Lumps, and Bumps, and Moles, Oh My!

Doctor’s Note

Welcome to Plain Talk About Plastic Surgery, a podcast that educates you about all things relating to plastic surgery procedures and operations, with down-to earth and honest information.

I’m your host, Dr. Elizabeth Kerner.  While you listen, I hope you’ll think of me as your sister, the plastic surgeon, who will tell you like it really is.

I have been in practice in Plano TX, a northern suburb of Dallas, for over 30 years.  I am an American Board of Plastic Surgery certified plastic surgeon, and have been a member of both the American Society of Plastic Surgeons and the The Aesthetic Society.

My practice is predominantly cosmetic surgery, doing about 80% cosmetic surgery and 20% reconstructive surgery.

I am a past president of the Texas Society of Plastic Surgeons.  I was also the first female president of the hospital medical staff at Texas Health Presbyterian Hospital Plano, where we have 1,400 doctors.

I am a member of the Texas Medical Association, and the Dallas County Medical Society. I have been on many leadership committees and boards over the years.

Each episode of Plain Talk About Plastic Surgery will focus on one area of plastic surgery in depth, discussing the anatomy, the operative technique, risks, potential complications, and most importantly, who would be a good candidate and who would not be a good candidate.

Useful Links

If you enjoyed this episode, you might also like:

• Learn about Kybella Injections
• Learn about Skin Cancer & Mohs Closure
• Meet Dr. Kerner and her staff
• Contact Us to schedule an appointment

Episode Transcript

Introduction

“Welcome to Plain Talk About Plastic Surgery. I’m Dr. Elizabeth Kerner, your host for this podcast.

I’m titling this podcast ‘Lumps and Bumps and Moles, Oh My!’

I’m going to discuss with you all the little lumps, and bumps, and moles that bring people into my office. Most of the time, these are all office procedures, although occasionally, something may be big enough or potentially serious enough that it would need to be done in the operating room.

About Lumps

So let’s get started with lumps.

Lipoma

Most people that come with a lump have either a cyst or a lipoma. A lipoma is just a collection of fatty tissue. We actually don’t know why it occurs. The only reason I know for sure why it will occur will be if you have had a trauma in an area.

Why that will stimulate the fat cells to grow and coalesce, and make a bump, we don’t know. There’s nothing different about the fat cells and the lipoma than the surrounding fat cells. So it’s just one of life’s little mysteries. Like almost everything I’m going to discuss in this podcast, medical science really doesn’t care about it, so no research has been done to try and determine the etiology of lipomas.

Lipomas vs Sebaceous Cysts

You can differentiate a lipoma from a sebaceous cyst because a sebaceous cyst is usually very much right underneath of the skin. And if you look closely, you can see a little pore that goes into the cyst.

Lipomas grow from the layer of fat, deep to the skin. They can grow pretty much in the upper part of the subcutaneous fat, or they can even be deeper where they’re down stuck onto the muscle. And some big lipomas will actually grow out of the muscle and be attached to the bone. Obviously, big ones like that have to be done in the operating room. And I find the ones that normally have to be done in the operating room are those in the shoulder or the back area. They just tend to be bigger and come up through the muscle layers.

Little lipomas along the arm and the legs are very common. There is a familial tendency towards this. It’s called familial lipomatosis, and they tend to occur along the edge of your forearm and along the outer aspect of your thigh and your calf.

Most of these are little pinch-out ones, at least that’s what I call them. We make a small cut over top – of course, the skin is numbed – and then do a circular dissection around it, and you can usually squeeze out a little wad of fat. And the fat tends to be very well circumscribed and so it comes out just as a big blob, and then you put a couple of stitches in.

Treating Lipomas with Kybella

I have had good experience with doing Kybella, which is the injection that we use to dissolve fat cells. It is not approved yet by the FDA, although I suspect it will be quite shortly. And unfortunately, insurance doesn’t cover that. And that might happen shortly because it would actually cost less money to inject it with Kybella than it would to remove it either in a pinch fashion or having to make a slightly bigger incision.

In the Kybella injection, just a shot is done into the fatty tissue and the Kybella, which is deoxycholic acid, is injected and it just kills the fat cells, and they get taken away. And so that’s how it goes away.

