [Figure 1]b and is attached to a syringe. One end of the cut IV tube to its needle end piece of 10 c.c. and 50 c.c. syringe in the other end. The basal rim of this 10 c.c. syringe is then applied to the fully stretched donor site. Suction is then given by 50 cc syringe to create negative pressure [Figure 1]d. Once the air is aspirated by 50 cc syringe, it is held by the assistant till the blister formation happens, and then, it is secured by tying with Mersilk sutures. After the blister formation, the 50 cc syringe is withdrawn after securing that end with an artery forceps. Both ends of the IV tube are now tied with Mersilk suture material [Figure 1]c, and artery forceps is withdrawn. Due to the negative pressure inside the basal rim of syringe, it remains adherent to the donor site in a vertical position along with the portion of IV tube properly secured, not to allow any air leak. Multiple such 10 cc syringes (8–10 or more) can be applied similarly next to each other as per the area of recipient site requirement. Excellent blister forms in 2–3 h time. Time required for separation is 45 min to 2 h. Blister is cut all along its border with curved iris scissors and its roof is reverted over glass slide.
|Figure 1: Parts of equipment used for blister formation. (a) Connector, (b) polyvinyl tubing, (c) Mersilk Suture material, and (d) vacuum device|
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The donor site (anterolateral aspect of thigh) was dressed with antibiotic ointment and gauze. After removing the roof of the donor- and recipient-site blister, donor graftable epidermis was placed on the recipient site, sutured with nylon, and then covered with antibiotic ointment and Vaseline gauze [Figure 2]c. To prevent shifting of the graft, wet sterile cotton was applied over the area and covered with sterile gauze, with the dressing firmly bound in place with a compression bandage. After surgery, a 7-day course of antibiotic was given, and the patient was advised to keep the site immobilized for a week. The dressing was changed after a week, and sutures were removed after 2 weeks. Repigmentation rates were evaluated by comparing images of the lesions every month for 3 months after surgery.
|Figure 2: Blister grafting procedure. (a) Raising suction blisters by the syringe method, (b) suction blister cut, and (c) grafting of blisters|
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| Results|| |
In this study, ten patients with stable vitiligo were evaluated for response following suction blister grafting, without pre- or post-graft phototherapy. Blister induction in the donor site was done on the day of surgery. Blister formations by vacuum technique are shown in [Figure 2]a and [Figure 2]b. First signs of pigmentation appeared after 2–4 weeks in the grafted site, and ultimately in all the ten patients treated, 80% pigmentation appeared after 12 weeks as shown in [Figure 3]. In all the patients, pigmentation progressed beyond the graft margins. Regression did not occur in the grafting site in any of the patients [Figure 2].
|Figure 3: Pre- and post-treatment pictures of patients. (a) Before treatment, (b) 3 months after suction blister technique surgery, (c) before treatment, and (d) 3 months after suction blister technique surgery|
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| Discussion|| |
Vitiligo is a fairly common pigmentary disorder of skin resulting from a loss of melanin which causes depigmentation of the skin. Vitiligo is not a life-threatening disease; however, it frequently induces emotional distress. A number of therapeutic options for repigmentation of vitiligo are available, yet they commonly show unsatisfying outcomes. Systemic or local administration of psoralen combined with UVA (PUVA) or topical corticosteroids is currently widely used. The success rate of PUVA treatment is relatively good, but recurrence after discontinuation is frequent. Among the treatment, methods for vitiligo are surgical procedures in which active melanocytes are transferred to the affected site. Surgical treatments are satisfactory when they are tried on patients with a stable type of vitiligo, which is unresponsive to conventional therapies.,,
Transplantation of cells cultured in vitro from a small piece of donor skin is also used for treatment of large areas by expanding the melanocyte population; however, this method is very expensive and requires special and advanced laboratory facilities. Suction blister grafting is accomplished by suction of viable epidermis from dermis, and pigmented epidermis is used for coverage of achromic areas. In most studies in the literature, when epithelization was completed (usually after 1 week), phototherapy was used to induce proliferation and migration of melanocytes in the recipient sites.,
In our study, reepithelialization was completed in about 2–3 weeks and skin color normalized in most cases about half a year later. In all the patients, >75% pigmentation was seen [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d. No serious complications were reported. The SBT showed satisfactory outcome for the treatment of lip vitiligo.
