A biopsy is considered incisional when only a portion of the lesion is removed.

Incisional biopsy is indicated when a lid lesion has not responded to medical management and the character of the lesion is unknown. It also is used when malignancy is suspected but it cannot be determined whether surgical removal of the lid lesion is indicated. In these cases, this technique is used to confirm the suspicion so that a complete second-step radical surgery may be planned. A classic indication is a case in which basal cell carcinoma is suspected. If a lid lesion clinically looks malignant, frozen section and reconstruction are preferred over incisional biopsy.

A local anesthetic agent with adrenalin is injected or infiltrated around the suspected tissue. A section of the tissue is grasped carefully with forceps, and a small piece of the lid tumor is removed with a scalpel blade. Punch forceps or scissors also may be used to excise a small piece of tissue. Ideally, the sample should be taken from the margin of the mucocutaneous junction. The central portion should be avoided, especially in ulcerated lesions, because histopathology may reveal only necrotic tissue and therefore will be inconclusive. If the quantity of tissue taken is not adequate, one should not hesitate to remove more. The success of the biopsy is of utmost importance for determining further treatment and management.

In shave biopsy, a technique used in cases of a suspected nevus or growth on the lid margin, the pathologic tissue is removed flush from the lid margin with a scalpel blade. The aim is to confirm the pathology of the lesion. This technique is used to confirm the character of the lesion on histopathology so the appropriate treatment can be planned.

Shave biopsy is indicated for a suspected nevus or growth on the lid margin when one is in doubt whether it is malignant or benign. The aim is not to remove the tumor, but rather to clinch a clinico-histopathological diagnosis.

The surrounding tissue is infiltrated, or a regional block is given. The growth is pulled with a small tooth forceps, away from the lid margin. A Bard-Parker no. 15 blade is used to shave the elevated mass from the lid margin. After the specimen is marked appropriately, it is sent for histopathologic evaluation. The slight oozing from the base usually can be stopped by applying a bit of pressure. If bleeding persists, cautery may need to be done at the base.

Punch biopsy is quite similar to incisional biopsy; the major difference lies in the use of a punch to take the specimen.

Punch biopsy is very useful for the diagnosis and confirmation of pigmented lesions suspected of being malignant, especially melanoma. This technique is especially indicated for lesions lying in the periorbital region and not involving the lid margin. This method is particularly helpful in assessing the depth of a lesion.