This document is intended to guide you through having skin surgery/ a skin biopsy.
What is a biopsy?
A skin biopsy is a procedure whereby a sample of skin is removed and sent to the pathology laboratory to be analysed under the microscope. A skin biopsy can help to diagnose a skin condition and guide treatment. A skin biopsy can also be taken to remove a lesion for cosmetic or functional purposes e.g. if it is getting caught on clothing.
Types of skin biopsy
Punch biopsy
A punch biopsy is a procedure in which a small circular shaped piece of skin is removed and sent to the laboratory for analysis, to establish a diagnosis. The patient remains awake during the procedure and the area is injected with a local anaesthetic to numb the skin being operated on. The skin is closed with one or two stitches which can be removed after seven to fourteen days by a practice nurse at the patient’s GP surgery.
You will usually have a small scar that appears as a fine line. Sometimes this heals as a circular indentation or puckering.
Incisional biopsy
An incisional biopsy is when part of a skin lesion is removed for analysis, using a scalpel (sharp surgical blade). The patient usually remains awake during the procedure and the area is injected with a local anaesthetic to numb the skin being operated on. The skin is closed with a few stitches, which can be removed by a practice nurse at the patient’s GP surgery.
The typical scar is a straight line that is around 1-5cm in length, depending on the size of the biopsy that is needed.
Shave biopsy
During this biopsy, the surface of a lesion is shaved off. A scab will form and will take a week or two to separate and lift off. Stitches are not used in this procedure. You will have a circular scar which is the same outline as the base of the lesion that has been removed. It may be slightly paler or darker than your normal skin colour and, although usually flat, it can be slightly elevated or depressed.
Curettage
The lesion is scraped off. A graze-like area remains which scabs and takes 1-2 weeks to heal (6 weeks on lower legs). Stitches are not used. A patch resembling the outline of the lesion remains. It may be slightly paler or darker than your normal skin colour and, although usually flat, it can be slightly elevated or depressed.
Excision
An excision biopsy is complete removal of a skin lesion/mole. The lesion and a small amount of normal looking skin around it is removed. The patient usually remains awake, and the area is closed with a few stitches.
You will typically have a straight-line scar that is usually 3-4 times the length of the lesion being removed.
Second intention healing
Occasionally a wound will be left open (rather than being stitched together) and left to heal by itself, filling in and closing naturally. This often avoids further (more extensive) surgery and can regularly produce excellent functional and cosmetic results. It will mean that you will need regular dressings to the area for up to six weeks (possibly longer on the lower leg), but the time to full healing depends on the size, depth and site of the wound.
Dressing changes may be carried out by your local practice nurse, or in some cases patients/relatives might be taught how to care for and re-dress the wound at home. Sometimes a single running suture is placed around the wound to pull the edges closer to each other. This will normally be removed after 7-14 days.
To prepare for the procedure you should take the following steps:
If you have diabetes, epilepsy, a pacemaker, cochlear implant or any implantable device, prosthetic heart valves or any other significant medical conditions then please let us know in advance.
It is important that you tell the doctor what medication you are taking (please bring a list if you are not sure) and if you are allergic to any medications. Please inform the doctor if you have ever had a reaction to a dentist’s injection.
Smoking impairs the skin’s ability to heal. If you are able to stop smoking for 2 weeks before and after the operation the overall wound healing will be improved.
You can eat and drink normally on the day of the procedure as you will only be having a local anaesthetic and won’t be put to sleep.
Wear loose clothing that is easy to remove if needed. For procedures on the feet or lower legs, wear loose footwear or sandals that can accommodate dressings.
Make sure you have a supply of paracetamol at home to take for discomfort after your operation.
It is preferable to arrange for someone to collect you or to travel with you on public transport. If you choose to drive following a skin biopsy, we recommend you check with your insurance company first to ensure you are covered.
Important information if you are on warfarin or other blood thinning medications
If you are on warfarin, your INR level needs to be 2.5 or less for the procedure to be carried out. Please inform your anticoagulation service of this and the date your procedure will be on. You should arrange to have an INR test 5 days before your surgery date. You should also follow the advice below:
If the INR is 2.5 or less five days before surgery, stay on the same dose of warfarin. A further INR test is not required.
If the INR is greater than 2.5 five days before surgery, please ask your anticoagulation service to reduce your dose accordingly. Arrange a further INR test 1-2 days before surgery if you can.
Bring your yellow book with you to your surgery.
If you are on Dabigatran, Apixaban or Rivaroxaban, it is usually necessary to omit the dose on the day of the procedure and on the day before. We ask that you confirm this with the prescriber in advance of your surgery date and we are happy to provide further details for them if this would be helpful.
If you are on aspirin, clopidogrel or dipyridamole, please continue to take these as usual unless you have been specifically advised not to by the doctor.
Important information if you have a pacemaker or implantable cardioverter defibrillator (ICD)
If you have a pacemaker or an implantable cardioverter defibrillator (ICD), please let us know well in advance of your procedure. Some skin surgery procedures involve equipment that can potentially interfere with these devices. In certain cases, we may need to contact your cardiology clinic or cardiac physiologist for specialist advice before proceeding, or make specific arrangements on the day of surgery.
