Consensus statement on the surgical management of vitiligo

Abstract

Vitiligo is a chronic skin disorder characterized by the loss of melanocytes, leading to depigmented patches on the skin. The global lifetime prevalence of vitiligo diagnosed by a physician or dermatologist was estimated at 0•36% in the general population, 0•67% in the adult population adults, and 0•24% in the child population. Vitiligo prevalence was higher in adults than in children across all regions. Central Europe and south Asia reported the highest prevalence 0•52% and 0•52%, respectively, in the general population. Vitiligo significantly impacts patients’ quality of life, causing psychological distress and social stigmatization. While medical treatments such as corticosteroids and phototherapy exist, they often fail to achieve satisfactory repigmentation, particularly in extensive or recalcitrant cases. In recent years, surgical interventions have gained prominence as effective alternatives for managing vitiligo. Techniques such as autologous melanocyte transplantation, suction blister grafting, split-thickness skin grafting, and punch grafting offer promising repigmentation results. However, the lack of standardized protocols and guidelines for vitiligo surgery presents challenges in patient selection, procedural approaches, and post-operative care. This study aims to review current surgical techniques, assess patient-specific factors influencing surgical success, and evaluate long-term outcomes, including repigmentation rates and patient satisfaction. Key factors include disease stability, lesion characteristics, and the involvement of exposed areas. Moreover, the study emphasizes the importance of post-operative adjuvant therapy, such as topical tacrolimus and excimer therapy, to enhance surgical outcomes. By establishing evidence-based protocols for vitiligo surgery, this study seeks to improve treatment efficacy and patient care, addressing gaps in current practices and advancing the field toward more consistent and successful outcomes in vitiligo management.

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Consensus Statement
Consensus statement on the surgical management of
vitiligo
Yogesh M. Bhingradia1, Somesh Gupta2, Deepti Ghia3, Samkit Shah4, Nandita Krishnagopal Patel5, T. Salim6, Pradeep Kumari7,
Biju Vasudevan8, Swapnil Shah9, Nitin Jain7, Piyush B. Borkhatariya10, Debdeep Mitra8, Davinder Prasad11
1Shivani Skin Care and Cosmetic Clinic, Surat, Gujarat, 2Department of Dermatology and Venereology, All India Institute of Medical Sciences, New
Delhi, 3Department of Dermatology, South Mumbai Dermatology Clinic, Jaslok Hospital, Mumbai, 4Department of Dermatology, Vedanta Institute of
Medical Sciences, Palghar, Maharashtra, 5Department of Dermatology, Kiran Hospital, Surat, Gujarat, 6Cutis Institute, Kozhikode, Kerala, 7Asia Institute
of Hair Transplant, Skin and Surgery International, Pune, Maharashtra, 8Department of Dermatology, Command Hospital, Chandigarh, 9Department of
Dermatology, Ashvini Medical College, Solapur, Maharashtra, 10Esthe Kayakalp Skin Hair Laser Clinic and Institute, Junagadh, Gujarat, 11Department of
Dermatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
INTRODUCTION
Vitiligo is a chronic skin disorder characterized by the progressive loss of melanocytes, resulting
in depigmented patches on the skin and mucous membranes.1 e global lifetime prevalence
of vitiligo diagnosed by a physician or dermatologist was estimated at 0·36% (95% credible
interval [CrI] 0·24-0·54) in the general population (28·5 million people [95% CrI 18·9-42·6]),
0·67% (0·43-1·07) in the adult population (37·1 million adults [23·9-58·9]), and 0·24% (0·16-0·37)
in the child population (5·8 million children [3·8-8·9]). Vitiligo prevalence was higher in adults
ABSTRACT
Vitiligo is a chronic skin disorder characterized by the loss of melanocytes, leading to depigmented patches on
the skin. e global lifetime prevalence of vitiligo diagnosed by a physician or dermatologist was estimated at
0·36% in the general population, 0·67% in the adult population adults, and 0·24% in the child population. Vitiligo
prevalence was higher in adults than in children across all regions. Central Europe and south Asia reported
the highest prevalence 0·52% and 0·52%, respectively, in the general population. Vitiligo signicantly impacts
patients’ quality of life, causing psychological distress and social stigmatization. While medical treatments such
as corticosteroids and phototherapy exist, they oen fail to achieve satisfactory repigmentation, particularly
in extensive or recalcitrant cases. In recent years, surgical interventions have gained prominence as eective
alternatives for managing vitiligo. Techniques such as autologous melanocyte transplantation, suction blister
graing, split-thickness skin graing, and punch graing oer promising repigmentation results. However,
the lack of standardized protocols and guidelines for vitiligo surgery presents challenges in patient selection,
procedural approaches, and post-operative care. is study aims to review current surgical techniques, assess
patient-specic factors inuencing surgical success, and evaluate long-term outcomes, including repigmentation
rates and patient satisfaction. Key factors include disease stability, lesion characteristics, and the involvement
of exposed areas. Moreover, the study emphasizes the importance of post-operative adjuvant therapy, such as
topical tacrolimus and excimer therapy, to enhance surgical outcomes. By establishing evidence-based protocols
for vitiligo surgery, this study seeks to improve treatment ecacy and patient care, addressing gaps in current
practices and advancing the eld toward more consistent and successful outcomes in vitiligo management.
