Pilonidal Lesions, Cysts, Lipomas

Deciding if removal is the right option.

There are several conditions that will cause a growth in your body that is different from the surrounding normal form. They are usually classified as benign or malignant (cancerous). Some are in between but are more rare. Thankfully most are benign. The most common forms more easily recognized by people are those that are on the skin or just under the skin in a layer called the “subcutaneous tissue.”

The general approach I discuss with patients is that if there is a lump or bump that is known or suspected to be benign and it is growing or symptomatic, meaning is bothers you in some way, high consideration should be given to having it removed. Most of these can be removed in the office unless too large, or would be too uncomfortable to have surgically excised without more than just ‘local’ numbing injection medication. An office procedure will save potentially hundreds or thousands of dollars in medical expense. Often these can be removed at the same time as your initial visit. When scheduling please let us know if you would prefer this possibility.

What happens in the office to remove these?

In a procedure room in the office the area is sterilized with cleaning solution. Local anesthetic medication is then injected with a small needle to keep you from feeling the procedure. The lesion is then removed and the opening closed with absorbable sutures in most cases and a dressing is placed. Patients can then leave immediately. Larger lesions may need a prescription for pain medication. Most people do very well with Tylenol and Ibuprofen until the discomfort resolves. Follow up can be as needed.

Risks

There is always some chance of bleeding or infection anytime a break in the skin occurs. Precautions are taken to prevent infection and the chance of that happening is low at a couple percent. Unless there is concern for contamination or an infected lesion antibiotics are not needed. Care to avoid excessive movement of the area or hard pressure contact will lessen the chance of healing problems. The absorbable sutures last for a couple months and allow plenty of time for the strength to return in the healing process. Activity can be as tolerated. Scarring will occur to some degree. Some people have more pronounced healing from surgical incisions than others. Careful surgery and allowing an area to heal without excessive forces to separate the skin edges are the best options for minimizing scaring from surgery.

Re-occurrence of the lesion may happen depending on the type that it is. Some are completely removed and will never return and others such has large embedded lipomas can if any cells remain. Every effort is made to completely remove a lesion without taking so much tissue that a larger defect remains, but enough to ‘get it all.’ Lesions that can be very deforming or are on the face may need to be addressed by a plastic surgeon.

Pain – Occasionally small nerves can be divided when removing any tissue. The result is numbness of the area or a sensitive/tender spot that can result in pain or tenderness. The chance of this happening is low and unpredictable. Steroid injection to a painful area may thin the scarring. Occasionally re-excising the area may help.

Lipomas

These usually cause a lump under the skin, occasionally are tender, and are not cancers. They are are benign fatty tissue growth under the skin that grow more than the surrounding fat. I call them a ‘wild fat cell collection.’ It is normal fat that starts growing more than it should.

Lipoma Excision

Sebaceous Cysts

These are a mass under the skin from a blocked oil gland that continues to grow over time. The most common areas where this happens is the scalp, back of the neck and back. There is usually a central ‘pore’ that can be seen where it originates. These have to be removed completely taking out the sac to keep them from filling back up again. Squeezing or a small cut to express the material will only be a temporary remedy.

Sebaceous Cyst Removal

Pilonidal Lesions

A pilonidal cyst is a cyst at the bottom of the tailbone (coccyx) that can become infected and filled with pus. Once infected, the technical term is pilonidal abscess. Pilonidal abscesses look like a large pimple at the bottom of the tailbone, just above the crack of the buttocks. It is more common in men than in women. It usually happens in younger people.

They are thought to be from pores which become larger, let small pieces of hair in. The result subsequently causes more irritation leading to a larger cavity that can become infected. They typically are in the middle of the ‘crack’ and are not sore unless they become swollen due to infection. Like other boils, it does not usually improve with antibiotics and needs to be drained.

Early in an infection of a pilonidal cyst, the redness, swelling, and pain may be minimal. Sitting in a warm tub may decrease the pain and may decrease the chance that the cyst will develop to the point of requiring incision and drainage.

Treatment

Antibiotics do not heal a pilonidal cyst. The preferred technique for a first pilonidal cyst is incision and drainage of the cyst, removing the hair follicles, and packing the cavity with gauze. This procedure can usually be done in the office. The procedure involves an incision to clean it out, leave it open for packing and allowing it to heal or have it closed after a few days when enough healing occurs.