Keywords punch incision - healing by secondary intention - facial lesions - skin biopsy punch
- PISH - SCAR
Introduction
“Scar” psychologically implies a horrid, distorting and devastating mark to most individuals.[1 ]
[2 ].
Smallest of small lesions can create an enormous physical and psychological impact
on one’s life, hence it is very important to treat them with techniques (surgical
and nonsurgical) which give an acceptable scar to the patient.[1 ]
[3 ] Traditional surgical removal of small lesions requires larger elliptical incision.
In this paper, we discuss the novel use of skin punch incision technique with healing
by secondary intention (PISH).
Materials and Methods
Materials
In total, 307 patients were operated by punch incision with secondary healing (PISH)
technique between August 2015 and August 2019 by the same operating surgeon. The details
of the nature of the procedure along with its pros and cons (including complications)
were explained to the patients and written informed consent was taken.
The inclusion and exclusion criteria are mentioned in ([Table 1 ]). Out of 307 patients operated, 138 were males and 169 were females. A total of
133 patients had some form of medical comorbidities which were controlled preoperatively
([Table 2 ]). Perioperatively the following characteristics were assessed:
Table 1
Patient criteria
Inclusion criteria:
1. Solitary or multiple cystic lesion (infected/noninfected) on face of any diameter.
2. Solitary or multiple noncystic benign facial lesions up to 6 mm in diameter.
Exclusion criteria:
1. Keloidal tendencies
2. Hypertrophic scarring.
3. Ruptured cyst/lesions.
4. Malignant lesions.
5. Recurrent lesions.
Table 2
Patient characteristics
Note: DM, diabetes mellitus; HT, hypertension.
No. of patients
307
No. of lesions
342
Age (years)
9–30 y
107
31–50 y
116
51–80 y
84
Comorbidities (HT,DM,HT + DM)
33HT, 36DM, 64HT + DM
Fitzpatrick skin type
Type 4
103
Type 5
204
Wound surface
Flat
70
Convex
108
Concave
164
Wound depth
Superficial
324
Deep
18
Location (aesthetic unit)
Type of lesion
Size of lesion
Wound size
Surface contour
Wound depth (underlying tissues exposed)
Scar/healing tendencies.
Operative Methods
Following adequate skin preparation, a field block was given by a 30-gauge needle
around and at the base of the lesion with 2% lignocaine and epinephrine (1:200000).
A sterile, disposable skin biopsy punch of varying diameter (2–6 mm) was used to create
a small circular incision ([Table 3 ]).
Table 3
Lesion types, lesion size, punch used, number of lesions managed, and follow up
LESIONS TYPE
LESION SIZE
PUNCH USED
NO OF LESIONS
FOLLOW UP
(IN MONTHS)
NON-INFECTED
<2.5 cms
3 mm
96
12–60
For small nerve sheath tumors and lipomas, an appropriate-sized punch was used to
create a circular incision in the center. Following a thorough perilesional dissection
with Westcott scissors, the swellings were excised in toto or in piecemeal fashion
([Fig. 1 ]). After stretching the skin for cystic lesions (sebaceous cyst,) an incision with
punch at the punctum was made through which the contents of the cyst were extruded
and the capsule was completely excised with the help of Westcott scissors. The cavity
was then inspected with the help of two skin hooks and a curette was used to remove
the remnants if any ([Figs. 2 ]and [3 ]). For nevus, an appropriate-sized punch was used to create a circular incision followed
by complete excision with 11 number blade ([Fig. 4 ]). Pyogenic granulomas being vascular lesions were shrunk with 2% timolol maleate
eyedrops (one drop twice daily for 3 weeks) and then an appropriate-sized punch was
used to create a circular incision followed by complete excision of the lesion with
11 number blade followed by cauterization of the base ([Fig. 5 ]). Hemostasis was achieved by adequate measures (manual pressure/cautery). Small
circular adhesive-dressing was applied onto the wound cavity after application of
antibiotic ointment. All specimens were sent for histopathological evaluation. Post-procedure
a 9-point instructions list was explained and handed out to the patients ([Table 4 ]).
