What to expect from my skin biopsy appointment?

Taking a sample from a skin lesion on the face or neck is a routine diagnostic procedure in our oral and facial department. A lot of the lesions we see in the clinic are benign lesions that don’t need a biopsy. Other lesions can vary from sun-damaged skin to skin cancer. There are also different pigmented lesions. Today I would like to discuss some questions that I come across almost every day at the hospital. Anticipating an appointment for this procedure can cause a lot of stress and sleepless nights. Even though we explain the procedure before booking the appointment, due to the anxiety of the moment and fear of the unknown, the explanation is forgotten as soon as the person steps out of the consultation room. We have all been there. We go home and start a Google search, and Google comes up with stories more appropriate for a horror movie. Nothing to do with reality. I would like to discuss this journey today to bring a bit more clarity and answer some questions.

What is a biopsy, and why do we need it? A biopsy means taking a piece from the lesion on the skin, and sending it to a lab where it is viewed under a microscope. We do this to get a formal diagnosis for the lesion and determine if any treatment is needed and whether it will be surgical treatment or other. There are different types of biopsies: incisional (only a small piece of the lesion is removed), excisional (the whole lesion is removed), and shave biopsy (it is a form of excisional biopsy. When the lesion is exophytic/verrucous, it can be shaved at the base).

Can I eat before the procedure? Yes, you can. This is a routine procedure that we carry out under local anaesthetic. It is actually adviseble to have something to eat before your appointment as if you are hungry you may feel a bit weak and dizzy. It will be easier to faint because of the anxiety and higher adrenaline. So, have a nibble before your appointment.

Am I going to be put to sleep for this procedure? The answer is no. This is a routine procedure that we carry out under local anaesthetic. This means a numbing injection around the lesion. The anaesthetic usually is the same type as the one that is used by your dentist when you have fillings, tooth extractions or gum treatments. The appointment itself will normally take between 20 and 30 minutes.

What if I am on blood thinners? Well, this can vary between different trusts, but for the trust that I work at, the advice is to omit the dose of blood thinner on the night before and on the morning of the procedure. This is because blood thinners can cause more bleeding and bruising than usual. Follow the advice you have been given by your consultant on your assessment appointment. After the procedure your doctor will advise you when to restart the blood thinner. Ideally we would like to have at least 6 hours without bleeding to be able to restart this medication. This advice will vary from person to person, so please follow the advice you have been given by your doctor.

How big is the sample going to be? There can be some variations with this, but usually the size of the sample can be 4 mm or 5 mm, depending on the size of the lesion. This is something we call a “punch” biopsy. We take the sample with an instrument that looks like a miniature “apple core”. This can sound a bit overwhelming, but I can assure you there is nothing to worry about.

Am I going to have stitches? The answer to this question in most cases will be yes. This again depends on what type of biopsy you are having. In our trust we usually put “dissolvable” sutures. Well, when I say “dissolvable”, that means the stitches will become “flaky” within a few weeks, and you will be able to rub them off with a flannel tissue or towel. If you only have a “shave” biopsy, your doctor can decide to stop the bleeding with cauterisation and leave the site to heal.

What is cauterisation? We use a bipolar diathermy machine to stop the bleeding after we have taken the sample. The bipolar cauterises (burns) the blood vessels in the wound prior to closure. The machine makes some “buzzing” noises, and there may be a smell of burning.

Am I going to have a scar? After a cut on the skin, we can expect a minimal scar. Luckily the head and neck are very well supplied with multiple blood vessels, which makes the healing much easier, and scarring is minimal. Stitches will keep the edges of the wound close together, which helps with this as well. The skin of the face has natural creases that can hide and mask most scars.

What can I expect after the procedure? There are few things we can expect after this procedure. These include some pain, swelling, minor bleeding, and bruising. The pain will be nothing that a normal paracetamol cannot deal with. You will be given a leaflet with the possible side effects and risks for this procedure, and these will be explained to you verbally as well. On the leaflet there will be some phone numbers to contact in case you need some advice. You can also attend the emergency department of the hospital in case intense bleeding or infection occur.

What recommendation should I follow after the procedure? You will need to keep the area of the biopsy dry for the next 3-4 days. If there is any delayed bleeding after the procedure, you can apply a clean tissue or towel and press on the area for 20-30 minutes. If the bleeding continues after this or if you are on blood thinners, you need to attend the emergency department of your local hospital. After a skin biopsy in our department, we give patients a tube of Chloramphenicol ointment to apply on the sutures 3-4 times per day until the tube finishes. If any signs of infection appear after the procedure, you will need to contact the department that performed the procedure or attend the emergency department at the hospital. We normally advise patients to avoid sleeping flat after procedures on the face, as any bruising and swelling can go towards the least resistance, which is the eyelids. You can feel your eyelids a bit puffier in the morning. This is related to gravity.

What would an infection look like? An infection will usually present as increased pain, redness and swelling, visible discharge from the wound or collection of pus. You can experience fever and general malaise. An infection can present 5 to 7 days after the procedure.

How long will I have to wait for the results? Once taken, the sample will be sent to a histopathology lab. Depending on the level of suspicion for malignancy, the sample can be sent as an “urgent”, which usually takes 2 weeks for the results to be back, or as a “routine”, which can take between 4 and 6 weeks. When the results are available, your consultant will review them, and the department will get in touch with you. This is commonly done with a letter.

I hope this answers some of the questions that arise regarding the skin biopsy journey. At least these are some of the questions I have been asked by many patients before the procedure. However, the recommendations can vary from trust to trust in the UK. Please follow the advice your doctor has given specifically to you. It will be the most accurate one.

If you have any questions, please let me know.

Till next time,

Venelina