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Introduction
CHAPTER 14 Superficial Biopsy
Techniques
Dirk M. Elston
SUMMARY
The biopsy of tissue for histological exam remains one of the most informative
and cost-effective tests in medical practice, and one of the most common procedures performed by dermatologists.
In general, all tissues removed during a surgical procedure should be submitted
for histopathologic examination.
Ultimately, the key factor in biopsy success is balancing the need for acquiring
an adequate sample for histopathologic evaluation with minimizing the cosmetic and functional sequelae of the biopsy itself on the patient.
Beginner Pearls
Local anesthesia is a prerequisite for a pain-free biopsy; while patients may rarely
request that a biopsy be performed without anesthesia, this should be discouraged, particularly as postbiopsy hemostasis may be more painful than the biopsy itself.
Patients should receive written instructions regarding wound care.
Shave biopsies are the cornerstone of dermatologic practice, and are useful in most
situations when performed appropriately.
Expert Pearls
The โexcisional biopsyโ that is recommended for pigmented lesions suspicious for
melanoma includes a deep shave or scoop biopsy.
Multiple scouting biopsies may be useful when assessing for lentigo maligna.
Donโt Forget!
When sampling for direct immunofluorescence, a punch biopsy from lower extremity
skin should generally be avoided both due to a risk of false-negative results and a slower rate of healing.
For alopecia, punch biopsy for transverse (horizontal) and vertical sections should
ideally be performed.
Pitfalls and Cautions
Often the greatest risk associated with a biopsy is not performing it at all; in the hands
of experienced dermatologic surgeons, small biopsies yield nearly undetectable scars, and the diagnostic benefits far outweigh the risks.
Biopsies from sebaceous skin, such as the nose, may leave pronounced scars that may
benefit from later dermabrasion or resurfacing.
Patient Education Points
Most biopsy sites heal very quickly, but patients should understand that surrounding
erythema or excess fibrin formation may be seen, particularly in areas that are subject to friction.
Preoperative biopsy-site photography may be helpful to reduce the risk of surgical site
identification challenges.
Billing Pearls
Biopsy coding is predicated on the assumption that the purpose of tissue removal is for
diagnostic purposes.
Site-specific biopsy codes should be utilized as appropriate.
CHAPTER 14 Superficial Biopsy