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  • The biopsy of tissue for histological examination remains one of the most informative and cost-effective tests in medical practice, and one of the most common procedures performed by those caring for patients’ skin.

  • In general, all tissue removed during a surgical procedure should be submitted for histopathologic examination.

  • Ultimately, the key factor in biopsy success is balancing the need for acquiring an adequate sample for histopathologic evaluation with minimizing the cosmetic and functional sequelae of the biopsy itself on the patient.

image Beginner Tips

  • Local anesthesia is a prerequisite for a pain-free biopsy; while patients may rarely request that a biopsy be performed without anesthesia, this should be discouraged, particularly as postbiopsy hemostasis may be more painful than the biopsy itself.

  • Patients should receive written instructions regarding wound care.

  • Shave biopsies are the cornerstone of dermatologic practice, and are useful in most situations when performed appropriately.

image Expert Tips

  • The “excisional biopsy” that is recommended for pigmented lesions suspicious for melanoma includes a deep shave or scoop biopsy.

  • Multiple scouting biopsies may be useful when assessing for lentigo maligna.

image Don’t Forget!

  • When sampling for direct immunofluorescence, a punch biopsy from lower extremity skin should generally be avoided both due to a risk of false-negative results and a slower rate of healing.

  • For alopecia, punch biopsy for transverse (horizontal) and vertical sections should ideally be performed.

image Pitfalls and Cautions

  • Often the greatest risk associated with a biopsy is not performing it at all; in the hands of experienced clinicians, small biopsies yield nearly undetectable scars, and the diagnostic benefits far outweigh the risks.

  • Biopsies from sebaceous skin, such as the nose, may leave pronounced scars that may benefit from later dermabrasion or resurfacing.

image Patient Education Points

  • Most biopsy sites heal very quickly, but patients should understand that surrounding erythema or excess fibrin formation may be seen, particularly in areas that are subject to friction.

  • Preoperative biopsy-site photography may be helpful to reduce the risk of surgical site identification challenges.

image Billing Pearls

  • Biopsy coding is predicated on the assumption that the purpose of tissue removal is for diagnostic purposes.

  • Site-specific biopsy codes should be utilized as appropriate.


The biopsy of tissue for histologic examination remains the most informative and cost-effective test in medical practice and one of the most common procedures performed by clinicians caring for a patient’s skin. A range of biopsy techniques are available to the clinician (Figure 11-1).


  1. A shave biopsy is performed from the breast. Note the three-point traction.

  2. The blade is gently passed through the lesion superficially using a back-and-forth motion.

  3. This continues along the course of the lesion of interest. In general, forceps are not needed for shave biopsies.

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