EVIDENCE-BASED ANSWER
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).
Clinical commentary
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. | |||||