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REMOVAL OF CYSTS

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SUMMARY

  • Cysts are a frequent patient complaint, and removal may be motivated by tenderness, functional compromise, or aesthetic concern.

  • Most cysts respond well to excisional approaches, ranging from small punch excisions to large elliptical approaches.

image Beginner Tips

  • Never attempt to excise an actively infected cyst; instead, consider I&D or a course of antibiotic therapy prior to attempting aggressive surgical intervention.

  • Cysts that have been previously treated, infected, or manipulated will be more recalcitrant to treatment and may require sharp dissection or full excision.

image Expert Tips

  • With experience, cysts may be delicately dissected en bloc from a small incision site.

  • Dead space minimization is vital for postoperative success, and may be accomplished via fascial plication sutures or percutaneous suture placement.

image Don’t Forget!

  • Though minimal access incisions may be tempting, this must be weighed against the undesirable smell associated with cyst rupture which may be disturbing to the patient.

  • Careful removal of all cyst contents and the entirety of the cyst wall will help mitigate the risk of recurrence or postoperative complications.

image Pitfalls and Cautions

  • Even expert diagnosticians may be fooled by cyst mimickers; therefore, all suspect cystic nodules should be removed, and every cyst should be sent for histopathology.

  • Excising large cysts overlying nerve danger zones may entail a risk of permanent nerve damage; this should be explained to patients as part of the informed consent process.

image Patient Education Points

  • Patients should always be told that they are trading the cyst for a scar; if they are at all hesitant, defer the procedure.

  • Even with complete excision, cysts may recur; patients should be warned that this is a possibility before starting surgery.

image Billing Pearls

  • Depending on clinical practice, most excised cysts are removed for symptomatic reasons, and are therefore billed with a benign series excision code (11400 series) coupled with a repair code (12000 and 13000 series).

  • Be sure to document the rationale for the medical necessity of cyst excision if it is to be billed to insurance.

  • Cysts removed purely for cosmetic reasons should not be billed to insurance.

INTRODUCTION

Cysts are frequently encountered in dermatologic surgery, and patients may present with a growing, irritated, or infected cystic nodule. While patients often present due to symptomatic concerns, they occasionally seek treatment for primarily aesthetic reasons. Most epidermal inclusion and pilar cysts can be identified clinically by their appearance and anatomic location, though excised cystic nodules should always be evaluated histopathologically, as other skin and soft-tissue tumors—everything from lipomas to Merkel cell carcinoma—can clinically mimic epidermal cysts.

EPIDEMIOLOGY

Many patients and nondermatologists refer to epidermal inclusion and pilar cysts colloquially as sebaceous cysts. This terminology should probably be avoided, as the only truly sebaceous cyst is a steatocystoma, which is encountered only infrequently, ...

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