Table 4
Post-procedure a 9-point instructions
1. If the wound bleeds press firmly and report/contact us.
2. After surgery maintain dressing for 48 h, till then cleanse face with wipes.
3. Remove dressing after 48 h and wash with copious amount of water and cleanse the
face with regular nonirritant face wash/soap and pat dry with a clean linen/towel.
4. Apply antibiotic ointment with a small circular adhesive dressing till the wounds
heals.
5. Not to manipulate the wound.
6. Report at earliest if any pus discharge, excessive bleeding, foul smell from the
wound, severe pain, or excessive redness around the wound.
7. Continue sunscreen and face moisturizer around the dressing and over the scar once
the wound heals.
8. Do not use face scrub for next 12 wk.
9. As wound heals a nodular swelling may be felt below the healed area, do not worry.
It is a part of normal wound healing.
Fig. 1 Nerve sheath tumor, its preoperative location on the lip unit, note the preexpanded skin due to the lesion per se (A ). Intraoperative views, (B–D ), showing dissection around the lesions with its complete in toto extraction via
a 3-mm skin punch incision. Postoperative views at 7th day with virtually invisible
scar by 12 months, (E,F ).
Fig. 2 Figure demonstrating detailed surgical steps while excision of a large sebaceous
cyst over right temple region. (A ) Preoperative profile view showing the site and size of the lesion. (B–D ) Intraoperative views showing application of 4 mm punch with extrusion of sebaceous
material and complete removal of cyst wall. Also note application of two skin hooks
for the assessment of cavity and removal of the remnant with curette if present (E, F ).
Fig. 3 Sebaceous cyst on face. Preoperative, postoperative, and follow-up views of noninfected
sebaceous cyst on forehead (A ), on right temple region (B ), and cheek while, (C, D ) showing infected cyst treated with PISH technique. Note the site and size of the lesion with the final resultant scar.
Fig. 4 Preoperative, postoperative and follow-up views of nevus on face. Note the barely
visible scar on follow-up.
Fig. 5 Pyogenic granuloma on face. Note the preop and postop wound size at day 7 and a near
normal color match with scar easily blending with surrounding irregularities by 1
year.
A weekly follow-up done till wound healed and then follow-up at 6 weeks/3 months/6
months and then yearly follow-up was performed. During 1-year follow-up, the patient
and nonoperating surgeons in the team assessed the scars of the patients on a facial
scar scoring scale devised by us with an acronym (SCAR or Scar Cosmesis Assessment
and Rating)[3 ] ([Table 5 ]). Each letter had three subunits under it with a set of scoring systems based on
our experience. The total score of the scale by adding 12 items ranged from 0 to 25,
0 being the lowest reflecting near normal skin and 25 the highest possible reflecting
the worst possible outcome. This scar grading system was evaluated by the patient
and nonoperating surgeons in the team.
