1. Introduction

2. Inject Local Block

3. Incision

4. Drainage

5. Post-op Remarks and Closure

Cutaneous cysts are closed, sac-like, or encapsulated structures that may be filled with air, liquid, or semi-solid material, and are generally benign. Many types of cysts can occur in almost any place throughout the body and can form in all ages. They are seen as slow-growing and painless lumps underneath the skin. However, some cysts may be painful if they are particularly large. Treatment depends on several factors including the type of cyst, location, size, and the degree of discomfort caused. Large, symptomatic cysts can be removed surgically, while smaller, asymptomatic cysts can be drained or aspirated. Here, we present the case of a 12-year-old male with a pus-filled cystic mass on his first left toe and discuss surgical management and follow-up. 

<h4>CHAPTER 1</h4>

<p>So this is a 12-year-old male with a mass here in the -
in the big toe, underneath.
It seems like solid tissue.
We'll see later.
So, I drew out an incision, which is like what we call a Z-
a Z-plasty, a Z-incision.
This should lessen out the tension because
this area would have a lot of movement
when he walks.
So, when he moves,
this will cause some problems if we just make a straight incision.
So this incision will allow more exposure,
more exposure for the mass to be removed easier,
and to also create less tension when he, when he walks, using this.
So I'll, I'll show you the incision later.</p>

<h4>CHAPTER 2</h4>

<p>Now, if you want to do a local block here -
the nerves go through the lateral parts of the,
of the big toe, here and here.
So, I'll have some local anesthesia here,
inject here and here until you go to the bone.
So you inject straight down, perpendicular to this bone.
Until you hit the bone.
And then you retract it a bit. Okay?
So here, this is my incision site.
So I go straight down to the bone.
There, until you hit it, then you\retract a bit.
You could aspirate. I'm not inside a vessel. I try injecting slowly.
There we go. We're hitting the nerve right there.
So I normally infiltrate around -
1 - 1.5 - 2 cc.
And I go to the other side.
I go straight down on the other side to the bone again.
There, once you hit the bone,
retract a bit. Aspirate. We're not inside a vessel.
You could again, infiltrate. It might sting a bit.
I insert around another 1 cc.
Then I just apply pressure to the area.
Massage it a bit so that the local anesthesia could,
could be absorbed by the tissues
and you'll have its effect after a few seconds.
I would also after, after I wait for these blocks,
this digital block, to work,
I'll be able to insert
another needle here,
to anesthetize the area.
But this will be less painful.
So, best to do the blocks first,
and then local - local anesthesia, please?
So I'll infiltrate superficially. He should have less pain now.
Here we go.
Okay.
I don't see - I don't see him reacting.
So, it feels like he should be okay.
As a general rule, they normally avoid using -
epinephrine with lidocaine with surgery on the digits, just to avoid any problems.</p>

<h4>CHAPTER 3</h4>

<p>So I'll start my incision. As I mentioned,
I'm doing a Z, a Z-type incision.
As you can see, it's like an inverted Z here.
I'll show you why later.
Sometimes you could also bring it down a bit here to expose more.
Or here. But let's see, sometimes we could do -
you could do just with this type of incision.
So, I'm starting.
Normally, you could use a smaller blade,
like a blade 15, but this is okay.
So make a small incision here.
Don't go too deep, so you don't hit the mass.
Some lidocaine's coming out, some pus.</p>

<h4>CHAPTER 4</h4>

<p>Well, I'm already squeezing it out actually.
It's not solid, it's -
there's some pus, and that's flat. There, you can see there.
So it seems like an infected,
infected cyst or else...
So it seems like an infected cyst.
So sometimes,
preoperatively you might think it's a mass, a solid mass.
Now after this\medial incision,
you can see some, a lot of pus came out.
Maybe we don't want it -
we don't need to do any further incision there.
So I just try to insert this.
There you can see more pus coming out. There.
So sometimes it's good that I just made that first incision,
and all the pus came out.
So I will avoid making a bigger incision.
So even just a small, small wound already drained out everything.
And I just have to just flush the area -
flush it out clean.
And maybe just leave this wound to heal
by secondary healing. So that we allow also some -
some more discharge to come out in the next few days.
So it's now flat. I don't see any... So I don't think it's -
it's worth to continue the incision to make it a bigger one
because I already drained out everything.
So I just make this into a - just to flush it out.
Clean the area inside with NSS.
You could use also hydrogen peroxide, if you want.
So I just clean the area.
And then you just press...
And we should be done.
I just put a dressing over it and allow
this wound to close in the next few days.</p>

<h4>CHAPTER 5</h4>

<p>So I normally don't - I normally don't put a suture anywhere here.
Because -
we want to drain it out.
So, we're done.
I just drained out the fluid.
It seemed like an infected cyst.</p>


Watch this full-length, narrated procedure of the drainage of a cystic mass on the first left toe. It was performed as part of a surgical mission to the Philippines with the World Surgical Foundation.

DOI
Publication Date	2023/12/07
Article ID	268.11
Production ID	0268.11
Volume	2023
Issue	268.11
https://doi.org/10.24296/jomi/268.11

Drainage of Cystic Mass on First Left Toe

Procedure Outline

Table of Contents

1. Introduction

2. Inject Local Block

3. Incision

4. Drainage

5. Post-op Remarks and Closure