FIGURE 9-6  Shave biopsy of PG on finger. (Copyright Richard P. Usatine, MD.)

FIGURE 9-8  Lentigo maligna melanoma. (Copyright Richard P. Usatine, MD.)

DISADVANTAGES OF

A SHAVE BIOPSY

As with the advantages of the shave biopsy, the disadvantages can also be categorized into those for the clinician and those for the patient. Disadvantages for the clinician include the following:

•If the lesion turns out to be a melanoma, the shave may interfere with determining the depth of the lesion if the shave did not get below the tumor and the whole lesion was removed.

•Shave biopsies of flat lesions are more challenging than elevated lesions and a punch biopsy may be easier for an inexperienced clinician.

FIGURE 9-7  Solar lentigo. (Copyright Richard P. Usatine, MD.)

For the patient, the disadvantages of shave biopsy include the following:

•An indentation (divot) may remain.

•Hypopigmentation or hyperpigmentation may result.

•Regrowth may occur.

•A second surgery may be needed if the whole lesion needs excision.

•Scarring may occur over the whole biopsy site.

A superficial shave biopsy should heal with little to no indentation of the skin.4 Deep-shave biopsies are more likely to leave an indentation. Persistence rates of melanocytic lesions for shave biopsy range from approximately 13% to 28%.5 Persistence does not always translate into regrowth. If regrowth does occur, it is important to have access to the original pathology report to avoid overdiagnosing a benign regrowth as a melanoma (pseudomelanoma). Methods useful to differentiate pseudomelanoma from melanoma include accurate clinical records of prior biopsy sites along with evidence of scarring within the current biopsy.5

EQUIPMENT

The minimum equipment necessary for a shave biopsy is a sharp blade (razor blade or No. 15 scalpel), a 3-mL syringe and needle for local anesthesia, and cottontipped applicators (CTAs) and aluminum chloride for hemostasis. It is handy to have a forceps to hold the lesion during the shave procedure or to transfer the tissue into the biopsy container. (The end of a CTA can also be used to do this transfer in many cases.) A surgical marking pen can be useful and is best used before administering the anesthesia.

The Personna DermaBlade is an excellent razor blade for shave biopsies. The blue plastic handle makes it easy and safe to grip the sharp razor blade and control the blade for an accurate and precise shave excision. The cost of the disposable DermaBlade is about the same as a standard disposable No. 15 scalpel. Other options

FIGURE 9-9  Shave biopsy with a double-edge Personna blade that was snapped in half before use. The blade easily cuts through this pigmented BCC. (Copyright Richard P. Usatine, MD.)

FIGURE 9-11  A nonpigmented growth on the cheek that could be an early nonmelanoma skin cancer. The subtle findings and lack of pigment make it a good candidate for preanesthesia marking with a surgical marker. (Copyright Richard P. Usatine, MD.)

include the Personna or Wilkinson double-edge razor blade. The Personna (or Personna Plus with Teflon coating) double-edge blade is very sharp and can be broken in half for easy use (Figure 9-9). Although these do not come in sterile packaging, they can be safely used for shave biopsies without using the autoclave. At approximately 15 cents per cutting blade (30 cents per two-sided blade), these are the most cost-effective tool for shave biopsies. They can be broken in half within their paper container to avoid cutting your hand prior to use. It might take some more time to get used to the bare blade, but once you have mastered its use, you will find this type of low-cost blade to be sharp and effective.

Miltex produces a BiopBlade flexible scalpel for shave biopsies. Its design is similar to that of the DermaBlade, using a single-edge razor blade with a plastic bendable handle. It is currently more expensive than the DermaBlade and has no advantages over the DermaBlade. The plastic handle can snap in half if the blade is bent incorrectly. The Personna single-edge razor blade is too rigid for shave biopsies. All of these blades (Figure 9-10) are available for purchase through Delasco (www.delasco.com) and some can be purchased through other suppliers.

