A 72-year-old woman presented with a sebaceous (epidermal inclusion) cyst of the scalp that interfered with her combing her hair. She was taken to the minor operating room for excision. The hair directly on the cyst was shaved and the surrounding hair controlled with paper tape. Note the dark punctum, representing the blocked sebaceous gland from which the cyst developed.
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A half and half mixture of 1/2% lidocaine and 1/4% marcaine without epinephrine was carefully injected into the thinned dermis over the cyst. Care is taken not to inject into and rupture the cyst. Injection was done with a 27g needle on a 1cc syringe. The smaller the diameter of the syringe, the more force there is per unit area and the easier it is to inject into dense tissue like dermis. The dermal wheal confers immediate anesthesia by the stretch of the tissue, even before the drug takes effect, allowing immediate incision.
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