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Drainage of Cystic Mass on First Left Toe

Jasmine Beloy1, Jaymie Ang Henry, MD, MPH2, Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES3
1Lake Erie College of Osteopathic Medicine
2Florida Atlantic University
2Philippine Children's Medical Center



So this is a 12-year-old male with a mass here in the... in the big toe, underneath. Uh, 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 is 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.


Now, if you want to do a local block here, uh, 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 to 2cc. 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 1cc. 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? 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, um, epinephrine with Lidocaine with surgery on the digital, on the digits, just to avoid any problems.


So I'll start my incision. As I mentioned, I'm doing a Z, Z-type incision. As you can see, it's like a 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.


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- so it seems like an infected, infected cyst. So sometimes, preoperatively you might think it's a mass, a solid mass. Now after, after this linear 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, 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. 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.


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.