Versatile Punch Surgery

BASIC/CLINICAL SCIENCE

Versatile Punch Surgery Khalid M. AlGhamdi and Madallah M. AlEnazi Background: Punch instrument is a circular blade that can be used for many diagnostic and therapeutic purposes in different medical and surgical specialties. Punch surgery (or biopsy) is achieved by using this versatile punch blade under local anesthesia. Basic punch surgery is quick and easy to learn. Complications such as bleeding and infection are minimal. Diagnostic punch surgery can obtain a part of or whole skin lesion for histologic examination. In addition to the skin, nail and mucous membrane tissue can be obtained by punch biopsy. Interestingly, punch biopsy can be used as an adjunctive to fine-needle aspiration to establish the diagnosis of tumors of solid organ such as the breast. Diagnostic punch surgery can be modified to overcome certain problems. The split-punch technique helps avoid crushing the tissue punch when trying to divide it for different examinations. The double-trephine punch facilitates obtaining subcutaneous tissue without the need for full elliptical excision. The string-of-beads technique obviates the need for dissection of tissue into pieces. In other nondermatology and dermatology conditions, such as nerve pathology, arteriosclerosis, melanoma mapping, and eyelid tumors, the diagnosis can be enhanced with the use of punch surgery. Therapeutic punch surgery can be used for excision of unwanted lesions such as nevi, as well as pathologic bone and cartilage tissues. Punch grafting is used in vitiligo surgery and hair transplantion. Punch evacuative surgery can help in the evacuation of unwanted tissue or materials such as lipoma, subungual hematoma, scrotal calcinosis, pseudocyst of the auricle, pilar cyst, and others. Reconstructive punch surgery includes correction of ear lobe defects and acne scars. Enhancement of wound healing can be achieved by use of the punch; therefore, it can help nonhealing ulcers. Anteće´dents: L’instrument de ponction est une lame circulaire qui sert a` diverses fins de diagnostic et de the´rapie dans un nombre de spećialite´s me´dicales et chirurgicales. La ponction biopsie se fait sous anesthe´sie locale, au moyen de cette larme polyvalente. La ponction biopsie de base prend peu de temps et s’apprend facilement. Les complications, telles que le saignement et les infections, sont minimes. La ponction pour fin de diagnostic permet d’obtenir une partie ou la totalite´ de la le´sion cutaneé pour l’examen histologique. En plus de la peau, la ponction biopsie permet des pre´le`vements sur les ongles et les muqueuses. Par ailleurs, la ponction biopsie peut eˆtre utiliseé comme comple´ment a` l’aspiration a` l’aiguille fine afin d’e´tablir le diagnostic de tumeur dans les organes solides comme le sein. La ponction aux fins de diagnostic peut eˆtre modifieé afin de contourner certains proble`mes. La technique du ‘‘split-punch’’ permet d’e´viter l’ećrasement du tissu lorsqu’on le divise pour diffe´rents examens. La ponction a` la tre´phine ‘‘double-trephine punch’’ facilite l’obtention de tissu sous-cutane´ sans le recours a` une excision elliptique comple`te. La technique ‘‘string-of-beads‘‘ e´vite le besoin de disse´quer le tissu en pie`ces. Dans d’autres conditions dermatologiques ou non, telles que les pathologies neurologiques, l’arte´rioscle´rose, le mappage des me´lanomes, et les tumeurs de la paupie`re, le diagnostic peut eˆtre ame´liore´ au moyen de la ponction biopsie. La ponction peut servir comme traitement dans l’excision de le´sions non voulues, telles que les naevi, ainsi que des os affecte´s et du tissu cartilagineux. La greffe par ponction est utiliseé dans les cas de vitiligo et de transplantation de cheveux. Finalement, la ponction e´vacuation sert a` e´vacuer les tissus ou les mate´riaux non de´sire´s: lipomes, he´matomes sous-ungueál, calcinose scrotale, pseudo-kyste de l’auricule, kyste pilaire, et autre. La chirurgie reconstructive par ponction comprend la correction de malformations au niveau du lobe de l’oreille et le traitement des cicatrices de l’acne´. La cicatrisation est plus rapide en utilisant l’instrument de ponction, donc la ponction contribue a` la gue´rison des ulce`res rećalcitrants.

