The Shave Biopsy

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9 The Shave Biopsy

The shave biopsy is one of the most useful approaches for obtaining tissue for diagnostic purposes and for the removal of benign surface neoplasms. It is especially fast, easy, and effective when the lesion is raised above the skin surface. The shave biopsy is also valuable for diagnosing many cutaneous malignancies, including basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs). It is also an effective tool for removing benign lesions such as intradermal nevi and seborrheic keratoses. After a shave biopsy, hemostasis is easily obtained with aluminum chloride. The surface is allowed to heal naturally, and no sutures are needed. The excision site usually heals well with a good cosmetic result.

Indications

The following lesions are among those that are frequently diagnosed by shave biopsy:

• BCC (Figure 9-1)

• SCC (Figure 9-2)

• Keratoacanthoma (KA) (Figure 9-3)

• Dysplastic nevus (Figure 9-4).

FIGURE 9-1 Elevated pearly lesion in the nasolabial fold with telangiectasias. A shave biopsy is performed to rule out a BCC.

(Copyright Richard P. Usatine, MD.)

FIGURE 9-2 Shave biopsy of SCC on the lip.

(Copyright Richard P. Usatine, MD.)

FIGURE 9-3 A keratoacanthoma on face is appropriate for a shave biopsy.

(Copyright Richard P. Usatine, MD.)

FIGURE 9-4 Dysplastic nevus can be shaved with a deep shave for diagnosis and treatment.

(Copyright Richard P. Usatine, MD.)

Shave excision can also be used to remove the following benign lesions:

• Benign melanocytic nevus

• Seborrheic keratosis (Figure 9-5)

• Sebaceous hyperplasia

• Pyogenic granuloma (PG) (Figure 9-6)

• Skin tag with a broad base

• Single large wart

• Neurofibroma.

FIGURE 9-5 Shave excision of a verrucous-appearing seborrheic keratosis on the forehead.

(Copyright Richard P. Usatine, MD.)

FIGURE 9-6 Shave biopsy of PG on finger.

(Copyright Richard P. Usatine, MD.)

When a pigmented lesion appears to be benign and its removal is for cosmetic reasons, it is acceptable to use a shave excision. However, it is essential to send biopsies of all potentially suspicious lesions for review by a pathologist. A typical skin tag does not need to be sent to pathology.

Contraindications

There are no contraindications for shave biopsy based on location of the lesion. The use of a shave biopsy to diagnose a melanoma is controversial with a wide range of opinions. A superficial shave biopsy of a suspected melanoma runs the risk of losing important depth information used for staging and margin determination. However, if the melanoma is thin and the shave biopsy gets below the tumor, then nothing is lost. On the other hand, if a punch biopsy is performed of a large lesion and the punch misses the area with melanoma, this false-negative result can lead to missing the diagnosis of the melanoma. Although doing a complete full-thickness biopsy of a small suspected melanoma is optimal, this may be too deforming for a large superficial pigmented lesion on the face that might possibly be lentigo maligna melanoma (LMM) but appears more consistent with a solar lentigo (Figure 9-7). A broad scoop shave biopsy of LMM (Figure 9-8) may give a better tissue sample than one or more punch biopsies and will not cause the cosmetic deformities of a large full-thickness biopsy. It is also common practice to use a broad scoop shave to remove an atypical mole suspected of being a dysplastic nevus.

FIGURE 9-7 Solar lentigo.

(Copyright Richard P. Usatine, MD.)

FIGURE 9-8 Lentigo maligna melanoma.

(Copyright Richard P. Usatine, MD.)

In reality, the biopsy type is based on suspected diagnosis, size, location, patient preferences, and time considerations. It is better to diagnose a melanoma by shave biopsy than to lose a patient with melanoma to follow-up because you did not have the time to do an elliptical biopsy.

Advantages of A Shave Biopsy

The advantages of a shave biopsy can be broken down into two categories: those that are related to the clinician and those that are related to the patient. Advantages of a shave biopsy for the clinician include the following:

• Can be performed rapidly.

• Sutures are not needed.

• Procedure is relatively easy to learn.

• Multiple lesions can be easily excised at one time.

• An assistant is not required.

• Strict sterile procedure is not required.

The following advantages of a shave biopsy benefit the patient:

• There are no sutures that need to be removed.

