Dr. Geoff Butler

In this video, I again refer to the #15 blade as #11 for which I apologize. I have to start thinking about that a bit more consciously. At any rate, there is a small punctum that you can appreciate at the beginning of the procedure. This peels off nicely later in the procedure and shows why you don't have to excise the whole area around a punctum so long as you clean of the capsular portions underneath. This healed nicely and without incident. Feel free to comment as always.

I regrettably misspoke at the beginning of this video when I was referring to the scalpel I was using. This one was a number 15 and not 11. The nape of the neck can be a challenging area to work on as there can be a lot of redundant tissue and instrumentation can be difficult. You could certainly have elected to do an elliptical incision here but I didn't think that would be necessary. In spite of the capsule opening up a little, you should be able to appreciate that this came out completely intact. This healed well, without incident. Feel free to drop me a line if you'd like.

The real teaching point with this procedure is in the appreciation with how superficial this cyst was sitting. I know that in other videos, viewers will complain about how long it takes to get down to the level we want to achieve but videos like this one show why it is prudent to go slowly. This cyst was covered by millimeters of epidermis and nothing else. Regardless, this was removed cleanly and without incident. The suturing starts around the 6:55 mark. I also apologize for the squeaky chair. I realize that it sounds terrible and I've since oiled it appropriately. Please feel free to drop any comments you'd like.

I regret that I didn't start taping until after we'd applied pressure to a significant fluctuant area along the previous incision. A large amount of pus cleared itself before we started taping. As well, at one point I scraped the incision margins which we lost when we spliced this video. The scraping of the tissue margins allows the underlying basement membrane to be exposed and allow subsequent proper adhesion. At any rate, this cleaned up okay and in follow up this had healed nicely. The real teaching point is to see the potential downsides of using running stitches in cases such as these.

This is a pretty standard injection for adhesive capsulitis. I do find the subacromial bursal injection is a bit harder as the anatomy makes the space a bit more narrow in some cases. Most patients have some degree of burning for the next 1-2 days but I usually quote to patients that 10-15% can have significant burning for 4-5 days. The injection still works well but they will be uncomfortable. If you 'hit' a nerve, which is rare, they can be REALLY uncomfortable for weeks and maybe even months, but again, the injection can still be effective.

This accumulated quickly for this patient likely secondary to an infected hair follicle. I mistakenly mention "cavity" instead of "capsule" when I'm differentiating between an abscess and an infected cyst. The latter has a capsule where the former does not. Also, at the end of this procedure, I also sent off a swab but I stopped the video before I did that step. This was obviously not sutured closed and was not packed either.

This is a simple procedure but is one that can be frustrating if you haven't done it before. Typically I prefer a number 11 blade for this as it cuts straight down a bit easier but the #15 was all that was available in clinic. I apologize for not filming the sutures but for the record, only one was necessary.

This patient had this cyst present for a number of years and it was more apparent then most cysts this size because he chose to shave his head completely. I apologize that the video is a bit out of focus from the 3-4 min mark. Sutures start going in at around the 7 min mark and these are just the superficial interrupted type. There was no need for dermal sutures here. This healed nicely and without incident.

This video demonstrates the value of using a punch biopsy for small cyst removals. Regrettably we stopped filming before the sutures were put in but that was somewhat on purpose as the resident was doing them and the video portion of things can stress them out a little bit. This healed well without any adverse consequence.

This lesion was present for years and pathology confirmed that this was a wart. Dermal sutures start at 6:24 while interrupted surface sutures start at 11:30. This went smoothly and the patient healed well.

This was a clean removal of a pilar cyst. At one point the anaesthesia had to be augmented, unfortunately, but that is unusual for these cases. I find that when I inject underneath the cyst bed that usually the anaesthesia is quite good. However, it is also easy to add more. There were no complications here and this healed well. I could have chosen to clip the hair down but I don't as I never find this interferes to any great degree. At the end of this procedure, however, the whole area was cleaned and the hair pulled out of the actual wound. As always feel free to leave a comment.

