Background Information:

What are the other Names for the Procedure?

• Keyes Punch Biopsy (named after the originator of the device used)

What is Punch Biopsy surgical procedure?

• Punch Biopsy is a procedure in which a skin specimen is surgically removed, usually for diagnostic purposes. It can be utilized to determine a diagnosis of the inflammatory diseases of the skin and rashes, as well as the specific diagnosis for benign and malignant growths on skin
• The punch device, or sterile forceps, consists of a circular sterile open cylinder of very sharp thin steel, on a metal or plastic handle
• The cylinder size results in the size of the specimen obtained. Instruments of 1 mm up to 8 mm are readily available

What part of the Body does the Procedure involve?

The Punch Biopsy procedure can be performed on almost every accessible skin region of the body, as well as on mucous membranes, including the genital areas.

Why is the Punch Biopsy surgical procedure Performed?

There could be a variety of reasons for performing Punch Biopsy procedure. Some of these include:

• The ability to harvest a well-defined skin specimen, leaving a defect of know dimension
• The ability to get a skin biopsy with depth through the dermis and into the subcutaneous fat

These two characteristics differentiate it from the more superficial shave biopsy technique. Either of these biopsy types could be chosen in some cases, based on the preference of the surgeon.

What are some Alternative Choices for the Procedure?

Some of the alternative choices for Punch Biopsy include:

• Shave biopsy
• Incisional biopsy
• Excisional biopsy

What are the Recent Advances in the Procedure?

Currently, no significant advances specific to Punch Biopsy procedure are reported.

What is the Cost of performing the Punch Biopsy procedure?

The cost of the Punch Biopsy procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding the Punch Biopsy procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple steps or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

https://www.aafp.org/afp/2002/0315/p1155.html (accessed on 05/16/2021)

https://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/cutaneous_nerve_lab/physicians/biopsy_procedure.html (accessed on 05/16/2021)

https://dermnetnz.org/topics/skin-biopsy/ (accessed on 05/16/2021)

Prior to Punch Biopsy surgical procedure:

How is the Punch Biopsy surgical procedure Performed?

The Punch Biopsy procedure is performed in the following manner:

• The skin is prepped with an alcohol wipe. The Punch Biopsy is usually a clean procedure, but not a sterile procedure. Thus, a sterile drape is used to keep the field clean, if sutures are used to close the defect
• The skin is anesthetized, usually with injected local anesthetic
• The correct size Punch Biopsy device is chosen based on the judgement of the surgeon
• The skin is stabilized by stretching under mild tension, by an assistant or the “off hand” of the surgeon
• The opening of the sharp cylinder is place at a typical area of the skin lesion or rash, then rotated in a circular fashion with mild downward pressure. Care is taken not to injure underlying tissues or structures. The punch device is removed
• A cylinder of skin has been cut free of the surrounding skin, and typically protrudes up, attached only by a little subcutaneous fat. The specimen is gently put in a bottle of formalin or other fixative, using the needle used for anesthesia, or a fine forceps
• There is generally little bleeding, which can be controlled with cautery, aluminum trichloride solution, or a few sutures

Where is the Procedure Performed?

The Punch Biopsy procedure is usually performed in a dermatology exam room, or surgical suite, or at a hospital bedside.

Who Performs the Procedure?

A physician, physician assistant, or advanced practice nurse usually performs the Punch Biopsy procedure.

How long will the Procedure take?

The Punch Biopsy procedure usually takes about five minutes. This does not include the time for the initial history, evaluation of the patient, or the decision to perform the Punch Biopsy and choice of the site(s) to be tested.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the procedure and helps avoid complications.

• Provide medical history such as diabetes, hypertension, heart disease, etc. (if any)
• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• Any medical or family history of bleeding disorders or blood clots
• Any unusual effects of local anesthesia 

What Preparations are needed, prior to the Procedure?

The physician performing the procedure will evaluate the patient prior to the procedure and discuss the details with risks for complications and obtain his/her permission (termed informed consent).

• As always, let the physician know if you have any condition or concerns before having a Punch Biopsy performed
• Pregnant women can have a Punch Biopsy safely performed, but must notify the physician of their pregnancy

What is the Consent Process before the Procedure?

