¿CIRUGIA PARA EL VITILIGO?
TRATAMIENTO QUIRÚRGICO
DEL VITILIGO
Dres. José R. Sardi B.,* Lisbeth Pérez Morales**
* Profesor de la cátedra de Dermatología de la Escuela de Medicina “Luis Razetti”. Universidad Central de Venezuela. Jefe de la
Sección de Cirugía Dermatológica en el Servicio de Dermatología del Hospital Universitario de Caracas.
** Dermatólogo del Hospital Privado “Centro Médico de Caracas”. Exadjunto en la Sección de Cirugía Dermatológica del Servicio de
Dermatología en el Hospital Universitario de Caracas.
Dres. José R. Sardi B., Lisbeth Pérez Morales,
Tratamiento Quirúrgico del Vitiligo. Derm
Venez, 2000, 38:64-68.
RESUMEN
Los autores analizan varios métodos de
autoinjerto, usados para el tratamiento quirúrgico
del vitiligo. Las técnicas principales emplean
respectivamente ampollas por succión, injertos
por sacabocados, injertos por dermatomos y empleo
de folículos pilosos.
Los autores hacen énfasis en este último y
describen sus técnicas, las cuales se basan sobre
procedimientos empleados originalmente para
trasplantes de pelos.
El vitiligo es una enfermedad relativamente
frecuente, afecta aproximadamente al 1 ó 2 por
ciento de la población, y perjudica notablemente a
quien la padece ya que la discromía suele ser
cosméticamente adversa, en especial en pacientes
de piel oscura. Para su tratamiento hay opciones
médicas, como la fotoquimioterapia, esteroides
tópicos o sistémicos, que resuelven parcialmente
el problema, pero no necesariamente satisfacen las
espectativas del paciente y del médico tratante.
Esto hizo que se desarrollaran técnicas quirúrgicas
como los injertos autólogos de piel.1
Los injertos de melanocitos para inducir la
pigmentación en las zonas acrómicas se pueden
obtener de diferente manera:
a. Por succión.
b. Por sacabocado. (“punch”).
c. Con dermatomo.
d. Con microinjertos de folículo piloso.
Mediante la succión continua (de 3 a 4 horas) de
la piel con el uso de aparatos construidos para tal
fin, se logra la separación dermoepidérmica,
provocando la formación de ampollas, el techo de
estas ampollas se coloca en la zona a tratar que
previamente, uno o dos días antes ha sido rociado
con nitrógeno líquido para promover la formación
de ampollas, éstas son eliminadas y se cubre el
piso con la epidermis separado por la succión. Si
la zona de préstamo se calienta a 40 ó 41 grado
centígrados se reduce el tiempo de la formación
de las ampollas a una hora. El doctor Skouge usa
un equipo sofisticado que le permite obtener las
ampollas en un tiempo tan corto como 15 ó 30
minutos, obtiene presiones negativas de succión
de 381 mm.Hg, y 40 °C de temperatura dentro del
cilindro que forma las ampollas.2
Este método es laborioso y creemos que es
superado por la técnica de microinjertos, más
práctica y más efectiva.3,4 En ella usamos la
epidermis, que obtenemos con sacabocados
pequeños (diámetros entre 1.25 mm a 2.0 mm), de
una zona de préstamo que puede estar en la región
mastoidea retauricular, cara interna de los brazos
próxima a la axila o en la región glútea, se cortan
con tijeras curvas a nivel de la unión
dermoepidérmica, se colocan luego en una placa
de Petri con suero fisiológico. En el área acrómica
se procede de igual manera, elaborando los
orificios receptores que luego son descubiertos con
los pequeños transplantes. Se cubre la zona con
Tegaderm®. Esta cura se levanta una semana
después. La región dadora se deja cicatrizar por
segunda intención. A partir de los 45 días ya se
comienza a ver el pigmento melánico, que se va
extendiendo radialmente hasta unirse con el
pigmento proveniente de los otros injertos y así
cubrir toda la región. Dependiendo del tamaño
que tenga la mácula del vitiligo habrá que hacer
varias sesiones de tratamiento.
microinjertos.
El uso del dermatomo pareciera en principio que
fuera una buena elección, porque nos ofrece
injertos muy finos y uniformes, pero tiene el
problema a nivel de la zona receptora, que hay
que prepararla mediante dermoabrasión, y no
siempre es posible lograr un lecho receptor
adecuado; se forman quistes de millium, o no
prende el injerto por falta de un adecuado aporte
sanguíneo para el injerto. Por otro lado, la zona
dadora suele quedar con marcos muy visibles,
hiperpigmentadas o hipopigmentadas.5
Otra forma de abordar el problema es con el uso
de folículo piloso,6 que es un reservorio
importante de melanocitos. Aplicamos variaciones
de las técnicas usadas en el transplante de pelos en
la alopecia androgenética. El folículo se corta en
su tercio superior y desechamos el vulvo pilar.
