Punch Incision Research Articles

BI30 Remission of a large plantar verruca vulgaris in an immunocompromised patient postincisional punch biopsy

Abstract We report the case of a 41-year-old renal transplant recipient who has been attending dermatology for skin surveillance following a cadaveric renal transplant. His immunosuppressive treatment consists of tacrolimus, mycophenolate mofetil and prednisolone 5 mg once daily. His primary dermatological complaint was that of a large wart on the plantar aspect of his right foot. Given the location of this lesion, there was significant associated pain, which also resulted in a functional impediment, impacting on his ability to exercise or work. On examination, he had a large, hyperkeratotic, papillomatous nodule measuring 3.5 × 3 cm on the plantar aspect of his right foot, clinically in keeping with verruca vulgaris. This had been recalcitrant to extensive treatment, including topical salicylic acid, 5-fluorouracil, cantharidin and numerous courses of cryotherapy and paring over the previous 6 years. Following administration of xylocaine 1% with adrenaline as the local anaesthetic, we performed three incisional 4-mm punch biopsies through the centre of the wart to the depth of the dermis. We ensured visualization of haemorrhage at the base of each punch incision. The biopsy cores were left in situ and the wound was dressed with petroleum jelly, Kaltostat® and Opsite. At his 6-week follow-up review, the verruca vulgaris had completely resolved. No postprocedural complications were noted by the patient. Further skin surveillance was scheduled for 6 months later, at which time no recurrence of this verruca vulgaris had occurred. Verruca vulgaris is a benign papillomatous proliferation of epidermal cells driven by human papillomavirus (HPV) infection, commonly acquired in childhood. For many patients, verruca vulgaris will spontaneously regress. However, it can represent a therapeutic challenge when persistent, as it is recalcitrant to multiple treatment modalities, particularly in immunosuppressed patients. To our knowledge, our case is the first documented resolution of a giant plantar wart in an immunocompromised patient using such an approach. Renal transplant patients represent a unique cohort in relation to verruca vulgaris, whereby impaired cell-mediated immunity can increase their susceptibility to HPV, thereby reducing effective treatment options and meaning definitive clearance may never be achieved. Our case highlights that incisional punch biopsy may represent an accessible and cost-effective approach to the treatment of verruca vulgaris in immunosuppressed patients, where alternative treatment options would necessitate numerous hospital visits.

Ultrasound-Guided Placement of Percutaneous Abutments for Bone Conduction Hearing Devices.

To introduce a minimally invasive and image-guided technique for staged placement of a percutaneous abutment after osseointegrated implantation. Adults undergoing temporal bone resection at two academic medical centers. Ultrasound-guided percutaneous installation of a bone conduction hearing device abutment. All patients had lateral temporal bone resection with osseointegrated implantation. Abutment placement followed as a planned staged procedure 3 to 6 months later depending on the use of radiotherapy. Ability to use a bone conduction hearing device and occurrence of skin reactions or wound complications. Twelve patients successfully underwent abutment installation through a 5 mm skin biopsy punch incision, nine of which had minimal to no skin reaction surrounding the abutment. Two patients developed Holgers grade 1 skin reaction (redness with slight swelling). One patient experienced an osseointegration failure 152 days after abutment placement. Ultrasound is a widely available imaging modality that can be used to precisely localize subcutaneous osseointegrated implants, allowing for minimally invasive percutaneous placement of an abutment under local or general anesthesia.

