What is the recommended surgical management plan for an epidermoid cyst on the chest?

Surgical Management of Epidermoid Cyst on the Chest

Complete surgical excision is the treatment of choice for non-inflamed epidermoid cysts on the chest. 1

Initial Assessment

• Evaluate cyst characteristics:
  • Size (cysts >1.5 cm warrant careful evaluation)
  • Signs of inflammation or infection
  • Suspicious features (rapid growth, fixation to surrounding tissues, ulceration)
  • Location on chest (consider cosmetic implications)

Surgical Management Algorithm

For Non-Inflamed Cysts

1. Complete surgical excision technique:

   • Use local anesthesia (lidocaine with epinephrine)
   • Plan incision along skin tension lines for optimal cosmetic outcome
   • Create an incision of appropriate size (typically 2-3 mm for minimal excision technique) 2
   • Express cyst contents through compression
   • Extract the entire cyst wall (crucial to prevent recurrence) 3
   • Ensure complete removal of the cyst capsule to minimize recurrence risk

2. Minimal excision technique considerations:

   • Suitable for smaller cysts (≤2.2 cm)
   • Requires only a 2-3 mm incision
   • Results in smaller scars compared to conventional excision
   • Shorter procedure time (average 16 minutes vs. 22 minutes for conventional excision) 4
   • May have slightly higher recurrence rate (8.3% vs 3.3% for conventional excision) 4

3. Punch incision technique:

   • Particularly effective for cysts 1-2 cm in size
   • Creates significantly smaller wounds (average 0.73 cm vs 2.34 cm for elliptical excision)
   • Shorter operative time (average 12.7 minutes vs 21.6 minutes)
   • Superior cosmetic results with comparable recurrence rates to conventional excision 5

For Inflamed Cysts

• Incision and drainage is the recommended initial treatment 1
• Postpone complete excision until inflammation has subsided 2
• Consider antibiotic coverage if signs of infection are present

Wound Closure Options

• Primary closure with sutures for conventional excision
• Minimal excision techniques may not require suture closure 2
• Consider wound location and tension when selecting closure method

Histopathological Examination

• Submit excised cyst for pathological examination if:
  • Cyst has suspicious features (rapid growth, fixation, ulceration)
  • Size >1.5 cm
  • Unusual clinical presentation or findings during excision 1

Post-Operative Care

• Keep wound clean and dry
• Remove sutures in 7-14 days (depending on location)
• Monitor for signs of infection or recurrence

Potential Complications

• Recurrence (2.2-8.3% depending on technique) 3, 4
• Infection
• Scarring
• Incomplete removal leading to higher recurrence risk

Follow-up

• Schedule follow-up visit to assess wound healing
• Instruct patient to return if signs of recurrence develop

Special Considerations

• For chest location, consider cosmetic impact of scar placement
• Punch incision or CO2 laser excision may be preferable for cosmetically sensitive areas 4, 5
• Marker sutures should be used for larger excisions to properly orient the specimen for pathological evaluation 6