As with any procedure, the first step should involve discussing the steps and rationale for the procedure with the patient and obtaining informed consent. The patient should then be placed in a comfortable position that allows exposure of the area in question, typically in stirrups on the examination table.

The lesion should be examined and the type of biopsy (punch or excisional) planned. The vulvar skin should be cleansed with antiseptic solution and the site of biopsy marked with a marking pen (Fig. 17.1). Local anesthetic should then be infiltrated into the dermis underlying the lesion, being certain to infiltrate the subcutaneous tissues surrounding the entire area to be excised (Fig. 17.2) Next the biopsy will be performed—either punch or excisional.

If performing a punch biopsy, the most abnormal appearing area should be biopsied. The 2 mm punch biopsy is usually of sufficient size to produce an accurate histologic diagnosis [3]. The skin surrounding the lesion should be placed on stretch and the punch placed perpendicular to the skin over the area to be biopsied (Fig. 17.3) Pressure is applied and the device is twisted until the subcutaneous tissues have been entered. Forceps are then used to elevate the core of tissue and iris scissors are used to transect the base of the specimen (Fig. 17.4) The specimen is then placed in the container to be sent to pathology. Pressure is applied to the wound with gauze pads. Hemostasis can be obtained with pressure or with the use of silver nitrate sticks. If a 3 mm or smaller punch was used, then skin closure is typically not required. If a larger biopsy punch was used, then simple sutures should be placed to reapproximate the skin edges to result in improved patient satisfaction of cosmesis [4].

Excisions are performed if the entire lesion needs to be removed. Langer’s lines of skin tension should be identified and the long axis of excision should parallel these lines. Using a 15-blade, an elliptical excision is made around the lesion to be removed. The elliptical excision allows for easier and more cosmetic skin closure. Next, the superior edge of the specimen is grasped with forceps and the specimen is removed from the subcutaneous fat using either the blade or iris scissors. Hold pressure to the skin with gauze pads and place the specimen in the specimen cup. Prior to placing the specimen in the cup, while the specimen is still in anatomic orientation, the superior edge of the specimen can be tagged with a suture to aid the pathologist in reporting margin status. Simple interrupted sutures of a small suture diameter are then used to reapproximate the skin edges.

The surgical wound should be kept moist and covered to aid in healing [5]. Applying an ointment to the wound can serve this role, and either petrolatum ointment or an antibiotic ointment, such as bacitracin, may be used for this purpose. One study showed that these two agents had similar results in terms of infection rates, but there was less contact dermatitis with the petrolatum ointment [6]. Sutures can then be removed in 7–10 days, which also gives the physician the opportunity to follow the patient’s progress and review pathology reports.