Punch Incision versus Elliptical Excision for Epidermal Inclusion Cysts: Systematic Review and Meta-Analysis

Punch incision is an alternative to elliptical excision for treating epidermal inclusion cysts, but its efficacy has not been systematically reviewed. This study assessed the efficacy and safety of punch incision versus elliptical excision for epidermal inclusion cysts. Randomized controlled trials published through January 2021 that evaluated the performance of punch incision versus elliptical excision on epidermal inclusion cysts were identified through electronic databases and clinical registries. Version 2 of the Cochrane risk-of-bias tool for randomized trials tool was used. Review Manager software was used for the meta-analysis. Two trials (100 participants) were identified. The primary outcomes were recurrence rate (risk ratio, 2.40; 95% confidence interval [CI], 0.37–15.60 [favoring elliptical excision]), mean operative time (mean difference [MD], −5.28; 95% CI, −12.72 to 2.16 [favoring punch incision]), and mean postoperative wound length (MD, −11.67; 95% CI, −20.59 to −2.76 [favoring punch incision]). The evidence was low to moderate due to the small sample size and its considerable heterogeneity. The use of punch incision shortened the mean postoperative wound length and had comparable safety to that of elliptical excision.

Punch Incision with Secondary Healing (PISH) Technique for Benign Facial Lesions: An Institutional Experience in 307 Patients.

Background Multiple or solitary facial lesions pose a unique challenge to the attending surgeon in terms of delivering the best cosmetic outcome. There are various methods in dealing with them and the preference of using them is based on the surgeon’s experience, patient expectations, and availability of instruments. One such tool, skin-punch, primarily designed for a biopsy can play a very important therapeutic role in this era of keyhole surgery. In this paper, we assess the technique of punch incision with its combination of secondary healing for various facial lesion. Methods This observational study, a total of 307 patients with solitary or multiple benign facial lesions were treated with punch incision technique using 2 to 6 mm sterile, disposable skin biopsy punches. Subsequently, the wounds were managed with healing with secondary intention. Results In our series all superficial wounds epithelized by 7 to 14 days while the deeper lesions epithelized by 14 to 28 days. We had three recurrences which were managed by fusiform excision and one patient had surgical site infection which was managed conservatively. On application of our self-devised facial scar scoring system (SCAR or Scar Cosmesis Assessment and Rating) 3 on all the scars, the mean score was 6 at 1 year followup. Conclusion Punch incision with healing by secondary intention is a relatively easy, effective, single-stage office procedure. This method can be considered as an alternative method for the removal of various skin lesions, especially on face, thus providing a simple solution to complex problems.

Impact of Biopsy Technique on Clinically Important Outcomes for Cutaneous Melanoma: A Systematic Review and Meta-analysis.

We performed a systematic review and meta-analysis to examine the relationship between the type of biopsy technique employed in the diagnosis of cutaneous melanoma and 4 clinically important outcomes: melanoma-specific mortality, all-cause mortality, Breslow tumor depth, or melanoma recurrence. Our database was obtained by searching PubMed, Ovid MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Library from inception until December 6, 2019. Studies were identified that compared biopsy techniques used to diagnose cutaneous melanoma with any of our study outcomes. We included 7 observational studies for our meta-analysis after screening 3231 titles and abstracts. Pooled data identified a significantly higher all-cause mortality in the punch biopsy group (risk ratio [RR], 1.520; P=.02). A higher, but nonsignificant, rate of melanoma-specific mortality (RR, 1.96; P=.22) and melanoma recurrence (RR, 1.20; P=.186) was also found for the punch biopsy group. Breslow tumor thickness was not significantly lower for punch incision (standardized mean difference, −0.42; P=.27). We found limited evidence for differences in clinically important outcomes across the spectrum of the most common methods employed in clinical practice for the initial diagnosis of cutaneous melanoma. A small, but significant, increase (P=.02) in all-cause mortality with punch biopsies was not seen for the other outcomes and was most likely due to small sample sizes and demographic differences in the included studies and unlikely represents a clinically important outcome. Our findings support the use of existing clinical practice guidelines for evaluating pigmented lesions suspicious for cutaneous melanoma.

