Lipoma Excision

GOHAR A. SALAM, M.D., D.O., Michigan State University, East Lansing, Michigan

Am Fam Physician. 2002 Mar 1;65(5):901-905.

Patient Information Handout (https://www.aafp.org/afp/2002/0301/p905)

Lipomas are adipose tumors that are often located in the subcutaneous tissues of
the head, neck, shoulders, and back. Lipomas have been identified in all age groups
but usually first appear between 40 and 60 years of age. These slow-growing,
nearly always benign, tumors usually present as nonpainful, round, mobile masses
with a characteristic soft, doughy feel. Rarely, lipomas can be associated with
syndromes such as hereditary multiple lipomatosis, adiposis dolorosa, Gardner's
syndrome, and Madelung's disease. There are also variants such as angiolipomas,
neomorphic lipomas, spindle cell lipomas, and adenolipomas. Most lipomas are
best left alone, but rapidly growing or painful lipomas can be treated with a variety
of procedures ranging from steroid injections to excision of the tumor. Lipomas
must be distinguished from liposarcoma, which can have a similar appearance.

Lipomas are slow-growing, nearly always benign, adipose tumors that are most often
found in the subcutaneous tissues.1 Most lipomas are asymptomatic, can be
diagnosed with clinical examination (Table 1) and do not require treatment. These
tumors may also be found in deeper tissues such as the intermuscular septa, the
abdominal organs, the oral cavity, the internal auditory canal, the cerebellopontine
angle and the thorax.2–4 Lipomas have been identified in all age groups but usually
first appear between 40 and 60 years of age.5 Congenital lipomas have been
observed in children.6 Some lipomas are believed to have developed following blunt
trauma.7

View/Print Table
TABLE 1
Differential Diagnosis of Lipoma

Epidermoid cyst
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 Subcutaneous tumors

Nodular fasciitis

Liposarcoma

Metastatic disease

Erythema nodosum

Nodular subcutaneous fat necrosis

Weber-Christian panniculitis

Vasculitic nodules

Rheumatic nodules

Sarcoidosis

Infections (e.g., onchocerciasis, loiasis)

Hematoma

While solitary lipomas are more common in women, multiple tumors (referred to as
lipomatosis) are more common in men.2,8 Hereditary multiple lipomatosis, an
autosomal dominant condition also found most frequently in men, is characterized
by widespread symmetric lipomas appearing most often over the extremities and
trunk2,9 (Figure 1). Lipomatosis may also be associated with Gardner's syndrome, an
autosomal dominant condition involving intestinal polyposis, cysts, and osteomas.8
The term Madelung's disease, or benign symmetric lipomatosis, refers to lipomatosis
of the head, neck, shoulders, and proximal upper extremities. Persons with
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 Madelung's disease, often men who consume alcohol, may present with the
characteristic “horse collar” cervical appearance.2,10 Rarely, these patients
experience swallowing difficulties, respiratory obstruction, and even sudden death.1,2

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FIGURE 1.
Multiple lipomatosis of the trunk (hereditary multiple lipomatosis).

Evaluation
Lipomas usually present as nonpainful, round, mobile masses, with a characteristic
soft, doughy feel. The overlying skin appears normal. Lipomas can usually be
correctly diagnosed by their clinical appearance alone.

Microscopically, lipomas are composed of mature adipocytes arranged in lobules,

many of which are surrounded by a fibrous capsule. Occasionally, a nonencapsulated
lipoma infiltrates into muscle, in which case it is referred to as an infiltrating
lipoma.5,11,12

Four other types of lipomas may be noted on a biopsy specimen. Angiolipomas are a
variant form with co-existing vascular proliferation.2,11 Angiolipomas may be painful
and usually arise shortly after puberty. Pleomorphic lipomas are another variant in
which bizarre, multinucleated giant cells are admixed with normal adipocytes.1,13
Pleomorphic lipomas' presentation is similar to that of other lipomas, but they occur
predominantly in men 50 to 70 years of age. A third variant, spindle cell lipomas, has
slender spindle cells admixed in a localized portion of regular-appearing
adipocytes.14,15 A newly described variant of superficial lipoma, adenolipoma, is
characterized by the presence of eccrine sweat glands in the fatty tumor; this type is
often located on the proximal parts of the limbs.1

A rare clinical consideration is Dercum's disease, or adiposis dolorosa, which is

characterized by the presence of irregular painful lipomas most often found on the
trunk, shoulders, arms, forearms, and legs.8 Dercum's disease is five times more
common in women, is often found in middle age, and has asthenia and psychic
disturbances as other prominent features.
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 Malignancy is rare but can be found in a lesion with the clinical appearance of a
lipoma. Liposarcoma presents in a fashion similar to that of a lipoma and appears to
be more common in the retroperitoneum, and on the shoulders and lower
extremities.8 Some surgeons recommend complete excision of all clinical evidence of
a lipoma to exclude a possible liposarcoma, especially in fast-growing lesions.8
Recently, magnetic resonance imaging has been used with some success to
differentiate lipomas and liposarcomas.16,17

Treatment
NONEXCISIONAL TECHNIQUES

Nonexcisional treatment of lipomas, which is now common, includes steroid

injections and liposuction.