Keywords: Consensus on vitiligo surgery, Surgical management of vitiligo, Vitiligo consensus
*Corresponding author:
Yogesh M. Bhingradia,
Department of Dermatology,
Shivani Skin Care and Cosmetic
Clinic, Surat, Gujarat, India.
yogeshbhingradia@gmail.com
Received: 03November 2024
Accepted: 20November 2024
Epub Ahead of Print: 22 January 2025
Published: 11 February 2025
DOI
10.25259/JCAS_117_2024
Quick Response Code:
https://jcasonline.com/
Journal of Cutaneous and Aesthetic
Surgery

Bhingradia, et al.: Consensus statement on the surgical management of vitiligo
Journal of Cutaneous and Aesthetic Surgery • Volume 18 • Issue 1 • January-March 2025 | 28
than in children across all regions. Central Europe and south
Asia reported the highest prevalence (0·52% [0·28-1·07] and
0·52% [0·33-0·82], respectively, in the general population).2,3
However, the true prevalence remains uncertain due to the
lack of comprehensive epidemiological studies. While not
life-threatening, vitiligo signicantly impacts patients’ quality
of life, leading to psychological distress, social stigmatization,
and reduced self-esteem.4
Despite extensive research and the availability of various
treatment modalities, including topical corticosteroids,
phototherapy, and immunomodulators, achieving satisfactory
repigmentation in vitiligo remains a signicant challenge.5
is is particularly true for patients with extensive or
recalcitrant disease, where conventional therapies oen yield
suboptimal results.
In recent years, surgical interventions have emerged as
promising alternatives for vitiligo management, oering
the potential for durable and cosmetically pleasing
repigmentation.6 ese surgical techniques aim to transplant
melanocytes or melanocyte precursors from unaected areas
of the body to depigmented skin regions, thereby restoring
pigmentation.
Autologous melanocyte transplantation, suction blister
graing, split-thickness skin graing (STSG), and mini-
punch graing are among the surgical modalities commonly
employed for vitiligo repigmentation. ese techniques vary
in complexity, invasiveness, and outcomes, necessitating
careful consideration of patient-specic factors, including
disease stability, lesion characteristics, and patient
preferences.6
Despite the growing interest in vitiligo surgery, there remains
a lack of standardized protocols and consensus regarding
optimal surgical techniques, patient selection criteria, and
post-operative management strategies. Variations in surgical
approaches, donor site selection, and follow-up protocols
across dierent centers underscore the need for unied
guidelines to streamline clinical practice and optimize
patient outcomes.
is study aims to address this gap by providing a
comprehensive review of the current consensus on vitiligo
surgery. By synthesizing existing evidence and expert
opinions, we aim to establish standardized protocols,
enhance treatment ecacy, and improve patient satisfaction
in the management of vitiligo.
Aim
is study aims to provide a comprehensive review of the
current consensus on vitiligo surgery, encompassing various
surgical techniques, patient selection criteria, and post-
operative management strategies.
Objectives
Assessing patient-specic factors: To thoroughly evaluate
patient-specic factors, such as disease stability, lesion
characteristics, and individual patient expectations, which
signicantly inuence the selection of the most appropriate
surgical techniques for achieving repigmentation in vitiligo.
Evaluating ecacy and safety: To systematically assess the
ecacy and safety proles of various surgical interventions,
including autologous melanocyte transplantation, suction
blister graing, STSG, and punch graing, in promoting
repigmentation in patients with vitiligo.
