Dermoid Cyst Excision Procedure Sample Report
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: A 0.8 cm dermoid cyst of the scalp x2.
POSTOPERATIVE DIAGNOSIS: A 0.8 cm dermoid cyst of the scalp x2.
PROCEDURE PERFORMED: Excision of dermoid cyst of the scalp x2 (0.8 cm).
SURGEON: John Doe, MD
ANESTHESIA: Local.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: This is a pleasant (XX)-year-old female who presents with recurrent scalp dermoid cyst. The patient has had dermoid cyst removal for scalp in the past and she presents for re-evaluation. She has two new dermoid cysts at the apex of her scalp, 0.8 cm in diameter, one is draining, and local management is unable to stop the drainage. She wishes to have this cyst removed. Next to this cyst is a second cyst, 8 mm in diameter. The patient wished to have both the cysts excised. The risks, benefits, expectations, alternatives, and complications of dermoid cyst removal were discussed with the patient including infection, bleeding, recurrence of the cyst, scar formation, cosmetic deformity, and possibility of future surgeries. The patient understands and she wished to proceed with excision of dermoid cyst of the scalp x2.
The risks, benefits, expectations, alternatives, and complications of dermoid cyst removal were discussed with the patient, including infection, bleeding, recurrence of the cyst, scar formation, cosmetic deformity, and possibility of future surgeries. The patient understands and she wished to proceed with excision of dermoid cyst of the scalp x2.
DESCRIPTION OF PROCEDURE: The patient was brought into the ambulatory area and placed on the table in the supine position. The dermoid cysts of her scalp were identified by the patient and marked on the patient’s skin. The patient’s hair was prepped and draped in the usual sterile manner using ChloraPrep solution.
An elliptical incision around the cyst was performed incorporating the cyst openings into the excision. The cysts removed and blocked and sent to pathology as two cysts, approximately 8 mm in size. Deep layers of the wound were controlled using Bovie electrocautery. Meticulous hemostasis was assured. The skin edges were reapproximated using 2-0 Prolene in a figure-of-eight stitch with excellent approximation. Antibiotic cream and a dry sterile dressings were applied.
The patient was discharged to home, to follow up in the office in 7 to 10 days for suture removal. No intraoperative complications were noted. The patient tolerated the procedure well.
