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Skin/Soft Tissue Lesions – Excisional and Incisional Biopsy

Goals/Objectives

Anatomy and Physiology Review
Indications
Technical considerations

Biopsy Techniques

Joseph F. Sobanko
Justin J. Leitenberger
Neil A. Swanson
Ken K. Lee

From Rigel DS, et al: Cancer of the Skin, 2nd edition (Saunders 2011)

F igure 56-1-1, Biopsy equipment. Some of the commonly used equipment, listed from left to right: Webster needle holder, small Metzenbaum scissors, Adson forceps with teeth, scalpel handle and #15 blade.

F igure 56-1-2, Punch biopsy. Disposable punch device. These range from 1.5 to 10 mm. Most commonly used sizes are 2, 3, 4, 6, and 8 mm.

F igure 56-1-3, Biopsy tray. A labeled specimen bottle should always be set out prior to the biopsy.

F igure 56-1-4, Anesthesia injection. 1% lidocaine with epinephrine is most commonly used for local anesthesia. A 30-gauge needle is used to infiltrate slowly into the dermis.

F igure 56-1-5, Punch biopsy. A, Traction is applied using two fingers perpendicular to the relaxed skin tension lines, providing a rigid surface for the cutting edge of the punch device. B, The punch is then pushed through skin while applying a circular back-and-forth motion. C, The specimen is gently grasped on one edge and transected at the level of the subcutaneous fat. D, The resultant defect is elliptical because the circular biopsy was done under traction. This allows for an easier linear closure. E, After closure with cuticular sutures.

F igure 56-1-6, Shave biopsy. A #15 blade scalpel is used to shave the raised component of the suspected cancer. A, The surrounding skin is squeezed together to provide an elevated and rigid plane or B, forceps are used for countertraction.

F igure 56-1-7, Shave biopsy. Dermablade® is flexed to fit the lesion and is slid side to side through the lesion.

F igure 56-1-8, Saucerization. A, The scalpel blade is angled at 45 degrees. The incision is made tangentially to create a disc-shaped specimen. B, The specimen is removed at the level of the fat.

F igure 56-1-9, Fusiform elliptical excision. A, A 1–2 mm margin is delineated around the lesion and oriented along the relaxed skin tension lines and/or direction of lymphatic drainage. B, Incision is made through the dermis into the fat. C, Defect is ready for layered closure.

F igure 56-1-10, Fusiform elliptical excision – closure. A, Wound is undermined using a skin hook and Metzenbaum scissors. B, Dermal suture is inserted from the deep aspect of the wound. Dermal suture is inserted from the deep aspect of the wound, then C, passed superficial to deep on the other side and D, knotted to create an everted wound. E, Final appearance.

F igure 56-1-11, Incisional biopsy. A, A large and ill-defined pigmented lesion on the cheek with variegate pigmentation. Punch biopsies can be taken from the darker areas, or B, an incisional ellipse is made through the most suspicious area. The lines demonstrate the axis of sectioning in order to maximize the cross-section seen by the dermatopathologist.

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