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Sebaceous Cyst Excision

Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES
Philippine Children's Medical Center

Abstract

Sebaceous cysts are closed sacs filled with foul-smelling, cheese-like material found underneath the skin. They form when a gland or hair follicle becomes blocked and are commonly found on the scalp, face, neck, or torso. Sebaceous cysts are non-cancerous and usually present as painless lumps, but can become tender when infected. In most cases, smaller sebaceous cysts may be ignored as they do not cause any symptoms; however, larger cysts may need to be removed with complete excision recommended to prevent recurrence. Oral antibiotics may be required when a sebaceous cyst becomes infected. Here, we present a 33-year-old male patient who underwent complete resection of a 2-year-old cyst.

Case Overview

Background

A sebaceous cyst, also called epidermoid, keratin, epithelial or epidermal cyst, typically presents as mobile, nontender, smooth, rounded mass ranging in size from millimeters to fist sized or larger1.The removal of this benign lump can prevent irritation, infection, and improve aesthetic appearance. Irritated sebaceous cysts can be excised under local anesthesia by initiating a small elliptical incision to drain and remove the capsule1.

Focused History of the Patient

A 33-year-old-male patient presents with a nontender, small sebaceous cyst located on his left cheek area that was noticed 2 years ago. The patient’s primary reason for intervention is cosmetic related. He has no known allergies.

Imaging

No imaging was necessary for excision of the sebaceous cyst.

Natural History

Sebaceous cysts are typically caused by a burst pilosebaceous follicle that causes duct obstruction resulting in the buildup of keratin and lipid under the surface of skin. The domed surface may contain a comedo, which is a dark pigmented, keratin composed plug that blocks the duct to the problematic sebaceous gland. If ruptured, the contents, made-up of keratin, fat, bacteria, and decomposition, flood into either the surrounding tissue or out onto the skin. If internalized, the inflammation process can ensue resulting in infection and scar formation2. These lesions can present almost anywhere on the surface of skin and can be removed by minor, local surgical excision.

Options and Rationale for Treatment

Minor cysts without irritating symptoms can be left untreated. If treatment is indicated due to infection, inflammation, or cosmetic preference, surgical incision is warranted. Simplifying the operation to drainage only, often results in recurrence and can require follow-up visits2. Ideally, a small incision under local anesthesia and careful technique to keep the capsule intact during removal is an effective treatment. In this case specifically, the island in which the patient resides does not have access to surgical care and the patient could not afford to travel the distance to a surgeon. A surgical mission provided his care.

Special Considerations

No special considerations were indicated for this patient.

Discussion

The goal for a successful treatment of this sebaceous cyst is to excise the entire capsule with the smallest incision. Preparation for the procedure included betadine and a drape over the location for incision. Local anesthesia composed of lidocaine and epinephrine was used to numb the area directly on and around the sebaceous cyst. The epinephrine is added to the solution to prevent excess bleeding due to the high vascularity of the face. In order to avoid unnecessary scarring, a small elliptical incision was created. A mosquito clamp was attached to the surface skin attached to the top of the mass as part of the ellipse. The connective tissue surrounding the capsule was cut to expose the cyst wall, consisting of a smooth shiny coating.

From here the capsule can be followed closely around its entirety using blunt dissection with scissors or hemostats to separate the sac from the surrounding connective tissue. Tension can be created by pulling the cyst to one side or the other and pressure can be applied to the skin under it to better visualize the site. One the cyst is freed on all sides; it can be removed. When sebum (contents of the cyst) leaked out during the procedure, we carefully removed it with gauze or contained it externally to prevent infection in the wound. The nick in the cyst wall was adjusted to expose a different plane to continue the procedure safely and to ensure the entire removal in order to prevent recurrence. A 5-0, inverted T suture, and simple interrupted suture technique was used to close the incision in order to prevent scarring as the excision was on the patient’s face. A simple band aid was used to cover the incision after cleansing. Antibiotics were used for infection prevention and Tylenol for pain management.

Prognosis for any cyst is excellent as most relieve themselves. If surgically removed as depicted here, antibiotics can be given to prevent infection and minor scarring may occur.

Equipment

Minimal equipment is necessary for sebaceous cyst removal.

  • Betadine or other antiseptic cleansing solution
  • 2-3ml lidocaine and epinephrine mixed syringe for local anesthesia
  • Scalpel
  • Sterile supplies – gloves, gauze, patient drape, bandages
  • Small tipped hemostats (mosquito)
  • Suture supplies
Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Citations

  1. Harvard Health Publishing. Epidermoid Cyst. Harvard Health. 2019. https://www.health.harvard.edu/a_to_z/epidermoid-cyst-a-to-z.
  2. Zuber, TJ. Minimal excision technique for epidermoid (sebaceous) cysts. Am Fam Physician. 2002;65(7):1409-1412.