To Cut or Not to Cut? A Review of Aesthetic Approaches to the Facial Subcutaneous Cyst

Facial cysts are a frequent reason for presentation to the dermatologist. The most common type of cyst of the head and neck, the epidermal inclusion cyst (EIC), is said to arise from the expansion of the infundibulum of the hair follicle, caused by loss of supporting perifollicular elastin, with subsequent accumulation of keratinocytic debris.^1-3 EICs may be linked to processes that obstruct the follicle or trauma to the follicular lining.^4-7 Some have suggested an association between EICs and smoking, specifically in males.⁸ EICs may also be seen in multisystemic syndromes, eg, Gardner syndrome, which is notable for cysts (epidermal and pilomatrical) in conjunction with premalignant adenomatous polyps of the colon.⁹ A recent study identified the prevalence of epidermoid cysts as 1.77% in a population of 67,448 Japanese patients who visited dermatologic clinics for several weeks in 2007 and 2008.¹⁰

The next most common variety of cyst, the trichilemmal cyst, arises from keratinocytes of the external root sheath of the follicle and may be inherited in an autosomal dominant fashion.¹¹ While trichilemmal cysts become inflamed infrequently (15%), approximately 50% of epidermal cysts become inflamed.¹² Other less frequently encountered cysts include dermoid cysts, congenital cysts found at the junction of embryonic fusion planes,¹³ and pilomatrical cysts, often seen in children.¹⁴

The noninflamed or mildly inflamed cyst may be aptly treated with intralesional corticosteroids or antibiotics, sometimes with significant improvement or resolution, though there is scant dermatologic literature to support this practice. Incision and drainage may also be effective in ameliorating symptoms,¹⁵ but if inflammation recurs or the cyst has become obvious and cosmetically unacceptable, surgical options are called for. For a young patient without apparent rhytides or sun damage, the traditional elliptical excision may result in an obvious and distressing facial scar. Of late, there have been multiple publications across surgical specialties regarding minimally invasive approaches to facial cyst removal. This review seeks to address these approaches, integrating subspecialty techniques to plan for an optimally aesthetic strategy.

The workhorse of cyst surgery is the elliptical excision, with removal of the cyst via a small elliptical resection of overlying skin approximating the diameter of the lesion, and subsequent dissection of the surrounding dermal attachments. In 1946, a surgeon named Joseph Danna described a technique of “electrosurgical marsupialization” to minimize scarring and produce a better cosmetic result.¹⁶ Using an electric current, he created a small opening over the top of the cyst, allowing the cyst to empty itself through the opening over 3 to 6 weeks with the cyst cavity shrinking down. Since then, others have described compatible strategies, whether utilizing electrical current or a mechanical means of creating an opening over the top of the cyst, permitting the cyst contents to evacuate with time.^17,18 By extension, work has shown that the punch excision, using a punch instrument to evacuate both the cyst contents and cyst wall through a small overlying circle, may be cosmetically superior to alternative approaches (Figure 1).^19,20 In 2002, Mehrabi et al demonstrated that the punch excision may have a shorter scar length and an equivalently low recurrence rate to traditional treatment. In a population of 646 patients