Overview of Jodhpur Technique
The Jodhpur Technique is an innovative, simple and extremely cost-effective method of skin grafting developed by a group of leading dermatology surgeons in Jodhpur, India. In simple terms, this technique uses your own cells, without the need for them to be grown in a lab or treated with certain enzymes. This is particularly useful in regions where hospitals may lack the necessary facilities to perform advanced skin grafting techniques.
Skin grafting is a surgical technique that has been used for a very long time to cover wounds or damaged skin caused by things like burns, accidents, long-term non-healing wounds, or after the removal of large skin growths. It can also be used to replace specific types of skin that lack certain cells, such as skin that has lost its color (melanocytes), with the goal of improving the skin’s appearance.
It’s important to understand that skin grafts are different from flap repairs. While flap repairs remain connected to a blood supply, skin grafts are not and need to be placed on a well-prepared area to receive nutrients from the body. Skin grafting is often used in treating a skin condition called vitiligo and for healings of long-term non-healing ulcers. They can also be used when the scar is revised and in burns that have left the skin without pigment.
Skin grafts can vary in their composition and technique of harvesting:
(1) Depending on the cells and tissue used in the graft:
* Split-thickness skin grafts – includes full epidermis and a outer part of the dermis.
* Full-thickness skin grafts – includes full dermis and epidermis, and a little bit of the fat under the skin
* Composite grafts – contain skin and another type of tissue, often cartilage.
Split-thickness skin grafts can be further divided into different types based on the thickness of the graft.
(2) Depending on how the graft is harvested:
* Tissue grafts – directly harvests layers of skin cells from the donor area. This might involve small skin punches or pulling out a thin sheet of skin using a dermatome or creating ultra-thin skin grafts with a special type of suction. While these techniques are less expensive, they can only cover a limited area in each treatment session.
* Cellular grafts – uses suspensions of pure melanocytes, or keratinocytes, with latest additions being specialized dermal cells and/or follicular cells. They could either be grown in a lab or be used as a non-cultured suspension. These can treat a larger skin area, but the cultured techniques are time-consuming and expensive because they require special culture media and specific temperature-controlled conditions for several weeks.
The non-cultured cellular grafting methods involve separating the skin cells using trypsin enzyme, and although less demanding than cultured techniques, it still requires special chemicals and lab facilities.
The Jodhpur Technique combines the advantages of cellular and tissue skin grafting techniques. It can treat a large recipient area with a small donor skin area, without the need for expensive facilities, chemicals, devices or culture media.
Anatomy and Physiology of Jodhpur Technique
The Jodhpur technique is a medical procedure used to treat certain skin conditions like non-healing ulcers (CNHUs) and stable patches of vitiligo, a disease that causes loss of skin color in blotches. If you are a patient with either condition, there are a few key things you should know about this method:
1) For treating vitiligo – The most important thing before moving forward with the Jodhpur method or any surgical solution for vitiligo is to ensure the disease is stable. This means there is no new emergence or spreading of the white patches. In the past, doctors would judge the stability of the condition based on observation. Today, using advanced technology, the doctor will use a tool that gives a closer look at your skin (a dermoscope). This helps them make sure your condition is stable before starting surgery.
Basically, if the white patches on your skin are not spreading or changing, you may be a good candidate for this surgery. This is to avoid graft failure – a situation where the transferred skin doesn’t survive in the new location or the vitiligo spreads to the new skin.
2) For treating non-healing ulcers – These sores that won’t heal are often found on the lower legs. They can happened for many reasons like poor blood flow due to gravity and frequent injuries. If you have one of these ulcers, doctors will first ensure that any modifiable factors are managed before moving to surgeries like the Jodhpur technique.
In CNHUs, the ulcer’s blood supply must be taken into account. Doctors may consider other options like flaps (transferring skin with its own blood supply), injections of growth factors (substances that encourage healing), use of platelet concentrates (part of your blood that aids healing), or hyperbaric oxygen (breathing 100% oxygen in a pressurized room), before deciding that the Jodhpur technique is the best solution.
