Epidermal inclusion cysts are a late complication of female genital circumcision, which is a practice that affects 125 million women primarily from Africa and the Middle East. A 30-year-old woman, gravida 4, para 1, presented to our clinic with an 8-year history of a slowly enlarging periclitoral mass. The patient had undergone female genital circumcision at the age of 5 years. We describe and video-illustrate the surgical technique of excising the 8-cm epidermal inclusion cyst. Using this technique, the entire cyst was resected intact, excess vulvar skin removed, and defect repaired. Postoperatively, she had minimal pain, no dyspareunia, and good cosmesis. Restoration of anatomy for this late complication of female genital circumcision is achievable with knowledge of anatomy, adherence to basic surgical principles that include tension-free closure, and close postoperative follow up.
Problem: Large epidermal inclusion cyst at the site of previous female genital circumcision
A 30-year-old woman of Sudanese heritage, gravida 4, para 1, presented to our clinic with a nontender, midline clitoral mass that had been present for 8 years. The patient’s health history was significant for female genital circumcision (FGC) when she was approximately 5 years old, 3 spontaneous first-trimester abortions, and 1 full-term vaginal delivery. On examination, the mass was 8×5 cm in size, nontender, cystic, and located in the midline above the urethra ( Figure 1 ). The prepuce, glands, and frenulum of the clitoris were not distinct from the mass. The labia minora was removed partially, and a thin rim of tissue remained. The labia majora and urethral meatus were normal in appearance, as were the vagina, cervix, uterus, and adnexa on palpation. The physical examination findings were most consistent with type II FGC with an epidermal inclusion cyst. A preoperative magnetic resonance image showed an 8.8×3.7×6.5–cm simple cystic lesion exophytically arising from the clitoris ( Figure 2 ). It contained proteinaceous material with a thin enhancing septation but was otherwise avascular and without nodularity or solid components.
Our solution
The patient underwent excision of the epidermal inclusion cyst under general anesthesia ( video supplement part 1 ). Dilute vasopressin was injected into the skin, and a 6-cm vertical incision was made. Allis forceps were used to retract the skin, and the cyst was enucleated from the surrounding tissue with sharp and blunt dissection. The fibrovascular base of the cyst was cut, and was electrocautery applied with good hemostasis. The cyst was removed intact. Redundant vulvar skin was trimmed, and the deep space was closed with 2-0 Vicryl sutures. The skin was then reapproximated with 3-0 Vicryl in a subcuticular, tension-free fashion. The introitus was confirmed to be patent, and the urethra unobstructed after closure ( Figure 3 ). Gross evaluation of the mass showed a 9×5.8×3.3–cm, unilocular cyst with thick, tan-brown sebaceous material.
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