BiopsyTechniques:

SkinLesions

Indications(indikasi)
Tomakeorconfirmhistopathologicdiagnoses
(utkmembuatataumengkonfirmasidiagnosis
histopatologi)
Definitivetreatmentofabnormal,malignant,
andatypicallesions
Electiveremovalforcosmeticreasons

Contraindications

Infectionatbiopsysite
Bleedingdisorder
Allergytolocalanesthetics

Risks
Bleeding
AvoidNSAIDsorASA10daysbeforelargeexcisions
Switchfromwarfarintoheparinforlargeexcisions

Infection
Scar
Morecommoninchildren,youngadults
Higherriskareas:mandible,chest,neck,shoulders,hands,feet
Previoushistoryofkeloidformation

Nervedamage
Facehighriskarea:facialmotornerverunsverycloseto
dermallayer.Nervesruninsubcutaneousfatplane.

Risks
Allergytolocalanesthetics
TypeI
canoccurw/opreviousexposure.Rare

TypeIV:delayedhypersensitivity.
Needspreviousexposure
Usuallylocalreactions,rash,contactdermatitis.

Amideagents
lidocaine,mepivicaine,bupivicaine,etidocaine
Mostcommonlyusedagents
AllergyisEXTREMEMLYrare.

Esteragents
procaine,tetracaine,chloroprocaine

Bacteriostaticsalineorinjectablediphenhydramine
Mildanestheticeffect.Lasts15minutes.

Risks
Allergytotopicalantibiotics
Neomycin.3rdmostcommoncontactallergeninU.S.
Bacitracin.6thmostcommoncontactallergeninU.S.

DescriptionofLesion
Flat
Macule<1cm
Patch>1cm
Raised
Papule<1cm
Nodule12cm
Tumor>2cm
Plaque.Flat,
elevatedwith
surfacearea>
height.
Indurated.Firm

Pedunculated

Howtochoseyourbiopsytype?
Flat
Punchorellipse

Raised
Punchorellipseifworriedaboutmelanoma
Shaveinothercases

Indurated
Punchorellipse

Pedunculated
Shaveorscissors

WhereshouldIbiopsy?
Pigmentedlesion
Exciseentirespecimen.13mmmargins

Rash

Developedbutnotexcoriatedlesion
Multiplebiopsies
Biopsyatedgeoflesions
4mmpunch

Blisteringdisorder
Exciseentireblisteroratblisteredge
Formalinforhistopathology

Biopsyperilesionalnormalskin
SalinesoakedgauzeforDirectImmunoflorescence(DIF)

Howdeepshouldyougo?

Throughepidermis/dermisinto
subcutaneousfat
Punch&ellipticalbiopsies
Whenconcernedaboutmelanoma

Prognosisbasedondepth
Easierextractionofspecimen

Throughepidermis&
dermis
Shavebiopsies
Raisedorpedunculated
Notworriedabout
melanoma

Supplies&Instruments
Prepsolution

Isopropylalcohol,povidoneiodine,chlorhexadine

Drapes
Gauze
Syringes
Needles

18or20Gtodrawup.25or30Gtoinject.

Anesthetic

Lidocaine(0.5,1or2%)withorwithoutepinephrine
Epinephrineokaytouseondigits/acralareas

Supplies&Instruments

Punchbiopsy(3mm8mm)
#15bladescalpel
Irisscissors,forcepswithteeth,needledriver
Suture
Nylon,absorbableorprolene(blue)
40or50withP3orFS3needle.60onface.

Hemostaticagent
Aluminumchloride(Drysol)
Silvernitratesticks.Maystainskinbrown

Processingsolution(formalin,saline,etc)
Dressingsupplies

Shavebiopsy
Createwhealtoelevate
lesion
Stretch&stabilizeskin
#15bladeheldparallel
toskin
Smoothsweepingstrokes
Nearendofexcision,placeforcepsontopoflesionto
stabilizeandpreventtearingwithexitofblade

PunchBiopsy
Determinedirectionofskintension
lines
Stabilizeskinwiththumb/forefinger
Considerstretchingskinperpendicular
toskinlinestocreateellipse
Placepunchperpendiculartoskin
Applyfirmdownwardpressurewitha
circularmotionuntilreachsubQfat.
Willfeelgive
Forcepstoremovelesion.Cutatbase

Fusiform(Elliptical)
Excision
Alignlongaxisofexcisionparalleltoskintensionlines
Drawellipse
25mmwoundmargins
30degreeanglesateachapex
Lengthis34timesthewidth

#15bladescalpel
UndermineatlevelofsubQfatwithscalpelorscissor
Placestitchatoneendofbiopsysample
Helpstoidentifyorientationofsample

Underminewoundedgesinpreparationforsuturing

Processingbiopsyspecimens
Histopathology
10%bufferedformalin

Directimmunoflorescence
Dxofblisteringdisease,SLE,etc.
Michelssolution
Salinesoakedgauze.Donotletspecimendryout

Bacterialorfungalcultures
Sterilecontainerwithnonbacteriostaticsaline

Viralstudies
Viraltransportmedia

Tosutureornottosuture?
Doesthisbiopsyneedastitch?

RCTcomparingprimary(suture)vssecondaryhealing
in4mmvs.8mmpunchbiopsies.

Sutures

Doctors:nodifferenceinhealingorcosmesis
in4mmor8mmbiopsies.
Patients:nodifferenceinhealingorcosmesis
in4mmbiopsy.Bettercosmesiswithsuturein8mmbx.

Monofilamentnylon(Ethilon)
Polypropylene(Prolene)

Whataboutabsorbablesutures?

Someevidence:absorbablepolyglactin(Vicryl)sutures
equaltonylonsuturesinratesofinfection,redness,
dehisence,scarhypertrophy,patientsatisfaction.

SimpleSuture

VerticalMattressSuture

PostProcedureCare
Woundsheelfasterwhenmoist
Vaselineorantibioticointment

Occlusiveorsemiocclusivedressing
Removebandageafter1224hrs
Cleansewithsoap/watertwicedaily
Bandageforapprox5daysoruntilreepithelialized
Showerokaywithsutures.Avoidsoaking
Avoidactivitiesthatwillputstressonsutures

SutureRemoval
Face
46days;applySteriStrips

Chest,abdomen,upperextremities,scalp
710days

Back,lowerextremities
1220days

PathologyForms:EssentialInformation
The6Ds
Demographics:age,gender,ethnicity
Description:
location,color,symptoms,otherareas ofinvolvement,
previoustherapyorbiopsy.
Diseases&Drugs
Durationofcondition
Diameteroflesionoreruption
Diagnosis:inorderoflikelihood
Canbebroadcategoriessuchas
malignancy,
dermatitis,infection.
Avoidtermslikeruleout

Documentation

Diagnosis:Reasonforprocedure
Descriptionandlocationoflesion
Procedure:Shavevs.Punchvs.Ellipse
Consent:Risksandbenefitsreviewed
PrepandAnesthesia
Descriptionofprocedure
Specimendisposition
Patienteducationandfollowup

Followupofpathologyresults
Nouniformrecommendations
Interpretationrequiresunderstandingof
clinicalscenario
Workcloselywithyourdermatologist
GettoknowYOURdermatopathologist

TheEnd