FIGURE 9-10  Equipment used to perform a shave biopsy. (Copyright Richard P. Usatine, MD.)

SHAVE BIOPSY: STEPS AND

PRINCIPLES

See video on the DVD for further learning. 

Three critical steps in the shave biopsy include:

•Using 1% lidocaine with epinephrine for anesthesia and hemostasis.

•Stabilizing the lesion to allow for controlled removal of the biopsy.

•Dealing with any residual tissue after the initial shave.

Preoperative Measures

•After determining that the shave technique is the best method for the patient, obtain informed consent. (See Appendix A for an informed consent form titled

Disclosure and Consent: Medical and Surgical Procedures.) By visual inspection and palpation, determine the likely depth of the lesion and plan the depth of your biopsy based on the probable diagnosis and your physical exam.

•Lightly prep the area with alcohol or another antiseptic. There is no evidence that this preparation decreases the already extremely low infection rate, but it is easy to do.

•If it appears that the lesion will have fewer visible margins after the anesthesia, it helps to mark the area to be shaved with a surgical marker. It need not be a sterile marker. Consider marking the margins of nonpigmented relatively flat lesions that may only be actinic keratoses or sebaceous hyperplasia (but are somewhat suspicious for early skin cancer), because after injection the margins of these lesions may not be visible (Figure 9-11).

•Inject local anesthesia. Use a 30-gauge needle with approximately 2 to 3 mL of 1% lidocaine and

epinephrine (buffer the lidocaine for less pain; see Chapter 3, Anesthesia). Start with the needle under the lesion (greater depth is less painful) and then give the last amount of anesthesia closer to the skin surface. If the lesion is flat, consider raising the lesion some with the anesthesia (Figure 9-12A).

CUTTING THE SHAVE BIOPSY

Using a Razor Blade

See video on the DVD for further learning. 

•Determine how you will use your forceps or other hand to stabilize the lesion to keep it from moving during the shave.

•Grasp one end of the razor blade between the thumb and the second and third fingers of your dominant hand, creating a gentle bend in the blade (Figure 9-12B). Place the blade on the skin surface and gently advance it into the lesion while moving the blade in a side-to-side fashion. Do not bend the blade too much to avoid causing an indentation in the middle of the shave. Ideally, the blade should be mostly flat in the area of the shave.

•Apply gentle forward pressure during this side-to- side sawing motion and allow the blade to move through the lesion without excess pressure. With the bare razor blade you may need to put one finger against the back of the blade to push it forward when the lesion is firm. Watch each side of the blade to make sure that it is cutting where you intend to cut.

•On some specimens, there is a tendency for the specimen to flip over at the end of the biopsy. If needed use the forceps or the stick-end of a CTA to stabilize the specimen for the final cut.

•Obtain hemostasis with aluminum chloride on a CTA (Figure 9-12C). Do not make the CTA too wet with aluminum chloride and use downward pressure with a twisting motion to get the best hemostasis. Occasionally a very vascular lesion will require electrocoagulation to obtain hemostasis.

Using a Scalpel Blade

See video on the DVD for further learning. 

•Hold the No. 15 scalpel blade (on or off a blade handle) parallel to the surface of the skin (Figure 9-13).

•Use the middle of the blade while cutting. Watch the scalpel blade on both sides of the lesion so as to remove the lesion in its entirety without affecting normal skin around the lesion.

•Move the blade through the tissue using a minimal sawing movement. The slight sawing motion helps the blade move through the tissue, but too much sawing will produce scalloped edges.

•Use the forceps or stick-end of a CTA to stabilize the specimen for the final cut.

Snip Excision with Scissors

See video on the DVD for further learning. 