Comparison of elliptical excision versus punch incision for the treatment of epidermal inclusion cysts: A prospective, randomized study

Comparison of elliptical excision versus punch incision for the treatment of epidermal inclusion cysts: A prospective, randomized study

Punch and Drill

To compare 2 surgical techniques for implantation of a percutaneous bone anchored hearing device: (1) a minimal skin punch incision without additional skin incision or soft tissue reduction and (2) implantation with an epidermal flap and soft tissues reduction. Prospective study. Tertiary care referral center. Forty patients consecutively implanted (18 males and 22 females). Twenty patients underwent implantation by means of epidermal flap and soft tissues reduction (dermatome group), and 20 patients underwent skin punch resection without soft tissues reduction (punch group). surgical adverse events, surgical time, skin healing, skin tolerance (Holgers classification), and skin appearance and implant failure. The surgical time was shorter with the punch technique (P < .05). The postoperative healing was satisfactory in both groups. All implants were loaded after the healing period. The skin tolerance was good in both groups by Holgers classification (punch, 85.7%/dermatome, 86%) with no significant difference. There were no severe adverse skin events in the punch group. The appearance of the skin around the implant was improved by the punch technique. The implantation of the currently available percutaneous bone anchored hearing implants with a minimal skin punch skin resection without additional skin incision or soft tissue reduction shortens the surgery and improves the postoperative appearance. The skin tolerance is at least as good as with techniques with that include soft tissue reduction.

Removal of corns by punch incision: A retrospective analysis of 15 patients

Hard corns are firm, small, dome-shaped papules with translucent central cores, which occur on the palmoplantar region of toes and hands due to repeated trauma. Medical management of hard corns is difficult and sometimes requires surgical excision. Punch incision is a technique which is performed using a circular blade or trephine attached to a pencil-like handle. We hypothesized that it might serve as an alternative method to surgical excision in the treatment of recalcitrant corns and performed the technique to treat 17 corns in 15 patients. The present study aimed to review these 15 patients retrospectively and evaluate the effectiveness of punch incision. A total of 15 patients with recalcitrant corns were treated using punch incision between April 2011 and December 2012 and were evaluated by photographs and patient satisfaction questionnaires. Out of the 17 corns, 3 corns persisted after punch incision and the patients were referred to the orthopedic clinic for further treatment; 2 of the 17 corns partially responded and required additional topical treatment; and 12 of the 17 corns responded completely to punch incision. Punch incision is a simple and effective technique for the treatment of small corns on the palms and soles.

Comparison of the Surgical Outcomes of Punch Incision and Elliptical Excision in Treating Epidermal Inclusion Cysts: A Prospective, Randomized Study

Comparison of the Surgical Outcomes of Punch Incision and Elliptical Excision in Treating Epidermal Inclusion Cysts: A Prospective, Randomized Study

Surgical Pearl: Removal of large oval lesions with a smaller round punch

M any patients request the removal of common moles and other unwanted lesions with entirely benign clinical features for cosmetic reasons or because they are repeatedly traumatized by clothing, shaving, jewelry, or body movements. The goal is to efficiently remove such lesions while minimizing the chance for recurrence and scarring. A variety of methods for removal of such lesions are available and include: elliptical, round, and shave excisions; shave excision followed by electrodessication; cryotherapy combined with curetting or scissor excision; and punch excision. The standard punch excision technique uses disposable punches, which are available in 3, 4, 5, 6, and 8 mm. Generally, a punch is chosen that is at least .2-mm larger than the maximum diameter of a mole or other benign lesion. Round excision of this type preserves normal tissue, but dog-ears may be produced when the wound is closed. In the case of keratinous cysts, pilar cysts, and lipomas, larger lesions can be removed through a small punch incision opening. We often encounter lesions that are larger in one diameter than the punch that would be chosen based on the narrower width of a lesion. In addition, an oval lesion measuring 6 3 11 mm might be considered too large to remove with the largest 8 mm—diameter punch. Using a modified punch excision technique, lesions with benign clinical appearance that exhibit these features are readily excised. Staff and physician time is preserved by avoiding a freehand wedge excision and the wound created has an oval shape that produces excellent cosmetic results.

