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29.12.2013, admin
Epidermoid cysts are asymptomatic, slowly enlarging, firm-to-fluctuant, dome-shaped lesions that frequently appear on the trunk, neck, face, scrotum or behind the ears. The minimal excision technique for epidermoid cyst removal is less invasive than complete surgical excision and does not require suture closure. These cysts occur predominantly on the scalp, are odorless and have less fat and more keratin than epidermoid cysts.
Vigorous expression of the cyst contents can cause material to literally fly across the room.
Most family physicians receive the necessary surgical skills during their residency training. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. The procedure is easy to learn, and most physicians experienced in skin surgery can perform the procedure after three to five precepted sessions. The skin overlying the cyst and the tissue to the sides and beneath the cyst are anesthetized with 2 percent lidocaine with epinephrine.2. Once the cyst contents have been squeezed out, a mass may be palpated adjacent to the cyst, suggesting that a tumor may be present.
This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. It involves making a 2- to 3-mm incision, expressing the cyst contents through compression and extracting the cyst wall through the incision.
These congenital cysts occur in the lines of cleavage and sublingually around the eyes and on the base of the nose. A fenestrated drape can be placed on the patient, with the lesion beneath the fenestration. It is recommended that the minimal excision technique be abandoned for a formal excision and biopsy if a solid tumor is detected.
Masks and eye protection may be needed for the physician, and care should be taken to avoid spraying the nursing personnel.
Most physicians experienced in skin surgery can perform these procedures unsupervised after three to five precepted procedures. Gauze or a splatter shield should be used to protect the physician from spraying of cyst contents. If malignancy is discovered in a cyst wall that is removed at the time of the minimal excision technique, the physician 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. Some physicians use a splatter control shield to avoid this problem.The Cyst Wall Will Not Come Out of the Tiny Incision.
The rarity of associated cancer makes histologic evaluation necessary only if unusual findings or clinical suspicion of cancer is present. The lesions can extend intracranially, and a preoperative computed tomographic (CT) scan is recommended.Milia. Others believe that all specimens should be sent for evaluation because the literature does note the occurrence of cancer.

Cysts that have previously ruptured or been inflamed may have significant adjacent scarring.
Inflamed cysts are difficult to e excise, and it is often preferable to postpone excision until inflammation has subsided. Duct obstruction of a sebaceous gland in the hair follicle can result in a long, narrow channel opening in the surface comedo. Certainly any atypical-appearing lesion or one associated with a palpable irregularity in the cyst wall should be sent for histologic analysis.Many lesions can be confused with epidermoid cysts.
Other causes include a developmental defect of the sebaceous duct or traumatic implantation of surface epithelium beneath 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. In addition, less-experienced physicians are often not vigorous enough when compressing the cyst. Incisional biopsy can be performed for very large lesions, and excisional biopsy for the smaller lesions. A tremendous inflammatory response (foreign-body reaction) ensues, often producing a purulent material.
These multiple, small, yellow, cystic nodules (a few millimeters in diameter) can be found on the trunk, upper arms, axillae and thighs.
Pilar tumors of the scalp are often confused with epidermoid cysts and may require wide excision because they can erode into the skull.Simple epidermoid cysts that appear to be completely excised do not generally require follow-up. Inability to remove the cyst should prompt the physician to perform a formal excision procedure.The Cyst Wall Breaks During the Procedure. Cyst wall breakage during the procedure may relate to the surgical technique or the anatomic location of the cyst. Multiple epidermoid cysts (associated with lipomas or fibromas of the skin) and osteomas should be considered as part of Gardner's syndrome, with associated premalignant colonic polyps. Cysts on the scalp (trichilemmal cysts, or wens) may have thicker walls than typical epidermoid cysts on the face. Dermoid cysts of the head 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 can be difficult if inflammation is present; it may be preferable to postpone excision until the inflammation has subsided. 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.
Some cysts can be associated with basal cell and squamous cell carcinoma, and some authors advocate histologic evaluation of the wall of all removed cysts. The rarity of associated cancer makes routine histologic evaluation necessary only when solid tumors or unusual findings are present.Cyst infection can develop spontaneously or following rupture. The hemostat can be reinserted, if needed, to assist with passage of the sebaceous material.4.
It is often unclear whether an inflamed cyst is infected, and many physicians prefer to treat these lesions with antibiotics, incision, and drainage.
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. 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 after the procedure.

Excision and closure can be very difficult with inflamed cysts, and it may be preferable to postpone the surgical procedure until the inflammation has subsided (typically one week).There are many surgical approaches to epidermoid cysts. An attempt should be made to gently remove the entire sac through the small opening (Figure 2). Direct pressure can also express any clot that may develop at this site.Expressing the Cyst Contents Is Tiring. 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. At the end of the procedure, the wound should be inspected to ensure that all of the cyst wall has been removed.
Despite the amount of work that is required, this technique can be very gratifying to the physician and patient.
The minimal excision technique involves a 2- to 3-mm incision, expression of the cyst contents, and extraction of the cyst wall through the incision.
The cyst wall can be pieced together to provide additional confirmation of complete removal.6.
Using the thumbs to express the cyst contents produces greater pressure.Cyst Contents Could Not Be Expressed. 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 closed with a single suture, although most physicians do not close this opening. The pilar cyst or pilar tumor of the scalp can be confused with a typical cyst, and the pilar tumor can invade surrounding tissues. A variation of this technique uses a punch 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.
The patient is encouraged to hold direct pressure (using gauze) to the site for one to two hours following the procedure.
Gauze can be used to cover the area as compression is applied, or a clear adhesive splatter-control shield can be used to cover the site. Some practices require the use of protective eye wear for the procedure.Simple incision and drainage of cysts frequently results in recurrence.
Two iodine crystals can be placed in the center of the cyst and, during the next few weeks, the cyst will become dark brown and hard.

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