Additionally, the Jodhpur technique is beneficial for treating vitiligo because it requires less skin to be taken from the donor site. Only 20 to 30% of the equivalent area needing treatment needs to be harvested, which means less damage to the healthy skin area.
Why do People Need Jodhpur Technique
The Jodhpur technique is a medical treatment that is currently used mainly for two conditions: stable vitiligo and chronic non-healing ulcers (CNHUs).
In simpler terms, stable vitiligo is a skin condition that causes loss of skin color in patches. A study was conducted on 154 patients with this condition, who had 437 patches of discolored skin treated using the Jodhpur technique and light therapy (PUVA). The study reported that 41% of the patches showed more than 75% return of skin color. Body parts that showed significant improvement included the thighs (100% improvement), face (75% improvement), and trunk (50% improvement). Unfortunately, patches on joints and areas farthest from the body’s center (acral areas) didn’t show as much improvement.
Chronic non-healing ulcers (CNHUs), on the other hand, are wounds, usually on the legs that do not heal easily. This technique has also been trialed for treating these ulcers, especially in patients who have not responded well to usual treatment methods. The patients in this trial had ulcers due to various reasons – 41.2% were because of diabetes, 23.5% were due to poor veins (chronic venous stasis) in patients who couldn’t undergo vascular surgery or it didn’t work for them, another 23.5% were ulcers that follow leprosy, and 11.8% were because of inflammation of blood vessels (vasculitis). Remarkably, all these ulcers got completely healed within five to six weeks of the treatment using the Jodhpur technique and did not cause any complications.
When a Person Should Avoid Jodhpur Technique
Vitiligo, a condition that leads to patches of light skin, and CNHUs, also known as ulcers, have certain shared factors that could make treatment more difficult. These include:
– Being allergic to the local numbing drugs used during procedures
– A personal history or likelihood of forming thick, raised scars
– Having disorders that affect the body’s ability to bleed or clot properly
– Suffering from chronic, serious illnesses that aren’t well-managed, like severe diabetes, or kidney or liver failure
– Being unable to cooperate with medical providers, or not being reliable, in sticking to the treatment plan
– Having expectations about the outcome of the treatment that aren’t realistic
– Having an active infection — bacterial, viral, fungal or herpes — on the skin area where the treatment is supposed to happen
When it comes to vitiligo, it is important that the white patches on the skin are not currently spreading. The spreading or “activity” of vitiligo can affect the outcome of the surgery and contribute to the start of new white patches at the site where the skin was taken for the surgery. Older methods were used to determine whether the vitiligo was active or not. These methods involved looking at the patient’s history, inspecting the patches, using ultraviolet light examination, testing with a small skin graft, as well as checking some lab and tissue results.
However, these methods have been largely replaced with simpler techniques. One such technique, called a dermoscope, allows doctors to look at the skin more closely. This technique is now considered the standard in predicting whether the vitiligo is likely to spread or not.
Also, for ulcer treatment, it’s crucial that the original, or primary, disease that caused the ulcer is under control. For instance, it can be difficult to treat an ulcer in a person whose diabetes is uncontrolled. Things like poor overall health and poor nutrition can also hinder the healing process after surgery.
Equipment used for Jodhpur Technique
The Jodhpur technique has some key advantages; it’s easy to use with minimal equipment and cost-effective supplies.
DEVICES
* Dermabrader – This is a device used to remove the upper layer of skin. It can either be a manual one, like the Manekshaw’s dermabrader, or a motorized version.
* Sterile glass slides – These are used to hold specimens for microscope examination.
SUPPLIES
* Sterilizing materials for the skin where the procedure’s being done – clean gauze pieces, a solution called betadine that’s used as a skin disinfectant, and surgical spirit, a type of alcohol used to clean skin before an operation.
* Local Anesthesia tools – Syringes and needles, and a medicine called lignocaine used to numb the area (without adrenaline).