From the Department of Dermatology, King Saud University, Riyadh, Saudi Arabia, and Dermatology Unit, King Khalid Hospital, Hafar Albatin, Saudi Arabia.

Address reprint requests to: Khalid M. AlGhamdi, MD, Department of Dermatology, King Saud University, PO Box 240997, Riyadh 11322, Saudi Arabia; e-mail: [email protected].

DOI 10.2310/7750.2011.10002 # 2011 Canadian Dermatology Association

Journal of Cutaneous Medicine and Surgery, Vol 15, No 2 (March/April), 2011: pp 87–96

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UNCH INSTRUMENT is a circular hollow blade attached to a pencil-like handle ranging in size from 1 to 8 mm.1 It is available as a disposable, reusable, and automated instrument. Disposable punches have the advantages of being presterilized, readily available, always sharp, and requiring no maintenance. Reusable steel punches are more expensive, require sterilization between procedures, get dull with repeated use, and must be maintained by proper, skilled sharpening.2

P

Basic Punch Technique A punch surgery tray should include alcohol pads, local anesthetic, a punch instrument of the desired size, forceps, scissors, and gauze. After preparation of the site, the fingers of the nondominant hand are used to stretch the skin perpendicular to the direction of relaxed skin tension lines to produce an oval defect that is easier to close. The punch is held perpendicular to the skin surface, and the specimen is bored out by pressing down firmly while twirling the punch down to subcutaneous tissue. The punch is withdrawn, and the specimen is retrieved by piercing it with the needle from the syringe used for anesthesia or by handling it with the forceps. If needed, scissors can be used to transect the subcutaneous tissue at its deepest portion. Hemostasis can be achieved with pressure, Gelfoam bandages, or simple stitching with nonabsorbable suture.3 The advantages of punch biopsy include the relative easiness to perform, minimal complications, and provision of a full-thickness sample; because of that, it is preferred over shave biopsy. Punch biopsy has some disadvantages. First, its small size and variable depth lead to difficulty in histopathologic interpretation in conditions involving adipose tissue such as morphea and panniculitis. Because of that, a modification called the double-trephine punch biopsy technique was proposed. Second, the shearing effect of the punch may cause loss of the blister roof. In such cases, a topical refrigerant such as ethyl chloride spray can be used to freeze the blister in place when a punch biopsy is taken.4

Diagnostic Punch Surgery Although there are many ways of performing skin biopsy for diagnostic purposes such as shave biopsy, excisional biopsy, and incisional biopsy, punch biopsy is the method preferred by most dermatologists. Punch biopsy provides a full-thickness skin sample; because of that, it is preferred over shave biopsy.1

Punch biopsy is an apparently simple procedure, but it has some pitfalls. Being aware of the pitfalls and ways to work around them helps in substantially improving the outcome of this diagnostic procedure. Most important is choosing the most representative lesion for the biopsy, which will yield a better diagnostic outcome. Always take a fully evolved, untreated lesion and avoid excoriated or ulcerated lesions unless there is no option. Avoid taking a biopsy over bony prominences or pressure-bearing areas as a sparse, nonspecific, lymphocytic infiltrate present over frictional sites can complicate its interpretation.4 Punch surgery does have certain risks, including possible disturbance of deeper underlying structures such as nerves and arteries. Therefore, physicians must be familiar with the underlying anatomy and the danger zones. Punch surgery in critical areas such as the digits or the eyelid overlying the globe are generally to be avoided. Caution should also be exercised over areas where there is little soft tissue between skin and bone because the punch can cut through the underlying bone.2

