# Fusiform Excisional Biopsy

## Overview

This module describes how to perform an excisional biopsy.

## Indications

## Contraindications

## Patient information and consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“I need to take a sample of your skin lesion to find out what it is. This method is called an excisional biopsy. I will use a small blade to cut out the whole lesion and close the wound with a few stitches afterwards. It should heal normally, but because people can sometimes form a scar, you need to sign consent for it.”

### What can my patient expect?

“I will give you an injection so that you will not feel me taking the sample. You may feel tugging and working in the area, but it will not be painful. The test results may take a few days

or longer

or longer

Histology often takes 6 weeks for results. If urgent, call the pathologist directly to discuss and expedite.

to come out.”

### What is my patient’s role?

“Let me know if you have any allergies or a bleeding tendency, or use blood thinners. Fearing blood or needles is normal, but tell me if you have fainted from it. Keep still while I take the sample. Afterwards, keep the plaster on for at least a day, and come back to remove the stitches in x days.”

## Preparation

Prepare a trolley with equipment.

### Documentation

### Equipment

## Site and Positioning

The patient should be positioned reclining or supine with the lesion within easy reach.

Always position good lighting on the site.

### Identify Langer Lines

If you do not have a chart indicating Langer lines, you will need to determine in which direction these lines lie at the biopsy site. Pinch the skin at the site, trying in two directions perpendicular to each other. The direction which produces the most wrinkles is the direction of the Langer lines in this area. When performing the biopsy, orientate the long axis of the elliptical incision in line with the Langer lines.

### Incision shape

The incision is elliptical, with 3:1 ratio of length to width, and a 2 mm margin of normal skin around the lesion. A 4 mm margin is required for suspected basal cell carcinomas, and a 5 mm margin for suspected melanoma in situ.

## Procedure

Follow medical asepsis with sterile gloves.

## Troubleshooting

I am unable to approximate the edges of the incision.

The incision might not be long enough. Check the measurements indicated above, and extend the incision if necessary.

The edges of the incision pucker when I approximate them.

There is too much tension on the skin edges. Check that your incision is long enough. If so, you may need to undermine the edges some more.

The skin I am holding with the forceps while undermining is becoming bruised.

Check that you are using non-toothed forceps rather than toothed forceps. Try to apply less force on the forceps, but if this is not possible, place a piece of gauze between the skin and the forceps.

I have nicked a vessel and the bleeding won’t stop with silver nitrate

Most venous oozing stops with pressure. If not, or the bleed is from a visible vessel, clamp the vessel (or the tissue if you are unable to visualise the vessel) with artery forceps in a plane parallel to the skin. Tie an absorbable suture such as chromic under the forceps, asking an assistant to partially release the forceps while you tighten the suture before the assistant tightens their grip again. Make another tie in the suture and ask the assistant to release the forceps, but only secure the knot when you are sure that haemostasis has been achieved. If unsuccessful, perform a figure of eight suture over the area of bleeding.

## Risks

## References