Kybella is a great option if you have a lot of little lipomas and you don’t want to have lots of little scars, especially because the ones on your arms can be visible and unfortunately can make it look like maybe you have a problem with cutting. You know, all these little white scars up and down your arms is a little bit suspicious.

Benign Lipomas vs Malignant Lipomas

Lipomas are almost always benign, as in 99.9%. There is a malignant lipoma called a liposarcoma. They tend to grow very rapidly, they’re firm, and pretty much even the patient and I can tell that something is really not quite right with that.

They are very rare. I’ve only seen one in the last 32 years. But because it is always a possibility, when I take a lipoma out, at least for the first one if someone has many, I’m going to send it to pathology just to make sure that it’s okay.

So, little lipomas we just do in the office. We make a cut and either squeeze them out or dissect them out, and then there are stitches underneath. Big lipomas may need to be done in the office. Lipomas that are about the size of a lime and above, I’m always going to do those in the operating room. There’s just no way to make the person comfortable in the office with local.

About Sebaceous Cysts

Sebaceous cyst are little collections of skin, the epidermal cells that collect right underneath of the skin, and the body makes a wall around it, a cyst wall. These come from a pore or an ingrown hair follicle, or you could have a bug bite, or some foreign body injury.

The skin cells which are supposed to go up the hair follicle and out the pore to create new epidermal layers, instead get trapped inside and you get this ricotta-cheesy, really smelly, looking inside it looks like white toothpaste. It smells really, really bad.

Those are almost always done in the office as well. We just numb them and then make a small elliptical cut over top. It is necessary to get the pore where it started from and all of the cyst wall. If you just do an I&D (Irrigation and Drainage), so you numb, make a cut and squeeze the contents out, and you’ve left the cyst wall, it will recur because the cyst wall is creating the gunky stuff inside.

It’s much easier to take them out before they’ve gotten infected. If they’ve gotten infected, they need to be drained and then allow that to heal, and then come back and take it out, because it’s almost impossible to see the edge of the wall and make sure you’ve gotten it all out if there’s an infection.

They will usually grow to be a size, whatever your body wants, and then they stop. If there’s sudden growth that is prognostication or a sign that they’re going to become infected.

Only really huge ones need to be done in the operating room. Occasionally, I’ll do bad ones that are on the face in the operating room just because I can get a better scar. These are always benign and I don’t send them to pathology. If I open it up and it has the white ricotta-smelly stuff inside, it’s about the only thing that could be.

About Dermoid Cysts

A fun little lump that I hardly ever get to see is a dermoid. And this is just a collection of cells that when you were in utero stopped its transit to wherever they needed to go. And it’s almost always going to be hair. They’re epidermal appendages, and it’s a little lump. And sometimes those lumps are hard to diagnose.

They’re pretty cool, though, because you open them up and they’ve got hair and skin cells and sometimes teeth. I’ve never seen anything really cool like a spine. There was one of those in somebody’s brain once that they took out. Dermoid cysts are very common in the ovaries. That’s where you probably will hear the most about dermoid cysts.

Glandular Tumors and Dermatofibromas

And then for other bumps and lumps, there are myriad of glandular tumors, 30, 40 different kinds that can come along, that are almost all benign. Some of them come from the sweat glands, some of them come from the epidermis, some of them come from the dermis.

The one that’s most common is called a dermatofibroma, and it’s a little pink wad of tissue. It looks like a hard little wad of scar tissue. When they come, they oftentimes look a little bit like a melanoma, and so people really want to have them off. The scar, because it is just scar tissue, comes from just everyday trauma, or for women, oftentimes, shaving their legs. We tend to see them on their legs the most.

Oftentimes, though, when you take them off, the scar ends up looking just about like the dermatofibroma did. So unless it’s causing a huge amount of problems, I tend to just recommend that you leave it alone. And I don’t think that steroid injections are too helpful for dermatofibroma.

Those are the most common lumps and bumps. Skin cancers would be a whole another podcast. But the way I treat skin cancers, if it’s a small one and it’s obvious this is what it is, or you’ve got a history of previous ones, we will normally just excise it in the office.