Standardizing protocols and guidelines: To develop
standardized protocols and evidence-based guidelines for
pre-operative assessment, selection of surgical techniques,
and post-operative management in patients undergoing
surgical interventions for vitiligo.
Determining long-term outcomes: To investigate long-term
outcomes, such as repigmentation rates, color matching, and
overall patient satisfaction, following surgical procedures for
vitiligo.
Enhancing patient care: To improve the quality of care and
enhance patient satisfaction in the management of vitiligo
through the implementation of evidence-based surgical
interventions and standardized clinical practices.
MATERIALS AND METHODS
Patient selection
Inclusion criteria
Stable vitiligo: Patients with no new patches or enlargement
of existing lesions for a minimum period of 1year. However,
in urgent social situations, such as imminent marriage or
when patches are located in highly visible areas, the shorter
duration of stability of lesion can be considered for surgical
intervention with induced stability.
Practice Point 1: Are there any tests necessary for assessing
lesional stability?
Answer: No specic tests are required; a detailed patient
history regarding lesion stability is generally sucient to
determine surgical candidacy. Serial photography and
dermoscopy are reliable tools for assessing stability, but the
use of biomarkers or mini punch graing to test stability is
generally deemed unnecessary.
Non-response to medical treatment: Patients who have not
achieved satisfactory repigmentation despite consistent
adherence to conventional medical treatments, including
topical corticosteroids, phototherapy, and immunomodulators.
Exposed areas: Priority was given to patients with vitiligo
aecting exposed areas, such as the face, hands, and other

Bhingradia, et al.: Consensus statement on the surgical management of vitiligo
Journal of Cutaneous and Aesthetic Surgery • Volume 18 • Issue 1 • January-March 2025 | 29
visible parts of the body, where cosmetic outcomes are of
signicant concern.
Patient factors
Age of patient: Patients of all age group can be considered for
surgery with special considerations for age group below 15
years and above 60 years of age [Tab le1].
Type of vitiligo: Both segmental and non-segmental vitiligo
patients were considered. Segmental vitiligo, typically
localized and stable, was oen deemed optimal for surgical
intervention. Long-standing segmental vitiligo is particularly
suitable for surgery unless the disease is evolving, in which
case medical management with or without phototherapy may
be necessary.
Area of involvement: Patients with both focal and extensive
areas of depigmentation were included. Surgical techniques
were adapted according to the size and extent of the aected
areas. For extensive body surface area (BSA) involvement, it
is advisable to prioritize surgery on exposed areas (100–300
sq cm) rst, followed by covered areas. In rare cases, for
extensive vitiligo, surgery on more than 300 sq cm may be
considered based on priority [Table 2].
Practice Point 2: Which surgery is preferred for an area less
than 100 sq cm?
Answer: Majority seniors believes in Non-cultured
epidermal cell suspension (NCES), followed by mini-punch
graing (MPG), ultrathin split thickness skin gra (SSS) and
Follicular unit extraction (FUE)
Practice Point 3: Which surgery is preferred for area between
100- 300 sq cm?
Answer: Majority of the experts prefers NCES, followed by
tissue graing and lastly FUE
Anatomical location of patches: e anatomical location of
vitiligo patches were carefully considered, with distinctions
made between hairy areas (e.g., scalp, beard) and non-hairy
areas (e.g., face, neck, hands).
Treatment History:
Practice Point 4: Can surgery be performed if the patient is
on immunosuppressants?
Answer: It is advisable to wait at least one year aer the
completion of immunosuppressant therapy before considering
surgical intervention, except in cases of social emergencies
Practice Point 5: Is adjuvant therapy necessary?
Answer: Yes, adjuvant therapy is recommended. Topical
tacrolimus with or without phototherapy is commonly used,
with initiation times varying post-surgery (30% aer wound
healing, 30% aer 4 weeks, 20% aer 3 weeks, and 10% aer 2
weeks). Excimer therapy is preferred by 80% of practitioners
over narrowband ultraviolet B (UVB), while 50% consider
oral cyclosporine post-surgery.
Operation criteria
Qualications: Surgery should be performed by a
dermatologist certied by the National Medical Council
with adequate training in vitiligo surgery, either during
postgraduate studies or at a dedicated vitiligo workshop.
Additionally, hands-on training under the guidance of an
experienced dermatosurgeon is recommended.