The physician will obtain permission for the Punch Biopsy procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is the approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

In case of minors and individuals unable to give informed consent, the parent or legal guardian or next of kin can sign the consent for the procedure.

What Tests are needed, before the Punch Biopsy surgical procedure?

In many cases, no tests are typically necessary prior to the Punch Biopsy procedure. However, if required, the healthcare provider may recommend the following tests such as:

• Blood and urine tests
• Imaging studies

The physician may suggest further tests depending on the health of the individual and their medical history.

What are some Questions for your Physician?

Some of the questions that you might ask your healthcare provider are as follows:

• What is a Punch Biopsy procedure?
• Why is this procedure necessary? How will it help?
• How soon should I get it done? Is it an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed? 
• What are the risks while performing the procedure?
• What are the complications that might take place during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• What are the costs involved?

During the Punch Biopsy surgical procedure:

What kind of Anesthesia is given, during the Procedure?

• Generally, local anesthesia by injection is used
• If the patient prefers, a topical anesthetic cream can be applied first, which makes the injection sting less

How much Blood will you lose, during the Procedure?

There is not much blood loss during an uncomplicated Punch Biopsy procedure. Occasionally a small vein or arteriole under the chosen site is cut, which leads to more than the typical scant flow. In these situations, the placement of a few sutures suffices to stop any bleeding.

What are the possible Risks and Complications during the Punch Biopsy surgical procedure?

There are general factors that increase one’s risk of getting complications during the Punch Biopsy procedure, which include:

• History of bleeding disorders
• Anti-clotting medication use
• Or, liver failure, may make bleeding more likely

Some of the possible risks and complications that may arise during a Punch Biopsy procedure include:

• Bleeding
• Injury to the underlying structures
• Local anesthetic complications

What Post-Operative Care is needed at the Healthcare Facility after the Punch Biopsy surgical procedure?

There is no requirement for any post-procedure care unless any complications arise. However, patients sometimes become faint, or may actually faint during the procedure. 

After the Punch Biopsy surgical procedure:

What are the possible Risks and Complications after the Punch Biopsy surgical procedure?

The risks and complications that may arise after Punch Biopsy include:

• Excessive bleeding that may sometimes require an additional surgical procedure
• Infection of the surgical wound
• Reaction to wound care medications
• Slow or poor healing

• Scar formation
• Local pigment changes

What is the Prognosis after the Surgery?

The prognosis after a Punch Biopsy procedure is typically excellent.

When do you need to call your Physician?

Complications from a Punch Biopsy of any severity are exceedingly rare. Do contact your physician or call 911 (or your local emergency number) based on the seriousness of any of the following symptoms:

• Fever and chills
• Severe pain
• Shortness of breath
• Bleeding or fluid discharge from the surgical wound
• Nausea and vomiting
• Signs of infection
• Severe fatigue
• Dizziness

What Post-Operative Care is needed at Home after the Punch Biopsy surgical procedure?

At home, the following post-operative care is recommended after a Punch Biopsy procedure:

• Resume showering and keep the wound clean and dry. Gently wash the surgical wound with mild unscented soap
• Replace dressing after showering
• Avoid any strenuous activity for a period recommended by the physician, which is usually a day (24 hours)
• Continue the usual prescribed medications after checking with your healthcare provider

How long does it normally take to fully recover, from the Procedure?

Punch Biopsy procedure healing time is typically one to three weeks. It depends on the size of the punch used, location on the body, and the underlying health of the patient.

Additional Information:

What happens to tissue/samples (if any), taken during the Procedure?

The samples/tissue are usually sent to the pathology department in the hospital, processed for examination, and subsequently disposed of, as per the standard hospital protocol.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The samples/tissue is processed in the laboratory under a pathologist's supervision
• Slide(s) are prepared once the tissue is processed and this is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week's time

Who will you receive a Bill from, after the Punch Biopsy surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The hospital or outpatient facility, if performed in any of these settings
• The dermatologist
• A pathologist (if the tissue was sent for analysis)

The patient is advised to inquire and confirm the type of billing before the Punch Biopsy procedure is performed.