Modified Diagnostic Punch Surgery Split-Punch Biopsy Technique The split-punch biopsy technique is used to obtain two tissue samples for different studies from one punch biopsy. It is done by advancing the punch just into the papillary dermis. This is followed by using a no. 11 blade held nearly perpendicular to the skin surface; the specimen is bisected to the subcutis. Then the punch is reintroduced and advanced to the subcutis. On removal of the punch, the bisected specimen is held in place only by a bit of subcutaneous tissue, which must be undercut to complete the procedure, resulting in a clean, bisected tissue split (Figure 1). This technique can be used to avoid taking two biopsies or splitting a single specimen, which might distort or crush the tissue.5 Double-Trephine Punch Biopsy The double-trephine punch biopsy technique is used to obtain tissue samples for diagnosis of dermatoses that affect the subcutaneous tissue and are not easily reached by standard punch biopsy. A 6 to 8 mm punch tool is inserted to the hilt of the instrument to obtain the initial sample. Once the superficial core is removed, a 4 mm punch is subsequently used within the center of the 8 mm defect to obtain the subcutaneous tissue.6

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Figure 1. Steps in obtaining a nondistorted split-punch biopsy specimen. A, After local anesthesia is obtained, the punch is advanced just into the papillary dermis. B, Using a no. 11 blade held nearly perpendicular to the skin surface, the specimen is bisected to the subcutis. C, The specimen is cleanly bisected. D, The punch is reintroduced and advanced to the subcutis. E, On removal of the punch, the bisected specimen is held in place only by a bit of subcutaneous tissue. F, The final result is a cleanly bisected, nondistorted, split-punch specimen. Reproduced with permission from Inman VD and Pariser RJ.5

String-of-Beads Biopsy Technique Diagnostic challenges often require a significant amount of tissue for a complete evaluation, which is done either by 6 to 8 mm punch biopsy or incisional biopsy followed by dividing the tissue sample into several pieces for multiple studies. These methods are time consuming, with associated risks of crush artifact on the specimen and a possible sharps injury to the physician. The string-of-beads biopsy technique is done by performing smaller, adjacent 4 mm punch biopsies in a row, and the individual biopsy defects may be closed in a linear or multiple O-to-Z/W design with nonabsorbable sutures placed using the simple interrupted suture technique. This method obviates the need for dissection of tissue in pieces.7 Use of a Skin Punch as an Adjunct to Fine-Needle Aspiration Fine-needle aspiration (FNA) is a percutaneous (‘‘through the skin’’) procedure that uses a fine-gauge needle (22 or 25 gauge) and a syringe to sample fluid from a cyst or remove clusters of cells from a solid mass. The advantages of FNA are that it is a fast, easy method for biopsy, the results are rapidly available, it does not require stitches, and patients are usually able to resume normal activity almost immediately after the procedure. An important disadvantage of FNA is that the procedure obtains only very small samples of tissue or cells from the lesion. If the sample is benign fluid (eg, a cyst), then the procedure is ideal. However, if the tissue is solid or if a

sample of cloudy, suspicious-looking fluid is obtained, the small number of cells removed by FNA allow only for a cytologic (cell) diagnosis. This can be an incomplete assessment because the cells cannot be evaluated in relation to the surrounding tissue. Moreover, it is difficult to use the FNA to aspirate lesions that are small, ill-defined, fibrotic, or dermal in location. Consequently, use of the punch might be very helpful in diagnosing solid organ tumors that are close to the skin surface, such as lymph nodes, the breast, and the thyroid, especially if the FNA yielded a nondiagnostic result.8 In one study, the use of a punch gave a diagnosis in 17 of 21 breast tumor cases in which FNA was nondiagnostic because of scant cellularity.9 Nail Unit Biopsy There are many types of nail unit biopsy, including biopsy of the nail matrix, which is done by retraction of the proximal nail fold; then a punch is introduced through the newly formed nail plate extending down to the periosteum of the terminal phalanx. In most instances, the plate will be avulsed first and the proximal fold retracted for complete visualization (Figure 2). Indications for nail biopsy include a pigmented streak in the nail plate; suspicion of skin cancer, either melanoma or nonmelanoma; and space-occupying lesions, either benign or malignant tumors. Biopsy of the nail matrix is not to be taken lightly because of the real possibility of scarring, a permanent nail

