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Which technique for removing nevi is least scarring?
A shave biopsy with a razor blade or #15 scalpel is the best approach for a facial nevus, assuming malignancy is not suspected. the resulting scar is usually flat, smaller than the lesion, has no suture lines, and—if shaved in mid or upper dermis—has a low risk of producing a hypertrophic or hypotrophic scar (strength of recommendation: C, expert opinion, committee guidelines).
Shave biopsies are quick and well-tolerated
Parul Harsora, MD
University of Texas Southwestern, Dallas
If you suspect malignancy in a nevus, obtain an excisional or incisional biopsy. Shave biopsies are best suited for raised, flesh-colored nevi and are generally quick, well-tolerated, and cost-effective. tissue from a shave biopsy can be submitted for histological evaluation.
Shave biopsies are preferred by patients because there are no sutures and scarring is minimized. the site may be pink and may take several months to develop a normal appearance. the final result may be unnoticeable, or leave an indentation or be hypo- or hyperpigmented.
Hairy, pigmented, and compound nevi are likely to do better with a punch biopsy. to prevent recurrence, seek histologic confirmation that the entire nevus has been removed.
Evidence summary
Numerous reports and guidelines indicate that if a nevus is even slightly suspicious for malignancy, it should be removed by excisional biopsy or sampled for diagnosis by punch or incisional biopsy. There are no randomized controlled trials or cohort studies comparing techniques for removing raised nevi from the face.
Shave biopsy has good outcomes
Expert opinion and individual prospective case series show acceptable outcomes for shave biopsy. One prospective study followed 55 patients after removal of nevi from the head and neck. These nevi were removed using a shave procedure with a#15 scalpel and hot cautery for bleeding. Of the 55 sites, 4 retained pigment and 30 had a visible scar with a mean diameter of 5 mm at 6- to 8-month follow-up.1 The mean diameter of the original lesions was 6 mm. There was no difference between the size of those lesions that scarred and those that didn’t.
Researchers conducting a second retrospective study, done at least 1 year after the procedure, used a questionnaire to ask 76 patients (with a total of 83 nevi removed from the face by shave excision) about their perceptions of the scar.2 Patients described their lesions as: no scar (33%), white and flat (25%), depressed (19%), raised (15%), and pigmented (7%). Eighty-six percent thought their scars looked better than the nevus and 79% were “happy with the way the scar looks now.” Two additional studies, based on both patient and provider perceptions, with similar conclusions, are presented in the (TABLE).3,4
TABLE
Favorable cosmetic results following shave biopsy of facial nevi
| STUDY | NO. PTS/NEVI | % WITH RET AINED PIGMENT OR RECURRENCE | % WITH VISIBLE SCARRING | FOLLOW-UP INTERVAL | EVALUATION/DONE BY |
|---|---|---|---|---|---|
| Hudson-Peacock1 | 55/55 | 13 | 55 | 6-8 mo | Cosmetically acceptable/patients |
| Bong2 | 76/83 | 28 | 67 | ≥1 yr | 86%: better than nevus/patients |
| Zanardini3 | 206/ 215 | 4 | 9 | 3 mo | 90%: excellent* 9%: good/surgeons |
| Ferrandiz4 | Not known/59 | 20† | 67 | 3 mo | 98%: better than nevus/pts; 92%: excellent or acceptable‡/surgeons |
| Excellent=no noticeable scar, good=slightly noticeable scar with normochromia or hypochromia, poor=depressed scar or intense dyschromia. | |||||
| † Some lesions not papular. | |||||
| ‡ Excellent cosmetic result=imperceptible scar without erythema, hyper- or hypo-pigmentation, hypertrophy or atrophy. Acceptable=scar better than original mole. poor=left scar worse than original mole. | |||||
Atypical lesions should be excised
Atypical lesions require excisional biopsy. The depth and architecture of the lesion, if melanoma, cannot be determined by shave biopsy, and both treatment and prognosis depend on those characteristics.
