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

Key Takeaways

Indication: stable segmental or focal nonsegmental vitiligo that failed optimized medical/light therapy.
Confirm stability: no new/enlarging lesions, quiet rim on Wood’s lamp, negative VIDA across ≥2 visits 3–6 months apart.
Technique match: SBEG for color match on face/neck; punch/minigrafts for small, scattered plaques; FUE for leukotrichia and hairy areas.
Post-op light: NB-UVB or excimer accelerates spread from graft islands; start after re-epithelialization.

Subtype: segmental (prime) or localized NSV with stability.
Stability: no extension, no confetti/Koebner, quiet border on Wood’s; VIDA = 0 for 6–12 months preferred.
Prior therapy: adequate trial of NB-UVB ± tacrolimus / steroid pulses.
Realistic goals: color match, border blend; acral zones have lower yield.

Table 1. Technique selection by site/need.

Scenario	Preferred technique	Why
Facial plaques, cosmetic priority	SBEG	Thin epidermal sheet → excellent color match
Small scattered macules (2–10 mm)	Punch/minigrafts	Fast “seeding” of islands
Leukotrichia / hair-bearing sites	FUE	Transfers melanocyte reservoirs with follicles
Acral borders	Punch ± SBEG adjunct	Higher resistance; consider combined approach

Donor: thigh/hip; raise blisters (negative pressure, ~200–300 mmHg) under local anesthesia; harvest epidermal roofs.
Recipient: dermabrade to superficial papillary dermis until pinpoint bleeding; place epidermal sheets; secure with non-adherent dressing.
Pearls: keep orientation; avoid overlap/folds; immobilize for 5–7 days; start light after re-epithelialization.

Donor punches: 1–1.5 mm; spacing on recipient 5–10 mm (“peppering”).
Depth: align to reach dermis without fat; avoid cobblestoning by size-match and gentle placement.
Use cases: digits, lips (careful), small plaques; can combine with excimer post-op to drive spread.

Concept: transplant follicular units (occipital donor) into depigmented, white-hair areas to import melanocyte reservoirs.
Sites: brows, beard, scalp margins, perioral; improves both hair and perifollicular skin pigment.
Adjuncts: excimer/NB-UVB post-take to accelerate perifollicular spread.

Immobilize grafted area; avoid shear/friction; non-adherent dressings 5–7 days (SBEG) or per protocol.
Begin NB-UVB or excimer 308 nm after epithelialization (typically 1–2 weeks) to stimulate island expansion.
Tacrolimus on off-light days after wound closure to support repigmentation and reduce inflammation.

Track with standardized photos and local VASI for the graft field; expect perifollicular or sheet-edge spread in weeks to months.
Facial SV shows highest take-rate; acral digits lowest.
Define success as color match and border blend; discuss potential need for touch-ups.

Instability relapse: screen carefully; active rim → defer surgery and treat activity first.
Cobblestoning (punch): oversize punches or superficial placement—use 1–1.5 mm and proper depth.
Mismatch/edge lines: ensure even dermabrasion (SBEG) and precise sheet placement.
Infection/hematoma: strict asepsis; compression where appropriate.