Minimal Excision Technique for Epidermoid (Sebaceous) Cysts

Am Fam Physician. 2002 Apr 1;65(vii):1409-1412.

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Article Sections

  • Abstruse
  • Other Types of Epithelial Cysts
  • Methods and Materials
  • Process Description
  • Follow-Upwardly
  • Procedure Pitfalls/Complications
  • Md Training
  • References

Epidermoid cysts are asymptomatic, dome-shaped lesions that ofttimes ascend from a ruptured pilosebaceous follicle. The minimal excision technique for epidermoid cyst removal is less invasive than complete surgical excision and does non require suture closure. The procedure is easy to acquire, and nearly physicians experienced in peel surgery can perform the process afterwards iii to five precepted sessions. It involves making a 2- to 3-mm incision, expressing the cyst contents through compression and extracting the cyst wall through the incision. Gauze or a splatter shield should be used to protect the doc from spraying of cyst contents. The rarity of associated cancer makes histologic evaluation necessary only if unusual findings or clinical suspicion of cancer is present. Inflamed cysts are difficult to e excise, and it is ofttimes preferable to postpone excision until inflammation has subsided.

Epidermoid cysts are asymptomatic, slowly enlarging, house-to-fluctuant, dome-shaped lesions that often announced on the trunk, neck, face, scrotum or behind the ears. Occasionally, a dark keratin plug (a comedo) can be seen overlying the cyst cavity. These epithelial, walled cysts vary from a few millimeters to 5 cm in diameter. The cysts are mobile unless fibrosis is present.

The term "sebaceous cyst" has fallen into decay; current terms include epidermal cyst, keratin cyst, epithelial cyst, and epidermoid cyst. Other types of cysts are included in Table 1. Epidermoid cysts often arise from a ruptured pilosebaceous follicle associated with acne. Duct obstruction of a sebaceous gland in the hair follicle tin result in a long, narrow aqueduct opening in the surface comedo. Other causes include a developmental defect of the sebaceous duct or traumatic implantation of surface epithelium below the skin.

The cysts contain keratin and lipid, and the rancid odor often associated with these cysts relates to the relative fat content, bacterial infection, or decomposition. Spontaneous rupture discharges the soft, yellowish keratin material into the dermis. A tremendous inflammatory response (foreign-body reaction) ensues, ofttimes producing a purulent material. Scarring makes removal more than hard.

TABLE 1

Table Major Lesions in the Differential Diagnosis

Branchial cleft cyst

Myxoid cyst

Dermoid cyst

Parotid tumor

Favre-Racouchot syndrome

Pilar cyst

Gristly tissue tumor

Pilonidal cyst

Gardner'due south syndrome

Preauricular cyst

Lipoma

Steatocystoma

Median raphe cyst

Thyroglossal duct

Milia

Nearly cysts are simple lesions, but a few special situations should be considered. Multiple epidermoid cysts (associated with lipomas or fibromas of the pare) and osteomas should be considered as office of Gardner's syndrome, with associated premalignant colonic polyps. Dermoid cysts of the caput often can be confused with epidermoid cysts, and attempted removal of a dermoid cyst can create a wound with Excision and closure of epidermoid cysts tin be hard if inflammation is present; it may exist preferable to postpone excision until the inflammation has subsided. intracranial communication. Some cysts tin be associated with basal jail cell and squamous cell carcinoma, and some authors abet histologic evaluation of the wall of all removed cysts. The rarity of associated cancer makes routine histologic evaluation necessary simply when solid tumors or unusual findings are present.

Cyst infection can develop spontaneously or following rupture. It is often unclear whether an inflamed cyst is infected, and many physicians prefer to treat these lesions with antibiotics, incision, and drainage. Excision and closure can be very hard with inflamed cysts, and it may exist preferable to postpone the surgical procedure until the inflammation has subsided (typically one calendar week).

