Lipoma Excision

Abstract

Lipomas are slow-growing lumps that occur as a result of overgrowth of fat cells. They present as doughy, moveable, and non-tender lumps usually found underneath the skin; however, they may occasionally be deeper. Lipomas occur in 1 in every 1,000 people and commonly grow on the upper back, shoulders, and abdomen. In most cases, lipomas are painless unless they affect joints, nerves, or blood vessels. A physical examination is the easiest way to diagnose a lipoma; however, imaging studies and biopsy may aid in the diagnosis when they are large, have unusual features, or appear deep. No treatment is usually necessary for a lipoma; however, if a lipoma is painful or growing, removal may be recommended by excision or liposuction. Here, we present a 35-year-old male who has a large and deep 8-year-old lipoma on his upper back. The lipoma was excised and sent for biopsy.

Case Overview

Background

Lipomas are a type of benign tumor associated with adipocytes in soft tissue that generally grow slowly¹ and appear surrounded by a fibrous capsule on histology.² They are most commonly found in the subcutaneous tissues in the head, neck, or shoulder region of the body. ² The prevalence of lipomas is roughly 1% of the population,² making them one of the most common neoplasms seen in patients throughout the world. The incidence of lipomas is higher in males than in females; however, the difference is minor.³ Lipomas can develop at any age, but most commonly develop in middle adulthood.³ Fortunately, lipomas carry an excellent prognosis and do not transform into liposarcomas,⁹ which have an estimated incidence of less than 15 per 100,000 individuals.¹⁰ One should be suspicious if multiple lipomas are found during the physical exam, as it may be an early manifestation of certain diseases such as Cowden syndrome or Gardner syndrome,³ where lipomas as well as malignancies are both expressions of the underlying pathophysiology. Surgical intervention is most often initiated by patient request for aesthetic preferences; nevertheless, in rare cases, they can present in unusual forms that affect muscles, nerves, and joints.²

Focused History of the Patient

This 35-year-old male patient presented with a large lipoma on his right upper back that began growing 8 years prior. There were no known allergies or contraindications.

Physical Exam

Physical examination revealed a healthy-appearing, well-nourished adult male. A soft, unilateral, palpable mass was located on the patient’s right upper back. No loss of function or range of motion was noted.

Imaging

Typically, no imaging is required for excision of subcutaneous lipomas.⁴ If available, an MRI scan can prove useful in viewing the size of the mass as well as identifying compression of adjacent structures by the lipoma itself.

Natural History

The specific pathophysiology of lipomas varies; however, it has been determined that nearly two-thirds are caused by mutations in chromosome 12.³ As they grow, fibrous capsules surround the tumors. The prognosis for benign lipomas is considered good, as they generally do not return once excised.²

Options for Treatment

Liposuction is a viable method of removing a lipoma,^5, 6 as is direct excision¹ and endoscopic excision.⁷ Selection of the appropriate method of removal depends on factors such as size and location of the patient’s lipoma, as well as the patient’s medical history. In this case, the patient’s lipoma was located near the upper back and was able to be removed via direct excision.

Rationale for Treatment

Typically, lipomas may be left untreated.³ The patient may request excision for aesthetic reasons. In rare cases, lipomas can be problematic when they grow to a size that compresses nerves or vessels, limits function, or otherwise negatively affects a person’s lifestyle.⁸

Special Considerations

No special considerations were considered for this patient.

Discussion

The procedure started with injection of a local anesthetic to the area where the lipoma was located while the patient lay prone. Standard regional anesthesia with 1% lidocaine is used for lipoma excisions. If the lipomas are larger, 1% lidocaine with epinephrine may be warranted. This anesthetic technique is also required if electrocauterization is to be utilized to control bleeding, as seen in this case.

An elliptical incision was made so as to excise the tumor and separate the fibrous capsule that encases the tumor from the surrounding tissue. Elliptical incisions are beneficial in cases such as this, as this technique minimizes the amount of skin that needs to be taken during the procedure. Additional anesthetic was required once the deep half of the tumor was reached, attributable to the size the tumor had grown to over the previous 8 years. This type of lipoma was unique in that the fibrous capsule had a stronger adherence to the surrounding tissue than that of a normal lipoma. Blunt dissection could be used towards the inferior portion of the lipoma; however, the majority of the dissection required use of a scalpel. Electrocauterization was used to control bleeds from smaller vessels, while internal sutures were required to close off the cavity to prevent the formation of a seroma.

As shown in the video, the patient was able to be discharged the same day as the procedure. As stated in the video, the patient noticed the tumor in the past, but has a busy life with his job and was able to live with the tumor for 8 years. This supports the literature on lipomas to the effect that, most of the time, lipomas are not life-threatening and are removed by request of the patient, likely for cosmetic purposes.³ Given the patient’s age, there was no concern for postoperative bleeding.

Equipment

No specialized equipment was used in this case.

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.