The Contents of the Cyst Sprayed. Vigorous expression of the cyst contents can cause material to literally fly across the room. Gauze should be loosely held over the site to prevent spraying. Masks and eye protection may be needed for the physician, and care should be taken to avoid spraying the nursing personnel. Some physicians use a splatter control 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 have significant adjacent scarring. The scarring may preclude removal with the minimal excision technique. In addition, less-experienced physicians are often not vigorous enough when compressing the cyst. Pressure 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 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. Cysts on the scalp (trichilemmal cysts, or wens) may have thicker walls than typical epidermoid cysts on the face. Many physicians report that it is easier to remove scalp cysts intact. Thin-walled cysts tend to break and may need to be removed in pieces; however, if adequate kneading of the skin occurs before attempted removal, many cysts can be removed intact.
A Blood Clot Developed After Cyst Wall Removal. Removal of large cysts can create a significant open space beneath the skin. Hematomas or infectious material can fill this space. 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. Direct pressure can also express any clot that may develop at this site.
Expressing the Cyst Contents Is Tiring. The minimal excision technique can be physically demanding when performed correctly. Despite the amount of work that is required, this technique can be very gratifying to the physician and patient. Using the thumbs to express the cyst contents produces greater pressure.
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 confused with a typical cyst, and the pilar tumor can invade surrounding tissues. If a solid tumor is suspected during minimal excision, it should be removed by a formal surgical excision and sent for histologic evaluation.
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