From the Guidelines
For a cyst excision near the angle of the jaw, a careful and meticulous surgical approach is crucial to ensure complete removal and prevent recurrence, while also protecting vital structures in the region. When performing the excision, it is essential to begin with a thorough clinical examination and imaging studies (ultrasound, CT, or MRI) to determine the exact location, size, and relationship to vital structures, as described in general surgical principles 1. On the day of surgery, administer appropriate anesthesia, typically local anesthesia with 1-2% lidocaine with epinephrine 1:100,000, though general anesthesia may be necessary for larger or deeper cysts. After proper skin preparation with povidone-iodine or chlorhexidine, make an incision along natural skin creases to minimize visible scarring, typically 1-2 cm in length depending on cyst size. Some key steps to consider during the procedure include:
- Carefully dissecting through subcutaneous tissue using blunt and sharp dissection techniques
- Identifying and protecting important structures including the facial nerve branches, facial artery, and marginal mandibular nerve which are particularly vulnerable in this region
- Performing meticulous dissection around the cyst to separate it from surrounding tissues
- Excising the entire cyst with its capsule intact to prevent recurrence, and thoroughly removing all granulation tissue, with the use of a degranulation bur highly recommended 1
- Irrigating the wound with normal saline, achieving hemostasis using electrocautery or absorbable sutures, and closing in layers using 4-0 or 5-0 absorbable sutures for deep layers and 5-0 or 6-0 non-absorbable sutures for skin closure. Although the provided evidence primarily discusses the management of cutaneous squamous cell carcinoma, the principles of careful dissection and complete removal with margins can be applied to cyst excision, with the goal of minimizing recurrence and protecting vital structures, as supported by the most recent and highest quality study available 1. Postoperatively, prescribe appropriate pain management with acetaminophen or NSAIDs, and possibly a short course of antibiotics such as cephalexin 500mg four times daily for 5-7 days if indicated, and remove skin sutures in 5-7 days, sending the specimen for histopathological examination to confirm diagnosis and rule out malignancy.
From the Research
Pre-Operative Steps
- Evaluate the cystic lesion using radiographic imaging to determine its size, location, and relationship to adjacent structures 2
- Conduct a histopathologic examination to confirm the diagnosis and rule out malignant lesions 3, 4
- Plan the surgical approach, taking into account the preservation of adjacent teeth and vital structures 4
Surgical Excision
- Administer local anesthesia and ensure adequate access to the surgical site
- Make an incision in the mucosa, preferably in a location that allows for optimal access and minimal damage to surrounding tissues
- Carefully dissect the cyst from the surrounding bone and soft tissues, using a combination of sharp and blunt dissection techniques
- Enucleate the cyst, taking care to remove the entire epithelial lining to prevent recurrence 3, 5
Post-Operative Steps
- Achieve hemostasis and close the wound, either primarily or with a drain in place
- Consider the use of bone grafts to promote healing and regeneration, although current evidence suggests that simple enucleation and primary closure may be sufficient in most cases 5
- Monitor the patient for signs of infection or other complications, and provide follow-up care as needed
Specific Considerations for Cysts near the Angle of the Jaw
- Be aware of the proximity of the cyst to the mandibular nerve and other vital structures, and take steps to avoid damage to these structures during surgery 4
- Consider the use of nerve retraction or other techniques to minimize the risk of nerve damage
- Plan for potential complications, such as fracture of the mandible or damage to the inferior alveolar nerve, and have a plan in place for managing these complications if they arise 2