CC BY
8UDC 617.52:616.13-004.6:616-073:616.53-006
RESULTS OF SURGICAL TREATMENT OF FACIAL SEBACEOUS CYSTS BY THE SPARING METHOD OF CYSTOSTOMY
S. G. Bezrukov, T. S. Grigoryeva, M. G. Lokyan
Abstract
The article presents the results of surgical treatment of sebaceou in 123 patients. A complex analysis of clinical and laboratory (LDF) investigations have shown that the surgical treatment of sebaceous cysts by the sparing method of cystotomy significantly reduces injuries of tissues and violations of microhaemodynamics and effectively improves the esthetic characteristics of the postoperative scar.
Key words: facial sebaceous cysts, cystostomy.
Department of Operative Dentistry, State Institution "Crimea State Medical University named after S.I. Georgievsky", Simferopol, Ukraine. Correspondence: 5/7, Lenin Avenue, Simferopol, 95006, Ukraine. e-mail: sci@csmu.strace.net
High aesthetic requirements to the results of the wound healing control the selection of the surgical technique. Multiple modifications of the traditional surgical treatment of such formations as sebaceous cysts cannot exclude a radical approach. Complications of the early postoperative period (excessive swelling, hematoma, wound suppuration, gapping), negatively influence the restoration processes, increasing the risk of a rough scar formation [1, 5]. These facts were the basis for development of a sparing surgical treatment of sebaceous cysts. This treatment helps to reduce the volume of injured (operated) tissues, supports a high level of efficiency. The purpose of our study was to provide the efficiency and aesthetics of the surgical treatment of patients with sebaceous cysts and reduce the frequency of postoperative complications through minimizing the surgical trauma.
MATERIALS AND METHODS
The clinical analysis was based on examination and treatment of 123 patients. All of them addressed the surgery dental clinic for treatment of sebaceous cysts in the maxillofacial area. In the control group (62 patients), the operative intervention was performed by the traditional method of cystectomy [2, 4]. Depending on the size and depth of the defect, we made two or three internal seams on the subcutaneous tissue, using the thread "Vicryl" 3/0, and continuous intradermal suture ("Prolen 4/0"). Externally we applied aseptic bandage. In surgical practice, cystotomy is commonly used as a sparing treatment of odontogenic (epithelial) cysts of the jaws. It involves partial removing of the bone wall and subsequent formation of the bay with the oral cavity. This method used in dentistry only for diseases of hard tissues was the prototype of our method of surgical treatment of epithelial cysts of the face including sebaceous cysts. Our choice is based on the results of a histomorphological study of 50 typical sebaceous cysts. The study shows that the sebaceous cyst shell consists of connective tissue
pavement and stratified squamous keratinizing (inclusion cyst) and not keratinizing epithelium (sebaceous cyst) [5].
In the patients of the basic groups (61 persons), the surgical treatment of cysts was performed by our method of cystotomy. After infiltration anesthesia, we made a cut through the skin over the cyst with a scalpel. The length of the section depended on the diameter of the formation, but did not exceed 5 mm. The capsule of the cyst was dissected, and the contents were evacuated. The inner surface of the capsule was processed with an antiseptic solution. The edges of the wound were cauterized by electric or thermo coagulation, creating a linear cut of a round hole. The wound was closed by an aseptic bandage. The wound dressings and examinations were performed daily (declarative patent of Ukraine «Method of surgical treatment of sebaceous cyst» № 61900 dated 25.07.2011).
Clinical assessment of the progress of inflammatory and recovery reactions was performed daily, using the data about the occurrence and severity of the local clinical signs (edema, hyperemia, infiltration, and pain).
We assessed the hyperemia extension degree as small (within 1-5 mm from the suture line), moderate (6-8 mm), and severe (above 9 mm). The post-operative swelling of soft tissues was also evaluated as for the symptom degree [1]. Insignificant swelling was confined to one anatomical region (the location of the section), extending up to its borders. Moderate edema extended to the borders of the controlled anatomical region, and expressed edema was beyond the boundaries of this area. We observed two degrees of the infiltration spreading: the small one (the infiltration covers a part of the postoperative area) and the pronounced one (the infiltration covers the whole area of the surgical trauma and comprises the whole postoperative wound). Pain manifestations were determined according to three degrees: weak, moderate, and expressed. To monitor the processes of disturbances and recovery of the microcirculation in the comparison groups we used the method of Laser Doppler ultrasonography (LDU) [3,
Crimean Journal of Experimental and Clinical Medicine 2013 Volume 3 N 3-4
6]. This study was based on registration of the blood flow changes in the microcirculation. The method uses noninvasive tissue sensing by laser radiation with subsequent computer processing of the radiation reflected from the tissue, based on the Doppler Effect [3]. The studies were performed the day before surgery and over seven days after it.
