DENVER – A little lidocaine and a punch biopsy tool allow physicians to tackle most cysts and lipomas in the office, providing effective treatment without interrupting patient flow.
The punch technique easily eliminates the contents of these annoying, sometimes painful, lesions, Dr. Robert T. Brodell said at the annual meeting of the American Academy of Dermatology. But more importantly, it allows the complete removal of the cyst wall, which is key to preventing recurrence, he said.
Despite dogma, it’s not really necessary deliver the entire cyst unbroken, a technique that requires a much larger incision, explained Dr Brodell, professor and chairman of dermatology and a professor of pathology at the University of Mississippi Medical Center, Jackson.
Dr. Robert Brodell
"When I was training, it was common for surgeons to excise cysts and hold them up ... to demonstrate that the entire cyst had been removed intact," he said. "But it doesn’t really matter if it is removed this way. What does matter is that the entire wall is removed. If you don’t, the remainder will keep making keratin and set up a foreign body reaction," or set the stage for cyst recurrence.
Pilar cysts and multiple painful lipomas on the forearms or legs seem to be the easiest to remove this way, Dr. Brodell said in an interview. Lesions on the back where the skin is quite thick are more difficult. But his early study on the technique found a recurrence rate of only 14% in these more difficult areas and an overall recurrence rate of 8% for all cysts.
Dr. Brodell’s preferred technique starts with an intradermal injection of 1% lidocaine plus epinephrine, enough to raise and blanch the overlying skin. "You don’t need any deep anesthesia," he said. "This seems to be enough to take care of the innervation of these structures."
A punch appropriate to the cyst size – usually 4-6 mm – is used to incise the lesion. A forceps is used to free the wall from the surrounding dermis. Dr. Brodell then manually expresses the contents with lateral finger pressure. Portions of the cyst wall will also be extruded. Looking through the punch excision defect, any remaining fragments of cyst wall are removed.
It most cases, it takes only a stitch or two to close the small wound.
Lipomas are slightly more complicated. After incising the lesion, Dr. Brodell again applies lateral pressure, and the contents will start to deliver. "If you grab the lipoma with forceps, a portion of the lipoma is incised and removed. Then more fat can be delivered through the punch incision hole and removed. The process continues until the entire contents are removed. "If I’m not getting all of it out, I’m getting at least 90%-95%, which seems to minimize the chance for recurrence," Dr. Brodell said.
He said that he finishes by making a bolster with gauze to place over the wound and wrapping it with a pressure bandage. This strategy prevents a hematoma from developing in the potential space where the lipoma was removed.
The technique also is appropriate for infected cysts, Dr. Brodell said, and in such cases it is accompanied by a standard course of systemic antibiotics.
"For most cysts, and for lipomas smaller than 2 cm, the process takes less than 5 minutes," Dr. Brodell said. "For a really big lipoma, maybe 15 minutes."
Punch excision carries benefits for both the provider and the patient. "You can do it in the office, without interrupting patient flow," said Dr. Brodell. "In some cases it saves the patient a trip to the surgery center. In this case it is certainly less expensive."
The charge is calculated according to lesion size, typically ranging from $130 to $350. "A trip to the surgery center is going to be at least $1,200," Dr. Brodell added.
Dr. Brodell began performing this procedure in the late 1980s. In 2002, he published a retrospective review of 299 patients who had undergone pilar or keratinous cyst removal via punch technique and who had complete follow-up data (Dermatol. Surg. 2002;28:673-7). Follow-up averaged 80 weeks.
Most of the patients (267) reported no recurrence. The recurrence rate was 9% for keratinous cysts, 5% for pilar cysts, and 8% overall. Recurrence was higher among back and ear lobe cysts (14% and 13%, respectively).
Most cysts (54%) recurred within 1 year of surgery; 24% recurred 1-2 years later.
Given the ease and convenience of this technique, and the excellent clinical results, Dr. Brodell encouraged physicians to reconsider their anti-cyst weaponry – and try putting down the scalpels and reaching for a punch.