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.
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 :
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.
(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:
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.
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.
Since the two chief indications of Jodhpur technique include repigmenting stable lesions of vitiligo, and induction of healing in CNHUs, few important aspects of the functional anatomy of these conditions should be known to the dermatosurgeons:
1) Vitiligo Surgery - The quintessential criteria to be fulfilled before considering a vitiligo patient as a suitable candidate for surgical intervention pertains to acceptable stability of the lesions and the disease to prevent graft failure, recurrence at recipient site as well as the appearance of vitiligo at the donor site due to Koebner's phenomenon. In the past, arbitrary clinical criteria suggested by many workers were considered to be sufficient for this qualification. But with the advent of discovery and reported publications on dermoscopic predictors of disease stability in vitiligo, recent recommendations are that in addition to those clinical criteria, the dermoscopic criteria of stable vitiligo should also be established before attempting any form of surgical correction of vitiligo, including the use of Jodhpur technique.
2) CNHUs - It is important to note that the diverse etiologies leading to non-healing ulcers mandate thorough pre-surgical evaluation, medical correction of any modifiable factors, and assessment of the possibility of the Jodhpur technique or any skin grafting method in healing them. The majority of CNHUs is located on the lower limbs, primarily owing to gravity-associated compromised vascular supply (whether overt or occult) and higher possibility of trauma. Since vascular replenishment of the ulcer bed is an important consideration in CNHUs (in contrast to vitiligo), consideration of flaps, techniques like platelet-rich plasma (PRP) and platelet-rich fibrin matrix (PRFM), injection of growth factors, hyperbaric oxygen, etc. must be considered before being convinced that the Jodhpur technique may suffice and provide healing without the logistic and infrastructural essentials required for the other approaches.
Coverage Ratio with Jodhpur technique
In cases of vitiligo, the Jodhpur technique allows coverage of a recipient area with the harvesting of as low as 20 to 30% of that area from the donor site.
The Jodhpur technique has been successfully used in two major indications [at present]:
(1) Stable Vitiligo - In one published study conducted in 154 patients, 437 vitiligo patches were treated with the Jodhpur technique followed by PUVA therapy. Researchers observed more than 75% re-pigmentation in 41% of the patches. The regions that showed high (over 75%) levels of repigmentation included the thigh (100%), face (75%) and, trunk (50%). showed maximal excellent improvement, whereas patches on joints and acral areas did not show much improvement.
(2) CNHUs - Recently, researchers attempted repurposing of the Jodhpur technique for chronic non-healing ulcers involving the leg, refractory to multiple ulcer-treatment modalities. Seventeen patients with lower limb CNHU of varied etiology were enrolled. Of these, 7 (41.2%) were of diabetic origin, 4 (23.5%) were secondary to chronic venous stasis (in patients who were either poor candidates for vascular surgery or had failed one), 4 (23.5%) were trophic ulcers secondary to leprosy, and 2 (11.8%) were of vasculitic origin. All (100%) ulcers showed complete healing within 5 to 6 weeks with no complications [data and study under publication].
COMMON TO VITILIGO AND CNHUs
The convenience factor of the requirement of minimal equipment and highly cost-effective consumables are key advantages of the Jodhpur technique:
One of the advantages of this technique is that the requirement of personnel (in terms of the number of surgeon(s) and paramedical staff), as well as the amount of their prior experience to perform a proper skin grafting by Jodhpur technique, are both minimal.
A single dermatology surgeon with exposure to 2 or 3 surgeries and preferably at least one-time assistance as a co-surgeon with a senior dermatology surgeon experienced and conversant with the Jodhpur technique is sufficient as the primary and the only required doctor. And although the availability of a general minor procedure room or minor operating theater staff nurse/technician helps expedite the completion of the surgery, the technique has been undertaken several times by the authors and their students single-handedly. Of course, in the latter scenario, it is expected that the surgical nurse/technician would have ensured the availability of all material and kept them sterile for the surgeon's use.
Preparation at recipient site [Figure 1]
Basic Principle - Recipient-site preparation is an essential step of any skin grafting procedure, and is performed to facilitate the access of the donor material to the sub-epidermal structures of the recipient site. The procedure entails removal of the epidermis from the underlying dermis at the dermo-epidermal junction (DEJ) or the upper papillary dermis; necessary for the adherence and nutrition of melanocytes and other supportive cells contained in the donor material. Grafting of the donor material at a adequately prepared recipient site of the necessary for melanocyte adherence and nutrition. After proper bandaging, plasmatic imbibition of the grafted material begins and continues for the first 24 to 48 hours, followed by neoangiogenesis that subsequently maintains the cellular nutrition.
Alternative methods for recipient site preparation:
In the classical Jodhpur technique, dermabrasion remains the preferred way of recipient site preparation owing to its simplicity, easy and cheap availability of both manual and motorized dermabraders, and well-defined endpoint of pinpoint bleeding. One must be aware of other approaches and may use them if machine availability and cost to the patient does not impede the very purpose of preferring the Jodhpur technique.
Various methods exist for recipient-site preparation in skin grafting for vitiligo. These include the cryogenic blister formation with liquid nitrogen, radiofrequency (RF) ablation with the ball probe, creating suction blisters by negative pressure technique, phototoxic ablation with psoralen plus ultraviolet A (PUVA), and ablative lasers such as the erbium: YAG and CO2 lasers. Each of these techniques has certain advantages and suffers the limitation of specific complications. It is important to remember that the endpoint of pinpoint bleeding has only become standardized in the context of using mechanical dermabrasion.
Harvesting the graft material from the Donor site [Figure 2]
Placing the graft over the Recipient site [Figure 3]
The expected time-period for the outcome
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:
The Jodhpur technique not only bridges the tissue and cellular grafting approaches, its overall efficacy outcome in vitiligo [Figure 4], and CNHU's are very encouraging.
The advantages of this approach include:
1) Need for minimum infrastructural and monetary support in terms of laboratory, specialized equipment, special media, etc.
2) A broad spectrum of donor sites that may be available in this technique, compared to the relatively limited options in other skin grafting techniques.
3) A relatively high coverage ratio: In cases of vitiligo, the Jodhpur technique allows coverage of a recipient area with the harvesting of as low as 20 to 30% of that area from the donor site.
4) An easy learning curve for the dermatologist or dermatology surgeon, and need for minimal personnel for conducting the procedure.
5) High efficacy and minimal complications (such as textural abnormalities, uneven pigment matching, etc., usually encountered with STSG and MPG).
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.
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