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accurate. Vertical sections of surgical specimens represent check points of the margin only 7 microns thick. This means that most of the surgical margin is not checked microscopically, allowing small tumor islands at the margin to remain undetected. To avoid this and be more accurate, a new punch with concentric cutting edges separated by 2 mm has been made to obtain a 2 mm strip of tissue representing the entire lateral border of the excision. This specimen is easily mounted as a flat section for frozen or paraffin processing. These sections will be cut to show the entire lateral excision margin to be checked for tumor. It requires little additional skill on the part of the surgeon and is easily handled by the pathology laboratory.12

Therapeutic Punch Surgery Punch Excision Figure 2. Punch biopsy of the distal nail matrix. A 3 mm punch biopsy is performed over the origin of a pigmented band after reflection of the proximal nail fold. The biopsy is taken down to and removed at the level of the periosteum. Reproduced with permission from Jellinek NJ.17

split, or other longitudinal dystrophy. The patient should be fully aware of these potential consequences.10 Diagnosis of Eyelid Tumors The management of eyelid tumors requires histologic diagnosis, which is usually obtained by biopsy. Although incisional biopsy is consistently recognized as the gold standard, a certain degree of surgical skill is necessary, and the procedure is time consuming. In a retrospective analysis of 20 consecutive incisional biopsies and 20 consecutive punch biopsies done by Rice and colleagues, the histology obtained by both biopsy methods was compared to that identified at the time of tumor excision.11 The accuracy rates were 95 and 85% for incisional and punch biopsy, respectively. Punch biopsy has the advantage of being a quick technique requiring minimum equipment. In addition, the operator requires no specific surgical skills. The biopsy specimen can easily be taken at the patient’s initial clinic visit, allowing a more rapid diagnosis and facilitating more efficient tumor management and fewer visits to hospital.11 Improving Histologic Examination of the Tumor Margin Histologic examination of the surgical margins of skin tumors removed by standard surgical excision is not always

Punch excision of the mole can be done for diagnostic or therapeutic reasons. A punch size is chosen that is 0.5 mm larger than the maximum diameter of the mole to ensure its complete removal. The depth of the excised tissue should be adequate to include all pigmented tissue. The procedure can be stopped here and the defect sutured or followed by grafting from the postauricular area a skin punch graft that is 0.5 mm larger than the recipient area to allow contraction of the graft and expansion of the recipient socket. The recipient site is dressed with nonadherent tulle. Alternatively, it can be dressed with lubricating jelly (KY).13 If the lesion is large and oval in shape, it can still be excised with a punch, as described by Warino and Brodell, where a punch is held at a 45u angle with the cutting edge of the punch touching the skin at one pole of the lesion.14 An oval mole is then squeezed into the opening of the punch as the handle is reoriented perpendicular to the skin, so that the cutting edge is flush with the skin surface; then the punch is rolled and excision is followed by suture closure. The use of punch for excision can be performed for other conditions, such as Spitz nevi15 and small tattoos.16 Periungual Exision The excision of inflamed tissue on chronic, refractory-totreatment paronychia can be done with nail-fold punch biopsy as described earlier (see Figure 2).17 Pathologic Bone Excision Osteoid osteoma is a benign skeletal neoplasm of unknown etiology that is composed of osteoid and woven bone. The tumor is usually smaller than 1.5 cm in diameter. It causes

