• Pearl: General rule of thumb is to shave a
tumor and punch a rash.
• Pitfall: A shave biopsy of a deep melanoma
destroys the prognosis/Breslow’s thickness.
Result: Now you must assume the worst
and put the patient through extensive
surgeries and chemotherapy. Moral: Fully
excise or refer all suspected melanomas.
• Pearl: Know where your biopsy is going.
Always specify “must be diagnosed by a
• Pitfall: If you do not specify as above it will
go to a general pathologist. They may give
you less than ideal diagnostic information
or even miss the diagnosis. Your patient
will not be impressed.
• Pearl: Communicate with your
dermatopathologist; “asymptomatic scaling
erythematous annular plaques with central
clearing localized to the bilateral shins for 2
weeks, consider tinea vs. granuloma
annulare vs. necrobiosis lipoidica” = high
• Pitfall: “itchy rash, leg” = low yield
• Pearl: When the patient asks “what do you
think it (the lesion) is?”, the correct answer
is “If I knew that I wouldn’t have to do the
• Pitfall: Never attempt to reassure the
patient by saying the lesion is “probably
going to be nothing at all”, they’ll wonder
why you’re putting them through all of this.
• “Doc, will this hurt?”
• “I’m not sure, they’ve
only let me try this on
animals so far”
• “No, it shouldn’t hurt
me a bit”
• “More than a tickle
but less than paying
• Pearl: fears of epinephrine induced necrosis
at distal sites (nose, ears, penis, toes,
fingertips) are largely unfounded.
• Pitfalls: patients with severe peripheral
vascular disease, diabetic angiopathy and
Raynaud’s phenomenon may be exceptions
to the rule.
• Local Anesthesia:
• Pearl: INJECT SLOWLY and your patients
will love you forever. Decreases pain more
than warming or adding bicarbonate.
• Pitfall: ALWAYS make sure they are lying
down, especially the patient who “talks
• Local Anesthesia
• Pearl: It is OK to give Xylocaine to
patients who had allergic reactions to
Novocaine at the dentist’s office, Lidocaine
is an Amide and Novocaine is an Ester.
• Pitfall: They may not know which
medication they reacted to: use
Bacteriostatic NS when in doubt.
• Local Anesthesia
• Pearl: For pediatric patients, let them sit in
the lobby with ELA-Max or EMLA covered
with Saran Wrap for 30 minutes.
• Pitfall: The above may fail. At this point
either refer or insert earplugs and proceed.
Remember: very few pediatric rashes will
require biopsy for diagnosis.
• Pearl: Insert needle at a 30 degree angle
and slowly retract the needle as you inject
the anesthetic. When the tissue blanches
you are at the right level.
• Pitfall: If you see a linear trail of blanched
skin radiating from the injection site you are
probably in a vessel.
• Regarding Coumadin.
• Pearl: Do not take patients off Coumadin to
perform a small dermatologic procedure
such as biopsy, excision or Moh’s surgery.
• Pitfalls: Depend on the reason why they are
on Coumadin in the first place. Also
problematic if you do not have tools for
• Endpoint is “pinpoint
• Indicates you are at
the level of the
• This is where scarring
begins and patient
• Pearl: Stay superficial
and you can achieve
• Pink atrophic area has
a full year to heal.
• Pitfalls: Skin of upper
chest and back scars
no matter what. Same
with Keloid prone pts.
• Twist punch tool until
buried to the hub*
• *Caveat: Have a firm
grasp of anatomy and
skin thickness in the
area you are punching
before you punch it.
• Finger tendons, facial
and neck structures.
• Hemostasis works best
in 2 steps.
• First use the Q-tip to
buy time to grab
needle driver and
• Suture so that closure
is low tension - simple
• Use 6-0 Prolene on the
• 4-0 Prolene most other
• Silk for mucosal areas.
• 2 simple interrupted
• Out 7d face, 10d otw
• Pearl: If you suspect melanoma excisional
biopsy DOWN TO FAT.
• Pitfalls: Punch biopsy, while deep enough is
NOT representative of the entire lesion.
Shave too shallow, prognosis destroyed.
• Pitfalls: Excision takes more time,
reimbursement same, but medicolegally still
a bargain because it is the standard of care.
• Using a Sharpie felt
tip pen mark a circle
around lesion with
about 1-2 mm margins
• Ellipse should be 3
times longer than
circle around lesion.
• Pearl: Try to postion
the final suture line
wrinkle lines / least
• Whether lesion is
malignant or not, your
patient will never
forget their scar.
• Sterile procedure!
• H2O2 and Betadine
• Pearl: Try not to
apply the above too
aggressively or to get
excess Xylocaine on
your ellipse drawing
• Pitfall: ink will rinse
away, now you’re lost!