All the results obtained were processed by the methods of variation statistics. The reliability of distinctions were estimated by Student's criterion, the interrelation of the studied parameters were determined according to the correlation coefficient.
RESULTS AND DISCUSSION
Clinical observations carried out at the early postoperative period showed the severity of manifestations of local inflammatory reactions in patients in the basic group was less intense (Tab. 1). Thus, the symptom of hyperemia in matched controls (the median of 7 days) was recorded in 46.99% of cases, whereas in the main group it was recorded in 31.13% of cases (P < 0.05). the maximum number of cases and the symptom intensity were observed on the first three days of the postoperative period.
Table 1 Relations of the median indicators (since the 1st day to the 7th day) of the local signs of inflammation in
the postoperative area in patients of groups of observation
Group observation Hyperemia Inflammation signs, in % (an average in 7 days) Edema Infiltration Pain
Control (n=62) 46.99 70.49 11.68 21.20
Basic (n=61) 31.13 56.89 2.86 5.85
Note: * - the difference from the control group is reliable, P < 0.05; n - the number of patients in the group.
An analysis of the intensity and duration of edema (Tab. 1) showed the following. Throughout the study period (since the 1st to the 7th day) the degree of severity was significantly lower in the main group (56.89%), where the removal of cyst was carried out by our proposed method (in the control group it was 70.49% of cases). The identified differences can be explained, in our opinion, by a significant reduction in trauma surgery, which leads to reduction of the intensity of the response to local vascular reactions.
In the operated tissues in the lumen of damaged capillaries, an adhesive substance appears, it is ungelated fibrin. When the blood circulation slows down in the vessels, the leukocytes adjoin the fibrin film. Then they pass through the capillary wall and go beyond the blood vessel into the inflamed fabric. This process is called infiltration. The results obtained in the comparison groups by logging the infiltration frequency (Tab. 1) revealed significant differences too. Thus, according to the average data (for 7 days), the absence of inflammatory infiltrate was observed in 97.13% of cases in the main group and in 88.3% cases of the control group (P <0.05). For the first time the manifestation of the symptom was noted on the 3rd day in the control group (4.84% of patients), reaching the maximum values on the 5th day - 19.35%.
It is important to note that on the 10th day of the postoperative period, we still observed a slight manifestation of the symptom (9.68%) in the control group, and we enhanced the treatment.
In the main group, the wound healing was accompanied by a lower frequency of infiltration. Here, the severe degree of symptom was not observed during the observation period (10 days), a minor manifestation of the symptom was recorded on the 4th day in 3.28% of cases. By the 10th day, the symptoms were wholly absent.
The intensity and nature of the pain component indirectly indicate the severity of the developing inflammatory process [1, 4].
An analysis of secondary indexes (average) by the sign of spontaneous pain revealed significant differences between
the groups (Tab. 1). Thus, the absence of symptoms in the control group was reported in 78.8% of cases, in the main on - in 94.14% (P <0.02). The pain component was detected in 21.2% and 5.85% (P <0.02), of the groups respectively.
Assessing the severity of the manifestations and extinction dynamics of the analyzed signs of inflammation (hyperemia, swelling, infiltration, pain) within 7 days of the early postoperative period in the comparison group, we noted the following characteristics. In the patients in the main group for whom we performed the surgical treatment of cysts by our proposed method, all these symptoms had significantly less severity and frequency of occurrence than in the control group. That greatly optimized the conditions for the process of wound healing.
The results of LDF-metry performed at the early postoperative period allowed to identify significant differences in the microhemodynamics indicators in the patients of the both comparison groups. We revealed high values ofthe microcirculation indicators in the control group, including the amplitude of pulse (Ap) and respiratory waves (Ar). These values evidence an increase of the blood filling in the vessels and disclosure of sphincters, which resulted in hyperemia and edema (hypostasis) of tissues [3, 6].