There are many surgical approaches to epidermoid cysts. While complete surgical excision can ensure removal of the sac and prevent recurrence, this technique is time-consuming and requires suture closure. The minimal excision technique has been proposed as a less invasive and successful intervention. The minimal excision technique involves a 2- to three-mm incision, expression of the cyst contents, and extraction of the cyst wall through the incision. Vigorous finger compression is used to express the cyst contents and loosen the cyst wall from the surrounding tissues to facilitate removal of the sac. The tiny wound can be airtight with a single suture, although most physicians do not close this opening. A variation of this technique uses a dial biopsy instrument to create the opening into the cyst.

Expression of the cyst contents through the small opening can cause the sebaceous material to spray across the surgery room. Gauze can exist used to cover the area equally compression is applied, or a clear adhesive splatter-control shield can be used to cover the site. Some practices require the use of protective middle wear for the process.

Elementary incision and drainage of cysts oft results in recurrence. Two iodine crystals can exist placed in the center of the cyst and, during the next few weeks, the cyst will go night brown and hard. This difficult nodule tin then exist expressed from the skin. This uncomplicated technique is inexpensive, but the need for a follow-upwards visit and the length of time for lesion removal may brand this technique less desirable to many patients.

Other Types of Epithelial Cysts

  • Abstract
  • Other Types of Epithelial Cysts
  • Methods and Materials
  • Procedure Description
  • Follow-Up
  • Process Pitfalls/Complications
  • Physician Training
  • References

  • Pilar or Trichilemmal Cyst (Wen). These cysts occur predominantly on the scalp, are odorless and have less fat and more keratin than epidermoid cysts. They are very amenable to removal past the minimal excision technique.

  • Dermoid Cyst. These congenital cysts occur in the lines of cleavage and sublingually around the eyes and on the base of the nose. These cysts have a rancid odor. The lesions can extend intracranially, and a preoperative computed tomographic (CT) scan is recommended.

  • Milia. These ane- to two-mm lesions can ascend spontaneously or can be caused past trauma. A small nick in the epidermis with a no. 11 bract allows expression of the keratinaceous white kernel.

  • Steatocystoma Multiplex. These multiple, small, yellow, cystic nodules (a few millimeters in bore) can be found on the trunk, upper artillery, axillae and thighs. The multitude of lesions may prevent cyst removal.

  • Favre-Racouchot Syndrome. These multiple lesions on the face upshot from profound sun damage. The pilosebaceous openings stretch, and the orifices fill with keratin material, producing comedones and cysts.

Methods and Materials

  • Abstruse
  • Other Types of Epithelial Cysts
  • Methods and Materials
  • Procedure Description
  • Follow-Up
  • Procedure Pitfalls/Complications
  • Physician Preparation
  • References

EQUIPMENT

Nonsterile Tray for Anesthesia

Identify the following items on a nonfenestrated pall covering a Mayo stand:

Nonsterile gloves and mask

1 inch of iv × 4 gauze soaked with povidone-iodine solution

1 inch of 4 × 4 gauze

5-mL syringe, filled with 2 percent lidocaine with epinephrine (Xylocaine with epinephrine) with a thirty-approximate needle

25-estimate, ane ¼-inch needle (for anesthetizing beneath the cyst)

Sterile Tray for the Process

Identify the following items on a sterile curtain covering a Mayo stand:

Sterile gloves

Fenestrated dispensable drape

Two sterile bandages to anchor the drape

Iii small-tipped hemostats (mosquito clamps)

No. xi blade

Needle holder for suturing (if needed)

Iris scissors

Adson forceps

2 inches of 4 × 4 sterile gauze

Suture materials (if needed)

Splatter control shield (if desired)

Some physicians employ the nonsterile gloves that were used to administer the anesthesia for the removal of small or superficial cysts.

Procedure Description

  • Abstract
  • Other Types of Epithelial Cysts
  • Methods and Materials
  • Process Description
  • Follow-Up
  • Procedure Pitfalls/Complications
  • Medico Training
  • References

1. The skin overlying the site is cleansed with povidone-iodine solution. The skin overlying the cyst and the tissue to the sides and beneath the cyst are anesthetized with two percent lidocaine with epinephrine.

two. A fenestrated pall can exist placed on the patient, with the lesion beneath the fenestration. A no. 11 blade is used to create a stab incision into the centre of the cyst. A pocket-sized-tipped hemostat is placed into the cyst, the tips gently opened and compression practical to allow the cyst con tents to pass through the opening (Figure 1).

