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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.
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.
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.
No imaging was necessary for excision of the sebaceous cyst.
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.
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.
No special considerations were indicated for this patient.
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.
Minimal equipment is necessary for sebaceous cyst removal.
- Betadine or other antiseptic cleansing solution
- 2-3ml lidocaine and epinephrine mixed syringe for local anesthesia
- Sterile supplies – gloves, gauze, patient drape, bandages
- Small tipped hemostats (mosquito)
- Suture supplies
Nothing to disclose.
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.
- Harvard Health Publishing. Epidermoid Cyst. Harvard Health. 2019. https://www.health.harvard.edu/a_to_z/epidermoid-cyst-a-to-z.
- Zuber, TJ. Minimal excision technique for epidermoid (sebaceous) cysts. Am Fam Physician. 2002;65(7):1409-1412.
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So this is a cyst in the face. Initially when I was feeling it, it felt like a fat cyst, lipoma, but after… it seems like there's an area there, central area, the pore, it could be a cyst. So I'm just, for the face, it's a little more vascular, so I'm going to dilute some epinephrine to my local anesthesia, just to lessen the bleeding later on. For orientation, his chin is here, his eyes are here. So if you're looking at the cheek, normally a good incision to lessen the scarring would be a curvilinear incision. Something like this, towards the chin. There's the right eye.
Injection now. Bevel up, you can see the needle. Bevel's up. One injection. It's spreading slowly through the skin. You can see it turning white. So that's the, that's a good block. Move a little back here. Here you can see it blanching again. Then you know that you're in the dermal layer. So normally, we wait for the epinephrine to take its effect, normally around 5 to 6 minutes. So then once we start the incision, it'll lessen the bleeding. So normally, face lesions are very vascular. So again, we- we just go around it. And I injected a little bit underneath. We're going to do a little under. Okay. It feels like a cyst. I think I got some infiltration inside the cyst. so you can see there's… Or you can see some anesthesia coming out. So we'll wait for 5 to 6 minutes, better if you're going wait 7 minutes, then better, but it will allow the epinephrine to take its effect on the capillaries in this area, which causes normally vasoconstriction. So, with vasoconstriction, when we make the incision, you won't have that much bleeding.
We start the incision as mentioned, a little curvilinear. There's the cyst wall. Here, you could see it, the cyst. Try to make a smaller incision, I try to avoid hitting it. I think I hit part of it there, you see it coming out. Very thin wall.
Again, it's important to get all the cyst wall to avoid its recurrence. Mosquito. Actually, it's on top, you can see this is, the cyst wall, here, differentiating it from a little shinier, which is the actual sebum already. So I think in this area, we- we opened it up. So I just stay- and not to be underneath. See the cyst coming out there? The cyst is almost out. There's some sebum coming out there. So here, I think this is still a good, still have a good cyst wall. Here, you can see the most inferior part. Here you could see, if you could do also this. Can I get a Mosquito? Just go right underneath the mass, and then just spread slowly. you can just see it popping out. There. Here I grab onto the lower tissue. And you're spreading it out slowly. Here you can see an opening here. There we go. I still got the cyst wall here, you can see the cyst wall is off. Here you go. So you should blunt dissection here to remove the whole cyst, completely. You have just a couple of more tissues still stuck, I just- use my blade to cut it off. Mosquito off. I cut everything off. So this is what I'm telling you about the cyst wall. Actual sebum coming out. Remove the whole mass, and it's not bleeding as much because of a combination of Lidocaine and epinephrine.
So I just make a small incision underneath. undermine it… to close it just medically better, just a small 5-0. Closing the tissues and muscle. I use an inverted T. I get a small bite of tissue underneath. I make another small suture here in the side.
When you cut the skin, probably don't go too deep, have a lighter incision. As you could see, I already nicked a bit of the capsule, but I followed it back down. So sometimes if you do get the capsule open, don't be worried. You could still find a normal capsule orientation to the normal tissues. for a better plane on another area. Even if you've popped it already open. So it's, again it's important for us to remove the whole capsule to avoid recurrence of the cyst. So at that one, I think I probably, and most surgeons, sometimes nick the capsule, maybe once you incise the- the skin, you could already use blunt dissection by using a Mosquito. I- as I mentioned, I prefer using the blade. it's quicker, but maybe safer would be blunt dissection after you- you've incised the skin. I think those are normal mistakes that, we surgeons do when we have sebaceous or epidermal inclusion cyst surgeries. So, once that happens, I think it just takes technique, takes experience, I try to go in a little lighter until you find normal anatomy and a good plane. So management, of course you use- use of sutures for this type of face lesions would be fine sutures to avoid the markings after, when you remove the suture. So a 6-0, 5-0, 6-0 will be good for a repair or outside stitch. Same management will be postoperatively by giving antibiotics for infection and pain reliever for discomfort and pain.
33-year-old, we removed the cyst from his face. We put a plastic dressing. So a cyst from his face. I'm showing him his cyst, which he said has been with him for almost 2 years. I asked him why he hasn't gone to a surgeon, so, for this island, he said that there is no surgeon. For them to have the surgery then, they go and do it… which they- they spent those to 500 pesos from here to… and another 500 coming back. So it's 1000 pesos. So he's a tricycle driver, and, and spending that much just to have his cyst removed would cost a lot of- financial costs for them and the family. So… So he's very thankful for, for us coming here and doing the surgery so that he could save up money and, and use the money that he earns as a tricycle driver for his family. So he has 2 kids, 2 children and a wife, so that money could go a long way for them, for weeks here in, in the island of Sibuyan.