La región que seleccionamos para tomar el
préstamo es el cuero cabelludo, en la región
temporal, por detrás de las orejas, se tomó una tira
de aproximadamente 1 cm. por 3 cms.; la herida se
cierra de la manera habitual y el cuero cabelludo
obtenido es cortado en fragmentos más pequeños
de manera transversal y con éstos confeccionamos
los microinjertos, tal como lo hacemos cuando se
realiza un transplante de pelo, sólo que a estos le
retiramos el vulvo, luego se van colocando en una
placa de Petri con suero fisiológico para que no se
deshidraten.
La zona receptora es preparada con los dilatadores
(“Solid Wire Needles”) que usamos en los
microinjertos de cuero cabelludo. Ellos son
insertados con el fin de crear los orificios
receptores, estos dilatadores se disponen
tangencialmente a la superficie de la piel, para
evitar el daño de los vasos de la dermis. Al retirar
el dilatador persiste un orificio en la piel, allí se
introduce el cilindro de cuero cabelludo con uno o
dos folículos; al cerrarse el orificio queda
atrapado el injerto. Puede originarse una ligera
hemorragia, que cede espontáneamente o
mediante la compresión digital.
Cuando las zonas de vitiligo son extensas y se
localizan en regiones no expuestas, modificamos
la técnica. El área receptora se prepara usando una
lámina de bisturí N° 15, y se hace una especie de
“bolsillo” con un corte por punción, también
dispuesto tangencialmente. Se obtienen injertos de
forma rectangular, que midan más o menos 1,5
mm de grueso por 3,0 mm de ancho, se consigue
así una columna de cuero cabelludo con 3, 4 y
hasta 6 folículos. A esta hilera de pelos se le
cortan sus vulvos como lo hicimos en la técnica
anterior, y se introducen en los “bolsillos”
receptores; el resto es igual. Cuando se retira la
cura de Tegaderm® una semana después, vemos
que por la cara adherente del plástico transparente
se vienen pegados los pelos, quedando incrustado
el resto del injerto.
Se recomienda escoger pacientes con vitiligo
“estables” considerando como estable a un
paciente que no tenga lesiones nuevas en los
últimos dos años, preferiblemente a enfermos con
lesiones unilaterales (vitiligo segmentario), que
muestre zonas de repigmentación espontánea, y
que las lesiones se localicen de preferencia en
zonas expuestas.
No siempre se logra la repigmentación, hay un
buen número de fracasos, y todavía no se tiene
una explicación válida para esto. Las regiones
acrales responden mal, en cambio los vitiligos
metaméricos suelen repigmentarse bien y los
pacientes de piel oscura responden mejor.
¿Qué críticas se le puede hacer a esta forma de
tratar el vitiligo?, lo peor es que no obtengamos
repigmentación, o que una vez repigmentada una
zona, ésta pierda nuevamente el color; lo hemos
visto en dos casos, este hecho ya se ha reportado
en la literatura.7 Igualmente hemos observado en
algunos casos, la presencia acrómica en los límites
del vitiligo, quedando como un borde blanco que
limita la zona repigmentada.
Con los injertos de folículo se elimina casi por
completo el efecto “empedrado” que puede verse
con los microinjertos tomados con sacabocado.
Otro hecho desfavorable es que pueda regenerarse
uno que otro pelo.8 Por último, se pueden ver
“quistes pilares”, como reacción a cuerpo extraño,
cuando algún folículo se profundice en la dermis y
la cicatrización epitelial lo cubra.
BIBLIOGRAFÍA.
1. Drake, L.A. Dinehart, S.M., Farmer, E.R. et
al: Guideslines of care for vitiligo. J Am
Acad Dermatol 1996, 35:620-626.
2. Skouge, J.W., Morrison, W.L., Diwan, R.V.,
et al: Autograftin and PUVA: A combination
therapy for vitiligo. J Dermatol Surg Oncol
1992, 18:357-360
3. Falabella, R.: Treatment of localized vitiligo
by autologous minigrafting. Arch: Dermatol.
1988, 124:1649-1655.
4. Falabella, R.F.: Mini-injertos. Una solución
simple para el problema de las leucodermias
estables. Res Soc Colombiana Dermatol 1992,
1:110-116.
5. Hann, S.K., Park, Y.K.: dermoabrasión and
epithelial sheet grafting. J Am Acad Dermatol
1996, 35:652.
6. Na, G.Y., Seo, S.K., Choi, S.K.: Single hair
grafting for the treatment of vitiligo. J Am
Acad Dermatol 1996, 38:580-584.
7. Kahn, A.M.: Surgical treatment of vitiligo.
Dermatol Surg 1999, 25:669.
8. Kim, J.C., Choi, Y.C.: Regrowth of grafted
human hair after removal of the bulb.
Dermatol Surg 1995, 21:312-313.
Comments
Comment from DR. Ali Sahili
Time March 22, 2009 at 10:53 pm
soy cirujano general y tengo vitiligo en cara, deseo hacer el tratamiento y aprender la tecnica de tratamiento quirurgico
Comment from Hayver Gutierrez
Time April 20, 2009 at 6:36 pm
Hola, mi pregunta es donde puedo conseguir informacion sobre la cirugia para el vitiligo, quien la realiza, donde, la informacion de los doctores que la realizan.
Gracias por su ayuda
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