Excisional Biopsy

Anatomy and Physiology

Proper perioperative planning is essential to minimize complications and achieve optimal cosmetic outcomes in excisional biopsies. Clinicians should carefully evaluate cutaneous landmarks, cosmetic units, and relaxed skin tension lines (RSTLs) when determining the biopsy site. Aligning incisions with RSTLs, which reflect the natural orientation of dermal collagen fibers, helps reduce scarring and enhances cosmetic results. Identifying RSTLs can be achieved by applying gentle skin compression and tension or observing natural movements, such as joint articulation or facial expressions, to reveal natural tension lines.[2] This strategic alignment ensures the resultant scar follows natural contours, improving functional and aesthetic outcomes.[3]

Indications

Excisional biopsies are indicated in several clinical scenarios where accurate diagnosis and comprehensive histopathologic evaluation are required. They are particularly valuable for lesions in which architectural features are essential for diagnosis, such as suspicious pigmented lesions, atypical neoplasms, or inflammatory skin conditions. The technique is also appropriate for deep dermal or subcutaneous lesions, where sampling the full depth of the lesion is necessary to obtain definitive diagnostic information.

Regarding melanoma, excisional biopsy is the recommended method for initial evaluation due to its ability to provide diagnostic and prognostic information, including the critical measurement of Breslow thickness.[4][5][6] This information guides staging and informs further management strategies, such as sentinel lymph node biopsy or wider excision.[7][8] Excisional biopsy is also preferred for lesions with atypical clinical presentations that may be inadequately characterized by shave or punch biopsy techniques. By offering a complete assessment of the lesion's depth and architectural features, excisional biopsy ensures optimal diagnostic accuracy and helps to tailor treatment plans.

Contraindications

Excisional biopsy is a valuable diagnostic tool, but its use requires careful consideration of contraindications and the choice of biopsy site to minimize complications and optimize outcomes. Contraindications can be patient-related, such as coagulopathy, local infection, or severe comorbidities like uncontrolled diabetes or immunosuppression, which increase the risk of bleeding, poor healing, and infection. Lesion-related factors, including large or complex lesions near vital structures or those in cosmetically sensitive areas, may also preclude excisional biopsy. Procedural limitations, such as inaccessible lesions or the urgency of diagnosis, may necessitate alternative approaches like punch or core needle biopsy.

The choice of biopsy site is equally critical. While excisional biopsies are generally performed on the trunk and limbs, sites below the knee, the central face, or the ventral forearm carry higher risks of infection, poor healing, or undesirable cosmetic outcomes.[2][9] For example, surgical sites on the back are prone to stretching and deforming. Advances like Mohs micrographic surgery have expanded the use of excisional biopsies in dermatology, enabling precise tissue removal with minimal margins and better cosmetic results.[10] By carefully considering these factors, clinicians can enhance diagnostic accuracy, patient safety, and aesthetic outcomes.

Equipment

Performing an excisional biopsy requires careful preparation of appropriate equipment to ensure patient safety, diagnostic accuracy, and optimal cosmetic outcomes. The following is a list of necessary items:

• Scalpel
• Surgical scissors
• Tissue forceps (usually Adson forceps) 
• Hemostats
• Sutures
• Needles
• Local anesthetic
• Syringes and needles (25- to 30-gauge needles for injecting the local anesthetic)
• Drapes 
• Gloves 
• Sterile gauze and bandages
• Electrocautery or silver nitrate sticks
• Specimen container
• Marking pen

Personnel

Depending on the location of the site of interest, excisional biopsies can typically be performed by a sole clinician. However, a surgical assistant may assist and increase efficiency by providing materials, maintaining a clean surgical field, and cutting sutures at closure time. Multidisciplinary collaboration is often beneficial, particularly when the lesion is complex or if Mohs micrographic surgery is considered. In such cases, the involvement of a dermatopathologist during surgery can assist with immediate histological assessment, allowing for real-time decision-making.

Preparation

Surgical mapping for an excisional biopsy involves identifying the lesion of interest and marking the area around the lesion with a surgical marker, including an appropriate margin around the lesion to ensure complete removal. As described above, 2 small triangles are drawn on either side of the lesion in the predetermined orientation of the surgical excision. The resultant shape is an ellipse with an ideal length-to-width ratio of 3:1.[10] This design is intended to reduce or eliminate redundant tissue at either end of the excision, preventing dog formation upon closure of the surgical site. The resultant scar should be long, thin, and linear, following the skin's natural contours.

