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Flip-top grafts
Flip-top grafts
Developed by McGovern, Bolognia, and Leffell in 1999, FTG is a technique that involves placing small grafts at the RS, which has a hinged flap of epidermis that serves as a biologic dressing.35 Using this method, a DS is selected from a normally pigmented area in either the upper medial arm or axilla. A 30-gauge needle attached to a syringe filled with 1% lidocaine with epinephrine is used to inject into the upper portion of the dermis, creating a small wheal. A 2- to 4-mm strip of raised epidermis with some dermis is obtained manually using a sterile razor blade. The graft is then placed on gauze, soaked in isotonic sodium chloride solution, and divided into 1- to 2-mm wide grafts. Similarly, a wheal is raised at the RS using 1% lidocaine with epinephrine and a sterile razor blade is used to elevate a flap of epidermis with minimal papillary dermis. A portion of the RS flap is left connected to the dermis, while the disconnected portion is flipped over, exposing the dermal side. The graft is then transferred to the RS with the dermal side down and the epidermal flap (with the epidermal portion of the graft in contact with the dermis of the hinged flap) is folded back over atop of the graft. Cyanoacrylate is used to tether the graft edges to the RS and dressings are applied. Graft survival is assessed after 1 week by the presence of pigmented macules under the flap, and repigmentation is assessed after 1 month.26,35
The FTG technique is notable for demonstrating pigment spread beyond the graft. Little scarring is observed and the lack of cobblestoning can be attributed to graft placement below the epidermis. Advantages of FTG include simplicity, lack of specialized equipment required, and low cost.35 A study compared FTG and MPG in 20 patients with stable focal, segmental, and generalized vitiligo types and found that both were equally effective in treating vitiligo. However, FTG was associated with higher graft uptake rate and pigment spread.36