These guidelines derive from well-designed, nonexperimental descriptive studies.5 However, a recent retrospective study compared the Breslow depth determination of 4 different biopsy techniques, performed by experienced dermatologists, with the subsequent depth on definitive surgery for melanoma. This study found that superficial shave, deep shave, and punch biopsy predicted the Breslow depth 88% (95/108) of the time.6 As expected, excisional biopsy predicted the depth 100% (30/30) of the time. The location of the biopsy sites were not reported. The choice of biopsy was influenced by the suspicion of melanoma; thin (< 1 mm) melanomas were more likely to be superficially shaved than deep-shaved or punched.
Recommendations from others
Guidelines on nevocellular nevi from the American Academy of Dermatology recommend a simple excisional or incisional biopsy; they do not discuss the method of removal for benign appearing facial lesions.7
The UK Guidelines for the Management of Cutaneous Melanoma recommend that suspicious lesions be excised completely (excisional biopsy) and sent for confirmatory histopathological examination.5 A biopsy that transects the depth of the lesion (for example, superficial shave biopsy) should be avoided because histological depth of invasion is the basic criterion for staging and shave biopsy makes the staging impossible in some cases.
1. Hudson-Peacock MJ, Bishop J, Lawrence CM. Shave excision of benign papular naevocytic nevi. Br J Plast Surg 1995;48:318-322.
2. Bong JL, Perkins W. Shave excision of benign facial melanocytic naevi: a patient’s satisfaction survey. Dermatol Surg 2003;29:227-229.
3. Zanardini Pereira CA, Alchorne AOA. angential excision of nevocellular nevus on the face. Int J Dermatol 2004;43:533-537.
4. Ferrandiz L, Moreno-Ramirez D, Camacho FM. Shave excision of common acquired melanocytic nevi: cosmetic outcome, recurrences, and complications. Dermatol Surg 2005;3(Pt 1)1:1112-1115.
5. Roberts DLL, Anstey AV, Barlow RJ, et al. U.K.Guidelines for the management of cutaneous melanoma. Br J Dermatol 2002;146:7-17.
6. Ng PC, Barzilai DA, Ismail SA, Averitte RL Jr, Gilliam AC. valuating invasive cutaneous melanoma: Is the initial biopsy representative of the final depth? J Am Acad Dermatol 2005;48:420-424.
7. Drake L A, Ceilley R I, Cornelison RL , et al Drake LA, Ceilley RI, Cornelison RL, et al. Guidelines of care for nevi I (nevocellular nevi and seborrheic keratoses). J Am Acad Dermatol 1992;26:629-631.
A shave biopsy with a razor blade or #15 scalpel is the best approach for a facial nevus, assuming malignancy is not suspected. the resulting scar is usually flat, smaller than the lesion, has no suture lines, and—if shaved in mid or upper dermis—has a low risk of producing a hypertrophic or hypotrophic scar (strength of recommendation: C, expert opinion, committee guidelines).
Shave biopsies are quick and well-tolerated
Parul Harsora, MD
University of Texas Southwestern, Dallas
If you suspect malignancy in a nevus, obtain an excisional or incisional biopsy. Shave biopsies are best suited for raised, flesh-colored nevi and are generally quick, well-tolerated, and cost-effective. tissue from a shave biopsy can be submitted for histological evaluation.
Shave biopsies are preferred by patients because there are no sutures and scarring is minimized. the site may be pink and may take several months to develop a normal appearance. the final result may be unnoticeable, or leave an indentation or be hypo- or hyperpigmented.
Hairy, pigmented, and compound nevi are likely to do better with a punch biopsy. to prevent recurrence, seek histologic confirmation that the entire nevus has been removed.
Evidence summary
Numerous reports and guidelines indicate that if a nevus is even slightly suspicious for malignancy, it should be removed by excisional biopsy or sampled for diagnosis by punch or incisional biopsy. There are no randomized controlled trials or cohort studies comparing techniques for removing raised nevi from the face.