Failure to inform us in advance may result in your procedure needing to be postponed or rescheduled.
On the day of the procedure
Please arrive on time for your appointment and check in at the reception desk. If you arrive late for your appointment, it may not be possible to complete the procedure in time, and you will be asked to rebook. You will still be charged for the missed appointment.
During the biopsy
The doctor will explain the procedure to you again and ask you to sign a consent form. You can bring a friend or relative into the procedure room for this discussion. We ask that only one individual accompanies you. After you have had the opportunity to ask any questions, the person accompanying you will be asked to sit in the waiting room, and you will be asked to lie on the couch.
The area to be biopsied will be numbed with an injection of local anaesthetic. You may experience some discomfort for a minute or so. The procedure will be carried out once the skin is numb. You may feel a pushing sensation in the area to be treated, but you should not feel any pain. If necessary, stitches will be placed.
Care of the wound and removal of the stitches will be explained to you once the procedure is finished.
How long will it take?
The procedure will take 20-60 minutes depending on the complexity and site that is being operated on.
Risks
Will I have a scar?
You will always have some sort of scar or permanent mark as it is impossible to cut the skin without leaving a mark. We will try to make the scar as neat and as unnoticeable as possible, although individuals do vary in how well they heal following surgery. Scar tissue is red for 3 to 6 months and then usually fades to white or brown depending on your skin tone. The appearance of a scar usually improves over 12 months as it ‘matures’.
Certain people may have an abnormal response to skin healing and, as a result, may get larger, more raised scars than usual. These are known as hypertrophic or keloid scars. Limiting exercise or stretching for wounds on the back or limbs will help the scar heal as finely as possible. Blood vessels (telangiectasias) can form around scars.
Bleeding
Slight bleeding in the few hours after surgery is common and is aggravated by activity. Hot drinks or bending down can cause bleeding especially on facial wounds.
If your wound bleeds, apply firm continuous pressure for 15 minutes without stopping with a clean tissue or dressing. If your wound is on your arm or leg, lift the limb upwards as this will help stop the bleeding. If the wound is on your head, ensure that you are sitting upright and avoid bending forwards. If the bleeding does not stop after 15 minutes, you must attend your nearest A&E department.
Swelling and bruising is common especially after facial surgery and can be lessened by use of an ice pack. Use extra pillows after facial surgery and elevate the leg after lower limb surgery.
Infection
If the wound becomes red, inflamed and painful, or starts discharging pus 48-72 hours after the procedure, it may be infected. You may need antibiotics and therefore must let us or your GP know.
Do not use make up near a wound until the surface has completely healed.
Numbness
Numbness from local anaesthetic can spread inside the mouth following procedures on the mid and lower face. It is important to avoid hot food and drinks for 4 hours or until full sensation in the mouth has returned as burns can develop.
Nerve damage
This is very unlikely, but sometimes nerves underlying the skin become damaged during the procedure. This can lead to numbness and/ or muscle weakness.
After the biopsy
The dressing applied in the clinic should be left on for 24-48 hours. Further instructions will be given in an aftercare leaflet following your procedure.
Stitches will be left in for 5-21 days depending on the procedure and location. You will be informed of this after the procedure by the doctor. Stitches can usually be removed by the nurse at your GP surgery. Alternatively, we can arrange this for you. If you would like us to remove your stitches, please book an appointment for this as soon as possible. It will likely be with one of the nursing team at 25 Harley Street.
You should refrain from strenuous physical activity and swimming until the stitches have been removed (or for at least 48 hours if you don’t have stitches). The scar will be strong by 30 days – and is at its weakest during the first few days after the stitches have been removed. Too much activity can put strain on the healing scar. This can lead to stretching of the scar or bursting of the wound. Surgical wounds on the lower leg generally take a lot longer to heal.
There may be some discomfort at or surrounding the surgical site, in which case you should take a painkiller, such as paracetamol. Avoid painkillers that may contain aspirin, ibuprofen or indomethacin.
The wound may be slightly red for a few days after the surgery, but if this gets worse, extends or there is any discharge, you should contact us or your general practitioner, as you may require antibiotics.
Alcohol – do not drink any alcohol for 24 hours after the operation.
Results
It is not possible to give you the results on the same day as the procedure as the sample will be sent to the laboratory and needs to be examined microscopically. For diagnostic biopsies, you will need to book a follow-up appointment within 2-4 weeks to be seen with the results.
For cosmetic lesion removals, the doctor can usually write to you with the final report instead, unless there are any unexpected results in which case we will recommend you book a follow-up appointment to discuss these face to face.
Further procedures
Depending on the report of your skin biopsy, sometimes further investigations or procedures will be required. In certain circumstances this may require referral to another specialist colleague e.g a Plastic Surgeon. Please not that these tests and referrals will have their own fees associated with them.