Practical Considerations for Cutaneous Biopsies Eric B. Harmon, MS, - PowerPoint PPT Presentation

Practical Considerations for Cutaneous Biopsies Eric B. Harmon, MS, MPAS, PA-C Dermatology Clinic P.C. Wilsonville/Salem/Keizer

Wilsonville Salem Keizer

Goals 1) Choose appropriate biopsy technique for a given lesion 2) Understand pros and cons of each biopsy technique 3) Optimize cosmetic outcome 4) Review wound care for cutaneous biopsies 5) Review anesthetic injection technique

Disclaimers Much of this discussion is my opinion/experience Images are from: Clinic DermQuest.com Vectorstock.com Dermnetnz.com

Lesion Types Papules Cystic Macules Keratotic Melanocytic Deep Nodules Vascular Superficial

Skin Anatomy Review

Types of Cutaneous Biopsies 1. Shave - superficial removal with blade epidermis/papillary dermis (Ex: SK’s, IDN’s, cosmetic, delicate areas (nose)) 2. Saucerization - deeper shave with blade epidermis/reticular dermis (Ex: R/O melanoma vs atypia vs nevus) 3. Punch - round hole epidermis/dermis/fat 4. Excision - ellipse of whole lesion epidermis/dermis/fat

Where are you trying to reach?

Pro & Cons Shave/Saucerize - Pro: quick; can minimize scarring (in my opinion) - Con: any “roots” remain; may get incomplete pathology report Punch - Pro: depth; better chance of complete removal - Con: round hole/suture marks; “dog ears”; bleeding; more time Excision - Pro: full depth and breadth; pathologist will like you; fun!! - Con: time; difficult closure in tight areas (feet/hands, nose, ears etc.); $$$; overkill??

Which to choose... 1. What is the Goal? Most accurate Dx? Cosmetic improvement? Symptom relief? 2. Is the lesion superficial or deep? - Superficial = shave or saucerize - Deep = excise, punch, maybe saucerize - Unsure = excise or punch 3. Location? Is it going to be difficult to close? → shave? 4. Vascular? (Ex: pyogenic granuloma) Is it going to be difficult to control bleeding? → excision?

Things to shave... In general: - Raised non-pigmented (or lightly pigmented) lesions - Risk of “recurrence” perhaps darker pigment than the original lesion - R/O BCC/SCC - often need broader margins anyway - R/O SK vs AK vs wart - Not R/O Melanoma (with exceptions)

Things to Saucerize... R/O Melanoma (thin) vs atypia vs nevus (but EXCISE if suspicion is high!!) In areas difficult to close Ex: feet, ears, etc. Large lesions that would require extensive suturing BCC/SCC you think you can get clear margins (Keep in mind ~25% chance falsely clear)

Dermablade

Dermablade

Saucerization

Things to punch... Punch Excision: - Small (2-6/8mm) non/pigmented nevi - Small r/o BCC/SCC - Nodules (Ex: dermatofibromas) - Small cystic (Ex: dilated pores) - Papules with deeper structures likely (Ex: congenital nevi, neurofibromas) - Cosmetic: when shave bx might leave a divot Punch Incisional Bx: lesion too large to excise or in a difficult location - Plaque-like lesion (ex: morpheaform BCC)

Punch Bx 2-6mm >8mm: consider excision 1. Fingers pull in direction perpendicular to tension lines 2. Use the blade!! - Circular motion with downward pressure 3. Subtle sense of “give way” 4. Pick up with forceps or needle - don’t crush tissue! 5. Snip 6. 2-3mm: consider gel foam 7. 4-8mm: close with appropriate suture

Cautions with punch... Location: Temple - nerves/vessels Forehead - bleeding Scalp: bleeding/closure Nose - closure Feet/Hands - closure Fingers/Toes - nerve/tendons/closure Shin: periosteum/closure Dog ears: can snip off edges Depth - sufficient for Dx?

Things to Excise... Anything you think is deep and >8mm - Suspected melanomas - Larger (>6-8mm) congenital nevi - Larger (>6-8mm) elevated nevi with terminal hairs - Larger vascular lesions - Cysts and neurofibromas -

Excision Tips Length = 3-4x the width ~30 degree angle Long axis = in direction of the skin lines Longer excision = less tension = better scar? Remember 90 degree contact with blade Undermining 3-5mm = less tension = better scar - No if hemostasis is a problem - Caution with surrounding nerves

Anesthetic Review 1% lidocaine with epi (1:100,000) buffered with 5mL 8.4% Sodium Bicarbonate 30-gauge needle Intradermal injection to blanch 90 degree angle Down hair follicle if possible Stay in blanched section Go slow and they’ll like you! Stay under 50mL total (which should be easy to do)

Simple Wound Care Consider cautery (heat or electric) vs AlCl Avoid topical antibiotics Aquaphor/Vaseline liberally Keep occluded as much as possible (prevent scab) Tegaderm works great!

What will you do...

What will you do...

What will you do...

What will you do...

What will you do...

Thank You