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Biopsy, soft tissue of back or flank; superficial

CPT4 code

Name of the Procedure:

Biopsy, soft tissue of back or flank; superficial.
Common name(s): Soft tissue biopsy, superficial biopsy of the back or flank.

Summary

A soft tissue biopsy of the back or flank involves removing a small sample of tissue from the surface layer (superficial) of the back or side areas of the body for laboratory analysis.

Purpose

The procedure helps diagnose diseases or conditions by examining the tissue under a microscope. It aims to identify abnormalities such as infections, tumors, or inflammatory conditions. The goal is to provide a definitive diagnosis to guide appropriate treatment.

Indications

  • Unexplained lumps or masses in the back or flank
  • Persistent pain or swelling in the area
  • Suspicion of cancer or other abnormal growths
  • Chronic infections
  • Non-healing wounds or ulcers in the area

Preparation

  • Follow fasting instructions if advised (usually not required for superficial biopsy)
  • Inform your healthcare provider about all medications and supplements you are taking
  • Adjust or stop certain medications (e.g., blood thinners) as instructed
  • Undergo any necessary diagnostic tests, like blood work or imaging studies

Procedure Description

  1. The patient will lie down in a comfortable position.
  2. The area of the biopsy will be cleansed with an antiseptic solution.
  3. Local anesthesia will be injected to numb the area.
  4. Using a small, sharp instrument, the doctor will remove a sample of superficial tissue.
  5. The tissue sample is placed in a container and sent to a pathology lab for examination.
  6. The biopsy site may be closed with a small bandage or sterile strips.

Duration

The procedure typically takes about 15 to 30 minutes.

Setting

Soft tissue biopsies are usually performed in an outpatient clinic, doctor's office, or surgical center.

Personnel

  • The procedure is typically performed by a dermatologist, surgeon, or qualified healthcare provider.
  • A nurse or medical assistant may assist during the procedure.

Risks and Complications

  • Minor bleeding
  • Bruising
  • Infection at the biopsy site
  • Pain or discomfort at the biopsy site
  • Allergic reaction to local anesthesia (rare)

Benefits

  • Provides a definitive diagnosis of the tissue condition
  • Helps in planning appropriate treatment
  • Minimal recovery time
  • Quick procedure with minimal discomfort

Recovery

  • Keep the bandage or dressing clean and dry
  • Follow any specific wound care instructions provided by your healthcare provider
  • Avoid strenuous activity for a day or two
  • Contact your doctor if you notice signs of infection such as increased redness, swelling, or drainage
  • Schedule follow-up appointments as recommended

Alternatives

  • Imaging studies (e.g., MRI, CT Scan): Non-invasive but less definitive
  • Fine-needle aspiration: Less invasive, suitable for fluid-filled masses but may not provide as much information
  • Core needle biopsy: More invasive but provides a larger tissue sample

Patient Experience

  • Mild discomfort or pressure during the procedure due to local anesthesia
  • Some soreness at the biopsy site post-procedure, manageable with over-the-counter pain relievers
  • Quick return to normal activities with minimal restrictions on daily life.

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