Shave Biopsy

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Shave Biopsy 01:32


Introduction

Shave biopsy is one of the most widely used procedures performed in primary care practice. The technique is used to obtain tissue for histologic examination and is useful for removing superficial lesions in their entirety. Pedunculated lesions above the skin surface are particularly well suited for this removal technique, but flat lesions that are high in the dermis and do not extend beneath the dermis also can be removed by shave technique. Horizontal slicing is performed at the level of the dermis, avoiding injury to the subcutaneous tissues. Cosmetic results generally are good, with the least noticeable scars occurring when lesions are removed from concave surfaces such as the nasolabial fold. 
Four techniques are commonly employed for shave biopsy. A no. 15 scalpel blade held horizontally in the hand can provide good control of depth. The ease of the scalpel technique makes it a frequent choice of inexperienced physicians. Horizontal slicing with a flexed razor blade is a time-honored method for shave biopsy. This technique is used less frequently because of the potential for injury from the large, exposed cutting surface. Scissors (e.g., iris scissors) can be effectively used to remove elevated lesions. Scissors removal of flat lesions can be more difficult. Radiosurgical loop removal is effective, although novice practitioners tend to create deeper, “scoop” defects in the dermis beneath the lesion being removed. 
Shave biopsy is performed deep enough to remove the lesion but shallow enough to prevent significant damage to the deep dermis. The deeper the damage in the skin, the more likely scar formation will leave a noticeable, hypopigmented scar. If a scoop defect is created, the edges can be feathered (i.e., smoothed) to blend the color change into the surrounding skin (see Shave Biopsy). Depressed scars can result after this technique, especially from areas where there is extensive muscle tension on the skin, such as the chin or perioral areas. 
Many physicians recommend not performing shave biopsy on pigmented lesions. If a lesion should turn out to be a melanoma on biopsy, using a technique that cuts through the middle of the lesion can create major problems for determining depth, prognosis, and therapy for the lesion. Some clinicians argue that the shave technique can be performed on melanomas and that the old adage of not shaving a pigmented lesion can be dropped. Most still recommend caution, and it is our recommendation that excisional biopsy (see Punch Biopsy of the Skin and Fusiform Excision) should be used for any pigmented lesion that is suspected to be a melanoma. 

Equipment

  • Instruments for simple biopsies are found in Appendix G and can be ordered through local surgical supply houses.

  • A suggested anesthesia tray that can be used for this procedure is listed in Appendix F.

  • Skin preparation recommendations are shown in Appendix E.

Indications

  • Lesions amenable to shave excisional technique include acrochordons (i.e., skin tags), angiomas, fibromas, basal cell carcinomas (i.e., well-defined, small, primary and not recurrent, and in low-risk sites), dermatofibromas, keratoacanthomas, cutaneous horns, molluscum contagiosum, nonpigmented nevi (e.g., intradermal nevi), papillomas, warts, syringomas, venous lakes, cherry angiomas, stucco keratoses, seborrheic keratoses, actinic keratoses, rhinophymas, sebaceous hyperplasia, porokeratosis, neurofibromas, and dermatosis papulosa nigra.

Relative Contraindications

  • Pigmented nevi

  • Skin appendage lesions (e.g., cylindromas, epidermoid cysts—should be full thickness)

  • Subcutaneous lesions (pathology often missed by shave technique)

  • Epidermal nevi (removal requires full-thickness excision)

  • Infection at the site (relative)

  • Severe bleeding disorders (relative)

  • Patients on warfarin or clopidogrel (relative)

The Procedure

Step 1

Prepare the site with isopropyl alcohol, povidone-iodine, or chlorhexidine gluconate. For removal of a flat (sessile) lesion, local anesthetic is placed beneath the lesion in an intradermal location (see Local Anesthesia Administration). The fluid raises the lesion upward, allowing easier removal. Administration of local anesthetic thickens the skin, making it less likely that the shave will penetrate the dermis into the subcutaneous fat. 
  • PEARL: Mask, gown, and sterile gloves are generally not necessary.

  • PITFALL: Unintentional penetration into the fat (i.e., yellow fat in the base of the wound) should prompt transforming the biopsy site into a sterile surgical wound. The wound should have the edges incised vertically, and the wound should be closed with sutures.

Step 2

A no. 15 blade is held horizontal in the dominant hand while the nondominant hand stabilizes surrounding skin or the lesion. The blade is brought across the base of the lesion with a back-and-forth movement until the lesion is removed, leaving a shallow crater in the dermis. 