Another variation of the shave excision for small raised lesions is the snip excision performed with sharp scissors (Figure 9-14). Anesthesia and hemostasis are executed in the same manner as for the other types of shave excision. The only difference is that the lesion is snipped off with sharp scissors rather than shaved with a blade. Lesions particularly amenable to snip excision are skin tags, small warts, and polypoid nevi. We recommend using a good pair of sharp iris scissors (straight or curved). Small lesions may be snipped without anesthesia, but larger lesions should be anesthetized with 1% lidocaine and epinephrine. The lesion is grasped with forceps and cut at the base with the scissors. The crushing effect of the scissor on the soft tissue helps to prevent bleeding. Additional hemostasis can be achieved with aluminum chloride or electrosurgery.

Electrosurgical Shave

See video on the DVD for further learning. 

A loop electrode may be used to perform an electrosurgical shave (Figure 9-15). The loop electrode can be

used to feather the remaining tissue and sculpt a nice result. One downside is that there will be burn artifact on the biopsy specimen. Also, if the lesion is caused by human papillomavirus (HPV), there is a very small risk of transmission of the HPV by the plume. Whether the instrument is set on cut only or cut and coag, it is important to not use too much power, which can result in unnecessary tissue destruction leading to increased scarring. (Also see Chapter 14, Electrosurgery.)

Scoop Shave (Deep-Shave

Saucerization Technique)

A saucerization technique involves the removal of the lesion using a deep shave or scoop technique with 1 to 2 mm of surrounding normal skin laterally and extending into the deep dermis (Figure 9-16).5 For thin and small-diameter melanocytic lesions, a scoop shave can remove the entire lesion.5 The National Comprehensive Cancer Network (NCCN) recommendations suggest

FIGURE 9-15  The use of a radio-frequency electrosurgical loop to perform a shave excision of a benign intradermal nevus. Note the two areas where two other nevi had been excised using this method with some mild feathering for an optimal cosmetic result. (Copyright Richard P. Usatine, MD.)

FIGURE 9-14  Snip excision of a skin tag. The scissor crushes the base and helps achieve quick hemostasis. (Copyright Richard P. Usatine, MD.)

FIGURE 9-16  Scoop shave of a dysplastic nevus that was not fully excised with the initial shave. (Copyright Richard P. Usatine, MD.)

deep-shave biopsies be used when the index of suspicion for melanoma is low.5 However, a deep-shave biopsy can also be performed for suspected melanoma in certain circumstances (see Chapter 8, Choosing the Biopsy Type).

It is easier to do a scoop shave with a DermaBlade or other razor blade than a scalpel. Start by marking the area to be cut, including the planned margin. If the lesion is suspected to be a dysplastic nevus, mark a 2-mm margin around the edge of the pigment. Direct the blade downward at an angle of 30 to 45 degrees with the skin to get underneath the pigment. Continue the shave straight across the base and come upward, leaving another 2 mm from the edge of the pigment. The scoop shave should go into the deep dermis. If a full-thickness biopsy is to be performed into the subcutaneous fat, it is suggested that this be performed with an elliptical excision and closed with sutures. If a few small fat globules are visible at the base of the shave, the area can heal well by second intention.

A pigmented lesion on the back suspected to be a superficial spreading melanoma can be easily and safely biopsied with a deep-shave approach (Figure 9-17). The scoop shave using a razor blade of the thickest pigmented area produces a good specimen for diagnosis of melanoma. (Breslow’s thickness of 0.6 mm was obtained in Figure 9-7.) In Figure 9-17 note how the shave went completely under the pigment and the depth information was not lost. If pigment were to be found below the shave, a deeper shave or full-thickness incisional biopsy could be performed of the remaining lesion.

When performing a deep scoop shave to remove a nonmelanoma skin cancer, it is appropriate to cut down deep enough so that small fat globules will be visible (Figure 9-18). If all margins are clear this can serve as the definitive treatment for less aggressive non­ melanoma skin cancers such as superficial or nodular BCCs (not sclerosing) or SCC in situ. This method is not recommended for skin cancers larger than 2 cm or in danger areas around vital structures. Definitive

treatment for invasive SCC and melanoma should include a full-thickness excision with appropriate margins. As with all skin cancers, regular examinations need to be done to investigate for recurrence and new cancers. A shave excision of any depth should never be the definitive surgery to treat a melanoma.

