Q: What are the pros and cons of punch excision?

Pros Punch excision is a minor in-office procedure, with minimal downtime (so long as you don’t mind being seen with very fine sutures for about a week). It usually leaves a smaller, lighter scar than the original. In most cases, side effects are minimal—think light bruising. Punch excision can be combined with other treatment options, including punch grafting, microneedling, dermal fillers, microdermabrasion, chemical peels, or laser resurfacing , for optimal results. It's suitable for most skin types and tones, although supplementary treatments may be recommended to minimize any risk of hyperpigmentation for people with tan, brown, or deep skin tones. It can remove a recurrent mole. Cons Punch excision may not be the best treatment for chicken pox scars. Not all doctors on RealSelf recommend punch excision, because it can be less precise than using a scalpel and may even leave a more noticeable scar.

Question 1

What is punch excision?

Accepted Answer

Punch excision is a surgical procedure that’s usually used for scar revision. It uses a sharp, cookie-cutter-like punch tool to "punch" around a scar and ultimately remove it. The remaining hole is then closed with a tiny suture.

The procedure can treat acne scarring, as well as some marks left by mole removal or other indented or atrophic scars. It works best for deep icepick or boxcar scars smaller than 3 millimeters. Anything bigger, such as a keloid or birthmark, probably won’t have a good outcome with punch excision.

“If the scar is approximately the size of a pencil eraser and is located in a high-tension area like the forehead, a punch excision is likely to yield a scar that will ultimately stretch again to about the same size of the original scar,” says Dr. Nelson Lee Novick, a New York City-based dermatologist.

Some doctors on RealSelf caution that punch excision can be less precise than other methods. “The depth can be too deep, which actually results in too much being taken out. Usually, physicians who aren’t comfortable with scalpels and excisions use a punch technique, but I’ve found you can actually customize depth and size with a regular excision. A lot of the time, a punch is actually worse because you have to widen the margins and depth more than is actually needed,” says Dr. F. Victor Rueckl, a dermatologist in Las Vegas.

A doctor with extensive experience in scar removal and skin resurfacing can create a tailored plan for your skin. “The majority of patients will have a collection of different scar types,” says Dr. Davin Lim, a dermatologist in Brisbane, Australia, in a RealSelf Q&A. “Careful examination, especially under angled lighting with scar mapping, will give you an understanding of the best options for your scars.”

RealSelf Tip: This procedure is sometimes referred to as punch biopsy, a technique used to remove some types of skin cancer. Learn more about skin cancer treatment options.

Question 2

What are the pros and cons of punch excision?

Accepted Answer

Pros

Punch excision is a minor in-office procedure, with minimal downtime (so long as you don’t mind being seen with very fine sutures for about a week).
It usually leaves a smaller, lighter scar than the original.
In most cases, side effects are minimal—think light bruising.
Punch excision can be combined with other treatment options, including punch grafting, microneedling, dermal fillers, microdermabrasion, chemical peels, or laser resurfacing, for optimal results.
It's suitable for most skin types and tones, although supplementary treatments may be recommended to minimize any risk of hyperpigmentation for people with tan, brown, or deep skin tones.
It can remove a recurrent mole.

Cons

Punch excision may not be the best treatment for chicken pox scars.
Not all doctors on RealSelf recommend punch excision, because it can be less precise than using a scalpel and may even leave a more noticeable scar.

Question 3

How much does punch excision cost?

Accepted Answer

The cost of punch excision can range from just $250 to as much as $1,750.

Your cost will depend on your provider’s level of experience, their practice location, how many scars you have treated at once, and other details of your procedure.

Question 4

What happens during punch excision?

Accepted Answer

Your doctor will select a punch biopsy instrument that matches the size of the scar, mole, or lesion they’re removing. After anesthetizing the treated area, they’ll punch into the skin to remove the scar. Then they’ll close the wound with a very fine suture.

Some doctors or dermatologists pair punch excision with punch grafting, which replaces the removed scar with a small skin graft from behind the ear.

Another option is punch elevation, which loosens and elevates the scarred skin to meet the level of the skin around it. The elevated skin then heals like a skin graft.

Question 5

How long does a punch excision take to heal?

Accepted Answer

You can expect the incisions to heal within about a week, but complete healing can take up to a year.

New skin cells start to regenerate within 24 hours, and the sutures are removed or dissolved after five to seven days. “At that point, they should be well-healed, and normal activities can be resumed. After any facial skin surgery, I recommend that my patients wait at least one week before resuming any exercise routines or heavy lifting,” says Frisco, Texas, facial plastic surgeon Dr. Matthew Richardson.

Side effects are rare, but the wound will look slightly inflamed for three to four months before it begins to mature and lighten, says Dr. Farbod Esmailian, a plastic surgeon in Los Alamitos, California.

For six to nine months, new collagen is produced to fill in the wound. “It isn’t until one year’s time that the scar has completely gone through the healing phase.”

Even after you’ve healed, you may still be left with a thin scar. “It may not be completely gone, but typically after punch excisions, the outcome is much better than the original scar,” says Dr. Elizabeth Rostan, a dermatologist in Charlotte, North Carolina, in a RealSelf Q&A.

At that point, Dr. Richardson recommends a skin resurfacing via a laser treatment, such as Fraxel, to further improve your results.

Question 6

How is punch excision different from subcision?

Accepted Answer

The two are very different types of acne scar treatments. While punch excision works best for ice pick scars, subcision is better for more shallow, "tethered" or rolling scars.

Rolling scars develop when a fibrous band of tissue pulls the skin down. During a subcision procedure, your doctor uses a slim needle to break up the fibrous scar tissue band, allowing the skin to lift and smooth out.

Question 7

Is it possible to get rid of icepick scars?

Accepted Answer

Icepick acne scars are a type of atrophic acne scarring that look like a deep, narrow hole in the skin. They never go away completely, but certain procedures, including punch excision, may improve their appearance.

Chemical peels like TCA Cross can also help and might even be preferable to punch excision, depending on the depth and size of your scars. For ice pick scars in particular, "the more conservative TCA Cross method involves topical application of 80-100% trichloracetic acid solution, which can also be quite effective," says San Diego dermatologist Dr. Bryan Chen. "If punch excision is done, usually some kind of resurfacing procedure should follow."

Some providers prefer to treat ice pick acne scars with dermal fillers, particularly Bellafill, the only filler that’s FDA approved to treat acne scars. Learn more about the best acne scar treatments.

PUNCH EXCISION

Karyn Repinski

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