Operation theatre
Setting: Outpatient dermatosurgery theaters are suitable for
procedures performed under local anesthesia, provided they
Tab le 1: Surgical consideration in patients below 15 years and
above 60 years of age.
Patient age Factors to be considered for
surgery
Children under 10 years Only if patches on cosmetically
sensitive areas, segmental vitiligo
over exposed sites, and patient
cooperation.
Adolescents (10–15 years): Only in the case of segmental
vitiligo
Geriatric patients (>60 years) Can be operated keeping
co-morbidities in mind
Tab le2: Top 3 Surgical options for the following body regions (according to experts).
Area 1st option 2nd option 3rd option
Eyebrow Follicular unit extraction Mini punch graing Non cultured epidermal suspension
Lips Mini punch graing Suction blister gra Non cultured epidermal suspension
Bony prominence
and acral areas
Mini punch graing Non cultured epidermal suspension Follicular unit extraction
Palms and soles Mini punch graing Non cultured epidermal suspension Suction blister gra
Genitals Follicular unit extraction Mini punch graing Non cultured epidermal suspension
Peri areolar area Mini punch graing Suction blister gra Non cultured epidermal suspension

Bhingradia, et al.: Consensus statement on the surgical management of vitiligo
Journal of Cutaneous and Aesthetic Surgery • Volume 18 • Issue 1 • January-March 2025 | 30
are equipped with the necessary tools for handling emergencies.
For extensive BSA surgeries, a hospital setting with anesthetist
support for light sedation is essential. In rare cases, a tertiary
hospital setup with laboratory facilities may be required.
Anesthetic backup
Requirement: Anesthetic backup is essential for large BSA
surgeries, though it is recommended to have anesthetic
backup available as well for all surgeries.
Pre-operative assessment
Comprehensive evaluation: Patients should undergo a
thorough pre-operative assessment, including:
Detailed history and physical examination to conrm
the stability of vitiligo and non-response to medical
treatments
Basic blood tests (Hemogram, Liver function test (LFT),
Renal function test (RFT), viral markers) and skin
biopsies as needed
Evaluation of patient expectations and psychological
readiness for surgery
Pre-operative medications (e.g., antibiotics, Non
steroidal anti inammatory drugs (NSAIDs),
cyclosporine) may be advised as needed.
Anesthesia
Techniques: Local inltration or topical anesthesia is usually
sucient. General anesthesia may be required for extensive
vitiligo surgeries or when operating on painful areas, using a
combination of lignocaine and bupivacaine under sedation.
Dermabrasion
Motorized dermabrasion gives good results as compared to
laser abrasion, which results in better cosmetic results. At the
same time, laser dermabrasion can be used for bony areas
and larger recipient areas [Ta ble 3].
Mini-punch graing (MPG)
e procedure involves harvesting tissue from concealed
areas of the body, typically the upper thigh or gluteal region,
using manual punches or an electric motor. e goal is to
maximize the number of gras obtained from7 a small donor
area. Once collected, the gras are kept in normal saline
before being transferred to the prepared recipient sites, and
both the donor and treated areas are secured with dressings
for up to 7days.
e current recommendation is to use same size punches for
both donor and recipient areas.
Additionally, for stabilizing the gras post-transplant,
surgical glue can be used, which is extremely helpful in
dicult areas like lips, eyelids, etc. (as per consensus).
Recent studies suggest that the pigmentation process may be
expedited, and cobblestoning can be minimized by the use of
MPG which is gra sizes lesser than 1mm.
Practice Point 6: How to prevent cobblestoning?
Answer: Using an electric micro-drill for gra extraction I.e.
motorised hair transplant punches with precise dimensions
(0.5–0.7 mm in diameter and 1.5–1.8 mm deep) can
minimized these issues
Practice Point 7: How to treat cobblestoning?
Answer: Common complications associated with this method
include cobblestoning and the polka dot eect, which can
aect the cosmetic results. However, advancements in the
technique, such as pinhole ablation using CO2 laser can
help in treatment of cobblestoning. 2–3 s of CO2 laser beam
is projected in the centre of the lesion to achieve depth of 2
mm, thus resolving the lesion.