Landscape Shave

The landscape shave samples a narrow portion across a large pigmented lesion so that the pathologist is able to compare the symmetry of melanocyte nests in determining the diagnosis. Because this biopsy has a tendency to curl, it may be placed on a Telfa pad, the nonadherent portion of a Band-Aid, or a piece of cardboard before placing it in the formalin. Write that this is a landscape shave on the pathology consult and suggest that the specimen be processed with longitudinal slices rather than bread-loafing along the short axis.

FIGURE 9-18  Deep shave showing a few glistening fat globules.

(Copyright Richard P. Usatine, MD.)

FIGURE 9-19  The forceps stabilize the raised lesion while the shave is performed. This cutaneous horn on the arm turned out to be a growth associated with a SCC. (Copyright Richard P. Usatine, MD.)

FIGURE 9-21  Shave biopsy with the end of a CTA stabilizing the lesion from flipping over, which can make it difficult to finish the final cut. (Copyright Richard P. Usatine, MD.)

Stabilization Techniques

Lesions should be stabilized during the shave biopsy to maximize the control during cutting. In Figure 9-19, forceps are used, and in Figure 9-20, the skin is pinched because the lesion is very flat. Note how the fingers of the nondominant hand are kept in the biopsy area to provide gentle countertraction and to stabilize the tissue. On certain areas of thin skin near vital structures such as the eye or hand, it may be necessary to pinch and elevate the surrounding skin with one hand while doing the biopsy with the other. The end of a CTA is useful for preventing the lesion from flipping over near the final portion of the cut (Figure 9-21). Raising a flat lesion with anesthetic just prior to excision can help stabilize the lesion but may increase the risk of indentation. Regardless of which method is used, it is important to not pull up on the lesion to avoid creating an unintended deep indentation.

FIGURE 9-20  The start of this shave biopsy is stabilized by pinching the skin between the thumb and index finger of the nondominant hand. Once the shave is begun the fingers can be removed away from the blade. Care must be taken to avoid cutting oneself. (Copyright Richard P. Usatine, MD.)

Hemostasis

Many shave biopsies can be performed within a minute after the injection of lidocaine and epinephrine. If the lesion is a very vascular (pyogenic granuloma) or the biopsy site is very vascular (such as the lip), it is best to wait 10 minutes for the epinephrine to take full effect (9-2). If enough time has elapsed between the administration of anesthesia and the start of the biopsy, the procedure can be virtually bloodless.

After the biopsy, blot the site with a dry cottontipped applicator or gauze to remove any pooled blood. Then roll and twist another CTA that has been dipped in aluminum chloride back and forth over the site. Apply downward pressure with the twisting applicator to stop the bleeding (Figure 9-12C). It is important to not leave wet blood in the field because this will dilute the aluminum chloride and minimize its effectiveness. Monsel’s solution (ferric subsulfate) may be used instead of aluminum chloride but it has a slight risk of tattooing the skin. If chemical hemostasis does not stop the bleeding or if it is desirable to destroy any remaining tissue then electrosurgery may be used (see Chapter 4,

Hemostasis).

Remaining Tissue after Shave Biopsy

Remaining tissue is often found at the trailing edge of the lesion where the blade finished the shave. First obtain hemostasis and then cut the remaining tissue off with your blade. If the tissue is too small to stabilize for a second cut, options to remove the remaining tissue include scraping with the blade perpendicular to the skin or using a curette or electrodesiccation (Figure 9-22). If using electrodesiccation, the charred tissue may be left alone or wiped away with a moist gauze pad or a curette.

Aftercare

After the procedure is complete, place a small amount of clean petrolatum and an adhesive bandage over the