the

Removal of an Epidermal Cyst at the Nape of the Neck

so this patients presents for evaluation

or removal of a mobile lesion that's

sitting right at the nape of his neck

right in through this area here we put

some anesthesia underneath it and we put

some over top of this to things to make

note of this field isn't infected so if

he feels discomfort other than just

pressure during the procedure we just

add some more in and sort of see how we

do from that perspective second this has

a lot of redundant tissue so sometimes

this is a little bit more complicated

than it seems now but it's not

impossible by any means the deeper ones

like this hard to get the entire capsule

out intact but as long as get the

capsule entirely it should be fine

nothing that should proceed okay so that

doesn't hurt at all

no pain there so for this fields again I

try to we've got some drapes across here

but this will run a little bit I've made

him aware that ahead of time to try to

prepare that as best you can so this is

the number 11 blade that we're using

like always with this I tell residences

to proceed slowly as best you can it can

be frustrating if you're watching this

type of thing you want this to move

along quicker but I until in reality you

know sometimes it seems like it's it's

right there it's far lower and other

times it's it's quite a bit deeper

you can see already here it looks like

it made a photo you can see that looks

like there might have been a punctum

here where it communicated with the

surface it was probably weakest at that

area

so what I want to do with these ones as

best I can I want to get down to the

level where I can see where the cyst

capsule is and if it ruptures it

ruptures but then we'll want to try and

see if we can dissect around it

as best we can

so this is again so here you'll notice

the hair is getting away a little bit

he's found us the favor of having his

hair cut recently which does help but

this year at the nape of the neck can

beat hard from that perspective you

can't can't really pin the hair down

well these baby hair as always sort of

get in the way

Zuse you do the best you can

so if you can appreciate that but there

seems like there's a weakness right

there you can see that so yeah so before

I go into it you should be able to see

that area looks more pearlescent right

there so that layer looks like it's at

the level we want it to be and here's

membrane just on top of this but I push

this in

you've seen me do this before once I get

to the right level I'll use this to

protect the underlying tissue

like that

so you should be able to appreciate that

that's the membrane sitting there

what I'm going to do is the same thing

from the other side

it's all I'm doing with these cry loser

snaps they often call them to is I'm

just breaking down additional adhesions

you can tell long this was pretty good

same thing here it's not bad

you're okay

this one's not bad it's just on the

bottom and where it's anything just a

little bit

you can see that rupture is just a

little bit there so if I put pressure on

that

this is just all keratin

see that's pulling out completely

you see here this is all the membrane

behind it there and this is where it

opened up here and that's where it seals

back in just like that no I'm doing here

they're just making sure there's nothing

residual it's in there

it's nice when they come out with one

piece or essentially in one piece like

that I'm pretty sure that you've got the

entire thing out no so if we take the

capsule out the risk of recurrence is no

greater than that of forming a new cyst

so it's not zero only because the fact

that you have one sister shows you're a

little bit predisposed to it but if we

don't get this this capsule out then

we're looking at about a 25% chance or

greater that that recurs so here again

this is one of the cases where I won't

use any dermal sutures because we didn't

take out we didn't make an elliptical

incision which is you could have argued

that the start and I could have hadn't

discussed about that as to whether you'd

want to do that or not and then on top

of which we took out mass so meaning

there's less volume underneath this

would be less pressure on these than

before

so again you know I would usually talk

about seven millimeters being the

distance I usually if I do choose to not

put in a dermal suture

I usually approximate them a little bit

more just kind of I find that balance

just to give a little bit more strength

while it's healing

so with these cases if this was this one

was relatively clean as these cases go

if we'd gotten a lot of it into his

little baby hairs and certainly we'd

have to clean that up afterwards but you

know certainly with these videos that I

do in probably just about every other

position you see you may not see that on

camera but most would clean that up for

sure because assuming choice you really

have in these cases hair nets can help

to a certain extent but there's

limitations there in terms of how much

they can do

narrow kr8 Oh crumbs

this is a little bit longer as previous

teachers

I would tell residents when you're doing

these your sutures make sure your needle

when you drive it in the skin you want

to be perpendicular to the skin then

even when you're doing superficial bites

you still want to make sure there's a

little bit of depth to your bite

so if you're too superficial and you're

just disguising the skin you're not

grabbing any you're not getting down to

dermis and making sure that that seals

together so what I mean by that is

you'll see here when I'm putting this in

I put my needle in perpendiculars

opposed if I'm coming in at this angle

I'm not getting much skin so even if I'm

doing a small bite I'm still getting a

decent amount of tissue

sorry about that stuck it on your hairs

a little bit

I know it so if you're just getting

started you know sometimes you're gonna

waste a lot of suture material cuz it

gets smaller they get a little bit

nervous if you're just new at this

you're not doing many this just don't

try to say the suture material if you

feel more comfortable getting a new

Paco then just get it out

so that should heal nicely we'll just

keep those in for seven to ten days then

those should come out we're good