FIGURE i.

Incision in the top of a cyst with a no. xi blade. The cyst is squeezed to remove all of the cyst contents. A hemostat can be placed in the incision and the blades opened while the cyst is squeezed to facilitate removal of the cyst contents.

3. The hemostat tin can be removed, and both thumbs are used to express the cyst contents. Gauze or a splatter shield can exist used to shield the physician from splatter. The hemostat can be reinserted, if needed, to assist with passage of the sebaceous material.

iv. Following vigorous and complete expression, the hemostat is reintroduced into the cyst cavity, and the capsule at the base of the wound is grasped and elevated. An attempt should be made to gently remove the entire sac through the small opening (Figure 2). The sac may break, and several pieces may need to be removed.

Effigy two.

Afterwards vigorous squeezing, removing the cyst contents and loosening the cyst wall from the surrounding tissue, a hemostat is placed in the wound, and the entire cyst wall is gently delivered through the small incision.

v. At the end of the procedure, the wound should exist inspected to ensure that all of the cyst wall has been removed. The cyst wall can be pieced together to provide additional confirmation of complete removal.

6. Direct pressure is practical to the site with gauze. Antibody ointment is applied and gauze is taped over the site. The patient is encouraged to hold straight force per unit area (using gauze) to the site for 1 to ii hours following the process. About small incisions do not require suture closure.

Follow-Up

  • Abstract
  • Other Types of Epithelial Cysts
  • Methods and Materials
  • Process Description
  • Follow-Up
  • Procedure Pitfalls/Complications
  • Physician Grooming
  • References

Cancerous growths may crave a second procedure to provide a wider margin of excision around the original lesion. Rarely, malignancy may be detected at the site of the original surgery. One time the cyst contents take been squeezed out, a mass may be palpated next to the cyst, suggesting that a tumor may be present. It is recommended that the minimal excision technique be abased for a formal excision and biopsy if a solid tumor is detected. If malignancy is discovered in a cyst wall that is removed at the time of the minimal excision technique, the doc may consider a second excision.

Because malignancy is rarely associated with a cyst, some physicians believe it is not cost-effective to send all epidermoid cyst walls for histologic evaluation. Others believe that all specimens should be sent for evaluation because the literature does note the occurrence of cancer. Certainly any atypical-actualization lesion or one associated with a palpable irregularity in the cyst wall should be sent for histologic assay.

Many lesions tin can be confused with epidermoid cysts. If a solid tumor is discovered at the fourth dimension of the procedure, a biopsy should be obtained. Incisional biopsy can exist performed for very big lesions, and excisional biopsy for the smaller lesions. Pilar tumors of the scalp are oft confused with epidermoid cysts and may require wide excision considering they can erode into the skull.

Simple epidermoid cysts that appear to be completely excised do not by and large require follow-up. If a recurrence is brought to the medico's attention at a later appointment, standard surgical excision should be attempted.

Procedure Pitfalls/Complications

  • Abstract
  • Other Types of Epithelial Cysts
  • Methods and Materials
  • Procedure Description
  • Follow-Up
  • Procedure Pitfalls/Complications
  • Doc Training
  • References

  • The Contents of the Cyst Sprayed. Vigorous expression of the cyst contents can cause material to literally fly beyond the room. Gauze should exist loosely held over the site to preclude spraying. Masks and eye protection may be needed for the md, and intendance should be taken to avoid spraying the nursing personnel. Some physicians apply a splatter command shield to avoid this problem.

  • The Cyst Wall Will Not Come Out of the Tiny Incision. Cysts that have previously ruptured or been inflamed may take significant side by side scarring. The scarring may forbid removal with the minimal excision technique. In addition, less-experienced physicians are often non vigorous enough when compressing the cyst. Pressure level applied with the thumbs can loosen the cyst wall from the surrounding tissues. Inability to remove the cyst should prompt the physician to perform a formal excision process.

