II. Indications: Elevated (exophytic) neoplasms

  1. Skin Tag
  2. Non-pigmented Nevus
  3. Keratocanthoma
  4. Dermatofibroma
  5. Seborrheic Keratosis
  6. Actinic Keratosis
  7. Cutaneous horn
  8. Possible small localized low-risk cancer
    1. Basal Cell Cancer
    2. Squamous cell cancer

III. Contraindications

  1. Do not Shave Biopsy possible Melanomas!
  2. Do not Shave Biopsy pigmented lesions (may be Melanoma)
  3. Avoid Shave Biopsy of subcutaneous lesions

IV. Technique

  1. Prep lesion with Povidone-Iodine (Betadine) or Chlorhexidine (Hibiclens)
  2. Local Anesthesia with intradermal Local Lidocaine
    1. Adequate Anesthesia requires 1 cm wheal around lesion
    2. Anesthesia also raises lesion above skin plane
  3. Shave tangential to skin with #15 blade or Dermablade (double-edged razor blade)
    1. Shave under lesion through Epidermis and into Dermis, but not deeper (1 mm depth)
      1. Angle blade slightly to obtain upper Dermis
    2. Avoid cutting into subcutaneous tissue
      1. Must be converted to standard biopsy
    3. Remaining defect is saucer-shaped
  4. Consider using Radiofrequency to smooth edges
    1. Effective at reducing scarring risk on face
    2. Use small electrosurgical loop electrode
    3. Set unit to 1.5 or 2.0
    4. Stabilize hand against skin with pinky finger
    5. Use shallow short strokes to smooth lesion edges
  5. Hemostasis
    1. Aluminum Chloride for face and mild bleeding
    2. Monsel's Solution or Silver Nitrate can be used on non-facial areas
      1. Risk of skin staining

V. Interpretation: Biopsy

  1. Benign positive wound edges
    1. Does not usually require re-excision
    2. Observe for lesion recurrence
  2. Positive wound edges for Basal Cell Cancer
    1. See Basal Cell Carcinoma for management
  3. Positive wound edges for squamous cell cancer
    1. Perform full-thickness re-excision
  4. Melanoma transected
    1. Never Shave Biopsy pigmented lesions!
    2. Accurate staging of transected Melanoma not possible
    3. Refer to skin-cancer specialist
    4. Transected Melanoma assumed intermediate to high risk
      1. Wide local excision with Sentinel Node biopsy
      2. Work-up may include chest, abdominal and skull CT
      3. Lymphoscintigraphy may be needed to define drainage
      4. Patient seen q3 months for 3 years, then q6 months
    5. References
      1. Salasche (1997) Dermatol Surg 23:578-82 [PubMed]

VI. Post-Operative Care: Avoid scab formation

  1. Promote moist Wound Healing for 1 week
  2. Apply ointment to incision site frequently
    1. Consider petrolatum (e.g. Vaseline Gauze)
    2. Consider topical Bacitracin
    3. Consider non-antibiotic (e.g. Aquaphor)

VII. Complications

  1. Scarring (higher risk on the face)
  2. Hypertrophic Scar in areas of excessive skin tension
    1. Shoulders
    2. Sternum
    3. Flexor creases

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