Suction blister epidermal graing (SBEG)
Suction blister epidermal graing (SBEG) procedure involves
the separation of the epidermis through the creation of blisters
using suction. SBEG works by using various suction devices
that apply negative pressure to form blisters, the roof of which
can then be used for graing. is method is widely recognized
for its simplicity and safety, making it particularly suitable for
use around sensitive areas such as the lips, nipples, and eyelids.
Suction blister graing gives best results on areas like nipple,
lips and eyelids but can also be used on bony prominences
if there is a small patch as third preference, 1st being non
cultured epidermal suspension, 2nd being Mini punch graing
A notable advantage of SBEG is that it has been simplied.
A syringe, with the plunger removed, can be utilized to
create the necessary suction by adhering one end to the skin
and connecting the other end to a suction device through a
needle hub.
Practice Point 8: How to decrease blister formation time?
Tab le 3: Classication of surgical methods for the treatment of
vitiligo.
Tissue gras Cellular gras
Mini-punch gra Cultured melanocyte gra
Suction blister epidermal gra Cultured epidermal gra
Split-thickness skin gra Non-cultured epidermal
melanocyte suspension
Jodhpur technique Non-cultured follicular root
sheath suspension
Hair follicle gra

Bhingradia, et al.: Consensus statement on the surgical management of vitiligo
Journal of Cutaneous and Aesthetic Surgery • Volume 18 • Issue 1 • January-March 2025 | 31
Answer: Typically, blister formation takes between 1.5 and 2 h,
although this can be shortened by modications like: Increasing
temperature, reducing diameter, hair dryer, tumescent
anesthesia, normal saline injection, etc.
Practice Point 9: What is the pressure needed to create
blisters?
Answer: Typically between 300 and 500 mmHg negative
pressure constantly for 1.5–2 h.
Consequently, techniques have been developed to optimize
blister formation, which includes the use of Hijama cups
and specialized automated devices like the CelluTome for
epidermal gra harvesting.
SBEG is associated with a very low risk of scarring, making
it suitable for blister formation on nearly any body part, with
the thigh and forearm being the most commonly chosen sites.
Ultrathin STSG
Ultrathin STSG for vitiligo requires the use of thin (0.15–0.3mm)
thickness of the harvested donor tissue. e thighs, buttocks,
back, arms, or forearms are commonly selected as donor sites
for gra collection. Asliver’s knife for harvesting the donor skin
is typically used for this purpose, ensuring that the skin ap
maintains uniform thickness throughout and electric dermatome
for abrading the recipient skin. Proper surgical expertise is crucial
to ensure the procedure is performed successfully.
e therapeutic outcomes depend on the gra thickness.
inner skin aps, compared to thicker ones, were associated
with fewer side eects, such as scarring or infection.
Although it has a good eciency in treating relatively large
areas of vitiligo, the recipient area to donor area ratio remains
1:1. Ultrathin STSG does have some limitations, including
potential mismatch in color, texture, and milia formation
between the graed and surrounding skin.
Practice Point 10: How to minimize the shrinkage of the Gra?
Answer: A masher is the device used to mesh the skin gra,
which involves creating small, regular perforations in the
gra. is process allows the gra to expand, converting a
larger surface area, and improves drainage of uids like blood
and exudates under the gra. Also, ultra thin gras lack
dermis and so it doesn’t shrink.
Jodhpur technique
e Jodhpur Technique is a rened approach to vitiligo surgery,
where the donor area is smeared with a thick layer of antibiotic
ointment (2% mupirocin). e donor area, is then dermabraded
using the manual dermabrasion or electric motor. e ointment
smeared serves to entrap the epidermal component consisting
of keratinocytes, melanocytes, free melanin, broblasts, etc. is
paste composed of a cellular mixture, is collected with a spatula
and then spread on the prepared recipient site.8
Post-operative care involves protecting the treated areas for
7–10 days, aer which initial repigmentation is typically
observed within 2–4weeks.
is technique is particularly suited for treating stable vitiligo
in focal or exposed areas due to its simplicity, cost-eectiveness,
and high success rates. It oers minimal donor site morbidity
and uses basic equipment, making it accessible even in
resource-limited settings. While it is highly eective for small,
localized lesions, its application to larger areas can be more
challenging. e Jodhpur Technique has gained recognition for
its reproducibility and promising outcomes, making it a valuable
option for dermatologists managing stable vitiligo cases.
