This method is for the areas which generally got higher failure rates due to cell detachments. Here the patient’s skin is used as dressing material to hold the cells for a longer time. Cell preparation is done in the same method as described earlier. Controlled blister formation is achieved over the recipient area using a cryo pen or cryo gun. With the modified form, cells are injected into these blisters. Artificial reservoirs are created over the recipient area. This method is helpful to treat patches on the lip, genital area, and acral vitiligo patches like fingertips. Such a method is also used in smaller patches and small resistant patches after initial cell transplantation.

Standard cell transplantation is based on warm trypsinization, where cell division is done at body temperature (37 degrees), which is faster and harsher. Although this is quicker, it achieves a much lesser viable cell yield. It makes it “tough to treat complex areas” successfully consistently. Also, there are chances of more severe cell damage or cell deaths, increasing autotransplantation of antigens which might aggravate vitiligo. The cold cell separation method or cold trypsinization, on the contrary, relies on slow and soft cell separation. This process produces higher viable cell yield and minimal cell damage or death with resultant advantages.

Combined cell suspension transplantation or Epidermal and Follicular suspension transplantation is the brainchild of Dr. Vijay Kumar. He had discovered this technique to combine the benefits of non-cultured follicular cell suspension transplantation and non-cultured epidermal suspension transplantation.

This innovative method of cell transplantation has the advantage of no dependence on skin grafts. Approximately 50 to 100 hair follicles are taken from the back of the scalp. Compared to the conventional follicular cell suspension method, this method doesn’t involve serial cell separation. This method involves single-cell separation. But, this method can not be used for larger spaces or areas because of unnecessary time consumption. This process has a higher possibility of cell presence and immunomodulation. It is also two steps or two-day procedure.

In a stable vitiligo spot, this process provides near-complete repigmentation and near-normal color and texture match. Our procedure uses recombinant reagents, which are suitable for clinical use. The cell suspension provided by our method gives a tremendous viable cellular yield as opposed to other standard techniques. We take ultra-thin skin grafts, which are typically 1/10th to 1/3rd the size of the receiver area depending on the site of the lesion. The donor area consequences like scarring are almost nil. Most patients will have transient hyperpigmentation. The cell transplantation depends on the ‘recipient dominance’ phenomenon where the recipient area will decide the color and texture match. This cell transplantation method mainly includes ideal requirements of vitiligo surgery like replacement of modified keratinocytes, replenishment of lost melanocytes, immunomodulation, efficient migration and proliferation of cells, and minimum organization of grafted cells. It is a two-step/two-day procedure.

Touch-up procedures are needed in cases where some resistant islands of white patches remain after successful cell transplantation. This situation is a highly challenging one and needs extreme expertise to overcome the resistant patches. Although the process is the same as the first procedure, one must be careful with the cell concentration and dressing methods. Touch up technique is done after six months of the initial process.

The conventional procedure uses a cell separation reagent that is of animal origin. One should look for the recombinant reagent-based process that is safer. We do an altered non-cultured epidermal suspension transplantation using safer substitutes. We use recombinant reagent, which is more reliable for clinical use. Comparatively, this reagent is more expensive than the conventional animal origin. The success with such a reagent depends on the expertise and needs particular protocol..