Surgical Options Beyond MKTP in Vitiligo: Suction Blister, Punch/Minigrafting, and FUE-Grafting

Key Takeaways

Stability first: no new/enlarging macules for ≥6–12 months, quiet Wood’s-lamp rim, and no Koebner activity.
Best sites: face/neck > trunk/limbs > acral. Leukotrichia benefits from hair-bearing graft options (e.g., FUE).
Technique choice: suction blister for color match and low cobblestoning; punch/minigrafts for small focal gaps; FUE for hairy areas and leukotrichia.
Adjuncts: NB-UVB/excimer post-op to consolidate islands and blend borders.

Indications: stable segmental/focal NSV, small-to-moderate patches, refractory rims, leukotrichia, facial/neck priority lesions.
Contraindications: active disease (positive VIDA, confetti at rim), keloid tendency, infection, poor adherence to post-op care.
Stability check: photos + Wood’s lamp at two visits 3–6 months apart; no new lesions/expansion.

Principle: negative pressure (200–400 mmHg) creates epidermal blisters on donor site (thigh/hip); roofs are transplanted to dermabraded recipient.
Steps: mark; anesthesia; suction (60–120 min); harvest roofs; dermabrade recipient to pinpoint bleeding; place grafts; secure with non-adherent dressing.
Pros: excellent color match, minimal cobblestoning.
Cons: time-consuming; limited area per session.

Principle: 1–2 mm punches transferred from donor to depigmented field in a grid (typically 5–10 mm spacing).
Pros: simple instrumentation; good for small focal patches and “peppering” islands.
Cons: risk of cobblestoning, polka-dot appearance if spacing/size suboptimal; color mismatch on acral.
Pearls: smaller punches (≤1.5 mm), tight hemostasis, adequate spacing, and post-op NB-UVB to blend.

Principle: follicular units (FU) harvested and implanted into depigmented skin; follicular melanocyte reservoir aids repigmentation.
Use cases: leukotrichia on face/brow/moustache, scalp margins, and select acral with hair-bearing potential.
Pros: addresses white hairs and skin simultaneously; durable islands from follicles.
Cons: requires FUE skillset; donor scarring risk if overharvested.

Immobilize graft site 7–10 days; avoid friction/pressure.
Start NB-UVB or excimer 308 nm after epithelialization (e.g., 2–3 weeks) to accelerate islands and blend borders.
Consider tacrolimus 0.1% on face/neck for maintenance after fill-in.

Table 1. Typical expectations (to populate with study numerics).

Technique	Face/Neck	Trunk/Limbs	Acral	Notes
SBEG	High	Moderate–high	Variable	Best color match
Punch/minigraft	Moderate	Moderate	Low–moderate	Watch for cobblestoning
FUE	High (hair-bearing)	Moderate	Selective	Leukotrichia benefit

Table 2. Common issues and management.

Issue	Technique	Prevention/Action
Graft displacement	All	Secure dressing; immobilize; educate on pressure avoidance
Cobblestoning	Punch	Use ≤1.5 mm punches; adequate spacing; gentle dermabrasion
Color mismatch	All	Prefer SBEG on face; adjuvant NB-UVB to blend
Donor scarring	FUE/Punch	Conservative harvest; hemostasis; proper aftercare
Infection	All	Asepsis; early review if pain/ooze; short antibiotics if indicated