However, a modication in these techniques to avoid the
associated comorbidities at 2 sites (donor and recipient) was
proposed. is technique involves receiving the gra from
the perilesional pigmented skin to eliminate the pain at the
donor site. e comorbidities are restricted to a single site,
making it an eective method for small patches.9
Hair follicle gra
A novel appro ach to vitiligo treatment involves the transplantation
of hair follicles, capitalizing on their reserve of melanocytes.
During repigmentation in vitiligo patients, there is a noticeable
increase in inactive melanocytes, which tend to accumulate in
the outer sheath of hair follicles. ese melanocytes, through
processes of division, proliferation, and maturation, contribute to
renewed pigment production in the aected skin areas.
e hair follicles are harvested for transplantation from the
occipital scalp, temporal scalp, pubic region, and beard area.
e follicles are then graed into pre-formed wells in the
aected area, spaced 3–5mm apart. Tools such as an 18 G, a
needle or hair transplant implantation device can be used for
this purpose. e donor and recipient sites are covered with
dressings, which are removed aer about 1week. Initial signs
of repigmentation are usually observed around 2weeks aer
the follicles have been graed.
is technique uses simple equipment, though the
repigmentation results may vary. It is very helpful for treating
hairy areas and patches with leukotrichia.
Cellular gras
Cultured melanocyte keratinocyte gra
e procedure involves harvesting a thin epidermal gra
trypsinization to separate the epidermis from the dermis,
and melanocytes are cultured in a medium enriched with
various factors to obtain high-purity cells. e newer culture
media are devoid of carcinogenic potential and hence can
be used more safely. However, it is time-consuming taking
around 21days to complete the cell culture cycles, and needs
an expensive laboratory setup for the same. is makes it

Bhingradia, et al.: Consensus statement on the surgical management of vitiligo
Journal of Cutaneous and Aesthetic Surgery • Volume 18 • Issue 1 • January-March 2025 | 32
dicult for a clinician to use it frequently. However, large
areas can be treated with relatively small donor areas.
e majority of the experts believe that cultured melanocyte
gras possess the risk of carcinogenic potential under certain
condition.10
Non-cultured melanocyte gra
Practice Point 11: Is Dulbecco’s Modied Eagle Medium
(DMEM) mandatory in NCES?
Answer: According to newer modications, ringer lactate or
phosphate buer can be used in place of DMEM
Practice Point 12: Is it necessary to use trypsin inhibitors in
NCES?
Answer: According to newer modications, phosphate buer
saline, patient’s serum, or ringer’s lactate solution can be used
in place of trypsin inhibitor
Non-cultured epidermal suspension is a promising technique
for treating stable vitiligo, oering a quicker alternative to
cultured melanocyte transplantation. e procedure involves
harvesting a small piece of skin from a normally pigmented,
low-exposure area, such as the inner thigh or buttock. is
skin is treated with an enzyme like trypsin to separate the
epidermis from the dermis, and the resulting epidermal
cells, which include melanocytes and keratinocytes, are
suspended in DMEM. e aected area is prepared through
dermabrasion, and the cell suspension is applied directly to the
depigmented patches. is method has shown positive results
in repigmentation with fewer steps than cultured melanocyte
graing, though risks such as infections, scarring, and
pigmentation irregularities remain.
Practice Point 13: Importance of hot and cold trypsinization?
Answer: It doesn’t make any dierence in repigmentation rate.
Practice Point 14: Preferred method for recipient size
debridement?
Answer: Motorized dermabrader is the rst choice of most of
the experts followed by ablative lasers for larger areas, bony
prominence and genitals
Practice Point 15: Role of platelet rich plasma (PRP) in the
melanocyte nourishment media?
Answer: Consensus experts believe in no role of PRP in
medium nourishment
Practice Point 16: Role of PRP in recipient site dressing?
Answer: Minority of the experts believes in PRP for faster
healing and nourishment of the gra, but the majority are
against it.
Hair follicular outer root sheath (ORS) suspension
Outer root sheath (ORS) suspension is a method used in
vitiligo surgery where hair follicles are harvested from the
occipital scalp, as the ORS is rich in melanocytes. ese
melanocytes are processed into a suspension using trypsin
or collagenase digestion, which helps in eectively separating
them. is suspension is then transplanted onto depigmented
areas.
Compared to NCES, ORS covers larger areas, with each
follicle covering up to 1 cm². e technique may also require
the use of a trypsin inhibitor post-digestion.
