Epidermal Cyst Excision

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Subject: Epidermal Cyst Excision

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Introduction

Epidermal or sebaceous cysts are frequently encountered in clinical practice. These slowly enlarging lesions commonly appear on the trunk, neck, face, and genitals and behind the ears. The term epidermal cyst is preferred over the historically used term sebaceous cyst. The cysts usually arise from ruptured pilosebaceous follicles or the lubricating glands associated with hairs or other skin adnexal structures. Within the cyst is a white to yellow, cheese-like substance commonly (but incorrectly) referred to as sebum. The rancid odor associated with some cysts reflects the lipid content of the cyst material and any decomposition of cyst contents by bacteria. 
Clinically, the cysts can vary in size from a few millimeters to 5 cm in diameter. Cysts generally have a doughy or firm consistency, and hard, solid-feeling lesions suggest the possibility of alternate diagnoses. The cysts usually are mobile within the skin, unless the cysts have surrounding scar and fibrous tissue from a prior episode of inflammation. 
The cyst contents induce a tremendous inflammatory response from the body if they leak out. Epidermal cysts can have a tremendous amount of associated pus when inflamed, but culturing these inflammatory cells often reveals a sterile inflammatory response. Because of the discomfort, redness, and swelling associated with an inflamed cyst, many individuals prefer to have cysts removed before they have the opportunity to leak and become inflamed. Inflamed cysts usually require incision and drainage of the pus and sebaceous material, with removal of the cyst wall at a later date. The inflamed tissues bleed extensively and are unable to hold sutures well for proper closure. After the inflammation resolves, standard incision and removal techniques may be employed to remove the entire cyst. Cyst recurrences are prevented by complete removal of the cyst wall. 
Most cysts are simple, solitary lesions. However, some clinical situations warrant added care. Multiple epidermal cysts that are associated with osteomas and multiple skin lipomas or fibromas may represent Gardner syndrome. Gardner syndrome is associated with premalignant colonic and gastric polyps. Dermal cysts of the nose, head, and neck often appear similar to epidermal cysts. However, a dermal cyst can have a thin stalk that connects directly to the subdermal space, and surgery can produce central nervous system infection. Multiple cysts, such as in the fold behind the ear, can be treated alternately with medical therapy (i.e., isotretinoin). When a cyst is removed with any technique, the medical provider should palpate the surgical site to ensure that no tissue or lesions remain. Rarely, the clinician may encounter basal cell carcinoma or squamous cell carcinoma associated with epidermal cysts, and histologic examination of cyst walls is recommended whenever unusual or unexpected clinical findings are encountered. 

Equipment

  • The basic office surgery instruments are used for the standard excision technique (see Appendix G).

  • A suggested anesthesia tray that can be used for this procedure is listed in Appendix F.

  • Skin preparation recommendations appear in Appendix E.

Indications

  • Lesions with the clinical findings or appearance of epidermal cysts

Contraindications (Relative)

  • Local cellulitis

  • Severe bleeding disorders

  • Failed previous minimum excision attempt on the specific lesion

The Procedure

Step 1

Anesthesia is accomplished with a 25-gauge, 1-inch-long needle on the syringe. Insert the needle laterally, angling the needle 45 degrees down to below (behind) the cyst (see Field Block Anesthesia). Place an adequate amount of anesthetic (usually 3 to 6 mL) beneath the cyst. Prep the skin with povidone-iodine or chlorhexidine solution, and allow it to dry (see Appendix E). 
  • PEARL: Prep a wide area so that an undraped area is not inadvertently exposed if the drape slides a little.

  • PITFALL: If the needle tip is placed inadvertently within the cyst, the anesthetic will increase pressure and cause the cyst to explode, often shooting the sebaceous material across the room.

Step 2

Make a fusiform excision that is large enough to remove the redundant skin caused by expansion of the cyst. Use care to cut only to the base of the dermis, not into the subcutaneous tissue. Make sure the long axis of the fusiform is parallel to the lines of least skin tension. If the pore is visible, the excision should be designed around it. 
  • PITFALL: Cutting too deeply increases the chances of inadvertent puncture of the cyst, with spillage of the cyst contents and resultant inflammatory response.