Steroid injections result in local fat atrophy, thus shrinking (or, rarely, eliminating) the
lipoma. Injections are best performed on lipomas less than 1 inch in diameter. A one-
to-one mixture of 1 percent lidocaine (Xylocaine) and triamcinolone acetonide
(Kenalog), in a dosage of 10 mg per mL, is injected into the center of the lesion; this
procedure may be repeated several times at monthly intervals.8 The volume of
steroid depends on the size of the lipoma, with an average of 1 to 3 mL of total
volume administered. The number of injections depends on the response, which is
expected to occur within three to four weeks. Complications, which are rare, are the
result of the medication or the procedure, and can be prevented by injecting the
smallest total amount possible and by positioning the needle so that it is in the
center of the lipoma.

Liposuction can be used to remove small or large lipomatous growths, particularly

those in locations where large scars should be avoided. Complete elimination of the
growth is difficult to achieve with liposuction.8,18 Office procedures using a 16-gauge
needle and a large syringe may be safer than large-cannula liposuction. Diluted
lidocaine usually provides adequate anesthesia for office liposuction.

PREPARATION FOR EXCISION

Surgical excision of lipomas often results in a cure. Before the surgery, it is often
helpful to draw an outline of the lipoma and a planned skin excision with a marker on
the skin surface (Figure 2). The outline of the tumor often helps to delineate margins,
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 which can be obscured after administration of the anesthetic. Excision of some skin
helps to eliminate redundancy at closure.

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FIGURE 2.
Proposed incision removing skin over the lipoma. The palpable borders of the
lipoma are marked to aid the surgeon in complete removal.

The skin is then cleansed with povidone iodine (Betadine) or chlorhexidine (Betasept)
solution, making sure to avoid wiping away the skin markings. The area is draped
with sterile towels. Local anesthesia is administered with 1 or 2 percent lidocaine
with epinephrine, usually as a field block. Infiltrating the anesthetic in the
subcutaneous area surrounding the operative field creates a field block.

ENUCLEATION

Small lipomas can be removed by enucleation. A 3-mm to 4-mm incision is made

over the lipoma. A curette is placed inside the wound and used to free the lipoma
from the surrounding tissue. Once freed, the tumor is enucleated through the incision
using the curette. Sutures generally are not needed, and a pressure dressing is
applied to prevent hematoma formation.

EXCISION

Larger lipomas are best removed through incisions made in the skin overlying the
lipoma. The incisions are configured like a fusiform excision following the skin
tension lines and are smaller than the underlying tumor. The central island of skin to
be excised is grasped with a hemostat, or Allis clamp, which is used to provide
traction for the removal of the tumor (Figure 3). Dissection is then performed
beneath the subcutaneous fat to the tumor. Any tissue cutting is performed under
direct visualization using a no. 15 scalpel or scissors around the lipoma. Care must
be taken to avoid nerves or blood vessels that may lie just beneath the tumor.

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FIGURE 3.
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 The skin inside the incision grasped with a hemostat to provide traction. The lipoma
is dissected from the surrounding tissue using scissors or a scalpel.

Once a portion of lipoma has been dissected from the surrounding tissue, hemostats
or clamps can be attached to the tumor to provide traction for removal of the
remainder of the growth. Once it is freed, the lipoma is delivered as a whole (Figure
4). The surrounding tissue in the hole can be palpated to ensure complete removal of
the tumor. Table 2 lists possible complications of excision.

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FIGURE 4.
Once freed, the lipoma is delivered as a whole, and hemostasis is achieved.

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TABLE 2
Complications of Lipoma Excision

Surgical infection/cellulitis/fasciitis

Ecchymosis

Hematoma formation

Injury to nearby nerves with permanent paresthesia/anesthesia

Injury to nearby vessels/vascular compromise

Permanent deformity secondary to removal of a large lesion

Excessive scarring with cosmetic deformity or contracture

Muscle injury/irritation
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 Fat embolus

Periostitis/osteomyelitis

Seroma

Adequate hemostasis is achieved following the removal of the lipoma using

hemostats or suture ligation. The dead space is closed beneath the skin using buried,
interrupted 3-0 or 4-0 Vicryl sutures (Figure 5). Occasionally drains may have to be
placed to prevent fluid accumulation, but this should be avoided if possible. The skin
is then closed with interrupted 4-0 or 5-0 nylon sutures. A pressure dressing is placed
to reduce the incidence of hematoma formation. The patient is given routine wound
care instructions, and the wound is checked in two to seven days. The sutures are
removed after seven to 21 days, depending on the body location. Specimens should
be submitted for histologic analysis.

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FIGURE 5.
Interrupted 3-0 or 4-0 Vicryl sutures are used to partially close the dead space.

Figures 1 and 2 were provided by Thomas Zuber, M.D., Department of Family and
Community Medicine, Emory University School of Medicine, Atlanta

The Author show all author info

GOHAR A. SALAM, M.D., D.O., is assistant director in the family practice residency
program at Saginaw Cooperative Hospitals in Saginaw, Mich., where he completed a
residency in family practice. He is also assistant professor of family practice at
Michigan State University, East Lansing. He is a graduate of Dow Medical College,
Karachi, Pakistan, and New York College of Osteopathic Medicine, Old Westbury,
N.Y....

REFERENCES show all references

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 1. Anders KH, Ackerman AB. Neoplasms of the subcutaneous fat. In: Freedberg IM,
Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, et al., eds. Fitzpatrick's
Dermatology in general medicine. 5th ed. New York: McGraw-Hill, 1999:1292–1300....

This article is one in a series of “Office Procedures” articles coordinated by Thomas J.

Zuber, M.D., Assistant Professor, Department of Family and Community Medicine, Emory
University School of Medicine, Atlanta.

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