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.)

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.

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.

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.

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.

FIGURE 9-23  The skin of an orange provides a good practice medium for the shave biopsy. (Copyright Richard P. Usatine, MD.)

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.)

•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).

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.

FIGURE 9-26  Pigment that returned after the shave biopsy of an intradermal nevus. (Copyright Richard P. Usatine, MD.)

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

FIGURE 9-27  For a BCC on nasal ala, a shave biopsy is preferred over a punch biopsy. (Copyright Richard P. Usatine, MD.)

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.

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 9-28  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.)

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.

CONCLUSION

The shave biopsy is one of the most useful techniques in dermatologic surgery. It is widely applicable to many skin lesions and can be performed rapidly in the office setting with minimal equipment. Every clinician who performs skin surgery should master this technique.

References

1. Grabski WJ, Salasche SJ, Mulvaney MJ. Razor-blade surgery. J Dermatol Surg Oncol. 1990;16:1121–1126.

2.Harrison PV. Good results after shave excision of benign moles.

J Dermatol Surg Oncol. 1985;11:668, 686.

3.Hudson-Peacock MJ, Bishop J, Lawrence CM. Shave excision of benign papular naevocytic naevi. Br J Plast Surg. 1995;48: 318–322.

4.Gambichler T, Senger E, Rapp S, et al. Deep shave excision of macular melanocytic nevi with the razor blade biopsy technique. Dermatol Surg. 2000;26:662–666.

5.Tran KT, Wright NA, Cockerell CJ. Biopsy of the pigmented lesion—when and how. J Am Acad Dermatol. 2008;59(5):852– 871.

6.Ferrandiz L, Moreno-Ramirez D, Camacho FM. Shave excision of common acquired melanocytic nevi: cosmetic outcome, recurrences, and complications. Dermatol Surg. 2005;31:1112– 1115.

7.Russell EB, Carrington PR, Smoller BR. Basal cell carcinoma: a comparison of shave biopsy versus punch biopsy techniques in subtype diagnosis. J Am Acad Dermatol. 1999;41:69–71.