Comparison of the Surgical Outcomes of Punch Incision and Elliptical Excision in Treating Epidermal Inclusion Cysts: A Prospective, Randomized Study

Punch incision has been introduced as an alternative method to surgical excision for troublesome epidermal inclusion cysts. To date, there is no randomized study directly comparing the long-term results of these two methods. To compare the surgical outcomes of these two procedures and to identify the characteristics of a lesion most suitable for the punch incision technique. In a 16-month period, 60 patients with noninfected epidermal inclusion cysts were randomly treated with either punch incision or elliptical excision. Demographic data, size, and location of lesion, length of wound, operative time, complications, recurrence, and patient satisfaction were compared statistically. The mean lengths of the wounds in the punch incision and elliptical excision groups were 0.73 and 2.34 cm, respectively (p<.001). Mean operative time was significantly shorter in the punch group (12.7 minutes) as compared with the surgical group (21.6 minutes) (p<.001). No complication occurred in the punch incision group. There was no significant difference in the recurrence rate. Punch incision produces a superior cosmetic result while keeping a low recurrence rate of cysts. Epidermal inclusion cysts measuring 1 to 2 cm that are located on the face or in an area of cosmetic concern are best treated with punch incision.

Comparison of the Surgical Outcomes of Punch Incision and Elliptical Excision in Treating Epidermal Inclusion Cysts

Comparison of the Surgical Outcomes of Punch Incision and Elliptical Excision in Treating Epidermal Inclusion Cysts

Histopathologic correlation in dermoscopy: a micropunch technique.

Dermoscopy is a simple-to-use, in vivo method for the diagnosis of malignant melanoma and the differential diagnosis of pigmented skin lesions. It uses an immersion technique and optical magnification to visualize structures not visible to the naked eye. The anatomoclinical correlation of dermoscopic with histopathologic findings is important, and while many articles have described different techniques to achieve this goal, no direct correlation with a visual control has been described. We recently developed a micropunch technique that allows for the first time this direct correlation. After applying local anesthesia, the physician makes a superficial round incision using a 1-mm micropunch in the area of interest and leaves the punch in place. The lesion is documented using digital dermoscopy before and after surgery. Using these images, the laboratory technicians can easily visualize the precise site of the punch and its correlation with the initial dermoscopic image, and the sections are chosen in a way that they pass through the punch incision. The punch incision can be easily identified in the histopathologic slides because of its clear-cut borders. Since the punch always stays in place, this technique does not interfere with the interpretation of the slides (eg, measurement of the Breslow thickness). The advantages of our technique are that it is easy to perform by any clinician in any setting after a short setup and training period for the clinician and the laboratory technicians. Unlike with other techniques, the physician need not be present at the laboratory at the moment of the step sectioning. It can be performed in private practice and for many other indications besides pigmented skin lesions. Finally, since this technique allows for the first time a direct correlation between dermoscopic and histopathologic findings, the clinician will be able to "guide" the pathologist and indicate the precise areas of interest or suspicion.

Removal of keratinous and pilar cysts with the punch incision technique: analysis of surgical outcomes.

The removal of keratinous and pilar cysts by the punch incision technique is an alternative to traditional excision methods. It is easy to perform with commonly available instruments, and quick. Faster healing and less scarring are advantages because of the small opening through which the cysts are removed. No previous studies have documented recurrence rates of cysts removed by this technique or the recurrence rates following either traditional excision surgery or other alternative minimal excision techniques. We provide data demonstrating that the removal of keratinous and pilar cysts by the punch incision technique is a viable option with an acceptably low recurrence rate. To evaluate the overall recurrence rates of keratinous and pilar cysts removed by the punch incision technique and rates of recurrence by location and using other cyst characteristics. A preliminary retrospective chart review of cysts removed exclusively by the punch incision technique from 1989 to 1998 was performed. The rate of cyst recurrence and average time to patient-initiated follow-up visit for evaluation and removal were determined. In a second study, a survey requested information on the presence of cyst recurrence. This was mailed to all 646 patients who had cysts removed by the punch incision technique from 1989 to 1998 to evaluate possible cyst recurrence in patients who did not choose to follow-up at the office. Statistical analysis was performed to determine the overall recurrence rates and recurrence rates based on location and other cyst characteristics. Preliminary chart review revealed a recurrence rate of 3.6%, with a mean time to patient-initiated follow-up of 79.3 weeks. In the second study, an analysis of cyst recurrence rates in patients returning the survey revealed an 8.3% recurrence rate. Subanalysis revealed a trend showing that inflamed cysts had a lower recurrence rate. Another trend noted was that cysts removed from the back and ear had the highest recurrence rates (13.8 and 13.0%, respectively) compared to those removed from other locations. Most cysts (54.5%) recurred within the first year after punch incision removal. This is the first study to document recurrence rates using the punch incision technique for removal of epithelial cysts. Though most recurrences occur within the first year, there is a delay in patients reporting to their doctors for reexcision, perhaps because recurrent cysts are often asymptomatic. Studies to determine the recurrence rates for cyst excision using other techniques should be performed. The punch incision technique, when properly performed, is a satisfactory removal method with a recurrence rate of less then 10%.