Local anesthesia is the most common form of anesthesia in cutaneous biopsies. Injection of local anesthesia is often a source of great anxiety for the patient and should be handled gently. Lidocaine, with or without epinephrine, is commonly used in dermatologic surgery. Adding epinephrine aids in decreasing bleeding, prolonging anesthetic effects, and reducing anesthetic toxicity. Additionally, buffering the anesthetic with sodium bicarbonate helps decrease the pain associated with infiltrating the acidic solution.[11] Using a small needle gauge, gently pinching the area to be injected, and avoiding multiple needle sticks through the epidermis also reduce patient discomfort. Local infiltration is achieved by injecting slowly intradermally or subcutaneously. While the onset of action of local anesthetics is almost immediate, full vasoconstriction provided by adding epinephrine requires up to 15 minutes.[11]

After administering anesthesia, the patient is placed in a comfortable position with good surgical lighting and at the surgeon's appropriate height. The surgical site is then prepped with antiseptic and draped. Popular agents used in antiseptic preparation include povidone-iodine and chlorhexidine. Special care should be taken in hair-bearing areas, such as clipping hair in the surgical field or securing hair with sterile clips, rubber bands, or tape.

The surgeon should thoroughly wash and dry their hands before the procedure. A formal surgical hand scrub is unnecessary as prudent and simple hand antisepsis is sufficient. Face masks can be worn as personal protective equipment but are unnecessary in dermatologic surgery. Surgical gloves should be worn and kept clean throughout the procedure. The need for sterile gloves in dermatologic surgery remains a topic of interest. Still, recent literature reports no significant difference in surgical site infections when comparing sterile and clean surgical gloves.[12]

Technique or Treatment

Start the incision with the point of the blade contacting the apex of the ellipse. Then, use the sharper belly of the blade to carry the cut along the arc in a smooth and directed fashion while maintaining traction of the surrounding area with the nondominant hand. Repeat the same process on the other side of the lesion. Mark the tissue with a nondissolvable suture or by nicking a specified location of the excision while in situ or after completely removing the tissue. Use toothed forceps to grasp and elevate the tissue at the apex while dissecting the tissue at the level of the subcutis with a scalpel or blunt-tipped scissors. Care should be taken to dissect the tissue along an even plane, yielding a defect with an even base and smooth walls.[10]

Hemostasis can be achieved with direct pressure or by cautery. While heat cautery works in a wet field, electric cautery only works in a dry field. Blotting with a gauze or cotton-tipped applicator helps to maintain a dry field for electric cautery. Larger vessels may require ligation with absorbable sutures.[2] Careful undermining with sharp or blunt techniques may assist in approximating wound edges or minimizing tension on the wound. Always remain mindful of the surrounding anatomy to avoid complications.

A layered closure consists of absorbable deep sutures and nonabsorbable superficial sutures. Deep sutures eliminate dead space, decrease tension on the wound edges of the dermis and epidermis, and facilitate wound edge eversion. If there is little tension on the wound, place the first deep suture in the center of the lesion and the remaining deep sutures halfway between the middle suture and the apices of the lesion. The distance between deep sutures is then progressively halved. If there is tension on the wound, place the deep sutures at the apices of the lesion and then incrementally closer to the center of the lesion. This method helps reduce the amount of tension as the deep sutures are progressively placed.[2] The buried sutures most commonly utilized in excisional biopsies are the buried vertical and horizontal mattress sutures.[10]

Once the deep layer is secured, superficial sutures are placed to approximate the epidermal wound edges. This is done with nonabsorbable sutures that require removal after the wound is given time to heal, usually 1 to 2 weeks. If the wound is not under tension and there is a good epidermal approximation, adhesive tapes or tissue adhesive may be used instead of superficial sutures.[10][13]

Complications

Complications of excisional biopsy are rare but can include:

• Bleeding
  • This is the most common intraoperative concern, and if inadequately managed, it may result in a postoperative hematoma.[14] Hemostasis during surgery and applying pressure dressings or ice afterward can minimize this risk. Persistent bleeding may require additional interventions, including sutures or cautery.
• Hematoma
  • Hematoma formation can occur if bleeding is not adequately controlled. This risk can be reduced by meticulous intraoperative hemostasis and postoperative care, such as applying pressure dressings and advising the patient to avoid vigorous physical activity.
• Surgical site infections
  • These are relatively uncommon and largely dependent on the patient’s adherence to proper wound care. Patients should be instructed to clean the wound daily, apply appropriate dressings, and change bandages. High-risk patients, such as those who are immunocompromised, may benefit from prophylactic antibiotics to reduce the risk of infection.[12]
• Nerve damage
  • This potential complication can occur if the biopsy is performed near sensory or motor nerves. To minimize this risk, clinicians must thoroughly understand local anatomy and use meticulous techniques to avoid excessive undermining or deep dissection.