Step 3

Biopsy can be performed with a razor blade (Dermablade) held in the hand, with tension applied to the two sides to create some curvature. The sharp surface is brought beneath the lesion for removal within the dermis. 
  • PEARL: Lesion removal can sometimes be facilitated by elevating and squeezing the surrounding skin.

  • PITFALL: The large, exposed, cutting surface of the razor blade and the hand tension required to maintain curvature of the blade provide great potential for injury. Some surgeons no longer advocate use of razor blades for shave biopsy because of this potential for injury.

Step 4

Small, pedunculated lesions can be removed easily with the scissors technique. The skin is stretched with the nondominant hand, and the lesion is removed with sharp iris scissors. Small lesions can be removed without local anesthesia or with 30 second application of ice if the pain receptors within the skin are stretched. 
  • PITFALL: The scissors must be flush with the skin surface to prevent leaving a residual stump, but no extra skin should be included within the scissor blades to prevent unintentional cutting of surrounding skin.

Step 5

Radiosurgical loop excision can be used to perform a shave biopsy (see Radiosurgical Skin Surgery (LEEP)). After anesthesia is placed, the loop or bent wire is activated and moved back and forth across the lesion until it is excised. The radiosurgical current can be set to provide hemostasis to the wound base if needed. 
  • PITFALL: Novice physicians tend to scoop with the loop. The loop must be brought under the lesion horizontally, and the lesion must not be excessively elevated to prevent large scoop defects from this technique.

Step 6

The wound base can be treated with pressure, coagulation, fulguration, 10% to 20% percent aluminum chloride, or ferric subsulfate (i.e., Monsel’s solution) for hemostasis. All of these methods should be applied to a dry wound bed, so the blood must be wiped away and the treatment applied immediately thereafter. Antibiotic ointment and a bandage are then applied. 
  • PITFALL: Ferric subsulfate can rarely produce permanent discoloration or “tattooing” of the skin. Consider using a 35% to 85% aluminum chloride solution on the faces of fair-skinned (light-complected) individuals to avoid this complication.

Complications

  • Bleeding

  • Infection

  • Scar formation

Pediatric Considerations

Generally, pediatric skin has excellent blood flow and heals very well. However, pediatric patients often find it difficult to sit or lie still during lengthy procedures. The patient’s maturity and ability to cooperate should be considered before deciding to attempt any out-patient procedure. Sometimes it is necessary to sedate the patient to repair the laceration (see Pediatric Sedation). The maximum recommended dose of lidocaine in children is 3 to 5 mg/kg, or 7 mg/kg when combined with epinephrine. Neonates have an increased volume of distribution, decreased hepatic clearance, and doubled terminal elimination half-life (3.2 hours). 

Postprocedure Instructions

Have the patient use a small amount of antibiotic ointment and cover the wound with a small bandage. Instruct the patient to gently wash the area after 1 day. Have the patient dry the area well after washing and use a small amount of antibiotic ointment to promote moist healing. Instruct the patient not to pick at or scratch the wound. 
Histologic evaluation of the shave specimen should be reported to the patient. If the evaluation of a benign growth reveals that the specimen margin was positive, the lesion can probably be closely followed or re-excised. Specimens that reveal positive margins for malignancy should prompt re-excision. If a shave specimen is reported to contain melanoma, consider referral to a subspecialist in skin cancer. 

Coding Information and Supply Sources

The following coding information is for shaving of epidermal or dermal lesions, including lesions on mucous membranes (MM). The codes are for single lesion removal. 
  • Hemostatic agents such as ferric subsulfate are available from surgical supply houses or the resources listed in Appendix G.

  • For practitioners wishing to perform shave biopsy with a razor blade, the disposable DermaBlade (Personna Medical, American Razor Company, Stauton, VA) enhances safety by allowing the operator to grasp the sure-grip teeth to the sides instead of directly handling the blade.

  • Radiosurgical generators; electrodes for dermatologic, gynecologic, plastic surgery, or ear, nose, and throat uses; smoke evacuators; and other accessories are available from

    • Ellman International, 1135 Railroad Avenue, Hewlett, NY 11557-2316 (phone: 800-835-2316; www.ellman.com)

    • Wallach Surgical Devices, 235 Edison Road, Orange, CT 06477 (phone: 203-799-2002; www.wallachsd.com).

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