• Wound care is usually simple.

• Restriction of activities is not needed during wound healing.

• The risks of infection and bleeding are reduced.

• It may give a better cosmetic result than a full-thickness excision.

• Even if a change in pigmentation occurs, it is easily covered by cosmetics.

A number of studies have shown the shave biopsy to produce a better cosmetic result than the punch biopsy and the fusiform diagnostic excision.¹^–³

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.

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 cotton-tipped 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 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.

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.)

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

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).

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.)

FIGURE 9-12 Pigmented lesion subjected to a shave biopsy to confirm clinical impression of seborrheic keratosis and rule out melanoma: (A) Anesthesia is given. (B) Shave is performed. (C) Aluminum chloride is used to stop any bleeding.

(Copyright Richard P. Usatine, MD.)

Cutting the Shave Biopsy

Using a Razor Blade

• 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

• 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.

FIGURE 9-13 Shave biopsies with a scalpel in tight places where a small No. 15 scalpel blade is easier to maneuver than a larger razor blade: (A) Shave of pigmented lesion on nose. Path showed SK. (B) Shave of nonpigmented lesion in ear. Path showed an actinic keratosis.

(Copyright Richard P. Usatine, MD.)

Snip Excision with Scissors

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.

FIGURE 9-14 Snip excision of a skin tag. The scissor crushes the base and helps achieve quick hemostasis.

(Copyright Richard P. Usatine, MD.)

Electrosurgical Shave

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.)

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.)

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 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).

FIGURE 9-16 Scoop shave of a dysplastic nevus that was not fully excised with the initial shave.

(Copyright Richard P. Usatine, MD.)

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.

FIGURE 9-17 (A) Pigmented lesion on the back suspected to be a superficial spreading melanoma. (B) The scoop shave using a DermaBlade of most of the highly pigmented area produced a good specimen for diagnosis of melanoma (Breslow’s thickness of 0.6 mm). Note how the shave went completely under the pigmented lesion 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. In most cases it is best to shave off the entire lesion to reduce the risk of sampling error.

(Copyright Richard P. Usatine, MD.)

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 nonmelanoma 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.

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

(Copyright Richard P. Usatine, MD.)

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.

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 9-19 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 9-20 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.)

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.)

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 cotton-tipped 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.

FIGURE 9-22 The Hyfrecator is used to destroy some remaining tissue on the edge of the excision. Note that the original hemostasis was obtained with aluminum chloride to minimize potential scarring that is more likely to occur with electrosurgery of the entire excision site.

(Copyright Richard P. Usatine, MD.)

Aftercare

After the procedure is complete, place a small amount of clean petrolatum and an adhesive bandage over the biopsy site and give the patient wound care instructions. See the patient handout titled Care of Your Skin after a Shave Biopsy in Appendix A.

Pathology and Follow-Up

Send all pigmented lesions and any lesion suspicious for cancer to the pathologist. Skin tags may not need to be sent if these are typical and benign in their appearance. If the pathologist reports that the lesion appears benign, does not have atypical features, but is incompletely excised, there is usually no need to do a further or deeper excision. However, if the pathologist recommends further excision because of suspicion for malignancy or there is a chance of malignant transformation, this recommendation must be followed.

If the lesion is premalignant (such as an actinic keratosis), it should be reexamined after it fully heals. If there is remaining scaling or evidence of the original lesion, it may be treated with cryotherapy instead of doing another excision.

If the lesion turns out to be nonmelanoma skin cancer (NMSC), definitive treatment will be necessary unless the original biopsy was deep and the pathologist unambiguously states that there are clear margins. If you intend to remove a whole BCC or SCC in situ with a shave excision using a deeper and broader approach, and your pathologist reports clear margins, you may give the patient the choice to not have additional surgery. Always perform full-thickness excisions for sclerosing, micronodular or infiltrating BCCs and invasive SCC (see Chapter 34, Diagnosis and Treatment of Malignant and Premalignant Lesions).

Suggestion for Learning the Shave Biopsy Technique

When learning the shave biopsy technique, it may be helpful to practice on an orange. Use a razor blade or No. 15 blade and attempt to remove portions of the outer skin without encroaching on the underlying pulp (Figure 9-23). Practice performing the shave at different depths and sizes.

