I am sure you have had your fair share of frustration with mucoid cysts in the past. We have all tried office-based treatments. Unfortunately, excision, cauterization, steroid injections and the like just do not work. It is unsettling for both you and your patient when the patient returns due to recurrence of the cyst.
Mucoid cysts have been well described in the literature and are commonly known as synovial cysts, periarticular fibromas, myxoid cysts, ganglion cysts, mucinous pseudocysts and mucous cysts. These benign cutaneous lesions are jelly filled, have a pearlescent appearance and are usually located in a periungual location. These cysts are more common on the fingers. I have had some unusual presentations over the years and I will share them with you.
I have some advice regarding communication with your patients about mucoid cysts. First and foremost, you must discuss the difficulty that you may have in resolving the cyst. I tell my patient that I will try once to excise the cyst and cauterize it with electrocautery. If the cyst comes back, then we will need to go to the hospital or surgery center for more extensive surgery.
I try to discuss the condition in simple terms. I use the analogy of a straw and balloon. I also use this description with patients that have traditional ganglion cysts as well. The cyst is the balloon and the straw is the communication stalk that fills the balloon from the underlying joint and/or tendon. So in a nutshell, I tell the patient that if the communication between the joint and cyst is not destroyed, then the cyst will come back. That is why most of the time, simple curettage and cautery fail to resolve the cyst in the long run.
So what is the best way to remove mucoid cysts? Assuming simple office-based treatment has failed, I will consider simple excision with a 3:1 double semi-elliptical full-thickness skin wedge. Also, burring down the bone at the joint or doing an arthroplasty may be necessary. I feel the bone work is important as it facilitates good bleeding and promotes scar tissue. This will ultimately destroy the communication between the joint and the cyst. In large cysts or atypical locations, however, it may be difficult to do any bone work or do a 3:1 excision.
My preferred method of surgical care for a mucoid cyst that is in a traditional periungual location is to excise the lesion, burr down the bone or perform an arthroplasty of the distal interphalangeal joint if feasible, and do a rotational skin flap. By rotating a full-thickness piece of skin, the stalk (or the straw as I tell my patients) will be eliminated.
Although I do not have to do many of these surgeries, I cannot remember a recurrence with this method.
Your patient may initially think that your proposed surgery is quite radical for such a “simple” pimple-like skin growth. However, after a thorough discussion of the condition and concerns of recurrence, patients are more than accepting of the proposed surgery.