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This activity reviews in detail an innovative surgical approach to skin grafting for vitiligo and chronic non-healing ulcers, known as the "Jodhpur technique," and explains the role of the healthcare team in the optimization of outcome in patients with stable vitiligo and non-healing ulcers who undergo this procedure as the preferred surgical approach. Objectives: Describe the essentials of the conventional skin grafting techniques highlighting the limitations associated with them, and how the Jodhpur technique offsets many of these problems. Summarize the basic requirements (devices & consumables) needed for the procedure, highlighting the simplicity of the procedure in terms of minimalistic requisites for infrastructure, and personnel. Explain the procedure of the Jodhpur technique and its modifications in a step-by-step fashion, walking through the technique for straightforward comprehension. Review the role of the interprofessional team in the Jodhpur technique in the treatment of vitiligo and chronic non-healing ulcers, and how collaboration and communication can improve patient outcomes. Access free multiple choice questions on this topic.

The JODHPUR TECHNIQUE is a very simple, yet very effective and extremely low-cost innovative modification of the standard skin grafting technique. In simplified terms, it refers to an autologous non-cultured, non-trypsinized keratinocyte-melanocyte cellular graft technique developed and perfected by a working group of leading dermatology surgeons of Jodhpur (a heritage city in the state of Rajasthan, India). The long learning curve of mastering tissue grafting techniques, and the lack of expert set-up requiring special cellular culture media, trypsinization, etc. in a majority of public sector hospitals in developing countries were the two main contributing factors that propelled the innovative improvisation of the Jodhpur technique.[1] Background Skin grafting is perhaps one of the oldest surgical techniques employed for the closure of a wound or coverage of desquamated/peeling skin resulting from burns, scalds, trauma, chronic non-healing wounds, and surgical removal of large skin growths. The second major application of skin grafting is in replacing a specific cell-deficient skin such as melanocyte-depleted depigmented skin or post-burn leucodermic scar with a normal donor skin with the intent of replenishing the cellular pool of the recipient area, thereby re-pigmenting it. It is essential to know the essential difference between a skin graft and a flap repair. In contrast to flaps that remain attached to a source of blood supply through a pedicle, skin grafts are completely avascular and replacement is necessary over a prepared recipient bed to restore the nourishment of the donor skin. In Dermatosurgery, skin grafting is most commonly used in vitiligo surgery and for the induction of healing of chronic non-healing ulcers (CNHL). It may also be needed during scar revisions and in post-burn leucodermic scars. Different types of skin grafts: Broadly speaking, skin grafts can fall into three classifications: (1) Based on the cellular/tissue composition of the graft [2]: Split-thickness skin grafts (STSG) - full epidermis and a superficial part of the dermis. Full-thickness skin grafts (FTSG) - full epidermis and full dermis, and a small part of the subcutaneous fat Composite grafts - these are composed of skin and another type of tissue, usually cartilage.

(1) Based on the cellular/tissue composition of the graft [2]: Split-thickness skin grafts (STSG) - full epidermis and a superficial part of the dermis. Full-thickness skin grafts (FTSG) - full epidermis and full dermis, and a small part of the subcutaneous fat Composite grafts - these are composed of skin and another type of tissue, usually cartilage. Split-thickness skin grafts further subclassify into ultra-thin STSG, thin or Thiersch–Ollier (0.125 to 0.275 mm) STSG, intermediate, or Blair–Brown (0.275 to 0.4 mm), and thick or Padgett (0.4 to 0.75 mm) split-thickness grafts.[3] (2) Based on the technique of harvesting the graft (2.1) Tissue grafts - These techniques refer to the direct harvesting of sheets of cells from the donor area. They may be procured by: Mini/Micro Punch grafts (MPG) - miniature or micro-sized punches of skin are harvested from the donor site and placed in punched out holes in the recipient skin STSG - Skin of the desired thickness gets harvested using a dermatome, and it comes out as a thin sheet Suction blister Grafts - Ultra-thin skin grafts get harvested by a special protocol of applying suction at the donor site Although the process of harvesting tissue grafts involves minimal surgical equipment and cost, tissue grafts can be useful for only a limited surface area per treatment session. (2.2) Cellular grafts - Cellular grafts include cellular suspensions of pure melanocytes, or keratinocytes, or their admixture, with latest inclusions being that of dermal cells and/or follicular cells. Cellular grafts are prepared from a smaller surgically harvested skin sample, by either culturing it or using it as a non-cultured suspension. The major advantage of these suspension and culturing techniques is that they permit treatment of affected skin manifold larger than the donor area.[4] Cultured cell suspension techniques - Although these provide treatment of a much larger surface area of the affected skin, the cultured techniques suffer from the limitations of being time-consuming, expense owing to the need for special culture media and specific laboratory conditions maintained over several weeks and need of highly trained personnel.