FIGURE 9-23 The skin of an orange provides a good practice medium for the shave biopsy.

(Copyright Richard P. Usatine, MD.)

Less Than Optimal Outcomes

Infections are rare complications of shave biopsies.

Expected but less than optimal outcomes that often occur after shave biopsies include the following:

• Producing an indentation or divot in the skin. This is expected after a scoop shave. Also this is more common in a shave done on a convex surface such as the nose (Figure 9-24).

• Erythema that may last for months and often resolves.

• Slow healing for deeper shaves and areas such as the lower leg.

• Hypopigmentation or hyperpigmentation that can be permanent (Figure 9-25).

• Regrowth of incompletely excised lesion. Pigment developing at the site of a nevus removed by shave biopsy is common (Figure 9-26).

FIGURE 9-24 Shave biopsy of a suspected BCC on the nose. Note how the nose is held between the fingers to stabilize it for the shave biopsy. An indentation would be acceptable cosmetically because the likelihood of skin cancer was high and the patient would need a second procedure to eradicate the BCC. This patient received Mohs surgery after the biopsy proved the lesion to be a BCC.

(Copyright Richard P. Usatine, MD.)

FIGURE 9-25 Hypopigmentation that occurred after a shave biopsy of a basal cell carcinoma on the face. The patient did not return for definitive surgery after the biopsy was made with a DermaBlade, but no further tumor growth occurred over the following year and the shave biopsy site was hypopigmented but appeared tumor free. The patient preferred watchful waiting and no further surgery.

(Copyright Richard P. Usatine, MD.)

FIGURE 9-26 Pigment that returned after the shave biopsy of an intradermal nevus.

(Copyright Richard P. Usatine, MD.)

Serious complications are extremely rare after a shave biopsy.

After shave biopsy, erythema may persist for months, and hypopigmentation may be permanent in some individuals. In the case of melanocytic nevi some will regrow after removal by this technique. In nevi with hair, the hair may regrow if the nevus is excised with a shave biopsy alone. This type of nevus may be best removed with a deeper elliptical excision. Alternatively, the hair follicles remaining after a shave biopsy may be destroyed with electrosurgery.

Cosmetic Results

Gambichler et al.⁴ examined the cosmetic outcome of macular melanocytic lesions utilizing the deep-shave biopsy technique with a razor blade followed by chemical hemostasis. During routine skin cancer screening 45 patients with 77 macular melanocytic nevi were prospectively recruited. Histologically, 88% of the melanocytic lesions were described as completely excised and 60% were diagnosed as atypical melanocytic nevi. At 6 months, 56 sites were available for evaluation and mild hypopigmentation was observed in 52%, hyperpigmentation in 32%, and erythema in 23%. Recurrent nevi occurred in 13% at 6 months. The evaluation of the cosmetic outcome by the patients was better than the evaluation by the physician.⁴

In another prospective study, shave excision of 204 common acquired melanocytic nevi was performed.⁶ Mid-dermal shave biopsies were performed using a No. 15 blade followed by gentle electrocoagulation. Three months after surgery, cosmetically excellent results occurred in 33% of the patients, acceptable results in 59%, and poor results in 8% as assessed by two dermatologists. The likelihood of having an imperceptible scar was significantly greater in lesions excised from the face. Of 192 patients surveyed, 98% stated that “the scar looked better than the original mole” and would undergo the procedure again. Clinical and dermatoscopic recurrences were observed in 19.6% of the scars.⁶

Our experience is that shave excisions heal with less scarring than electrodesiccation and curettage (ED&C), which often leads to hypertrophic scarring.

Making A Diagnosis

It helps to have a good idea of the differential diagnosis before choosing the biopsy type and location. For most shave biopsies, a clinician should excise the whole lesion or sample the portion of the lesion that appears to have the worst pathology. However, for bullous disorders such as pemphigus or pemphigoid, it is best to use a scoop shave under an intact bulla or at the border of a bulla. A punch biopsy at the border of the bulla may yield an equally good specimen. Both methods help to keep the epidermis attached to the dermis at the edge of the bulla.

