- Email: [email protected]
Surgical Pearl: Double-trephine punch biopsy technique for sampling subcutaneous tissue
PEARLS Stuart J. Salasche, MD Surgical Pearls Editor
Mark G. Lebwohl, MD Medical Pearls Editor
Surgical Pearl: Double-trephine punch biopsy technique for sampling subcutaneous tissue Cuong T. Ha, MD, and H. Carlos Nousari, MD Baltimore, Maryland
M
any dermatoses can affect the subcutaneous tissue. The clinical presentation is polymorphous as in cutaneous polyarteritis nodosa, exhibiting the spectra of inflamed nodules, deep ulcers, digital infarcts, livedo reticularis, and stellate scars. Consequently, a reliable, clinically guided, histologic examination is crucial in achieving an accurate diagnosis. Unfortunately, clinicopathologic incongruity is not uncommonly encountered–the fault occasionally lies in sampling of inadequate tissue. To circumvent this problem, incisional wedge biopsies have been considered as the gold standard for the evaluation of these disorders.1 The potential disadvantage of incisional biopsies, however, is the time consumption of using this technique on multiple locations. Sampling of tissue with intense, perilesional fibrosis and necrosis such as an ulcer makes hemostasis and closure of an elliptic defect nearly impossible. Another limitation of the incisional biopsy is that the sample is taken along a single axis. For example, a biopsy of an ulcer aligned in the 12 o’clock to 6 o’clock axis would, therefore, not be able to include histologically relevant tissue at the 3 o’clock edge. To address these issues, we describe a technique called the “double-trephine punch.” Although the trephine punch tool used in hair transplants has been previously proposed for the diagnosis of panniculitis, the tool is not readily available in a dermatology clinic,2 and subcutaneous tissue would also be difficult to recover from such a small and deep From the Department of Dermatology, Johns Hopkins University School of Medicine. Funding sources: None. Conflict of interest: None identified. Reprint requests: H. Carlos Nousari, MD, Division of Immunodermatology, Johns Hopkins University School of Medicine, 720 Rutland Ave, Room 771, Baltimore, MD 21205. E-mail: [email protected]. J Am Acad Dermatol 2003;48:609-10. Copyright © 2003 by the American Academy of Dermatology, Inc. 0190-9622/2003/$30.00 ⫹ 0 doi:10.1067/mjd.2003.88
defect (Fig 1). Our proposed technique can be regarded as a compound punch biopsy using common, disposable, cutaneous punch tools. Sampling may occur at various locations along the margins and within the center of the lesion. Such a procedure is quickly and easily performed and would not require a second office visit for more involved biopsies. The tools necessary to perform the double-trephine punch are simply that which are used in a standard punch-biopsy procedure. An additional 8-mm punch tool is necessary, and the optional availability of electrocautery and Gelfoam (Pharmacia & Upjohn Company, Kalamazoo, Mich). The site for sampling is chosen to ensure the highest yield. Observing standard, clean, surgical procedure techniques, the lesion is prepared and locally anesthetized. Countertraction is applied with the nondominant hand, and the 8-mm punch tool is inserted to the hilt of the instrument to obtain the initial sample (Fig 2, left). Once the superficial core is removed, subcutaneous tissue should be readily
Fig 1. The double-trephine punch biopsy shown on the right samples more subcutaneous tissue than the single, 4-mm punch shown on the left.
609
610 Pearls
J AM ACAD DERMATOL APRIL 2003
Fig 2. Initial 8-mm punch (left) followed by 4-mm punch (right).
visible. A 4- or 6-mm tool is subsequently used within the center of the 8-mm defect to obtain the subcutaneous tissue (Fig 2, right). All tissue samples and requisitions should be annotated conspicuously as “two pieces” for analysis. Wound closure can be accomplished with a combination of deep, everting, intradermal sutures using absorbable material of one’s choice and interrupted nylon sutures. Occasionally, closure of the defect may not be possible, especially within the bed of a
Direct all Surgical Pearl submissions to Dr Stuart J. Salasche, 5300 N Montezuma Trail, Tucson, AZ 85750.
necrotic ulcer. Because the defect is small relative to an incisional wedge biopsy, hemostasis can be achieved with electrocautery, Gelfoam, or pressure dressings without the use of sutures. REFERENCES 1. Requena L, Sanches Yus E, Panniculitis: part I, mostly septal panniculitis. J Am Acad Dermatol 2001;45:163-83. 2. Tok J, Abrahams I, Ravits MA, Silvers DN. Surgical pearl; the trephine punch for diagnosing panniculitis. J Am Acad Dermatol 1996;35:980-1.
