DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Posterior scalp mass.
POSTOPERATIVE DIAGNOSIS: Posterior scalp sebaceous cyst.
PROCEDURE PERFORMED: Excision of posterior scalp sebaceous cyst with enucleation technique.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
COMPLICATIONS: None.
SPECIMENS REMOVED: Posterior scalp sebaceous cyst in entirety with overlying skin island.
ESTIMATED BLOOD LOSS: Less than 5 mL.
DRAINS: None.
INDICATION FOR PROCEDURE: The patient is a (XX)-year-old male with a history of a bulge on his posterior scalp for several years. The patient denies any skin changes, fevers, or drainage from this area. The patient has noted that it has slightly enlarged and has become tender to the touch. The patient was seen in the outpatient surgical clinic and on exam felt to have a benign cyst versus lipoma at that time. At this time, risks and benefits of excision of this lesion were discussed with the patient, and informed consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed on the table in a prone position. The scalp was then shaved, prepped, and draped in the usual sterile fashion. Ten mL of 1% lidocaine with epinephrine was then infiltrated into the skin overlying the mass as well as surrounding the mass. At this time, a brief time-out was taken to identify the patient and the planned procedure.
An elliptical incision was then made overlying the mass. This was carefully taken down to the level of the cyst capsule. At this time, it was clear that this was a sebaceous cyst, and therefore, flaps were raised bilaterally, carefully, using sharp dissection. Once a good portion of the cyst was free of the overlying soft tissue, a hemostat was used to bluntly dissect circumferentially around the cyst. Manual pressure bilaterally allowed partial enucleation of the cyst. The cyst remained tethered at its base, and therefore, careful blunt dissection along with the use of electrocautery was carried out to free the base of the cyst.
Once the cyst was entirely enucleated, the wound was copiously irrigated with sterile saline, and electrocautery was used to obtain hemostasis. The cyst was then inspected and was completely intact with the skin island overlying this. This was sent for permanent pathology. The wound was then closed in layers using interrupted 3-0 Vicryl sutures for a deep dermal layer and then interrupted 3-0 Prolene sutures for the skin edges. There were no complications encountered during this case.
