Chapter 36
Surgical Treatment
Patient Evaluation and Expectation Assessment
Venkataram Mysore, Madhulika Mhatre, and Revanta Saha
Contents
Introduction
Patient Expectations
Assessment of Suitability of a Patient for Vitiligo Surgery
Conclusion
Appendix 1
References
Introduction
Vitiligo is a pigmentary disorder of the skin associated with considerable social stigma. Patients seek treatment for improving aesthetic appeal. Treatment aims at stabilization of pigmentation and repigmentation of involved areas. This leads to improvement in the cosmetic appearance and skin tolerance to sunburns [1]. There are a great number of treatments available for vitiligo. Surgery for vitiligo forms one of the cornerstones of treatment. The principle of surgery for vitiligo is to obtain cosmetically acceptable repigmentation of vitiliginous lesions. Patients with vitiligo suffer psychologically and are often desperate to seek relief due to the stigma attached to the disease. Hence, proper evaluation of not only the clinical but also the psychological aspects is required. Counseling of the patients with respect to the disease, treatments, and outcomes is vital in order for patients to have realistic expectations.
Patient Expectations
Patients expect that they will be completely cured of the disease with respect to both regaining color and stopping fresh lesions from occurring. Regaining color should be complete, and the treated skin should merge with the surrounding skin imperceptibly. Hence anything less than 100% pigmentation, while it may be impressive and significant to the doctor, may not satisfy the patient. However, such complete recovery is possible only in a minority of patients. Surgically grafted areas may look normal, hyperpigmented, or even hypopigmented post-intervention. In most patients, even after surgery, other modalities such as topical therapy and phototherapy may need to be continued.
Patients also need to be told about how the donor area will look after surgery—some hyperpigmentation is common after grafting. Koebnerization may occur, and this needs to be addressed.
Patients also need to be told about postoperative recovery—need for immobilization, pain, dressing, visits to the clinic, etc. A detailed instruction sheet may be given to the patient.
Assessment of Suitability of a Patient for Vitiligo Surgery
To date, none of the medical or surgical therapeutic choices can assure guaranteed success for all cases of vitiligo. This is primarily because of the obscure etiopathogenesis and elusive activity profile of the disease. Not only with medical therapy but also with any of the surgical modalities deployed, proper selection of cases is of paramount importance.
The concept of stability
Stability of vitiligo is the most important parameter before opting for any transplantation technique [1]. The commonly accepted guidelines for clinical stability are:
•No new lesions should appear
•Existing lesions should remain the same size
•Absence of Koebnerization
•Spontaneous repigmentation
•Positive minigraft test, especially when minigrafting is performed
Various authors have added additional parameters to these criteria of evaluation of stability prior to undertaking surgery, such as consideration of induced versus spontaneous stability, the concept of cellular stability, overall stability versus regional stability versus lesional stability, etc. There has been no consensus regarding these additional factors and their importance; however, we will discuss these aspects in detail in this chapter.
Duration: Despite many studies, there is no consensus regarding the minimum required period of stability. The recommended period of stability in different studies has varied from 4 months to 3 years (Table 36.1) [2]. The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Task Force recommends a period of stability of 1 year before undertaking surgery.
Test Grafting