If it’s an area where tissue concerns are high, as in the face or the eyelids, or the lips, the nose, I may have you go see a specialist in dermatology, a Mohs surgeon, who will excise it. And then I come along and close up the hole. And we usually do that by rotating skin to fill in the defect.

If it’s an area, say, on your arm or your leg or your tummy, and there’s no problem with having sufficient skin to close the area, I will normally just excise these in the office. If I’m at all concerned about whether the margin, meaning the edges, are clear of skin cancer, we will trot it down to the pathologist who will freeze the edges and make sure that we’ve gotten all of the skin cancer out.

About Skin Cancer and Melanoma

If I’m not sure whether it’s a skin cancer I’ll biopsy it first. There are several different kinds of skin cancers, and if it’s a squamous cell, I need to take a bit more normal skin around it than if it’s a basal cell. I’m not trying to get two procedures out of anybody, it just will modify my plan for taking care of that.

Of course, melanoma is the biggest concern, and those are usually relatively obvious. And when we do a melanoma, we don’t want to do a shave. We want to do a full incision to biopsy it or take the lesion off. Then depending on the depth of the melanoma, how deep it is, and the thickness of it, that will determine how big of a chunk of skin around it needs to come out, and whether you need to have lymph nodes out, and whether you need to have radiation and chemotherapy, etc.

Melanoma is mostly treated with immunotherapy now. And because I don’t do sentinel nodes, which is what would be needed if you had a more aggressive melanoma, I will almost always refer you to a surgical oncologist to have this treated appropriately.

About Moles and Mole Removal

Moles are usually excised. I can shave them, but if there’s mole cells that are a little bit deep and we shave, I have to scoop out so much skin that you end up with a pockmark. And I think the scar looks better than having pock marks.

If it’s just a bothersome mole and I’m not concerned about whether there’s an issue with it and it’s sitting up looking kind of “plumpy”, then I will shave it off. And if a little bit comes back, then we can just reshave it down the road because we’re not worried about it. But most moles, if I’m taking them off, are almost always going to be excised.

The problem with excisions is they leave scars. Everybody has the wrong opinion that if you go to plastic surgeon then you won’t have a scar. You will hopefully have a better scar, but once your skin is cut, you will always have a scar. We try and make the scar hide into lines that are natural crease lines or into shadowed areas, and know how to move skin around to try and get you the best result. We also do better suturing, so I think that you don’t have to worry about the big old railroad track marks that you might get with just your general practitioner removing a mole.

About Skin Checks and Cancer Screening

I do lots of skin checks in January. You just come in and we just take a look over your body and see if there’s anything at all concerning. Are there areas that are red and scaly that might indicate that you have an early skin cancer? Are there moles that are of concern, especially in your back or back of your legs where you can’t see very well, up in the scalp?

You can also go to a dermatologist to have this done. And if you do have a personal or a family history, certainly melanoma or skin cancers, you should be having someone check your skin at least every six months. It can also be a spouse or a partner as long as they know what they’re looking for.

Conclusion

This is just a quick recap on lumps and bumps and moles. Each of these, we could go into at least 20 to 30 minutes on what the differential diagnosis is, the means of treatment, and risks and complications, and realistic expectations for what the scar is going to look like.

But everybody is different with what they present; how they present; how much it bothers them; whether it needs to come off. Can it be done in the office? Does it need to be done in the operating room? Do we need pathology? That it really is a patient by patient discussion to really get into the details.

So I’ve done the 20,000 foot glossy overview just to give you an idea of the more normal things that we do see in the office and are happy to take care of.

Thank you for listening to this podcast of ‘Lumps and Bumps and Moles, Oh My!’ For more information, you can go to my website, www.drkerner.com. That’s d-r-k-e-r-n-e-r.com. I don’t actually have much written – I don’t think anything written – on the website except for skin cancers and pre- and post-op examples of closing defects from removal of skin cancers, especially on the face, and especially on the nose, because that’s the hardest part to do.

But there’s out there lots and lots of resources if you want to look online. And of course, I know everybody’s favorite is Dr. Pimple Popper, and you can certainly gorge on videos of removal of lots of these things that we’ve talked about.

Thanks again for listening. Bye!”

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