Additional Examples for Shave Biopsy

Basal Cell Carcinomas

In Figure 9-27, a shave biopsy is preferred on the nasal ala rather than a punch biopsy. After the diagnosis was made, this patient was referred for Mohs surgery. One study showed that specimens from punch and shave biopsies of suspected BCCs produced equivalent diagnostic accuracy rates: 80.7% and 75.9%, respectively. Either biopsy technique is appropriate for a BCC.⁷ The woman in Figure 9-28 has had multiple BCCs and had chosen to have a shave excision of a small BCC on her cheek. A previous biopsy had proven the diagnosis and she wanted less invasive surgery than a full elliptical excision. The margins were clear and the area healed with minimal scarring.

FIGURE 9-27 For a BCC on nasal ala, a shave biopsy is preferred over a punch biopsy.

(Copyright Richard P. Usatine, MD.)

FIGURE 9-28 Shave excision of a small BCC on the cheek. A previous biopsy had proven the diagnosis and the patient wanted less invasive surgery than a full elliptical excision. The margins were clear and the area healed with minimal scarring.

(Copyright Richard P. Usatine, MD.)

Pyogenic Granuloma

Most pyogenic granulomas are easy to distinguish based on their clinical appearance and behavior. The rare amelanotic melanoma can appear similar to a pyogenic granuloma. Thus, it is best to send all suspected pyogenic granulomas for histologic confirmation. The easiest way to do this is to do an initial shave excision before performing ED&C of the base of the pyogenic granuloma. In Figure 9-29 an electrosurgical loop is being used for the initial shave biopsy. This could easily be done with a razor blade. Most importantly the remaining tissue is curetted and the base is treated with electrodesiccation. See Chapter 33, Procedures to Treat Benign Conditions.

FIGURE 9-29 Electrosurgical shave of PG on a finger. This is followed by curettage and electrodesiccation of the base to stop bleeding and prevent regrowth.

(Copyright Richard P. Usatine, MD.)

Psoriasis

Psoriasis is frequently a diagnosis made on clinical appearance and history only. Sometimes psoriasis presents in an atypical pattern and a biopsy is needed to make the diagnosis. The patient in Figure 9-30 developed a rash on his penis and had no other skin findings. A shave biopsy of the lesion allowed the diagnosis of psoriasis to be made. While a punch biopsy would have provided adequate tissue, greater risks are involved in a punch biopsy of the penis. Having a definitive diagnosis was helpful to guide treatment of this disturbing eruption.

FIGURE 9-30 A shave biopsy of a plaque on this penis demonstrated psoriasis.

(Copyright Richard P. Usatine, MD.)

Coding and Billing Pearls

The shave procedure is either used as a form of biopsy and billed under the biopsy codes or used to fully excise a lesion that is benign and then billed under the shave excision codes. It can be confusing sometimes to decide whether the procedure is a “biopsy” or “excision.” Clear-cut examples of shave biopsies include sampling a possible skin cancer or removing a piece of skin to determine the cause of an unknown rash. Shave excisions are those procedures that are used to remove a benign nevus, a seborrheic keratosis, or another benign lesion. The intent is to excise the whole lesion, and even though it is recommended that all pigmented lesions be sent for confirmatory pathologic diagnosis, the primary reason for the procedure was not a “biopsy” but a removal of the lesion itself. Make sure that the documentation is consistent with the procedure that is billed. If the shave is done as a biopsy, call it a shave biopsy, but if the shave is done as an excision, call it a shave excision or just an excision.

CPT codes and fees for shave biopsies are summarized in Table 38-7 of Chapter 38, Surviving Financially. Note that, although these codes cover shave biopsies, they also cover biopsies done by punch or curette. The codes are based on location only and not on the size of the biopsy or lesion. The codes are also independent of whether the lesion turns out to be benign or malignant, so there is no need to wait for the pathology result to submit the bill.

Selected CPT codes and fees for shave excisions are provided in Table 38-10 of Chapter 38. These codes are based on size and location, so it is crucial to measure the lesion before excising it. Do not estimate the size later because estimates are usually rounded to the nearest centimeter and the reimbursement goes up 0.1 cm above each rounded number (e.g., payment is greater for a shave excision of a 1.1-cm lesion than a 1.0-cm lesion). Location also matters but these codes are generally used for benign lesions rather than skin cancers. Most skin cancers will be excised deeply or destroyed and there are codes specific to these procedures on malignant lesions.