By implementing proper perioperative strategies and educating patients on postoperative care, clinicians can significantly reduce the likelihood of these complications and promote optimal healing.

Clinical Significance

Excisional biopsies are a cornerstone of diagnostic and therapeutic dermatology, oncology, and general surgery interventions. Their clinical significance lies in their ability to provide a complete histopathologic evaluation of a lesion, which is essential for accurate diagnosis, staging, and treatment planning. Unlike other biopsy techniques, excisional biopsies remove the entire lesion, allowing pathologists to assess architectural features and margins in their entirety. This is particularly valuable for diagnosing malignancies, such as melanoma, where assessing depth (eg, Breslow thickness) and other pathological parameters informs prognosis and guides surgical and adjuvant treatment strategies.

Beyond malignancy, excisional biopsies are integral in diagnosing dermal lesions, inflammatory dermatoses, cutaneous and subcutaneous tumors, and atypical lesions that require comprehensive evaluation.[15] They also provide therapeutic benefits by entirely removing symptomatic, cosmetically distressing, or precancerous lesions. In addition, the technique supports personalized care, as it allows for molecular and genetic testing, which can influence targeted therapies in conditions such as lymphoma or sarcoma. From a clinical perspective, excisional biopsies are safe, cost-effective, and definitive diagnostic procedures. When performed with meticulous technique and appropriate perioperative planning, they yield high diagnostic accuracy, improve patient outcomes, and enhance clinician confidence in managing complex lesions.

Enhancing Healthcare Team Outcomes

An excisional biopsy requires a multidisciplinary approach to optimize patient-centered care, safety, and outcomes. Clinicians must master technical skills, including precise incision, tissue handling, and layered wound closure. At the same time, nurses ensure patient preparation, maintain aseptic conditions, and provide postoperative wound care education. Pharmacists provide support by recommending appropriate local anesthetics, prophylactic antibiotics for high-risk patients, and postoperative pain management. Strategic preoperative planning, including lesion site selection and patient counseling, aligns diagnostic and cosmetic goals, reducing procedural risks and enhancing outcomes.

Effective interprofessional communication and care coordination are essential. Accurate documentation and information-sharing allow team members to address patient-specific needs, from scheduling follow-ups to promptly managing complications. Any concerning findings should be communicated in the medical record and directly, if appropriate, between clinicians.[16] Clear communication fosters shared decision-making and patient engagement, enhancing satisfaction and adherence to care plans. By working collaboratively, the team ensures a seamless process, improving procedural efficiency, minimizing complications, and promoting optimal healing. This integrative approach aligns with evidence-based practices and supports a culture of safety and excellence in patient care.

Nursing, Allied Health, and Interprofessional Team Interventions

Nursing and allied healthcare professionals are essential in caring for patients undergoing excisional biopsy procedures. Nurses should educate patients on wound care, including instructions for dressing changes, signs of infection, and when to seek medical advice. Additionally, nurses must support the patient through emotional and psychological aspects, especially in cases of skin cancer or other serious conditions. Allied healthcare professionals, such as wound care specialists, may be consulted for complex cases or to optimize postoperative recovery. Interprofessional collaboration is critical in monitoring patients for potential complications such as infection, excessive scarring, or delayed wound healing. Early identification and intervention can prevent severe complications and ensure patients heal with minimal cosmetic impact.

Nursing, Allied Health, and Interprofessional Team Monitoring

Postprocedure monitoring is critical to ensure optimal healing and identify early signs of complications. Patients should be monitored for signs of infection, including redness, swelling, warmth, or purulent drainage. In high-risk patients, monitoring may be more intensive, including checking for systemic signs of infection or complications such as hematoma formation.

The interprofessional team should work together to monitor the biopsy results and follow-up care. Nurses, pathologists, and the primary care team must ensure that follow-up appointments are scheduled and patients are promptly informed of their results. Coordinated care helps provide patients with clear instructions on caring for the wound at home while healthcare professionals address any concerns or complications.