Cultured cell suspension techniques - Although these provide treatment of a much larger surface area of the affected skin, the cultured techniques suffer from the limitations of being time-consuming, expense owing to the need for special culture media and specific laboratory conditions maintained over several weeks and need of highly trained personnel. Non-cultured cellular grafting techniques - To obviate the logistic and cost issues of cultured techniques, the harvested skin gets subjected to cell separation by incubating it with trypsin/trypsin-EDTA at 37 degrees C for 20 to 30 minutes. The resultant suspension is thoroughly rinsed with lactated Ringer's solution, followed by complete manual separation of any dermal tissue. The epidermal fragments are centrifuged for a few minutes to create a homogenous cell pellet, which then gets resuspended in lactated Ringer’s solution. Thus, despite being technically and logistically less demanding than the cultured techniques, the non-cultured techniques, most common being the melanocyte-keratinocyte transplant procedure (MKTP), also involve special chemicals such as trypsin for cell separation and need for a decent laboratory back-up with at least an incubator and centrifuge.[5] As we learn the intricacies of the Jodhpur technique in subsequent sections, one would realize that it is, in fact, a marriage of the cellular and tissue skin grafting techniques. It provides the advantage of large recipient area coverage with a small donor skin area (typical of cellular techniques), albeit without the need of an expensive infrastructure, chemicals, devices or culture media.

The Jodhpur technique is by and large free of any significant complications. Still, one must be aware of the expected peri- and post-operative events, sometimes construed as 'adverse-effects' or complications by the patients, as well as potential complications that may arise in an odd case: PERIOPERATIVE Pain at the recipient and/or donor site - It rarely causes discomfort, and any troubling painis rare, usually the case of a patient who received local anesthetic agent from a technically dysfunctional batch. But awareness of rare cases of true resistance to local anesthetics, which may be genetic [24], or acquired. There are only rare reports of actual acquired resistance in patients with specific spinal neuropathy. There are reports of delayed onset of analgesics and some local anesthetics in chronic smokers.[25] Surgical site infection - this is uncommon, and the use of broad-spectrum antibiotics can further minimize the possibility started immediately after the procedure. DELAYED Keloid/Hypertrophic scar formation - Keloid formation is most common in patients who have a keloidal tendency (which may be known or unknown to them), and despite pre-operative work-up, this information does not come to the attention of the dermatology surgeon. Hypertrophic scarring, on the other hand, may occur in rare cases, especially if the healing delays for any reason and if the surgical sites involve the areas around the joints such as the knee or elbow. In either case, 2 to 4 shots of intralesional scar suppressive therapy three times weekly, using triamcinolone, and/or verapamil or 5-fluorouracil with/without silicone sheet compression therapy is often sufficient to resolve this complication. Failure of repigmentation of the recipient site OR healing of CNHU - This has been observed in only 10 to 15% of the patients only. Partial repigmentation or complete failure of repigmentation after any surgical grafting technique depends on predictable factors like inappropriately/inadequately performed procedure (e.g., superficial or very deep dermabrasion, delay in starting or delivery of suboptimal phototherapy energy) as well as the unpredictable factor of individual skin response. A second session may be curative, but needs further investigation for confirmation.

Failure of repigmentation of the recipient site OR healing of CNHU - This has been observed in only 10 to 15% of the patients only. Partial repigmentation or complete failure of repigmentation after any surgical grafting technique depends on predictable factors like inappropriately/inadequately performed procedure (e.g., superficial or very deep dermabrasion, delay in starting or delivery of suboptimal phototherapy energy) as well as the unpredictable factor of individual skin response. A second session may be curative, but needs further investigation for confirmation. Koebnerization at the donor site in vitiligo patients - This is also extremely rare, and is expected to happen only if the pre-operative evaluation regarding patient's fitness for surgery (irrespective of the technique used) has occurred in haste or inadequately (vide supra).

Although this technique can be quickly learned and mastered by any surgeon (dermatologist, general surgeon, plastic surgeon, burn specialist) who is conversant with the basic principles of skin grafting, at present, it is probably best for dermatologists who have observed and assisted in few procedures under the apprenticeship of a dermatology surgeon experienced in this technique. However, the primary objective of developing this technique, i.e., empowering all medical professionals involved in the care of patients with vitiligo and/or CNHU's with this straightforward and cost-effective technique, is not difficult to achieve. Inter-specialty exchange of knowledge and skills during focused conferences and/or workshops on skin grafting, vitiligo surgery, management of CNHU's, etc. are already becoming popular globally. Inclusion of JODHPUR TECHNIQUE in the program of such inter-specialty CMEs, preferably with video demonstration, may serve the purpose of realizing the objective as mentioned earlier. Similarly, training of surgical nurses/technicians as proficient assistants to the surgeon is also relatively straightforward and easy. It must be undertaken at individual centers to improve therapeutic outcomes and prevent complications. This procedure requires coordination from the entire interprofessional healthcare team. CURRENT EVIDENCE LEVEL OF JODHPUR TECHNIQUE [9] [1]: For vitiligo - LEVEL 5 [two published case series involving a total of 455 vitiligo lesions treated with Jodhpur technique] For CNHUs - LEVEL 5 [one published case report, one large case series under publication process & expert opinion]