* Sterile spatulas – These are tools used to apply or mix medications.
* Normal saline – A saltwater solution commonly used in medicine, and saline-soaked sterile gauze pieces.
* 2% mupirocin ointment, or another broad-spectrum (this means it fights many types of bacteria) topical (applied to the skin) antibacterial ointment.
* Collagen dressings – These are bandages that help wounds heal by attracting new skin cells to wound sites; they can be wet or dry.
* Sterile cotton pads, micropore tapes, and bandages. This is to clean and dress the site where the procedure was performed.
Who is needed to perform Jodhpur Technique?
The technique of Jodhpur skin grafting has several benefits. One such benefit is that it doesn’t need a lot of medical staff or a highly experienced surgeon to be performed correctly. You really only need one skin doctor (dermatologist) who has seen or assisted in two or three similar surgeries. Also, it’s preferred if this doctor has assisted a more experienced doctor with this technique at least once before.
Having a nurse or technician in the room where minor surgeries are performed can help speed things up. But, the authors and their students have done this technique on their own many times. If this is the case, the nurse or technician would just make sure all the necessary tools and materials are available and sterile (free of germs) before the surgery starts for the doctor to use.
Preparing for Jodhpur Technique
In simpler terms, preparing the recipient site is a crucial part of any skin grafting procedure. This prep work helps the donated skin graft stick to the area and get the nutrients it needs from the body. The doctor removes the top layer of skin at the grafting site, which extends only as deep as where the outer and inner layer of skin meet, or slightly further into the inner layer of skin. Once the grafting material, or donated skin, is placed on this prepared site, it begins to absorb and integrate with the body’s fluids, a process that lasts about one or two days. Simultaneously, new blood vessels start to form and provide the necessary nutrients for the cells in the graft.
The area that’s going to receive the graft needs to be prepared first so that the donated skin can be put in place as soon as it’s ready. Local Anesthesia is used to numb the area before the graft, with a special note that adrenaline shouldn’t be used because it can interfere with skin preparation and cause graft to fail or scars to form.
The area receiving the graft is then lightly scraped or planed using a special tool to achieve a smooth surface. This surface is ready for the graft when there’s small, uniform bleeding. Keeping this area moist until the graft is ready is also quite important.
There are several alternative methods to prepare the recipient site, each with its own advantages and disadvantages. These include the use of frostbite through liquid nitrogen, electric currents using an RF ball probe, suction to form blisters by negative pressure, UV exposure following ingestion/application of psoralen, and lasers such as the erbium:YAG and CO2 lasers. The best method to use can vary depending on the circumstances, such as the size and shape of the recipient site, patients’ comfort, the potential risks, and timing requirements.
It’s important to remember that grafting can sometimes be a delicate and complex process. It’s always necessary to carefully consider the options and choose the method that best suits the patient’s needs to ensure an optimal outcome.
How is Jodhpur Technique performed
When performing a grafting procedure known as the Jodhpur technique, we sometimes need to collect what we call ‘graft material’ – tissue from another part of your body. This tissue usually comes from areas like the outer part of your thighs, buttocks, or the outer aspect of your arms, in a step we call ‘harvesting from the donor site’. Quite simply, we’re looking for locations with healthy skin to use. What’s fascinating about the Jodhpur technique is that we can reuse a spot where successful surgery was done in the past!
A unique aspect of the Jodhpur technique is choosing a donor site close to the skin area requiring treatment—or even a previously treated spot. This approach helps reduce any discomfort you might feel since we’re only focusing on one site. Ideally, this graft material would also better match the colour and other characteristics of the surrounding skin.
Once we’ve picked a donor site, we’ll numb it with a local anesthetic. Then, we’ll gently remove some of the skin layers using a technique called ‘dermabrasion’. To collect the cells needed for the transplant, we’ll smear a thick layer of antibiotic ointment over the area before dermabrasion. This ointment captures the essential skin cells as they separate during the procedure. The end result is a paste containing the skin cells we need to help you.
