Beyond vitiligo: An unconventional use of non-cultured epidermal suspension in post-burn scar

INTRODUCTION

Post-burn scars, especially on the face, can have profound functional and psychosocial impacts. Conventional management strategies focus on contracture release, scar revision, and pigment modulation. However, achieving simultaneous improvement in dermal fibrosis and dyspigmentation remains a therapeutic challenge.^[1] Non-cultured epidermal suspension (NCES) is widely utilized in stable vitiligo to facilitate re-pigmentation through melanocyte transfer. In this report, we explore an unconventional application of NCES in burn scar revision aiming to address both pigmentary irregularities and dermal fibrosis.^[2,3]

CASE REPORT

A 26-year-old male presented with a longstanding facial post-burn scar resulting from a thermal injury sustained at 18 months of age. The scar demonstrated diffuse hyperpigmentation and severe dermal fibrosis [Figure 1]. Conventional resurfacing and grafting techniques offered limited prospects for addressing both pigmentation and fibrosis concurrently. Therefore, we conceptualized a modified application of NCES, hypothesizing that deep dermabrasion would facilitate mechanical scar remodeling while NCES would enable pigment normalization through targeted melanocyte transfer.

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Figure 1:

(a, b) Post-burn scar in a 26-year-old male with diffuse hyperpigmentation and fibrosis.

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NCES surgery protocol with modification

Following informed and written consent, the donor site (lateral aspect of left thigh) was prepared under local anesthesia using a mixture comprising 4 mL of 2% lignocaine with adrenaline, 2 mL of 0.5% bupivacaine, and 4 mL of normal saline. Split-thickness skin graft harvesting was then performed. Post-extraction, the donor area was dressed with a topical antibiotic and covered with paraffin gauze. The harvested graft was transferred to a Petri dish containing 0.25% trypsin-ethylenediaminetetraacetic acid using nontoothed forceps and incubated at 35–36 °C for 45 min.

Simultaneously, under local anesthesia with 2% lignocaine and adrenaline (1:200,000), extensive dermabrasion of the recipient scarred site was performed [Figure 2]. The inclusion of adrenaline was crucial due to the patient’s history of coagulopathy, aiming to minimize intraoperative bleeding.^[4] Unlike the superficial dermabrasion typically employed in vitiligo NCES procedures, deeper dermabrasion was carried out to release intradermal fibrotic bands using both motorized and manual dermabraders. Manual instruments were specifically preferred for anatomically sensitive areas such as the glabella, periorbital region, and nasal bridge. The endpoint of dermabrasion was slightly deeper pinpoint bleeding, indicating access to the mid-dermis.

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Figure 2:

Post deep dermabrasion using manual and motorized dermabraders.

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Following incubation, the graft was washed with a trypsin inhibitor and transferred to Dulbecco’s Modified Eagle Medium. Cellular separation was performed manually followed by centrifugation at 3000 rpm for 5 min, followed by a 5 min rest period. The resulting cell pellet was collected and resuspended in hydroxypropyl methylcellulose ophthalmic solution to form the autologous NCES, which was applied to the dermabraded site. Due to the presence of dense fibrosis and the likelihood of delayed re-epithelialization, postoperative care involved the application of a dry collagen sheet (Xenoderm) and chlorhexidine-impregnated gauze (Bactigras), secured with a firm Elastocrepe bandage. This dressing was maintained for an extended duration of 14 days, exceeding the conventional 7–10-day protocol.^[5]

RESULTS

At 2 weeks, early epithelialization was observed. The patient demonstrated favorable graft uptake without evidence of infection or graft loss [Figure 3]. At 2 months follow-up, mild hyperpigmentation developed due to recurrent sun exposure, for which strict sun protection and topical kojic acid were advised [Figure 4]. At 6 months, there was significant improvement in pigmentation uniformity and scar pliability which was evident [Figure 5]. The patient reported high satisfaction with both the esthetic and functional outcomes.

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Figure 3:

At 2 weeks post-procedure, early epithelization noted.

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Figure 4:

(a, b) At 2 months post-procedure, mild hyperpigmentation observed.

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Figure 5:

(a, b) At 6 months post-procedure, increased pigmentation uniformity and scar pliability noted.

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DISCUSSION

This case illustrates the potential for repurposing non-cultured epidermal suspension in burn scar management. However, standard NCES procedures may be insufficient when dealing with burn scars, as these scars often involve significant dermal fibrosis, which may hinder cell uptake and graft integration.^[5] In such cases, modifications to the surgical technique are necessary. One critical modification is the use of deeper dermabrasion, which is designed to disrupt the fibrotic tissue to cause mechanical scar remodeling and create a more receptive bed for cell transfer.

By addressing both the superficial and deeper layers of the scar, this approach can enhance the graft’s success and improve overall scar pliability. The efficacy of dermabrasion, whether manual or motorized, has been well-documented, though the choice of technique may depend on the nature of the scar and the surgeon’s preference. While motorized techniques can offer precision and consistent results, manual dermabrasion may be more suitable for certain cases, particularly where finer control is required.^[6]

The use of adrenaline in local anesthesia is another key modification in this procedure. Adrenaline acts by inducing vasoconstriction, which helps reduce intraoperative bleeding and extends the duration of anesthesia.^[4] This is particularly important in burn scar revisions, where meticulous surgical manipulation is required, and minimizing blood loss is crucial for maintaining a clear surgical field.

Other modifications, such as extending the post-operative dressing duration, are also important in optimizing graft survival, particularly in fibrotic tissue which is less vascular, where re-epithelialization may be delayed. Extended dressing times, typically up to 14 days, provide more time for grafts to heal, ensuring better integration and survival rates.^[5] In addition, combining NCES with other adjunctive therapies such as laser resurfacing or fat grafting could further enhance both the esthetic appearance and functional recovery of burn scars by addressing both pigmentation and texture.

Beyond its established role in vitiligo management, non-cultured epidermal cell suspension (NCES) has demonstrated potential in the treatment of various pigmentary and structural skin disorders, including post-burn dyspigmentation, piebaldism, post-herpetic depigmentation, chemical leukoderma, and depigmentation associated with discoid lupus erythematosus.^[2,7] It has also been applied in stable cases of lichen sclerosus, post-burn reconstruction, acne scars, and congenital melanocytic nevi.^[7] Due to its regenerative cellular composition, NCES is being investigated for its utility in enhancing wound healing and facilitating scar remodeling. Furthermore, in vitiligo patients undergoing surgical interventions, NCES has shown promise in addressing post-operative challenges such as color mismatch, variegation, and textural irregularities.^[2]

Although the use of NCES in burn scar revision is still an emerging area of research, early case reports of eight patients with burn scars treated using non-cultured regenerative epithelial suspension by Ren et al.^[7] and a single case report of NCES in a post-burn skin graft by Mehta et al.^[2] show promising results. Clinical data suggest that NCES can significantly improve pigmentation and texture in burn scars, with faster healing times and improved scar quality compared to conventional treatments. These findings support the potential of NCES as an effective adjunct in burn scar revision surgeries, particularly when combined with surgical modifications tailored to the specific needs of the scar. Given these early successes, further research is needed to refine the technique, establish optimal procedural protocols, and confirm the long-term benefits of NCES in this setting.

CONCLUSION

NCES can be effectively repurposed for post-burn scar management, particularly when pigmentation irregularities and fibrosis co-exist. This case highlights the importance of procedural customization and supports further investigation into NCES as a dual-action therapy in burn scar revision.