Shave biopsy has good outcomes
Expert opinion and individual prospective case series show acceptable outcomes for shave biopsy. One prospective study followed 55 patients after removal of nevi from the head and neck. These nevi were removed using a shave procedure with a#15 scalpel and hot cautery for bleeding. Of the 55 sites, 4 retained pigment and 30 had a visible scar with a mean diameter of 5 mm at 6- to 8-month follow-up.1 The mean diameter of the original lesions was 6 mm. There was no difference between the size of those lesions that scarred and those that didn’t.
Researchers conducting a second retrospective study, done at least 1 year after the procedure, used a questionnaire to ask 76 patients (with a total of 83 nevi removed from the face by shave excision) about their perceptions of the scar.2 Patients described their lesions as: no scar (33%), white and flat (25%), depressed (19%), raised (15%), and pigmented (7%). Eighty-six percent thought their scars looked better than the nevus and 79% were “happy with the way the scar looks now.” Two additional studies, based on both patient and provider perceptions, with similar conclusions, are presented in the (TABLE).3,4
TABLE
Favorable cosmetic results following shave biopsy of facial nevi
| STUDY | NO. PTS/NEVI | % WITH RET AINED PIGMENT OR RECURRENCE | % WITH VISIBLE SCARRING | FOLLOW-UP INTERVAL | EVALUATION/DONE BY |
|---|---|---|---|---|---|
| Hudson-Peacock1 | 55/55 | 13 | 55 | 6-8 mo | Cosmetically acceptable/patients |
| Bong2 | 76/83 | 28 | 67 | ≥1 yr | 86%: better than nevus/patients |
| Zanardini3 | 206/ 215 | 4 | 9 | 3 mo | 90%: excellent* 9%: good/surgeons |
| Ferrandiz4 | Not known/59 | 20† | 67 | 3 mo | 98%: better than nevus/pts; 92%: excellent or acceptable‡/surgeons |
| Excellent=no noticeable scar, good=slightly noticeable scar with normochromia or hypochromia, poor=depressed scar or intense dyschromia. | |||||
| † Some lesions not papular. | |||||
| ‡ Excellent cosmetic result=imperceptible scar without erythema, hyper- or hypo-pigmentation, hypertrophy or atrophy. Acceptable=scar better than original mole. poor=left scar worse than original mole. | |||||
Atypical lesions should be excised
Atypical lesions require excisional biopsy. The depth and architecture of the lesion, if melanoma, cannot be determined by shave biopsy, and both treatment and prognosis depend on those characteristics.
These guidelines derive from well-designed, nonexperimental descriptive studies.5 However, a recent retrospective study compared the Breslow depth determination of 4 different biopsy techniques, performed by experienced dermatologists, with the subsequent depth on definitive surgery for melanoma. This study found that superficial shave, deep shave, and punch biopsy predicted the Breslow depth 88% (95/108) of the time.6 As expected, excisional biopsy predicted the depth 100% (30/30) of the time. The location of the biopsy sites were not reported. The choice of biopsy was influenced by the suspicion of melanoma; thin (< 1 mm) melanomas were more likely to be superficially shaved than deep-shaved or punched.
Recommendations from others
Guidelines on nevocellular nevi from the American Academy of Dermatology recommend a simple excisional or incisional biopsy; they do not discuss the method of removal for benign appearing facial lesions.7
The UK Guidelines for the Management of Cutaneous Melanoma recommend that suspicious lesions be excised completely (excisional biopsy) and sent for confirmatory histopathological examination.5 A biopsy that transects the depth of the lesion (for example, superficial shave biopsy) should be avoided because histological depth of invasion is the basic criterion for staging and shave biopsy makes the staging impossible in some cases.