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focal bone pain at the site of the tumor. The lesion can be completely excised with a skin punch. This method has proven to be both minimally invasive and effective in the management of patellar osteoid osteoma.18 Excision with Replacement Graft for Pathologic Cartilage Chondrodermatitis nodularis helicis is a painful inflammatory condition that affects the helix of the ear. A punch biopsy, of a diameter similar to that of the lesion, is applied perpendicular to the skin surface and advanced until a deep punch of underlying cartilage is cut. Then the same-sized punch of a full-thickness skin graft from the postauricular area donor site can be harvested along with underlying fat. The graft is fixed in place with 6-0 interrupted sutures, such that the contour of the helical rim is preserved (Figure 3).19 Punch Grafting Punch grafting can be used on many depigmented diseases, such as vitiligo, chemical leukoderma, lichen sclerosus, and postburn leukoderma.20,21 Punch grafting is also used on hair transplant procedures. Refractory and stable vitiligo can be treated with surgical replenishment of melanocytes by various methods. One of these methods is punch skin grafting. Punch grafts of 1 to 2 mm diameter are taken from donor areas from hidden, nonvitiliginous skin. These are grafted into recipient sites in stable vitiligo lesions, which are created using punches 1 to 2 mm in diameter. To ensure a better fit, recipient punches are generally smaller by 0.5 mm than donor punches. A smaller-sized graft (1–2 mm)

may be used to yield better cosmetic results. Sockets are created in the recipient area at a distance of 5 to 10 mm, and harvested grafts are placed in these sockets.22–24 The cosmetic result and cobblestoning problem depend on the punch size. The smaller the punch size, the better the cosmetic result and the lesser the cobblestoning.

Punch Evacuative Surgery Use of the punch for extraction and removal of the unwanted tissue or material is described in many reports. Lipoma Extraction Evacuation of lipoma by the narrow-hole extrusion technique (NHET) is widely used. In this technique, the lipoma is removed through a narrow punch hole done by punch biopsy, and the site is left to heal secondarily or one to two interrupted cutaneous sutures are placed.25,26 Modification of the NHET, called the pot-lid technique, aiming to improve the aesthetic outcome, was described recently.27 After doing a punch, the punched-out piece of skin is kept in normal saline. Then you proceed with extrusion of lipoma, as in the NHET, and then the punched-out piece of skin is repositioned to cover the defect and sutured into place (Figure 4). Window Nail Plate Avulsion Nail problems limited to a confined portion of the nail bed can be accessed using a window plate avulsion. This technique is helpful when removing a localized foreign

Figure 3. The punch and graft technique illustrated in sequence. A–C, Punch excision series. D and E, Punch full-thickness skin graft series. Reproduced with permission from Rajan N and Langtry JA.19

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neutralized with sodium bicarbonate. Use of a tumescent anesthetic exerts a hydrodissecting effect, thereby separating the cysts from surrounding connective tissue and the superficial scrotal fascia. Then you can pinch scrotal skin to highlight the subcutaneous nodules; after that, incise the skin with an appropriate-sized punch. Suture closure is not necessary because of the small-sized wounds, the hemostatic effect of the tumescent agent, and the contractile nature of the scrotal skin.30 Evacuation of Pseudocyst of the Auricle Pseudocyst of the auricle is a benign, asymptomatic, noninflammatory pseudocyst that contains yellow, viscous fluid resembling olive oil. If left untreated, a permanent deformity may occur. It can be treated by a small, superficial punch incision on the lower part of the cyst to allow for open drainage, avoiding cartilage injury, until an oily viscous fluid is drained from the punch biopsy opening. Then taped with a pressure bolster as dental roll for 2 weeks, with daily cleaning and reapplication of the bolster.31 Others

