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Medial Orbital Dermoid Cyst Removal

Dermoid cysts are the most common orbital tumor in childhood. It is a developmental benign choristoma, arising from ectodermal sequestration along the lines of embryonic fusion of mesodermal processes. It is lined by keratinized stratified squamous epithelium and expands slowly due to constant desquamation and dermal glandular elements. They are usually smooth, painless, mobile, or partially mobile lesions mostly present at the fronto-zygomatic suture with proptosis, displacement, ptosis, or diplopia, depending on depth and extent1. 

Although lateral orbital dermoid cysts are common, medial orbital dermoid cysts are rare2. Our patient had a right medial orbital congenital dermoid cyst since birth. At the presentation, the patient was 2 years old. On CT, the cyst measured 5 mm at the upper lid/medial canthus of the right orbit with subtle bone remodeling. He had a mildly clogged tear duct on the left but was otherwise asymptomatic. The decision was made to surgically remove the dermoid cyst. 

In this video, we present a case of removal of a medial orbital dermoid cyst in a 2-year-old patient. 
An incision was planned directly over the lesion. It was marked following the natural skin tension lines of the face to give the most natural esthetic appearance.
A small amount of Local anesthetic (0.5 ml of Lidocaine and Epinephrine) was injected under the skin to promote hemostasis and postoperative pain control.
A continuous Incision was made with a #15 blade on the skin.
Westcott scissors were used to dissect further through the subcutaneous tissue to expose the cyst and slowly dissect it from the normal tissue surrounding it.
Extra care was made to protect the integrity and avoid the rupture of the cyst.
After the entire cyst was freed from the surrounding tissue,  it was carefully removed from its attachments to the periosteum using Westcott scissors.
The incision was closed in a two-layer fashion.
The deeper layer was closed by 6.0 Vicryl in a vertical mattress fashion with 2 interrupted sutures.
Next, wound edge eversion was achieved by placing two interrupted, superficial 5.0 fast-absorbing gut sutures. This will minimize the scar appearance.
Dermabond was applied next and the sutures were protected by a small piece of Tegaderm. This will be left in place until it spontaneously falls off.

An incision was planned directly over the lesion. It was marked following the natural skin tension lines of the face to give the most natural esthetic appearance. A small amount of Local anesthetic (0.5 ml of Lidocaine and Epinephrine) was injected under the skin to promote hemostasis and postoperative pain control. A continuous Incision was made with a #15 blade on the skin. Westcott scissors were used to dissect further through the subcutaneous tissue to expose the cyst and slowly dissect it from the normal tissue surrounding it. Extra care was made to protect the integrity and avoid the rupture of the cyst. After the entire cyst was freed from the surrounding tissue, it was carefully removed from its attachments to the periosteum using Westcott scissors. The incision was closed in a two-layer fashion. The deeper layer was closed by 6.0 Vicryl in a vertical mattress fashion with 2 interrupted sutures. Next, wound edge eversion was achieved by placing two interrupted, superficial 5.0 fast-absorbing gut sutures. This will minimize the scar appearance. Dermabond was applied next and the sutures were protected by a small piece of Tegaderm. This will be left in place until it spontaneously falls off.
Dermoid cysts are benign. The main indication to remove them is to improve functional and aesthetic outcomes for patients. Early removal of all dermoid cysts in view of bone changes is recommended3.
No absolute contraindications are noted for dermoid cyst removal. Specific contraindications are case by case based on patients' demographics as well as the cyst site, extent, presence of inflammation, and possibility of intraoperative rupture.
For procedure setup, the patient was positioned supine and placed under general anesthesia. Povidone-iodine was used to disinfect the peri-orbital skin. Sterile drapes were placed over the face and head. A piece of Tegaderm was placed over the eyelids to protect the eyes.
It is important to know about the variable presentations of orbital dermoid and the surgical techniques. They can be adopted based on the site, extent, age and aesthetic needs, presence of inflammation, and possibility of intraoperative rupture1. Anesthesia work-up. Imaging only obtained for specific reasons4.
Eye lids, eye brow, lacrimal punctum, lacrimal canaliculi, lacrimal sac, medial canthus, lateral canthus, lacrimal gland
n/a
Post-surgical ecchymosis is common after. Cysts can rupture intra-operatively, which can be highly inflammatory, in which a lipogranulomatous inflammatory reaction may occur. This can be mitigated by copious irrigation at the time of surgery. Cysts extending through bony sutures often cannot be removed without rupture. Abscess formation and orbitocutaneous fistula may occur if the cyst was incompletely removed5.
None
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1. Bansal, Rolika et al. “Orbital dermoid cyst.” Indian journal of ophthalmology vol. 70,2 (2022): 709. doi:10.4103/ijo.IJO_145_22 2. Ing, Edsel B et al. “Medial orbital dermoid cyst.” Canadian journal of ophthalmology. Journal canadien d'ophtalmologie vol. 55,6 (2020): 531-532. doi:10.1016/j.jcjo.2020.05.011 3. Pushker, Neelam et al. “Orbital and periorbital dermoid/epidermoid cyst: a series of 280 cases and a brief review.” Canadian journal of ophthalmology. Journal canadien d'ophtalmologie vol. 55,2 (2020): 167-171. doi:10.1016/j.jcjo.2019.08.005 4. Yen, Kimberly G, and Michael T Yen. “Current trends in the surgical management of orbital dermoid cysts among pediatric ophthalmologists.” Journal of pediatric ophthalmology and strabismus vol. 43,6 (2006): 337-40; quiz 363-4. doi:10.3928/01913913-20061101-02 5. EyeWiki on the American Academy of Ophthalmology website.https://eyewiki.aao.org/Dermoid_Cyst#Surgery

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