A shave biopsy with a razor blade or #15 scalpel is the best approach for a facial nevus, assuming malignancy is not suspected. the resulting scar is usually flat, smaller than the lesion, has no suture lines, and—if shaved in mid or upper dermis—has a low risk of producing a hypertrophic or hypotrophic scar (strength of recommendation: C, expert opinion, committee guidelines).
Shave biopsies are quick and well-tolerated
Parul Harsora, MD
University of Texas Southwestern, Dallas
If you suspect malignancy in a nevus, obtain an excisional or incisional biopsy. Shave biopsies are best suited for raised, flesh-colored nevi and are generally quick, well-tolerated, and cost-effective. tissue from a shave biopsy can be submitted for histological evaluation.
Shave biopsies are preferred by patients because there are no sutures and scarring is minimized. the site may be pink and may take several months to develop a normal appearance. the final result may be unnoticeable, or leave an indentation or be hypo- or hyperpigmented.
Hairy, pigmented, and compound nevi are likely to do better with a punch biopsy. to prevent recurrence, seek histologic confirmation that the entire nevus has been removed.
Evidence summary
Numerous reports and guidelines indicate that if a nevus is even slightly suspicious for malignancy, it should be removed by excisional biopsy or sampled for diagnosis by punch or incisional biopsy. There are no randomized controlled trials or cohort studies comparing techniques for removing raised nevi from the face.
Shave biopsy has good outcomes
Expert opinion and individual prospective case series show acceptable outcomes for shave biopsy. One prospective study followed 55 patients after removal of nevi from the head and neck. These nevi were removed using a shave procedure with a#15 scalpel and hot cautery for bleeding. Of the 55 sites, 4 retained pigment and 30 had a visible scar with a mean diameter of 5 mm at 6- to 8-month follow-up.1 The mean diameter of the original lesions was 6 mm. There was no difference between the size of those lesions that scarred and those that didn’t.
Researchers conducting a second retrospective study, done at least 1 year after the procedure, used a questionnaire to ask 76 patients (with a total of 83 nevi removed from the face by shave excision) about their perceptions of the scar.2 Patients described their lesions as: no scar (33%), white and flat (25%), depressed (19%), raised (15%), and pigmented (7%). Eighty-six percent thought their scars looked better than the nevus and 79% were “happy with the way the scar looks now.” Two additional studies, based on both patient and provider perceptions, with similar conclusions, are presented in the (TABLE).3,4
TABLE
Favorable cosmetic results following shave biopsy of facial nevi
| STUDY | NO. PTS/NEVI | % WITH RET AINED PIGMENT OR RECURRENCE | % WITH VISIBLE SCARRING | FOLLOW-UP INTERVAL | EVALUATION/DONE BY |
|---|---|---|---|---|---|
| Hudson-Peacock1 | 55/55 | 13 | 55 | 6-8 mo | Cosmetically acceptable/patients |
| Bong2 | 76/83 | 28 | 67 | ≥1 yr | 86%: better than nevus/patients |
| Zanardini3 | 206/ 215 | 4 | 9 | 3 mo | 90%: excellent* 9%: good/surgeons |
| Ferrandiz4 | Not known/59 | 20† | 67 | 3 mo | 98%: better than nevus/pts; 92%: excellent or acceptable‡/surgeons |
| Excellent=no noticeable scar, good=slightly noticeable scar with normochromia or hypochromia, poor=depressed scar or intense dyschromia. | |||||
| † Some lesions not papular. | |||||
| ‡ Excellent cosmetic result=imperceptible scar without erythema, hyper- or hypo-pigmentation, hypertrophy or atrophy. Acceptable=scar better than original mole. poor=left scar worse than original mole. | |||||
Atypical lesions should be excised
Atypical lesions require excisional biopsy. The depth and architecture of the lesion, if melanoma, cannot be determined by shave biopsy, and both treatment and prognosis depend on those characteristics.
