he narrated that when he was in second grade ( age 7 ) , he and a fellow student were irritating his neighbor in the classroom .
the patient mentioned that the point broke off in his thigh and was never extracted .
he complained that the site still hurt intermittently and after all this time , he wanted the lump and the reported pencil point to be removed . examination of the anterior left thigh skin revealed a palpable 0.5-cm subdermal / subcutaneous elliptical lump in the skin .
there was a tinge of black to blue to it as if it had been tattooed .
the patient was explained the indications , risks and benefits of the procedure and he provided consent . a time - out was performed .
firm tan dermal - based soft tissue nodule with associated dark graphite precipitate was removed . in the midst of the removed tissue , a 4-mm cone - shaped pencil ( graphite )
two buried absorbable sutures were placed and three simple interrupted 4 - 0 vicryl sutures were used to close the wound . a triple antibiotic ointment was applied and the wound dressed in sterile fashion .
the patient was put on cephalexin to prevent secondary infection . the surgical wound healed without complications or significant scarring .
the literature reports on hyperpigmented nodules in the skin secondary to a retained pencil core .
hatano et al .   in 2000 reported on a pencil core granuloma from a pencil tip injury that had occurred about 30 years prior .
fukunaga et al .   in 2011 summarized 9 previously reported cases of pencil core granulomas , the oldest of which was 58 years old .
our case is unique in that we were able to recover the cone - shaped pencil tip and still write with it ( fig .
1 ) . in previous examinations of pencil core granuloma , giant cells and epithelioid cells had been observed .
histologic examination in our case similarly revealed foreign body reaction with abundant entrapped dark black pigment and chronic reparative changes , including dense sclerosis and focal granulation tissue formation ( fig .
furthermore , one report suggested more rapid growth of lesions and greater degree of tissue injury by colored pencils when compared to non - colored graphite pencils . a number of authors have commented on temporal changes in the granuloma , going from a relatively unchanged appearance to a rapid growth phase , ultimately leading to excision . the decision to explore and excise a pencil core granuloma can be thus based on changes in the skin lesion and/or concern for possible malignancy .
 a pencil core with an intact pencil tip was excised from the thigh of a 60-year - old male 53 years after a puncture wound . 
 histologic examination of the excised pencil core and the surrounding tissue revealed a foreign body reaction with abundant entrapped dark black pigment and chronic reparative changes , including dense sclerosis and focal granulation tissue formation . 
Case Report
Discussion
Statement of Ethics
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