The technique is inexpensive and easy and obviates the need of cumbersome and heavy equipment. Our results showed satisfactory outcome for the treatment of vitiligo patches in neck and lips [Figure 3]. In the proposed method, there is no need to use any manometer or inject intradermal saline into the blisters as blisters formed were appropriate and chances of small or improper blisters was very rare. The use of IV polyvinyl tubing and securing the ends with suture instead of three-way connectors or any vacuum creating devices is very cost-effective and promising method to create intact and proper blisters in SBT.
| Conclusion|| |
Suction blister grafting is a cost-effective procedure; with a slight modification, it can be done in a minor operation theater.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Yaghoobi R, Omidian M, Bagherani N. Vitiligo: A review of the published work. J Dermatol 2011;38:419-31.
Kyriakis KP, Palamaras I, Tsele E, Michailides C, Terzoudi S. Case detection rates of vitiligo by gender and age. Int J Dermatol 2009;48:328-9.
Krüger C, Schallreuter KU. A review of the worldwide prevalence of vitiligo in children/adolescents and adults. Int J Dermatol 2012;51:1206-12.
Ding X, Du J, Zhang J. The epidemiology and treatment of vitiligo: A Chinese perspective. Pigment Disord 2014;1:148.
Falabella R, Barona MI. Update on skin repigmentation therapies in vitiligo. Pigment Cell Melanoma Res 2009;22:42-65.
Agrawal K, Agrawal A. Vitiligo: Repigmentation with dermabrasion and thin split-thickness skin graft. Dermatol Surg 1995;21:295-300.
Lahiri K. Evolution and evaluation of autologous mini punch grafting in vitiligo. Indian J Dermatol 2009;54:159-67.
] [Full text]
Falabella R. Grafting and transplantation of melanocytes for repigmenting vitiligo and other types of leukoderma. Int J Dermatol 1989;28:363-9.
Koga M. Epidermal grafting using the tops of suction blisters in the treatment of vitiligo. Arch Dermatol 1988;124:1656-8.
Njoo MD, Westerhof W, Bos JD, Bossuyt PM. A systematic review of autologous transplantation methods in vitiligo. Arch Dermatol 1998;134:1543-9.
Drake LA, Dinehart SM, Farmer ER, Goltz RW, Graham GF, Hordinsky MK, et al.
Guidelines of care for vitiligo. American academy of dermatology. J Am Acad Dermatol 1996;35:620-6.
Parsad D, Dogra S, Kanwar AJ. Quality of life in patients with vitiligo. Health Qual Life Outcomes 2003;1:58.
van Geel N, Ongenae K, De Mil M, Naeyaert JM. Modified technique of autologous noncultured epidermal cell transplantation for repigmenting vitiligo: A pilot study. Dermatol Surg 2001;27:873-6.
Ozdemir M, Cetinkale O, Wolf R, Kotoǧyan A, Mat C, Tüzün B, et al.
Comparison of two surgical approaches for treating vitiligo: A preliminary study. Int J Dermatol 2002;41:135-8.
Maleki M, Javidi Z, Ebrahimi-Rad M, Hamidi H. Treatment of vitiligo with blister grafting technique. Iran J Dermatol 2008;11:55-9.
Falabella R, Arrunategui A, Barona MI, Alzate A. The minigrafting test for vitiligo: Detection of stable lesions for melanocyte transplantation. J Am Acad Dermatol 1995;32:228-32.
Kahn AM, Cohen MJ. Vitiligo: Treatment by dermabrasion and epithelial sheet grafting. J Am Acad Dermatol 1995;33:646-8.
Anstey AV. Disorders of skin colour. In: Burns T, Breathnach S, Cox N, Griffiths CE, editors. Rook's Textbook of Dermatology. Vol. 58. Hoboken New Jersey: Wiley Blackwell; 2010. p. 47-50.
Awad SS, Abdel-Raof H, Hosam El-Din W, El-Domyati M. Epithelial grafting for vitiligo requires ultraviolet A phototherapy to increase success rate. J Cosmet Dermatol 2007;6:119-24.
[Figure 1], [Figure 2], [Figure 3]