These guidelines derive from well-designed, nonexperimental descriptive studies.5 However, a recent retrospective study compared the Breslow depth determination of 4 different biopsy techniques, performed by experienced dermatologists, with the subsequent depth on definitive surgery for melanoma. This study found that superficial shave, deep shave, and punch biopsy predicted the Breslow depth 88% (95/108) of the time.6 As expected, excisional biopsy predicted the depth 100% (30/30) of the time. The location of the biopsy sites were not reported. The choice of biopsy was influenced by the suspicion of melanoma; thin (< 1 mm) melanomas were more likely to be superficially shaved than deep-shaved or punched.
Recommendations from others
Guidelines on nevocellular nevi from the American Academy of Dermatology recommend a simple excisional or incisional biopsy; they do not discuss the method of removal for benign appearing facial lesions.7
The UK Guidelines for the Management of Cutaneous Melanoma recommend that suspicious lesions be excised completely (excisional biopsy) and sent for confirmatory histopathological examination.5 A biopsy that transects the depth of the lesion (for example, superficial shave biopsy) should be avoided because histological depth of invasion is the basic criterion for staging and shave biopsy makes the staging impossible in some cases.
1. Hudson-Peacock MJ, Bishop J, Lawrence CM. Shave excision of benign papular naevocytic nevi. Br J Plast Surg 1995;48:318-322.
2. Bong JL, Perkins W. Shave excision of benign facial melanocytic naevi: a patient’s satisfaction survey. Dermatol Surg 2003;29:227-229.
3. Zanardini Pereira CA, Alchorne AOA. angential excision of nevocellular nevus on the face. Int J Dermatol 2004;43:533-537.
4. Ferrandiz L, Moreno-Ramirez D, Camacho FM. Shave excision of common acquired melanocytic nevi: cosmetic outcome, recurrences, and complications. Dermatol Surg 2005;3(Pt 1)1:1112-1115.
5. Roberts DLL, Anstey AV, Barlow RJ, et al. U.K.Guidelines for the management of cutaneous melanoma. Br J Dermatol 2002;146:7-17.
6. Ng PC, Barzilai DA, Ismail SA, Averitte RL Jr, Gilliam AC. valuating invasive cutaneous melanoma: Is the initial biopsy representative of the final depth? J Am Acad Dermatol 2005;48:420-424.
7. Drake L A, Ceilley R I, Cornelison RL , et al Drake LA, Ceilley RI, Cornelison RL, et al. Guidelines of care for nevi I (nevocellular nevi and seborrheic keratoses). J Am Acad Dermatol 1992;26:629-631.
1. Hudson-Peacock MJ, Bishop J, Lawrence CM. Shave excision of benign papular naevocytic nevi. Br J Plast Surg 1995;48:318-322.
2. Bong JL, Perkins W. Shave excision of benign facial melanocytic naevi: a patient’s satisfaction survey. Dermatol Surg 2003;29:227-229.
3. Zanardini Pereira CA, Alchorne AOA. angential excision of nevocellular nevus on the face. Int J Dermatol 2004;43:533-537.
4. Ferrandiz L, Moreno-Ramirez D, Camacho FM. Shave excision of common acquired melanocytic nevi: cosmetic outcome, recurrences, and complications. Dermatol Surg 2005;3(Pt 1)1:1112-1115.
5. Roberts DLL, Anstey AV, Barlow RJ, et al. U.K.Guidelines for the management of cutaneous melanoma. Br J Dermatol 2002;146:7-17.
6. Ng PC, Barzilai DA, Ismail SA, Averitte RL Jr, Gilliam AC. valuating invasive cutaneous melanoma: Is the initial biopsy representative of the final depth? J Am Acad Dermatol 2005;48:420-424.
7. Drake L A, Ceilley R I, Cornelison RL , et al Drake LA, Ceilley RI, Cornelison RL, et al. Guidelines of care for nevi I (nevocellular nevi and seborrheic keratoses). J Am Acad Dermatol 1992;26:629-631.
Evidence-based answers from the Family Physicians Inquiries Network