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  • Presentation

Biopsies in Challenging Locations: A Review for the General Dermatologist

Description

This presentation focuses on the techniques and considerations for performing biopsies in challenging areas, particularly around the eyelid and oral cavity, relevant for general dermatologists. Dr. Amy Green discusses the importance of understanding eyelid anatomy, emphasizing that most eyelid tumors are basal cell carcinomas, and that a solid grasp of the anatomical structures—including the orbicularis oculi muscle and various eyelid layers—is crucial for successful biopsy procedures. She highlights the need for careful anesthesia administration, preferably with transconjunctival lidocaine injections, and the importance of utilizing the right instruments, such as punch and shave biopsy tools. She also addresses hemostasis techniques, recommending the use of electro-desiccation due to the rich vascular supply in the eyelid region. Dr. Ken then transitions to oral cavity biopsies, stressing the necessity to consider patient factors such as allergies and positioning, and to choose appropriate biopsy methods depending on the clinical context. He provides insights into the relevant oral anatomy and the effective use of topical anesthetics. In summary, understanding the anatomy, appropriate techniques, and patient comfort are key to successfully executing biopsies in these delicate areas.

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Conclusions

  • 5-10% of cutaneous malignancies occur on the eyelid, highlighting the importance of being comfortable performing biopsies in this area.
  • The majority of eyelid tumors, specifically malignant ones, are basal cell carcinomas comprising 80-95% of cases.
  • Understanding the complex anatomy of the eyelid is crucial for performing successful biopsies and addressing complications.
  • Different regions of the eyelid exhibit varying degrees of tissue adherence, with the pretarsal area being more tightly connected compared to the preseptal area.
  • Transconjunctival injections for anesthesia can enhance patient comfort and safety during eyelid biopsies.
  • Careful vascular management is essential during eyelid biopsies due to robust blood supply, with a focus on avoiding chemical hemostasis to prevent corneal irritation.
  • After performing a biopsy, proper hemostasis should be achieved using pressure or electrosurgery, rather than chemical agents like aluminum chloride.
  • Utilizing ocular shields can provide an additional layer of protection when performing procedures around the eye.
  • Biopsy coding requires specificity based on the area of the eyelid involved, with dedicated codes for procedures on the lid margin and conjunctiva.
  • Essential procedural instruments include forceps and various types of blades, emphasizing the need for refined techniques to avoid tissue trauma.
  • Shih, S, et al. Use of Eye Shields for Mohs Micrographic Surgery of the Eyelids and Periorbital Area. Dermatologic Surgery 45(2)
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  • Dermatologic Surgery 39(11):p 1592-1601, November 2013.
  • Hupp James R et al. Contemporary Oral and Maxillofacial Surgery. 7th ed. Elsevier 2019.
  • Oral Pathol Med. 2019 Mar;48(3):239-243.