Table 5
(SCAR)3 Facial scar scoring scale 0 to 25
S3
Satisfaction overall
Impressed
0
Happy
1
Neutral
2
Unhappy
3
Ugly
4
Suppleness
Same of adjacent
0
Soft
1
Firm
2
Nodular
3
Scar regret
Absent
0
Present
1
C3
Color
Exact match
0
Minor
mismatch
1
Major
mismatch
2
Complete
mismatch
3
Contour
Same level
0
Depression
1
Elevation
2
Corrections
If needed
None
0
Nonsurgical
1
Surgical
2
Combination
3
A3
Any distortions
(Static/Animation)
Absent
0
Present
1
Associated pain
Absent
0
Present
1
Associated pruritis
Absent
0
Present
1
R3
Reactions by others
Unnoticed
0
Barely Noticed/Ignored
1
Unhappy
2
Shocked
3
Regularity of scar
Regular
0
Irregular
1
Recommendation to others
Yes
0
Neutral
1
No
2
Results
We treated 307 patients with 342 facial lesions (solitary or multiple) on OPD basis
with PISH technique. Distribution of lesions over facial units include: nose (76),
cheek (64), eyelids (57), chin (46), forehead (44), lips (32) and pinna (23). They
are under follow-up till date. The overall mean operative time for surgery was 8 minutes
(5–21 minutes). For cystic lesions (sebaceous cyst, 97 patients) greater than 2.5
cm, it took on an average of 18 minutes (14–21 minutes) for complete procedure. We
managed 18 infected cystic swellings with PISH technique. Once treated, all of them
resumed their routine activity after 1 to 2 hours. In our series no untoward adverse
effects like bleeding, hematoma, hypertrophic granulation tissue was seen .One patient
of noninfected sebaceous cyst developed localized wound infection, which was managed
conservatively without any further surgical intervention. One patient developed hypertrophic
scar (forehead region with 4 mm punch) which was managed with intralesional steroids
and silicone gel sheet application. All superficial wounds involving skin and subcutaneous
tissue were epithelized by 7 to 14 days, while deeper lesions healed by 14 to 28 days.
Initially, during the proliferative phase (within 2 weeks) all patients noticed a
firm nodular swelling under the punch incision site which subsided without any intervention
by 4 to 6 weeks .
We had three recurrences (two infected sebaceous cysts and one dermoid.). The sebaceous
cysts recurred at the end of 6 months, while dermoid recurred by 12 months which were
managed with traditional elliptical incision along relaxed skin-tension lines (RSTLs).
In 279 patients post inflammatory hyperpigmentation (PIH) subsided by 6 to 12 weeks
with routine use of moisturizer and sunscreen. PIH which persisted for more than 3
months (28 patients) was managed with 6% glycolic acid and tretinoin 0.025% cream
along with sunscreen. PIH was seen mainly in inflamed lesions and in lesions with
the punch size of more than 5 mm in diameter. Currently, all our patients are on a
regular follow-up with none requiring scar revision ([Table 3 ]). On the application of SCAR[3 ] facial scar scoring scale our average score was 6 (range, 4–9).
Discussion
Punch creates a uniform and architecturally most basic shape—a circle .[4 ] Circular wounds created by punch incision tend to produce more uniform circular
centripetal contraction thus further minimizing the total defect. This consequent
circular scar is easy to camouflage in patients having acne scars or any other textural
abnormalities as against a linear scar. In fact, in majority of the cases it may just
appear as a small dot by 1 to 2 years, which can easily blend-in with the surrounding
irregularities like acne scars. Once the wound fully contracts, the residual defect
is filled-in/bridged by deposition of collagen and fibrous connective tissue—the scar
tissue. A sub-centimeter wound under favorable circumstances contracts by 70% and
the rest is filled in by the scar tissue so the final cicatrix is small.[5 ]
PISH technique creates a small incision length which eventually leads to reduced scarring
without compromising the efficacy, a similar finding observed by Lee et al, in a prospective
randomized trial while comparing punch incision and elliptical incision for noninflamed
sebaceous cyst.[6 ] The degree of cutaneous wound contraction depends upon the preliminary wound size,
site, surface, adjoining skin laxity, depth, and underlying muscle.[7 ] To tackle this primary determinant of size, various methods of area reduction like
tissue under-mining with purse string closure and its modifications have been described
in the literature with good outcome.[8 ] In punch size of 5 mm and more we recommend 2 to 3 mm subcision just at the edge
which can lead to better progress and effective wound contraction.
Conventional elliptical incision requires removal of extra skin for smooth tapering
of its edges to prevent standing cone deformity which causes the defect to enlarge
and may encroach onto the adjacent facial units which is not observed in PISH technique.
This is of overwhelming benefit while dealing with facial lesions.[6 ]
[9 ] Multiple concurrent occurrences of facial lesions can present a unique challenge
to the attending surgeon which can be easily managed with the PISH technique.