Figure 4. Various steps in the pot-lid technique for the removal of a lipoma. Reproduced with permission from Gupta S et al.27

body in the nail bed, exploring the nail bed for a welldemarcated neoplasm, evacuating a subungual hematoma, or draining an acute paronychia. It is performed using a 5 mm, 6 mm, or larger punch to drill through the localized area of nail plate. Then a no. 11 blade is used to pry open and lift the circular porthole window of the nail plate, exposing the underlying bed. Then a smaller punch can be used to biopsy the appropriate underlying tissue, if necessary. If these windows of nail plate do not require processing for pathology or microbiology, they can be replaced and secured with a single suture or Steri-Strips.28 The procedure can be faster if the punch is heated.29 Scrotal Calcinosis Removal Sometimes scrotal calcinosis requires excision if the subcutaneous nodules are symptomatic, draining chalky white material, or causing deformity to the scrotum. This can be done with a pinch-punch excision, using tumescent anesthesia, 1:10,000 epinephrine and 0.1% lidocaine

Extrusion with a punch hole has been used with good outcome in other cutaneous conditions, such as small, isolated epidermal cysts or hidrocystomas, drainage of infected or inflamed cysts,32 and epidermal inclusion cysts.33 Removal of pilar cysts can also be achieved using the standard punch incision technique. First, inject 1% lidocaine with epinephrine overlying the cyst; then use a 4 mm punch to incise the lesion. After that, the contents of the cyst are expressed with lateral pressure.34,35 Use of the Punch to Enhance Wound Healing To increase granulation tissue, the punch is used in nonhealing ulcers and central ear lobe defects. Nonhealing Ulcers Nonhealing ulcers create a great therapeutic challenge to the clinician. Large ulcers that fail to epithelialize with local dressings for 3 to 4 weeks despite healthy granulation tissue are usually taken up for grafting. The fullthickness punch grafts (using a 3 mm punch) are harvested from the buttocks or thigh. Punch holes (2 or 2.5 mm) are made in the floor of the granulating ulcer 5 mm from each other, and grafts are pushed into these


recipient holes (Figure 5).36 Moreover, use of skin punch biopsy to provide an autologous full-thickness skin substitute for healing chronic wounds is reported to have a high success rate.37 External Ear Defect External ear defect can be healed with secondary intention if the surrounding intact cartilage has its perichondrium. Granulation and reepithelialization will proceed somewhat more slowly than when the perichondrium is intact, but if the denuded cartilage is more than 10 mm in diameter, trephining with 2 mm punches to expose the perichondrium and dermis of the posterior aspect of the ear may facilitate development of granulation tissue in the wound bed and speed healing.38

Figure 5. Nonhealing ulcer immediately after full-thickness punch grafting. Reproduced with permission from Thami GP et al.36

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Reconstructive Punch Surgery Acne Scars There are two types of acne scars: atrophic deep dermal scars and hyperplastic scars. Atrophic scars include icepick, rolling, and boxcar scars. The icepick scars are usually smaller in diameter (, 2 mm) and deep with tracts to the dermis or subcutaneous tissue. Boxcar scars are deep (. 0.5 mm) and are often 1.5 to 4 mm in diameter. They have sharply defined edges with steep, almost vertical walls. Soft, rolling scars can be circular or linear, are often greater than 4 mm in diameter, and have gently sloped edges that merge with normal-appearing skin. Examples of hyperplastic acne scars are hypertrophic scars and keloids.39,40 Punch biopsy is a treatment option for deep dermal scars through different techniques such as punch excision, punch elevation, and punch replacement grafting. Punch excision, done for scars less than 3.5 mm, removes a pitted scar with a straight wall by a punch that is slightly larger than the scar being addressed. The site may then be allowed to heal by second intention, or sutures may be placed to close the wound.37 This technique is preferred for icepick scars.3 A scar requiring a punch larger than 3.5 mm is repaired by elliptical excision or punch elevation because these larger defects lead to ‘‘dog ear’’ formation on the face.3 Punch elevation is similar to punch excision except that the scar that is punched out is not discarded. It is useful if the scar is 3 mm in diameter or greater with a good color match and straight walls.41 The tissue cylinder is incised down to the level of the subcutaneous fat. The scar is allowed to float up until it is the same level as the surrounding skin. If it does not rise easily, it may be transected free at the level of the fat. The cylinder of tissue will be fixed in place by the patient’s serum and sits as a graft, held in position by some surgical tape.39,42 Punch elevation is a method of treatment for boxcar scars.40 Punch replacement grafting is useful for deep fibrotic scarring. The scar is excised as with the basic punch excision technique. The scar is discarded and is replaced with a slightly larger full-thickness punch graft, usually from the postauricular area. It is critical to allow each anesthetic wheal to flatten completely to prevent distortion of scars. Unless the graft is traumatized, it will usually survive well. Some of the grafts will heal with the same skin surface level and some will be elevated.37,39 Donor holes should be approximately 0.5 mm larger than the recipient holes. These seal in 5 to 7 days with a fibrin clot.39