Removal of Keratinous and Pilar Cysts With the Punch Incision Technique

BACKGROUND The removal of keratinous and pilar cysts by the punch incision technique is an alternative to traditional excision methods. It is easy to perform with commonly available instruments, and quick. Faster healing and less scarring are advantages because of the small opening through which the cysts are removed. No previous studies have documented recurrence rates of cysts removed by this technique or the recurrence rates following either traditional excision surgery or other alternative minimal excision techniques. We provide data demonstrating that the removal of keratinous and pilar cysts by the punch incision technique is a viable option with an acceptably low recurrence rate. OBJECTIVE To evaluate the overall recurrence rates of keratinous and pilar cysts removed by the punch incision technique and rates of recurrence by location and using other cyst characteristics. METHODS A preliminary retrospective chart review of cysts removed exclusively by the punch incision technique from 1989 to 1998 was performed. The rate of cyst recurrence and average time to patient-initiated follow-up visit for evaluation and removal were determined. In a second study, a survey requested information on the presence of cyst recurrence. This was mailed to all 646 patients who had cysts removed by the punch incision technique from 1989 to 1998 to evaluate possible cyst recurrence in patients who did not choose to follow-up at the office. Statistical analysis was performed to determine the overall recurrence rates and recurrence rates based on location and other cyst characteristics. RESULTS Preliminary chart review revealed a recurrence rate of 3.6%, with a mean time to patient-initiated follow-up of 79.3 weeks. In the second study, an analysis of cyst recurrence rates in patients returning the survey revealed an 8.3% recurrence rate. Subanalysis revealed a trend showing that inflamed cysts had a lower recurrence rate. Another trend noted was that cysts removed from the back and ear had the highest recurrence rates (13.8 and 13.0%, respectively) compared to those removed from other locations. Most cysts (54.5%) recurred within the first year after punch incision removal. CONCLUSION This is the first study to document recurrence rates using the punch incision technique for removal of epithelial cysts. Though most recurrences occur within the first year, there is a delay in patients reporting to their doctors for reexcision, perhaps because recurrent cysts are often asymptomatic. Studies to determine the recurrence rates for cyst excision using other techniques should be performed. The punch incision technique, when properly performed, is a satisfactory removal method with a recurrence rate of less then 10%.

A bone biopsy procedure for neonatal pigs

Neonatal pigs were used to develop a surgical biopsy procedure to remove bone tissue from the ilium of small animals, with potential application for infants and small children. While the neonatal pig was under general anaesthesia, a scalpel was used to make a punch incision down to the ilium. Then a Craig Biopsy Trephine was used to remove a core sample of the bone. The samples ranged from 5 to 15 mm in length and 2 to 3 mm in diameter, with an average dry weight of 34.4 mg. The samples were adequate for mineral (calcium and zinc) analysis in our laboratory and may be equally suitable for histological or biochemical analyses. Surgical trauma was minimal, which permitted each pig to be biopsied every 7 days for 5 weeks without adverse consequences.