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It’s Sometimes Unnecessary to Suture Punch Biopsy Sites

Second-intention healing works well for smaller punch biopsies on the trunk and extremities.

Traditionally, punch biopsy sites have been sutured, but the benefit of this practice has never been scientifically demonstrated. In this prospective, randomized, method-comparison study, 82 healthy volunteers had paired 4-mm or 8-mm punch biopsies taken from the outer thighs, outer upper arms, or upper back. One of the two sites was then sutured with one or two 4-0 nylon simple, interrupted sutures, and the matching site was allowed to heal by second intention. Hemostasis of the second-intention healing site was achieved with gel foam. Wound care consisted of Tegaderm dressings changed weekly until the sites were healed.

Examination of the biopsy sites in the 77 patients who came in for a 9-month follow-up visit showed no significant differences in the appearance of the resulting scars (sutured sites garnered a mean of 59 points on a 100-point visual-analog scale measuring appearance vs. 57 points for the second-intention sites). Suture tracks were evident in 64% of the sutured sites. The subjects were significantly more satisfied with, and preferred four-to-one, the appearance of sutured sites in 8-mm biopsies, but they saw no significant difference between sutured and unsutured 4-mm biopsy sites. They reported pain significantly more often with second-intention healing, especially in the 8-mm biopsy sites. An average of two Tegaderm dressings was necessary for the sutured sites and three for the second-intention healing sites. The additional costs associated with suturing, both direct (suture, suture placement by physician, suture removal kit, suture removal by nurse) and indirect (travel, parking, and lost work time to come in for suture removal), were estimated at $37 per site (excluding the cost of gel foam and dressings).

Comment: Four-mm punch biopsy sites on the trunk and extremities can heal by second intention without adversely affecting the final outcome, as sutured wounds in these areas tend to heal with suture tracks and scar spread due to the skin tension. Patient preferences, as expressed in this study, favored the suturing of larger punch biopsies. These results cannot be extrapolated to the head and neck regions, where sutured wounds usually heal without suture tracks and without scar spread, making the suturing of punch biopsy sites almost always beneficial. The cost difference between suturing and second-intention healing could be reduced dramatically by using absorbable sutures, having a physician’s assistant place the sutures, and using reusable suture-removal kits; in comparing costs, clinicians should also consider the cost of gel foam and extra dressings used for second-intention healing sites.

— George J. Hruza, MD

Published in Journal Watch Dermatology October 11, 2005

Citation(s):

Christenson LJ et al. Primary closure vs second-intention treatment of skin punch biopsy sites: A randomized trial. Arch Dermatol 2005 Sep; 141:1093-9.

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