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Figure 6. A, Preoperative appearance of an incomplete earlobe cleft. B, Cautery tip stripped of its plastic hub and inserted into the earring hole as a guidewire. C, A 4 mm punch is pushed perpendicularly through the anterior and posterior aspects of the earlobe. D, Complete epithelial tract on the guidewire cautery tip. E, Resultant nonepithelialized wound. F, Simple primary closure of each side of the earlobe. Reproduced with permission from Tan EC.44

Earlobe Repair Piercing earlobes is a common practice all over the world. Several methods have been described for repair of an unwanted lengthened earring hole. One of these methods is using a punch technique that removes the preexisting hole and then subsequently suturing the newly created nonepithelialized tract (Figure 6).43,44

cutting angle of a standard curet. With alternating flexion and extension of the wrist, one can use the punch as a curet (Figure 7).45

Other Uses of Punch Surgery Punch can be used as an alternative to other surgical tools, such as curettage. Curettage with a punch has the advantages of low cost and easy availability, which makes it a good alternative when a curet is not available. It can be used for debulking tumor before excision, curettage and desiccation, and treatment of benign conditions such as warts, molluscum, or syringomas after light electrodesiccation. The punch has a sharp circular cutting edge similar to that of the disposable curet. It can be held like a pencil or a pen, which can mimic the

Figure 7. When the punch is held properly, it can mimic the cutting angle of a curet.


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Conclusion

Acknowledgment

Punch surgery is a simple, readily available, cheap tool that has many advantages, such as easiness to perform and no need for general anesthesia. Punch surgery also has a low risk of infection and bleeding and can be done in an outpatient setting. Uses of the punch to diagnose and treat many medical and surgical conditions make it important to many other specialties beside dermatology. Our aim is to draw the attention of other specialties to the various diagnostic and therapeutic uses (Table 1) of this simple and versatile tool.

Financial disclosure of authors and reviewers: None reported.

Table 1. Various Uses of Punch Surgery Diagnostic punch surgery

Therapeutic punch surgery Punch excision

Punch grafting

Punch evacuative surgery

Use of punch to enhance wound healing Reconstructive punch surgery Other uses of punch surgery

Regular diagnostic punch surgery1–4 Split-punch biopsy technique5 Double-trephine punch biopsy technique6 String-of-beads biopsy technique7 Skin punch as adjunct to fine-needle aspiration8 Nail unit biopsy10 Diagnosis of eyelid tumors11 Improvement of histologic examination of tumor margin12 Improvement of breast cancer grading9

Mole excision13–16 Periungual exision17 Pathologic bone excision18 Excision with replacement graft for pathologic cartilage19 Excision of Spitz nevi15 Vitiligo surgery22–24 Vogt-Koyanagi-Harada syndrome20 Lichen sclerosis et atrophicus21 Chondrodermatitis nodularis helicis19 Lipoma extraction25–27 Window nail plate avulsion29 Scrotal calcinosis removal30 Evacuation of pseudocyst of the auricle31 Removal of epithelial cysts34 Removal of keratinous and pilar cysts35 Removal of epidermal inclusion cysts33 Nonhealing ulcers36,37 External ear defect38 Acne scars39–42 Earlobe defects repair43,44 Curettage with a punch45

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