While studying the advantages of healing with secondary intention on face, Zitelli
observed, wounds over concave surface of face like nasolabial fold, nasoalar sulcus,
medial canthal area, and alar crease heal with imperceptible scar and wounds over
convex areas heal with variable results.[5 ]
[7 ]
[10 ] This may be attributable to thicker/denser dermis which has more collagen and elastic
fibers preventing optimal wound contraction. Similarly, in our study superficial wounds
over concave surfaces healed early and beautifully while the deeper wound on the same
area also healed with good aesthetic outcome. Senile skin has less collagen and elastin,
more laxity, more surface irregularities (rhytids), and more pigmented irregularities
making them perfect candidates for healing by secondary intention.[7 ] Re-pigmentation of a scar, although poorly understood, in our study we observed
that superficial wounds (small and large) had good/satisfactory re-pigmentation, while
deeper wounds were unpredictable. This could be due to the fact that superficial wounds
had some adnexal elements especially hair follicle which were reservoir of melanocytic
stem cells.[11 ] With time, remodeling occurs making the scar eventually smaller, hypopigmented,
and at the same level or slightly depressed off the surrounding. Lastly, if the need
for scar revision arises after PISH technique, the total scar length may be smaller as compared with an elliptical incision
planned for the initial lesion.
Although various minimally invasive ablative techniques like radiofrequency ablation
and CO2 laser ablation have been described to treat facial lesions, these methods are not
cost effective and require sophisticated instruments[12 ]
[13 ]
[14 ] The excessive production of heat due to laser or radiofrequency carries a potential
risk of undesirable dyspigmentation.[15 ] On the other hand punch incision with excision is an easy, cost effective technique
to perform which does not require sophisticated instruments.
In our series, recurrences were observed in infected sebaceous cyst and dermoid. They
were eventually managed with conventional elliptical incision. On retrospection, we
learnt the lesson of thoroughly inspecting the wound cavity particularly its edges,
with the help of two skin hooks especially in sebaceous cyst measuring more than 2.5
cm diameter under adequate illumination and loupe magnification. Based on our experience,
we recommend the use of this technique for noncystic lesions up to 4-mm punch size.
For noninfected cystic lesions we recommend 3 to 4mm punch. For infected sebaceous
cyst and large cystic lesions, we advocate using punch of 4 or 5 mm and patiently
assessing the cavity for remnants and if necessary two, 1 to 2 mm supplementary incisions
approximately 180 degrees apart can be placed perpendicularly along the RSTL which
can make dissection easy. Advantages of PISH technique are shorter learning curve, easy to master with reproducible results, lesser
operative time, smaller incisions without compromising the safety with equally good
or better aesthetic outcomes using basic and easily available biopsy punch. Since
these lesions are slow growing and frequently ignored, a longer follow-up is recommended.
Based on our experience we have following recommendations ([Table 6 ]).
Table 6
Recommendations
Whom to recommend?
1. Cystic lesions on face (infected and noninfected).
2. Sebaceous cyst irrespective of the size and located anywhere on the body.
3. Noncystic superficial lesions and multiple lesions amenable to punch incision.
4. Smaller lesions where scar can easily blend in natural/surrounding imperfection
(especially in and acne scars).
5. Concave areas on face.
6. Older patients.
7. Lastly, where active surveillance is needed (especially in suspicion of malignancy).
Whom to avoid?
1. Large lesions other than epidermoid cyst on convex areas of face.
2. Areas with near anatomical margins, which can be distorted as the cicatrix contracts.
3. Noncystic big and deep lesions more than 6 mm in diameter.
Conclusion
PISH , a minimally invasive technique described here could offer a modern-day answer to
numerous facial lesions. It is simple and safe method with good cosmetic outcomes.
In selected patients it has a potential to replace conventional fusiform excision.
Appropriate patient selection remains the ultimate key to success for using this method.
