Flashcards in Incision, draining and exteriorization techniques Deck (85):
Tumescent anaesthesia should not be used when removing larger cysts and lipomas.
The incision for removal of a lipoma should be one-half to one-third of the lesional diameter of the underlying lipoma.
Lipomas are not usually encapsulated
F They usually are
Lipomas will usually be lighter in colour and firmer than the surrounding adipose tissue.
Infiltrating lipomas frequently require an incision which is larger than for ordinary lipomas.
Lipomas frequently become inflamed
For lipoma removal local anaesthetic is injected over and around and under the lesion
When removing forehead lipomas, the frontalis muscle bundles should be dissected in a horizontal orientation.
F Vertical if possible.
After removal of an epidermal cyst, the wound should be irrigated with saline.
There is no indication to start antibiotics when excising epidermal cysts.
F Start if cyst inflamed.
Multiple epidermal cysts may be associated with Gardner syndrome and basal cell nevus syndrome
If considerable fibrosis is encountered during removal of a cyst, the best course is to perform a fusiform excision including the fibrotic area and underlying cyst.
When infiltrating local anaesthetic during epidermal cyst removal, avoid direct injection into the cyst cavity to prevent distention and possible rupture.
Treated milia tend to recur.
Pilar cysts more commonly require removal of redundant overlying skin.
Carbon dioxide laser can be used to exteriorize and destroy steatocystomas.
Local anaesthesia is often less effective in infective tissues because of the low pH of infected tissues.
Incision and drainage of inflammatory lesions is considered the preferred surgical treatment method for hidradenitis suppurativa.
F Exteriorisation of cysts and sinus tracks.
Unroofed areas left after surgical management of HS should be grafted.
F Leave to heal by second intention if possible.
Infiltrating lipomas and forehead lipomas are much deeper than they appear and are often under or between muscle.
Cysts which have been drained previously or which have been traumatised will often have significant scar tissue associated with them.
Infiltrating local anaesthetic in and around a cyst helps to dissect it free from the surrounding tissue.
After incision and drainage of an abscess, a wick of material can be left extruded from the gauze packing – this should be advanced approximately 1 cm per day with each dressing change until it is removed.
Once a cavity of an infected cyst has been irrigated with saline a decision is made whether packing the wound or insertion of a drain is necessary
Packing of wounds can be performed with iodoform or plain gauze
Scrotal cyst excision sites generally heal faster.
F Slower – leave sutures in longer.
If drains are used after the removal of a subcutaneous lesion, these are typically removed in 24 hours.
CT or MRIs should be performed pre-operatively for infiltrating lipomas to determine the extent of involvement.
In removing milia, steatocystomas and apocrine hidrocystomas, minimal surgery should be done to avoid possible excess scar formation.
Scrotal cysts may be calcified and more fibrotic, lending themselves to fusiform excisions.
Medical treatment of hidradenitis suppurativa is topical antibiotics only
F Topical and oral Abx
In hidradenitis suppurativa exteriorization of cysts and sinus tracts is considered the preferred method of treatment
After surgical treatment of hidradenitis suppurativa the wound is closed with primary closure
F Secondary intent, large defects are left to granulate
For cysts and lipomas make an initial incision equal to the diameter of the lesion
Under no circumstances should a cyst be decompressed
Lipomas on the forehead are often underneath the frontalis muscle
Lipomas are non-encapsulated subcutaneous lesions
Most lipomas are asymptomatic
Lipomas rarely become inflamed
Lipomas on the upper extremities may be deep and involve the muscles and neural and vascular structures
The incision length of a lipoma should be ½-1/3 of the lesion diameter
Inject the LA in the lipoma
Inject the LA over, around and under the lipoma or cyst
Injecting the LA around the lesion may help it get dissected
Blunt dissection of a lipoma via a haemostat, Ragnel or Metzenbaum
Apply vertical compression to enable lipoma to squeeze it through the incision line
If drains are used should be removed in 72-96 hours
The supratrochlear and supraorbital nerve bundles may be injured if care is not taken during removal of a lipoma of the forehead
In order to access a frontalis associated lipoma, the frontalis muscle is dissected horizontally to separate the muscle fibres
A pressure dressing is helpful post removal of a frontalis associated lipoma
Intermuscular lipomas are poorly demarcated
Intramuscular lipomas are firmer than normal lipomas
If a lipoma is located near Erb’s point, a nerve stimulator should be used
The initial incision for removal of a cyst or lipomas is half the radius of the lesion
equal to the radius
Multiple epidermoid cysts is associated with Cowden’s syndrome and Gorlins
Gardners and Gorlins
When excising an epidermoid cyst, make the incision line through the epidermal pore
The incision line can be made into a fusiform excision if there is significant fibrosis or scar
Oral abs that cover pseudomonas should be given when excising cysts that are mildly inflamed
F – staph and strep
Trichilemmal cysts are more commonly seen in men than women
Trichelemmal cysts often have a punctum
Pilar cysts have a thick wall
The inelastic nature of the scalp makes undermining and closing the dead space more difficult
There may be a fibrous capsule at the lateral margin surrounding the lesion
The thick wall allows the pilar cyst to be easily delivery through the incision
The pilar cyst is the true sebaceous cyst
The most common site of a steatocystoma is the scalp
Steatocystomas often have an overlying pore
Steatocystomas may be associated with surrounding open comedones
Apocrine hidrocystomas are usually in the periocular area
The blue discolouration of an apocrine hidrocystomas is due to the tyndall phenomenon, extravasated rbcs, and lipofuscin
BCCs are softer and smoother than hidrocystomas
Topical antibiotics are not recommended for removal of periocular lesions
Infected tissues have a higher pH and therefore LA is less effective
Infected cysts may require packing or a wound drain
Packing can be performed with iodoform or plain gauze
Broad spectrum Abs should be given after I&D
Medical treatment of hidradenitis suppurative includes topical and oral abs
The primary cause of problems in HS is the inflammation of apocrine, eccrine and sebaceous glands
The exteriorization of cysts and sinus tracts should be allowed to heal by primary intention
Large lesions should be allowed to granulate
When I&D milia, the cyst wall will often be extruded with the keratinous contents
Epidermoid cysts are easier to remove than steatocystomas
Scrotal cysts/lesions may require fusiform excision
Scrotal lesions heal quickly