The initial (normal) level of the amplitude of pulse rhythms (Ap) was 4.01 perf.unit. The volume of Ap reflects the increasing flow of the arterial blood into the soft tissues of the postoperative area. Clinically this is accompanied by a greater intensity of the local inflammatory reactions [6]. In a day after the surgical treatment of sebaceous cysts, in the patients of the control group, the Ap was higher by 59.85% above the norm, while in the main group it was 18.7% (P1< 0.05). The difference between the groups was 41.15 % (P2 <0.01). By the 7th day, with the development of the recovery processes, the Ap index showed a downward trend. It is important to note that the indicator exceeded the initial values more significantly in patients of the control group (40.9%) than in those of the main one (11.47%).
A similar trend was observed in the nature of changes of respiratory wave amplitude, reflecting hyperemia of the
venules and the intensity of postoperative swelling of soft tissues [6]. The normal value was 5.54 perf.unit. In a day after the operation, in the patients of the control group we recorded higher values - the Ar level increased by 63.9% (P1< 0.01), whereas in the main group it increased by only 20.76 % (P1<0.01). The difference between the groups was significant too (43.14 % at P2<0.01). A week later, due to lower clinical manifestations of the intensity of soft tissue edema, there was a decrease in the amplitude values of respiratory rhythms. However, in the control group, the level of Ar in this target date was still above those of the main group by 35.2% (P2<0.01). It indicates to remaining violations in the venous outflow against more expressed postoperative swelling of soft tissues.
Thus, by using laser Doppler flowmetry, we received another valid evidence to the fact that the patients in the control group in which the operation was carried out by the traditional radical procedure had a more expressed and longer edema of the soft tissue. That was reflected in increasing values of the parameters Ar and Ap.
The long-term results of the treatment were observed in six months and one year. Relapses in the patients of the both groups were not observed. The wide scar type was not detected in the main group after one year of observation, whereas in the control group the indicator value was 13.79%. In addition, there have been reports about formation of an uneven step scar and postoperative deformation of the soft tissues. The shares of the medium and thin types of the scar in the main group were 15.62% and 84.37% and 24.13% and 62.07% in the control group respectively.
CONCLUSIONS
The analysis of the clinical features of postoperative wound healing process in the first 7 days of the recovery
period reveals intergroup differences by signs of hyperemia, edema, infiltration and pain component. It specifies a less severe local inflammatory reaction developing after cystotomy of sebaceous cysts of the face.
The results of LDF monitoring carried out in the early postoperative period gives an evidence of significant differences in the basic parameters of microhemodynamics (Ar and Ap) in the patients of the comparison groups. This reflects a more severe disturbance of microcirculation developing on the background of performed traumatic radical surgery in the patients of the control group.
The long-term results of treatment of patients with sebaceous cysts of the face point out to the advantages of the proposed sparing surgical technique that allows performing the operation through a small surgical access, preserving high curative effect and increasing the aesthetic indexes of the postoperative scar.
REFERENCES
1. Belousov A.E. [Hems as global problem of plastic surgery]. Transactions on plastic and estetic surgery. 2004;4:41-42. Russian.
2. Bezrukov S.G., Grigoryeva T.S. [Gistomorfological feature of a structure of sebaceous cysts of the face]. Tavricheskiy mediko-biologicheskiy vestnik. 2013; 1(61):16-52. Ukraine.
3. Krupatkin A. I., Sidorov V. V. Laser Doppler flowmetry of micro blood circulation. Moscow: Medicine; 2005. 254 р.
4. Timofeev A.A. Maxillofacial surgery. Monograph. Kiev: Medicine; 2010. 576 pp.
5. Yeliseyev V. G., Afanasyev Y.I., Kotovsky E.F., Yatskovsky A. N. Atlas of microscopic and ultramicroscopic structure of cages, fabrics and organs. St. Petersburg: Medicine; 2004. 448 pp.
6. Fagrell B. Problems using laser Doppler on the skin in clinical practice. London: Med-Orion Publishing; 1994. p. 127-134.
