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sion for pathologic evaluation. Differential diagnosis includes lipoma, fibroma, neuroma, and fibrohistiocytoma
(potentially malignant), hence the need for pathology review.
Inflamed: Although antibiotics can control and sometimes reverse the inflammation of an abscess, those that
appear to be infected and unresponsive to conservative therapy should be incised and drained (I&D). This
however, creates an open wound that requires dressing changes for 1-2 weeks. An EIC can be excised as
opposed to incised as a non-inflamed mass if it is not actively inflamed. An attempt should be made to remove
the entire cyst wall. If the wound remains sterile (the cyst is not accidentally opened during the procedure), it
can be closed at the end of the procedure. If the EIC is actively infected, treat it as an abscess.
What You Need: Sterile prep and drape, needles: 18 and 24-27 ga, 10 cc syringe, alcohol prep pads,
local anesthetic, preferably with epinephrine, scalpel: #15 blade, irrigation: sterile NS/LR/water or hydrogen
peroxide, sterile gloves, sterile 4x4s, sterile hemostat, Adson pickups, Metzenbaum or Iris scissors, Allis
clamp (if available), specimen container and label (store/send in a watertight container [e.g., urine cup] filled
with formaldehyde), saline, IV fluid or sterile water, tape and dressings.
Excision: 3-0 dissolvable suture (taper needle), back lesion: 2-0 nylon (cutting needle), extremity or scalp
lesion: 3-0 nylon (cutting needle)
I&D: 2x2 or 4x4 gauze (or iodoform) for packing, tape
What To Do:
Prep: For inflamed and non-inflamed lesions, scrub and prep the area around the lesion with Betadine and
drape with sterile towels. Infiltrate local anesthetic in a field block at 2-4 sites around the area of the lesion.
This is a much more tolerable approach to anesthetizing the inflamed lesion, but works well in providing pain
control for either lesion. Try not to inject the EIC, as the distention of the capsule can cause increased pain or
spray the contents of the lesion out through the EIC orifice back at the surgeon. Allow several minutes for the
anesthesia to take effect. Subcutaneous lesions (lipomas, etc.) require deeper anesthesia, but they should
likewise NOT be injected. Plan an incision along the Lines of Langer (natural lines of tension) to minimize the
scar formation and promote efficient healing. Make the incision: use an elliptical incision for excision of an
epidermal mass or EIC, but use a straight incision for an abscess or subepidermal lesion. Include the entire
epidermal lesion, as well as the EIC (skin overlying cyst plus punctate, follicular orifice), in the excised tissue
to prevent recurrence. Similarly, remove deeper masses in their entirety.
Non-inflamed superficial mass:
Do not remove these lesions unless they fit the criteria above. Make an elliptical incision around any
superficial mass. Grasp the tissue to be excised with a clamp to allow retraction and demonstration of the
lines of tension of the surrounding tissue. Dissect under the mass, remaining in the dermis if the mass is
indeed superficial. Remove the tissue plug. Control hemostasis by gentle pressure. Irrigate the wound then
close it in one layer with nylon suture.
Standard guidelines: The specimen should be sent to the pathologist for evaluation. Use mattress suture
technique rather than simple interrupted technique in areas of higher tension (i.e., back, joints) to prevent
dehiscence of the wound. A dry bandage should be kept in place for 36-48 hours to allow re-epithelialization
of the wound. Sutures should be left in 5 days on the face, 7-10 days elsewhere, and 10-14 days on
high-tension areas. No antibiotics are needed. Profile of the soldier/patient should include limited movement
of the surgical wound for 2-3 weeks.
Non-inflamed subcutaneous mass:
Do not remove these lesions unless they fit the criteria above. Unless the lesion is an EIC, make a single
incision through the skin over the mass, large enough to allow visualization and dissection in the wound. If it
is an EIC that is not actively inflamed, make an elliptical incision as above for a superficial mass. Be certain
the ellipse will include both the EIC and its epidermal opening. Gently spread the subcutaneous tissue to
locate the mass, and use scissors when needed to dissect the mass out of the wound intact. The capsule of
the EIC is usually adjacent to the dermis. Dissection should proceed carefully in order to prevent rupture of
the EIC capsule and spillage of the foul smelling contents. If the mass has a capsule that ruptures, attempt to
remove the mass and capsule “piecemeal.” Inspect the wound for retained fragments of wall. If the rupture