This turned out to be quite a large epidermal cyst that I ended up taking out in pieces. At one point the patient describes feeling pressure and while eventually I added some additional anaesthesia, I didn't initially as I simply avoided the area where he said he felt something. I apologize for some of the 'blurry' video, there must have been something on the lens or interfering there. Similarly my hand does get in the way a little bit from time to time. This was sealed with both dermal sutures (that start at about 12:30) and interrupted surface prolene sutures. Otherwise this healed well and the cyst was entirely removed. Please feel free to comment as always.

This BCC was slowly growing over a few years. The procedure itself was fairly uneventful and the skin margins came together nicely. The only point I would make to residents is that you will see, after my initial incision, that a small vessel was bleeding towards the one apex. You could certainly have chosen to cauterize this or tie it off but typically this will naturally happen with both dermal sutures and interrupted sutures so I wouldn't panic. Feel free to comment as always. Take care.

This patient had an irregular growing nail for years that would intermittently cause him pain. He had portions of it removed and even the entire nail taken off but it had always regrown in an unhealthy fashion. It was therefore decided to take the nail off and chemically ablate the nail matrix using phenol. This procedure went well, without any specific complications.

This procedure essentially serves as a detailed biopsy. This did turn out to be a squamous cell cancer and the patient had to have a more extensive procedure done after this. I do apologize for the interference with the sound that using the hyfrecator creates. I appreciate that it sounds awful and is quite annoying. I really wanted viewers to appreciate how abnormal tissue responds differently to cautery. It should have been appreciated that as we cleared some of the atypical tissue, that the cautery was working much better. Thanks again for your comments.

This patient was seen in clinic and presented with a rapidly expanding, and painful, lesion just under his left ear. As a result of the infection, it was impossible to remove any type of capsule and that will have to be reassessed in the future. Regrettably, this video was cut a little bit short and irrigation and swabbing was not captured. The other thing I would note is that packing was not used in this case and neither was it necessary to place the patient on antibiotics. As a final note, this patient was completely cleaned up before he left the clinic and the small amounts of keratin and pus that had made their way into his hair, were removed. Thanks again and as always, feel free to comment.

This patient had slammed his right thumb nail in a door a few days prior. Many physicians would elect to do nothing here as often times the thought is that this area has started to clot already. That being said, I've always found burr holes effective, irrespective of how far out the injury is, and the patient will feel better and have a greater chance of saving the nail. Certainly a simple procedure to learn.

This is another fairly straight forward removal. In this case the cyst ruptures but the entire capsule comes out easily. I would caution again against shaving the area. Clipping the hair could be an option but especially with short hair, this would be glaringly obvious and not appreciated by the patient. Shaving increases the risk of infection and should be avoided. This healed nicely without consequence.

This was a good example of removing a pilar cyst cleanly. While this is always the goal and honestly happens quite often, sometimes it does not and that shouldn't dissuade anyone from not doing these procedures. So long as the capsule is removed, be it intact or in pieces, then the risk of recurrence drops drastically and that should be considered a successful procedure. Throughout this procedure, the patient was entirely comfortable and while I certainly could have pinned his hair down a little, it didn't interfere with the overall procedure. Viewers should realize though, that even if the procedures become quite messy, that patients are always cleaned up completely before the procedure is considered complete. Thanks again for your comments....even the nasty ones. Take care.

Regrettably, the first part of this video, where I take out a small triangle of scar tissue, was misplaced and the simple removal of the pilar cyst is all that remains. I still think it is useful for a couple reasons. First, the actual removal of the cyst is quite simple and shows, again the utility of going slowly and removing only superficial tissue as this was directly beneath the scar. Secondly, it also shows how a somewhat irregular scar can easily come together with appropriate suturing. This healed nicely and was without incident. I am going to try, in the near future, to film these in progression and show the final results as well. Take care.