Next, we transfer this cell-rich paste to a slide and mix it with saline to form a uniform mixture. We then smear a thin layer of this mixture over the area where you need new skin. Once complete, we apply a series of dressings and a cotton pad, secured with a bandage.
After the procedure, we’ll provide you with instructions to care for the dressing, including leaving it in place for at least seven days and avoiding getting it wet. You may be prescribed some medicine, like antibiotics or anti-inflammatory drugs, to support your recovery. If you experience anything unusual during this period, we encourage you to contact us.
A week after the procedure, we’ll remove the dressing and check the site for any signs of infection. We’ll then decide if a small dressing needs to be applied to protect the area as it continues to heal. For skin color restoration conditions like vitiligo, you may need additional light therapy treatments to help encourage the development of new skin color.
The length of recovery varies. For vitiligo, new pigmentation usually begins to appear 8 to 12 weeks after the procedure, and complete, even color typically returns within 16 to 20 weeks. For other conditions, substantial healing generally occurs within 5 to 6 weeks.
Possible Complications of Jodhpur Technique
The Jodhpur method, a type of surgery, is generally safe. However, patients should be aware of possible complications or ‘side effects’ that might occur during and after the procedure:
DURING SURGERY
– Pain at the surgery site: It’s rare, but sometimes, patients might feel pain at the place where the surgery is happening or where tissue was taken from. This usually happens if the anesthesia, the medicine used to numb the area, doesn’t work properly. Rarely, some people have a resistance to anesthesia. This can either be a genetic trait or a condition that develops over time. There are also reports indicating that pain relief can be delayed in people who smoke regularly.
– Infection at the surgery site: This does not happen often. The chance of infection can be lowered if the patient is given antibiotics right after surgery.
AFTER SURGERY
– Formation of keloids or hypertrophic scars: Keloids, which are raised scars that grow larger than the wound, are common in people who have a genetic predisposition. Hypertrophic scars, thick and raised scars, might also form, especially if the wound heals slowly or if the surgery is performed near a joint like the knee or elbow. Both of these can often be treated with injections that help reduce scar tissue and by using a silicon sheet to flatten the scar.
– Failure of the skin color to return or the receiving site not healing: This has been seen in only 10 to 15% of patients. Sometimes, the skin may not regain its color if the procedure was not done correctly, if there was a delay in the start of light therapy, or if the individual’s skin does not respond as expected. A second session of treatment might be helpful, but more research is needed. In very rare cases, the place where the skin was taken from might develop vitiligo, a condition that causes loss of skin color. This usually happens if the doctor did not check the patient’s health properly before performing the surgery, regardless of the method used.
What Else Should I Know About Jodhpur Technique?
The Jodhpur technique is a method used to treat conditions like vitiligo, a skin condition that causes loss of skin color in patches, and has shown promising results. “Vitiligo” might sound like a big word, but it simply means areas of skin lose their color and become white.
What makes the Jodhpur technique special?
1) It’s cost-effective and doesn’t require a high-tech laboratory or tons of special equipment.
2) It allows doctors to choose from a wide range of possible donor sites, which means they have more options compared to other skin-graft methods.
3) It allows doctors to cover a large area of skin damage using only a small piece of skin from the donor area. For example, in vitiligo cases, if you need to cover an area on your skin, the doctor would only need to use a skin piece that’s 20 to 30% the size of the damaged area.
4) It doesn’t take a long time for doctors or skin surgeons to learn how to use this method, and it doesn’t need a lot of extra staff to carry out.
5) It’s highly effective with minimal complications. It’s usual with other skin grafting techniques like STSG (Split thickness skin graft) and MPG (Meek micrografting) to encounter problems like uneven skin textures and colors, but with the Jodhpur technique, these problems are quite rare.
So, if you’re looking for an effective and less complicated solution to conditions like vitiligo, the Jodhpur technique might be just what you need!