  • The Cyst Wall Breaks During the Procedure. Cyst wall breakage during the process may relate to the surgical technique or the anatomic location of the cyst. Cysts on the scalp (trichilemmal cysts, or wens) may have thicker walls than typical epidermoid cysts on the face up. Many physicians report that it is easier to remove scalp cysts intact. Thin-walled cysts tend to break and may demand to be removed in pieces; still, if adequate kneading of the skin occurs before attempted removal, many cysts tin can exist removed intact.

  • A Claret Jell Adult After Cyst Wall Removal. Removal of large cysts tin can create a significant open space beneath the skin. Hematomas or infectious material can fill this infinite. Major bleeding is rarely associated with this procedure, and hematomas can be avoided by having the patient apply firm pressure (using gauze) to the surgical site later the procedure. Direct force per unit area tin likewise express any clot that may develop at this site.

  • Expressing the Cyst Contents Is Tiring. The minimal excision technique can be physically enervating when performed correctly. Despite the amount of work that is required, this technique tin be very gratifying to the doc and patient. Using the thumbs to express the cyst contents produces greater pressure level.

  • Cyst Contents Could Not Be Expressed. Solid tumors may masquerade as a typical epidermoid cyst. The pilar cyst or pilar tumor of the scalp can be dislocated with a typical cyst, and the pilar tumor can invade surrounding tissues. If a solid tumor is suspected during minimal excision, information technology should be removed by a formal surgical excision and sent for histologic evaluation.

Physician Training

  • Abstract
  • Other Types of Epithelial Cysts
  • Methods and Materials
  • Process Clarification
  • Follow-Up
  • Procedure Pitfalls/Complications
  • Doctor Grooming
  • References

Formal grooming is needed for the techniques of anesthetic administration, lesion excision, and closure, if it is performed. Most family physicians receive the necessary surgical skills during their residency training. Others could obtain this training with the aid of an experienced preceptor. Most physicians experienced in skin surgery tin perform these procedures unsupervised after three to five precepted procedures.

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Adjusted with permission from Zuber TJ. Office procedures. Baltimore: Lippin-cott Williams & Wilkins, 1999.

RESOURCES

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Cruz AB, Aust JB. Lesions of the skin and subcutaneous tissue. In: Hardy JD, Kukora JS, Laissez passer HI, eds. Hardy'due south Textbook of surgery. Philadelphia: Lippincott, 1983:319–28.

Domonkos AN, Arnold HL, Odom RB. Andrews' Diseases of the skin: clinical dermatology. 7th ed. Philadelphia: Saunders, 1982.

Foroughi D, Britton P. When is a "wen" a "wen"? A diagnostic dilemma. Br J Plastic Surg. 1984;37:379–82.

Habif TP Clinical dermatology. second ed. St. Louis: Mosby, 1990.

Humeniuk HM, Lask GP Treatment of benign cutaneous lesions. In: Parish LC, Lask GP, eds. Artful dermatology. New York: McGraw-Hill, 1991:39–49.

Johnson RA. Cyst removal: punch, push, pull. Skin. 1995;1:14–v.

Klin B, Ashkenazi H. Sebaceous cyst excision with minimal surgery. Am Fam Physician. 1990;41:1746–8.

Morgan RF, Dellon AL, Hoopes JE. Pilar tumors. Plast Reconstr Surg. 1979;63:520–4.

Parlette HL. Management of cutaneous cysts. In: Wheeland RG, ed. Cutaneous surgery. Philadelphia: Saunders, 1994:647–63.

Vogt HB, Nelson RE. Excision of sebaceous cysts: a nontraditional method. Postgrad Med. 1986;fourscore:128–34.

Part Procedures forms on minimal excision technique for epidermoid (sebaceous) cysts are provided on pages 1417, 1418 and 1420.

This article is one in a series adapted from the Academy Collection book Part Procedures, written for family unit physicians and designed to provide the essential details of commonly performed in-office procedures, and published by Lippincott Williams & Wilkins.

Copyright © 2002 by the American University of Family unit Physicians.
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