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204 HIGHSMITH ET AL.

Figure 1. Patient presented for MMS for a biopsy-proven squamous cell carcinoma on
his “right temple” that healed well and is difficult to locate. He initially refused treatment
but eventually rescheduled, and the lesion was excised using MMS. Note the biopsy site is
difficult to confidently locate because of background solar damage, rhytids, and scarring.

should be considered a valuable tool for the derma- METHODS
tologic surgeon in the pre-operative consultation. Many of the problems encountered with a biopsy
Wrong-site surgery has been identified as one of site selfie (BSS) may be overcome by using a key strat-
the most common adverse events (13.1%) reported egy we have named BIOPSY 1-2-3. The three steps
by The Joint Commission (TJC) (4). To reduce these of the technique are as follows:
errors, TJC has implemented a “Universal Proto-
col,” thereby mandating pre-procedure verification, 1. First, it is optimal to have one other person
surgical site marking, and a “time out” to prevent take the photo.
surgical errors (5). Wrong-site surgeries are also a 2. Next, make sure there are two anatomical land
common cause of medical malpractice lawsuits affect- marks in the image.
ing fellowship-trained Mohs surgeons (14.3%) (6). 3. Finally, verify there are three photos of each
Identifying the correct biopsy site is complicated by site.
background sun damage, adjacent skin conditions, With each biopsy site, have one person who is not the
biopsy technique (e.g., deep scallop versus superficial patient take the photograph to avoid problems inher-
shave), and the amount of time between the biopsy ent with a BSS. This is recommended because often
and planned curative procedure (7). Biopsy sites often the secondary self-facing camera on the smartphone
heal very well and can be difficult to locate, leading device is typically inferior to the primary camera,
many patients to refuse an excision or at least question which results in lower quality photographs. Also,
the need for another procedure as in the case example BSSs tend to be excessively zoomed in and out of
in Figure 1. An estimated 25% of patients present- focus. Having someone else take the picture with the
ing for Mohs Micrographic Surgery (MMS) could patient’s device allows the picture to be taken with the
not correctly identify their biopsy sites (8). While a primary camera at an adequate distance. The pictures
pre-operative biopsy may result in complete tumor can be taken at home by the patient’s family member
removal in 15% to 42% of cases, identification of the or even at the office by the patient’s nurse at the time of
correct surgical site is imperative to ensure definitive their visit. Always mark the area that was, or is about
treatment of most cutaneous neoplasms (9,10). Given to be, biopsied, as in Figure 2 of the case example. Use
the previously identified value of patient involvement a dark pen, highlighter, or marker to circle the lesion
and the ease of access to smartphone technology and to distinguish between two nearby dyspigmented
digital photography, the purpose of this project was patches at a later date. Next, have two body parts
to describe a methodology to improve the process for (e.g., ear and nose) or two joints (e.g., elbow and
capturing biopsy site photographs and including those wrist) visualized in at least two of the pictures. Lastly,
photos in decision making to maximize cutaneous have at least three pictures of every site. It is best if
surgical outcomes. each photograph is taken from a different vantage