What are the steps involved in a shave biopsy procedure?

Shave Biopsy Procedure Steps

A shave biopsy should be performed using a deep shave/saucerization technique that extends into the deep papillary or superficial reticular dermis to provide adequate tissue sampling while preventing transection at the base of the lesion. 1

Patient Preparation

• Position patient prone or supine depending on the biopsy site (never seated to avoid risk of air embolus or fainting) 1
• Explain and practice breathing technique with patient (avoid deep breaths and coughing during procedure) 1
• Sterilize skin entry site with standardized antiseptic solution 1

Anesthesia Administration

• Infiltrate cutaneous and subcutaneous tissue with lidocaine (up to 20 ml of 2% solution) 1
• Avoid anesthetizing the pleura directly if performing lung biopsy as this increases pneumothorax risk 1
• For superficial skin lesions, local anesthesia should be administered to the area surrounding the lesion 1

Biopsy Technique

1. Select appropriate biopsy site based on clinical characteristics of the lesion 1
2. For deep shave/saucerization:
   • Use a scalpel blade or specialized shave biopsy tool
   • Angle the blade to extend into the deep papillary or superficial reticular dermis
   • Make a smooth, controlled horizontal cut beneath the lesion 1
   • Ensure the entire breadth of the lesion is included with 1-3mm margins 1
   • Achieve sufficient depth to prevent transection at the base 1

Hemostasis

• Apply topical hemostatic agents such as aluminum chloride or ferric subsulfate solution (preferred over electrocautery) 1
• Add topical coagulants (absorbable gelatin) if needed 1
• Spot electrocautery may be necessary to control postprocedural bleeding if hemostatic agents are insufficient 1

Specimen Handling

• Place specimen in appropriate fixative (typically formalin)
• Provide pertinent information to the pathologist, including:
  • Patient demographics
  • Anatomic location
  • Clinical appearance and size
  • History of prior treatment at same site 1
  • Suspected diagnosis 2

Post-Procedure Care

• Apply appropriate dressing (occlusive dressings may promote faster healing and less pain) 3
• Provide wound care instructions to the patient
• Schedule follow-up as appropriate based on suspected diagnosis

Important Considerations

• Superficial shave biopsies may underestimate Breslow thickness for melanoma and are generally discouraged for cutaneous melanoma diagnosis 1
• Exception: For macular lesions suggestive of melanoma in situ (lentigo maligna type), a broad shave biopsy extending into the deep dermis may provide more thorough histologic assessment than multiple punch biopsies 1
• For suspicious pigmented lesions, saucerization biopsy is preferred over superficial shave 4
• Tangential shave biopsy is best suited for small, raised, benign lesions 5
• Saucerization shave biopsy is deeper and appropriate for atypical nevi, squamous and basal cell carcinomas 5

Remember that the choice of biopsy technique should be guided by the clinical characteristics of the lesion, including morphology, expected histologic subtype and depth, anatomic location, and patient factors such as bleeding risk 1.