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The Cutting Edge
November 1999

Flip-Top Pigment TransplantationA Novel Transplantation Procedure for the Treatment of Depigmentation

Author Affiliations


Arch Dermatol. 1999;135(11):1305-1307. doi:10.1001/archderm.135.11.1305

Cutaneous depigmentation afflicts millions of people worldwide. For example, vitiligo affects an estimated 1% of Americans1 and 0.38% to 1.13% of individuals worldwide.24 Although some patients may respond to treatment with topical corticosteroids or topical or oral psoralen plus UV-A (PUVA),5 many do not, and therefore, they seek additional therapy. Several surgical procedures have been devised to repigment depigmented skin.6 These include the transfer of autologous melanocytes derived from split-thickness skin grafts,7 full-thickness skin grafts,8 punch grafts,9 pinch grafts,10 or suction-induced blister roofs.11 Autologous melanocytes have also been obtained from tissue cultures of melanocytes alone12 or melanocytes plus keratinocytes.13 Recipient sites may be prepared in a number of ways, including dermabrasion,14 suction blisters,15 liquid nitrogen–induced blisters,11 PUVA-induced blisters,16 laser ablation,17 or by removal of skin with a dermatome.7 Some of these methods leave undesirable scarring (eg, cobblestoning), are time intensive, and/or require special equipment.6

Report of cases

Four patients with stable vitiligo (at least 1 year without spread) and 1 patient with traumatic vitiligo presented to our clinic (Table 1). The patients with vitiligo had either received PUVA and were no longer responding, or they did not wish to undergo PUVA therapy. Each patient desired repigmentation.

Characteristics of 4 Patients Treated With the Flip-Top Pigment Transplantation Procedure for Vitiligo*
Characteristics of 4 Patients Treated With the Flip-Top Pigment Transplantation Procedure for Vitiligo*
Therapeutic challenge

We wanted to develop a minimally scarring, effective, and efficient method of melanocyte grafting that could be performed with equipment found in any dermatology office.


We developed the Flip-Top Pigment Transplantation Procedure. A total of 25 grafts were transplanted during 12 procedures (Table 1). A normally pigmented donor site was identified in each patient's axilla or medial upper arm. One percent lidocaine with epinephrine was administered through a 30-gauge needle into the upper dermis of the donor site to raise a small wheal. A razor blade (Acu-Razor; Acuderm Inc, Fort Lauderdale, Fla) was used to shave 2 to 4 mm of donor epidermis containing minimal underlying dermis. Donor skin was placed on gauze soaked with isotonic sodium chloride solution and sectioned into 1- to 2-mm grafts for transplantation.

One to 5 recipient sites were chosen at 5- to 10-mm intervals within a depigmented patch. Wheals were raised with 1% lidocaine with epinephrine as at the donor site. A razor blade was then used to elevate a 5-mm flap of epidermis containing minimal papillary dermis. A 1- to 2-mm-diameter graft was then placed dermal side down at each recipient site so that the epidermis of the graft was juxtaposed to the dermal side of the elevated flap. Each recipient site was then covered with approximately 0.1 mL of cyanoacrylate (KrazyGlue; Elmer's Products, Columbus, Ohio) so that each flap adhered at its edges, and the graft was sealed beneath the flap. After the cyanoacrylate dried, a transparent polyurethane dressing (Tegaderm; 3M Company, St Paul, Minn) was placed over the recipient site(s).

The polyurethane dressing was removed after 1 week, and at that time, a pigmented macule was seen under each flap if the graft had survived. Repigmentation was noted in 22 (88%) of 25 grafts in the first 3 patients (Figure 1). The grafts in patient 4 did not take. Continued spread of pigment up to 2 to 3 mm beyond the graft perimeter was seen in 22 (100%) of 22 successful grafts. In patient 3, who had vitiligo on the right forearm, the first graft did not survive, but the subsequent 2 grafts were successful. No visible scarring occurred at any of the graft sites, and patient satisfaction with the procedure was high.

Left, Patient 2 after the first 2 grafts have been placed. Right, Five months after the last of 9 grafts have been placed. This patient had 2 to 3 mm of circumferential pigment spread within 3 months of grafting.

Left, Patient 2 after the first 2 grafts have been placed. Right, Five months after the last of 9 grafts have been placed. This patient had 2 to 3 mm of circumferential pigment spread within 3 months of grafting.


For at least 4000 years, patients with vitiligo have tried various methods to regain their normal pigmentation. During the last 50 years, these methods have focused primarily on medical therapy, in particular PUVA and topical corticosteroids. Unfortunately, up to 70% of patients with vitiligo will have only a partial response.18 Particularly poor response rates occur when treating sites such as the fingers, toes, and lips, areas with the lowest concentrations of hair follicles.19,20

It is said that surgical therapies should be reserved for those with depigmentation that is refractory to medical therapy.18 However, sites known to have poor response rates should also be included in this category. Haxthausen21 was the first to report a surgical method for repigmentation in 1947 when he described the exchange of thin, split-thickness skin grafts between areas of vitiligo and normally pigmented skin. As outlined above, several different methods have been introduced in the past 30 to 40 years to surgically treat depigmentation, and methodologic improvements have led to improved cosmetic results.6,22

We describe a new method termed the Flip-Top Pigment Transplantation Procedure. Each graft is a small, thin pinch graft, and each recipient site has a flip-top or hinged flap of epidermis placed atop the graft. The advantages of the Flip-Top Pigment Transplantation Procedure include the speed and ease of performing the grafts, the minimal clinical scarring, the spread of pigment beyond the grafts, and no need for special equipment or a laboratory to culture melanocytes. In previous studies, only pinch grafting and punch grafting methods have resulted in subsequent pigment spread beyond the original graft borders. Some of the authors, however, reported a cobblestone appearance at treatment sites after pinch and punch grafting.2326 The Flip-Top Pigment Transplantation Procedure takes advantage of the desirable pigment spread of pinch grafts but seems to minimize or eliminate the undesirable cobblestoning by placing the graft beneath a flap of in situ epidermis.

With a little practice, we believe that any surgically oriented physician can learn this method. This is the only surgical repigmentation method in which the epidermis at the site of depigmentation is not removed before placing the graft. Perhaps this epidermal remnant aids the healing process, resulting in minimal to no clinically detectable scarring. Of course larger numbers of grafts with longer follow-up in more patients must be performed to verify the lack of scarring observed in these 4 patients.

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