Direct all Medical Pearl submissions to Dr Mark G. Lebwohl, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1048, New York, NY 10029.
Mark G. Lebwohl, MD Medical Pearls Editor
Surgical Pearl: Double-trephine punch biopsy technique for sampling subcutaneous tissue Cuong T. Ha, MD, and H. Carlos Nousari, MD Baltimore, Maryland
M
any dermatoses can affect the subcutaneous tissue. The clinical presentation is polymorphous as in cutaneous polyarteritis nodosa, exhibiting the spectra of inflamed nodules, deep ulcers, digital infarcts, livedo reticularis, and stellate scars. Consequently, a reliable, clinically guided, histologic examination is crucial in achieving an accurate diagnosis. Unfortunately, clinicopathologic incongruity is not uncommonly encountered–the fault occasionally lies in sampling of inadequate tissue. To circumvent this problem, incisional wedge biopsies have been considered as the gold standard for the evaluation of these disorders.1 The potential disadvantage of incisional biopsies, however, is the time consumption of using this technique on multiple locations. Sampling of tissue with intense, perilesional fibrosis and necrosis such as an ulcer makes hemostasis and closure of an elliptic defect nearly impossible. Another limitation of the incisional biopsy is that the sample is taken along a single axis. For example, a biopsy of an ulcer aligned in the 12 o’clock to 6 o’clock axis would, therefore, not be able to include histologically relevant tissue at the 3 o’clock edge. To address these issues, we describe a technique called the “double-trephine punch.” Although the trephine punch tool used in hair transplants has been previously proposed for the diagnosis of panniculitis, the tool is not readily available in a dermatology clinic,2 and subcutaneous tissue would also be difficult to recover from such a small and deep From the Department of Dermatology, Johns Hopkins University School of Medicine. Funding sources: None. Conflict of interest: None identified. Reprint requests: H. Carlos Nousari, MD, Division of Immunodermatology, Johns Hopkins University School of Medicine, 720 Rutland Ave, Room 771, Baltimore, MD 21205. E-mail: [email protected]. J Am Acad Dermatol 2003;48:609-10. Copyright © 2003 by the American Academy of Dermatology, Inc. 0190-9622/2003/$30.00 ⫹ 0 doi:10.1067/mjd.2003.88
defect (Fig 1). Our proposed technique can be regarded as a compound punch biopsy using common, disposable, cutaneous punch tools. Sampling may occur at various locations along the margins and within the center of the lesion. Such a procedure is quickly and easily performed and would not require a second office visit for more involved biopsies. The tools necessary to perform the double-trephine punch are simply that which are used in a standard punch-biopsy procedure. An additional 8-mm punch tool is necessary, and the optional availability of electrocautery and Gelfoam (Pharmacia & Upjohn Company, Kalamazoo, Mich). The site for sampling is chosen to ensure the highest yield. Observing standard, clean, surgical procedure techniques, the lesion is prepared and locally anesthetized. Countertraction is applied with the nondominant hand, and the 8-mm punch tool is inserted to the hilt of the instrument to obtain the initial sample (Fig 2, left). Once the superficial core is removed, subcutaneous tissue should be readily
Fig 1. The double-trephine punch biopsy shown on the right samples more subcutaneous tissue than the single, 4-mm punch shown on the left.
609
610 Pearls
J AM ACAD DERMATOL APRIL 2003
Fig 2. Initial 8-mm punch (left) followed by 4-mm punch (right).
visible. A 4- or 6-mm tool is subsequently used within the center of the 8-mm defect to obtain the subcutaneous tissue (Fig 2, right). All tissue samples and requisitions should be annotated conspicuously as “two pieces” for analysis. Wound closure can be accomplished with a combination of deep, everting, intradermal sutures using absorbable material of one’s choice and interrupted nylon sutures. Occasionally, closure of the defect may not be possible, especially within the bed of a
Direct all Surgical Pearl submissions to Dr Stuart J. Salasche, 5300 N Montezuma Trail, Tucson, AZ 85750.
necrotic ulcer. Because the defect is small relative to an incisional wedge biopsy, hemostasis can be achieved with electrocautery, Gelfoam, or pressure dressings without the use of sutures. REFERENCES 1. Requena L, Sanches Yus E, Panniculitis: part I, mostly septal panniculitis. J Am Acad Dermatol 2001;45:163-83. 2. Tok J, Abrahams I, Ravits MA, Silvers DN. Surgical pearl; the trephine punch for diagnosing panniculitis. J Am Acad Dermatol 1996;35:980-1.
Direct all Medical Pearl submissions to Dr Mark G. Lebwohl, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1048, New York, NY 10029.