Popaholics I would look at the 4:00 - 5:20 part, 7:10ish and again at 11:20ish. This was an interesting procedure for a number of reasons. First I would make the following comments. At around the 5:15 mark I actually add a little anaesthesia but this wasn't captured on film. As well, I realize that the hair may bother some people but I don't find it particularly difficult to work with and at the end we always clean the patient up entirely before he/she leaves the office. I also mistakenly call the #15 blade that I use in this procedure a #11 which it is not. The #11is much pointier and used to pierce more than it is to incise. You'll notice that the colour of this keratin seems almost 'dirty' and that's because the cyst was very superficial and was starting to oxidize. As well, at the 7:10 point when I remark that the keratin coming out was simply some left in the cavity from the removed cyst I was wrong. I should have realized, by the way that keratin squirted out that there was a second underlying cyst behind the first. This isn't typical, however, which is why I mischaracterized it. Finally, while this may look like a lot of blood loss, it really isn't. It doesn't take much blood to stain the hair and you shouldn't panic when some degree of oozing starts. This level of bleeding will never result in anything problematic. As a last remark I would also comment that I continue to work on the camera angle and amount of zoom I am using. This one did 'move' more than I'd like and made me a little dizzy watching it. I'm trying to improve on this as best I can. Thanks again and take care.

Popaholics I'd fast forward to the 7:35 mark and for those interested in just suturing, that starts around the 11:00 mark. For those trying to learn the procedure, the teaching points I would make are the following. First, the lower back, in and of itself is a bit challenging when you go looking for lipomas (especially) and likewise for cysts. There can be an enormous amount of subcutaneous tissue and you can 'lose' your target fairly easily. For this reason, many physicians opt to start with an elliptical incision as they have a greater chance of localizing their target. I did not do so here as a linear incision is less traumatic and seals up a bit simpler in the end. However, had I had difficulty localizing the lipoma, I would have felt very comfortable extending my incision into a broader elliptical one. Second, if you simply cannot find the cyst or lipoma there is nothing wrong with suturing the patient closed and sending them to someone with more experience. I realize that this is not something anyone, the patient included, wants to hear but it isn't the end of the world either. As opposed to simply digging and digging, if you are out of your depth then simple suture the patient closed and send them along. The reality is that this will almost never happen and even if it did, the next surgeon would likely incorporate your incision into his process without creating a much more significant scar. At any rate, this procedure went fairly smoothly and I must apologize again for my hand getting in the way at times. I have been working on this lately and hopefully the newer videos will be of a higher quality. Thanks and take care.

Popaholics, I'd fast forward to the 2:43 mark. For anyone trying to learn the procedure I would make note of the punctum just above my initial incision. Typically I would do an elliptical excision to ensure that this was fully removed. If this is small, however, so long as I remove the capsule from underneath, this will heal shut and the cyst won't recur. Why would I not simply do an elliptical excision? There are some advantages to a basic linear incision. First, I likely won't need dermal sutures, which certainly isn't a major issue but does simplify the procedure and in general I find simpler is better. You do sacrifice some strength across the suture line so I would only do this when you aren't worried about additional tension across the incision. Second, it does diminish the formation of 'dog ears' when you are suturing. Again, this isn't a major issue but is something to consider. Overall, this went well and the patient had no complications and healed nicely.

This patient had developed a cyst along the crease of his upper leg and buttocks that had been rubbing for years and scarred down a little. I had meant to show the opening of this cyst, after I completed the procedure, and then I forgot. It was quite calcified and firm. At any rate, this came together nicely and healed well.

Popaholics, I'd fast forward to the 5:50 mark and watch from there. For those trying to learn this procedure I apologize that I lost the first part of this video as that detailed the real challenge of this case which is the anaesthesia. For those doing these in the office setting, that always becomes the challenge. This was done doing a circumferential block and was certainly about as large as I'd ever attempt. You'll see bigger ones taken out on youtube but they'll be done under general anaesthesia or with a tumescent technique that's far more effective than just typical local anaesthesia. This won't be viewed nearly as much as cysts will be, but that's really a shame because the technical challenge here was quite a bit higher. The blunt technique I utilize may not be as 'viewer' friendly but is something I'd advise all residents to learn. It is highly effective and involves far fewer risks as you can actually feel what you are breaking down.