Key considerations
Leukotrichia: Patients with white or grey hairs in the
depigmented area may have poorer outcomes, as these follicles
lack melanocytes. Addressing leukotrichia is important to
ensure complete pigmentation in the treated area.
Ringer lactate is enough to stop the digestion process by
trypsin.
Overall, the ORS technique allows larger treatment areas
compared to NCES, oering a promising option for vitiligo
patients.11
POSTOPERATIVE MEDICATIONS AND
FOLLOWUP
Monitoring and follow-up: Patients should undergo regular
post-operative monitoring to assess repigmentation rates,
color match, and any adverse events.
Hyperpigmentation: Post-surgery, areas around gras
may show hyperpigmentation due to increased melanin
production. Topical depigmenting agents such as
hydroquinone or retinoids can help lighten these areas.
Hypopigmentation: In cases where repigmentation is slow or
incomplete, treatments like excimer laser or narrowband UVB
(NbUVB) can be initiated to stimulate melanocytes.
Follow-up: Regular follow-ups are essential to monitor gra
take, healing, and any pigmentation changes.
Dressing removal: Typically, the rst dressing is removed
7days post-surgery. Care should be taken to ensure the gras
are not disturbed during this period.
When to start cyclosporine: In cases where immune
modulation is necessary, cyclosporine can be considered,
starting at 1–2 weeks post-operative, based on individual
response and consultation with a specialist.
Excimer laser: Can be started aer healing is complete
(approximately 2–3 weeks post-surgery) to promote
repigmentation in treated areas.
NbUVB: As per the majority of the experts, treatment can
begin aer wound healing to stimulate repigmentation and
boost melanocyte activity. Sessions are typically administered
2–3times a week.

Bhingradia, et al.: Consensus statement on the surgical management of vitiligo
Journal of Cutaneous and Aesthetic Surgery • Volume 18 • Issue 1 • January-March 2025 | 33
Serial photography: Documenting the progression using
standardized photography helps in monitoring the success of
the gras and overall repigmentation. Photos are usually taken
before the procedure and at regular intervals during follow-up,
like every 4weeks, to assess changes accurately.
Subsequent surgery: If needed, 2nd surgery can be planned
aer 6months of previous surgery as per experts.
CONCLUSION
Vitiligo surgery is becoming increasingly sought aer as more
patients seek eective treatment options, and there is a growing
need for more dermatologists to perform these procedures.
Fortunately, the learning curve for vitiligo surgery is relatively
straightforward, making it accessible for practitioners to learn
and master. Setting up for these surgeries is not overly expensive,
as it primarily requires developing ne surgical skills and
attention to detail rather than heavy investment in equipment.
Dermatologists must learn all the dierent surgical
techniques available, as each case of vitiligo is unique and
may require a personalized approach. While cellular graing
methods, like melanocyte-keratinocyte transplants, are
gaining popularity due to their potential for excellent results,
tissue graing, such as punch and split-thickness graing,
remains the mainstay treatment. ese methods are versatile
and eective, particularly for stable vitiligo, and continue to
be widely used.
By acquiring expertise in various vitiligo surgery techniques,
dermatologists can tailor their approach to suit individual
patients, ensuring better outcomes and expanding the
availability of these life-changing procedures.
Authors’ contributions: Dr. Yogesh Bhingradia, Dr. Somesh Gupta,
Dr. Dipti Ghia, Dr. Samkit Shah, Dr. Nandita Patel: Involved in writing
the manuscript, conducting surveys, providing expert inputs and
conceptualization of manuscript. Rest all the authors were involved in
providing the experts inputs and conceptualization of the manuscript.
Rest all the authors were involved in providing the experts inputs and
conceptualization of the manuscript.
Ethical approval: Institutional Review Board approval is not
required.
Declaration of patient consent: Patient’s consent not required as
there are no patients in this study.
Financial support and sponsorship: Nil.
Conicts of interest: ere are no conicts of interest.
Use of articial intelligence (AI)-assisted technology for
manuscript preparation: e authors conrm that there was no
use of articial intelligence (AI)-assisted technology for assisting
in the writing or editing of the manuscript and no images were
manipulated using AI.
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How to cite this article: Bhingradia YM, Gupta S, Ghia D, Shah S, PatelNK,
Salim T, et al. Consensus statement on the surgical management of vitiligo.
JCutan Aesthet Surg. 2025;18:27-33. doi: 10.25259/JCAS_117_2024