Step 3

Carefully open a dissection plane between the skin and the cyst wall. The center of the fusiform incision may be grasped with pickups to assist in manipulating the cyst. 
  • PEARL: If the cyst is accidentally entered, use a small hemostat to clamp the hole. It is much easier to excise a full cyst than a deflated one.

  • PITFALL: The clinician should not be positioned directly over the cyst. Opening a cyst that is under pressure can result in upward spraying of the cyst’s contents. Hold some gauze in the nondominant hand to act as a shield when opening the cyst.

Step 4

Dissect around the side of the cyst. Gradually change the angle of the scissors to follow the wall of the cyst. Semisharp dissection usually provides rapid removal with a minimal risk of perforating the cyst. 

Step 5

Continue the removal until the base of the lesion is free. 
  • PITFALL: When attempting to dissect the base of the cyst, be care to not remove excessive normal tissue below the cyst, because this creates a large deep defect that must be closed.

Step 6

The wound can be sutured immediately, usually using simple interrupted sutures (see Simple Interrupted Suture). If a significant defect is present under the skin, place a deep buried suture to close the deep space and approximate the skin edges (see Deep Buried Dermal Suture). 

Step 7

Incise the cyst and make sure it completely deflates. If there is any thickness or masses in the cyst wall, send it for histologic analysis. 

Complications

  • Bleeding

  • Infection

  • Scar formation

  • Recurrence

Pediatric Considerations

Although epidermal cysts are rare in the pediatric population, when present, the removal process is the same. 

Postprocedure Instructions

Simple epidermal cysts that appear to be completely excised do not generally require follow-up, except for suture removal. If a recurrence is brought to the physician’s attention at a later date, standard surgical excision should be attempted. 
Instruct the patient to gently wash an area that has been stitched after 1 day but to not put the wound into standing water for 3 days. Have the patient dry the area well after washing and use a small amount of antibiotic ointment to promote moist healing. Recommend wound elevation to help lessen swelling, reduce pain, and speed healing. Instruct the patient not to pick at, break, or cut the stitches. 

Coding Information and Supply Sources

Use the benign excision codes (11400 to 11446) for removal of these lesions. The code selected is determined by size and location of the lesion. The codes include local anesthesia and simple (one-layer) closure, although the codes can be used if the minimal incision technique is used and no suturing is required. The sites for these codes include the following: trunk, arms, or legs (TAL); scalp, neck, hands, feet, or genitalia (SNHFG); and face, ears, eyelids, nose, lips, or mucous membrane (FEENLMM). 

Bibliography

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Grocutt M, Fatah MF. Recurrent multiple epidermoid inclusion cysts following rhinoplasty— an unusual complication. J Laryngol Otol .  1989;103(12):1214–1216. [View Abstract]
Kowand LM, Verhulst LA, Copeland CM, et al. Epidermal cyst of the breast. Can Med Assoc J .  1984;131(3):217–219. [View Abstract]
Leppard B, Bussey HJ. Epidermoid cysts, polyposis coli and Gardner’s syndrome. Br J Surg .  1975;62(5):387–393. [View Abstract]
Lopez-Rios F. Squamous cell carcinoma arising in a cutaneous epidermal cyst: case report and literature review. Am J Dermatopathol.  1999;21:174–177. [View Abstract]
Nakamura M. Treating a sebaceous cyst: an incisional technique. Aesthetic Plast Surg.  2001;25:52–56. [View Abstract]
Suliman MT. Excision of epidermoid (sebaceous) cyst: description of the operative technique. Plast Reconstr Surg .  2005;116(7):2042–2043. [View Abstract]
Zuber TJ. Skin Biopsy, Excision and Repair Techniques . Kansas City: American Academy of Family Physicians;  1998:94–99.
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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