A Review of Techniques and Procedures for Lipoma Treatment Pdf
Lipoma Excision
Am Fam Md. 2002 Mar 1;65(5):901-905.
Patient Data Handout
Article Sections
- Abstruse
- Evaluation
- Handling
- References
Lipomas are adipose tumors that are often located in the subcutaneous tissues of the head, neck, shoulders, and dorsum. Lipomas have been identified in all age groups but usually kickoff appear between twoscore and 60 years of age. These slow-growing, nearly e'er benign, tumors usually present every bit nonpainful, round, mobile masses with a characteristic soft, doughy feel. Rarely, lipomas tin can be associated with syndromes such as hereditary multiple lipomatosis, adiposis dolorosa, Gardner's syndrome, and Madelung's disease. At that place are as well variants such as angiolipomas, neomorphic lipomas, spindle prison cell lipomas, and adenolipomas. Most lipomas are all-time left alone, but quickly 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 tin take a similar appearance.
Lipomas are slow-growing, almost e'er benign, adipose tumors that are about often institute in the subcutaneous tissues.1 Nigh lipomas are asymptomatic, tin can be diagnosed with clinical examination (Table one) and exercise not require treatment. These tumors may likewise be constitute in deeper tissues such as the intermuscular septa, the abdominal organs, the oral cavity, the internal auditory canal, the cerebellopontine bending and the thorax.2–4 Lipomas accept been identified in all age groups just usually get-go appear between 40 and threescore years of age.five Built lipomas have been observed in children.6 Some lipomas are believed to take developed following edgeless trauma.7
TABLE 1
Differential Diagnosis of Lipoma
| Epidermoid cyst |
| Subcutaneous tumors |
| Nodular fasciitis |
| Liposarcoma |
| Metastatic illness |
| Erythema nodosum |
| Nodular subcutaneous fatty necrosis |
| Weber-Christian panniculitis |
| Vasculitic nodules |
| Rheumatic nodules |
| Sarcoidosis |
| Infections (e.one thousand., onchocerciasis, loiasis) |
| Hematoma |
While solitary lipomas are more mutual in women, multiple tumors (referred to as lipomatosis) are more mutual in men.2,eight Hereditary multiple lipomatosis, an autosomal dominant condition also found most oft in men, is characterized by widespread symmetric lipomas appearing almost oft over the extremities and trunk2,9 (Effigy 1). Lipomatosis may also be associated with Gardner'due south syndrome, an autosomal ascendant condition involving intestinal polyposis, cysts, and osteomas.8 The term Madelung'south illness, or benign symmetric lipomatosis, refers to lipomatosis of the head, neck, shoulders, and proximal upper extremities. Persons with Madelung's illness, often men who consume booze, may present with the characteristic "horse neckband" cervical appearance.two,x Rarely, these patients feel swallowing difficulties, respiratory obstruction, and even sudden decease.one,ii
FIGURE one.
Multiple lipomatosis of the trunk (hereditary multiple lipomatosis).
Evaluation
- Abstract
- Evaluation
- Treatment
- References
Lipomas normally present as nonpainful, round, mobile masses, with a feature soft, mashy feel. The overlying skin appears normal. Lipomas can commonly be correctly diagnosed past their clinical appearance solitary.
Microscopically, lipomas are composed of mature adipocytes arranged in lobules, many of which are surrounded past a fibrous capsule. Occasionally, a nonencapsulated lipoma infiltrates into muscle, in which case information technology is referred to equally an infiltrating lipoma.5,11,12
4 other types of lipomas may be noted on a biopsy specimen. Angiolipomas are a variant class with co-existing vascular proliferation.2,11 Angiolipomas may be painful and unremarkably arise shortly afterward puberty. Pleomorphic lipomas are some other variant in which baroque, multinucleated giant cells are admixed with normal adipocytes.one,xiii Pleomorphic lipomas' presentation is like to that of other lipomas, only they occur predominantly in men 50 to 70 years of historic period. A third variant, spindle jail cell lipomas, has slender spindle cells admixed in a localized portion of regular-appearing adipocytes.fourteen,15 A newly described variant of superficial lipoma, adenolipoma, is characterized past the presence of eccrine sweat glands in the fatty tumor; this blazon 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 past the presence of irregular painful lipomas most often constitute on the trunk, shoulders, arms, forearms, and legs.eight Dercum's disease is 5 times more common in women, is oft establish in center age, and has asthenia and psychic disturbances as other prominent features.
Malignancy is rare only tin exist constitute in a lesion with the clinical appearance of a lipoma. Liposarcoma presents in a way similar to that of a lipoma and appears to be more than common in the retroperitoneum, and on the shoulders and lower extremities.8 Some surgeons recommend complete excision of all clinical prove of a lipoma to exclude a possible liposarcoma, especially in fast-growing lesions.eight Recently, magnetic resonance imaging has been used with some success to differentiate lipomas and liposarcomas.xvi,17
Treatment
- Abstruse
- Evaluation
- Handling
- References
NONEXCISIONAL TECHNIQUES
Nonexcisional treatment of lipomas, which is at present mutual, 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 one inch in bore. A one-to-one mixture of i percent lidocaine (Xylocaine) and triamcinolone acetonide (Kenalog), in a dosage of 10 mg per mL, is injected into the middle of the lesion; this process may exist repeated several times at monthly intervals.8 The volume of steroid depends on the size of the lipoma, with an average of one to iii mL of total volume administered. The number of injections depends on the response, which is expected to occur within 3 to four weeks. Complications, which are rare, are the result of the medication or the process, and tin be prevented by injecting the smallest total amount possible and past positioning the needle then that it is in the centre of the lipoma.
Liposuction tin can be used to remove small or large lipomatous growths, peculiarly those in locations where large scars should be avoided. Complete elimination of the growth is difficult to attain with liposuction.viii,18 Office procedures using a 16-approximate needle and a large syringe may be safer than large-cannula liposuction. Diluted lidocaine usually provides adequate anesthesia for role liposuction.
Training FOR EXCISION
Surgical excision of lipomas oftentimes results in a cure. Before the surgery, information technology is oft helpful to describe 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, which can exist obscured later on administration of the anesthetic. Excision of some pare helps to eliminate redundancy at closure.
FIGURE ii.
Proposed incision removing skin over the lipoma. The palpable borders of the lipoma are marked to aid the surgeon in consummate removal.
The skin is then apple-pie with povidone iodine (Betadine) or chlorhexidine (Betasept) solution, making sure to avoid wiping away the skin markings. The expanse is draped with sterile towels. Local anesthesia is administered with i or 2 percent lidocaine with epinephrine, usually as a field cake. Infiltrating the anesthetic in the subcutaneous area surrounding the operative field creates a field block.
ENUCLEATION
Small lipomas can exist 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 complimentary 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 pare overlying the lipoma. The incisions are configured like a fusiform excision post-obit the peel tension lines and are smaller than the underlying tumor. The central isle 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 three). Dissection is so performed beneath the subcutaneous fatty to the tumor. Any tissue cut is performed nether direct visualization using a no. 15 scalpel or scissors effectually the lipoma. Care must be taken to avert nerves or blood vessels that may prevarication just beneath the tumor.
FIGURE 3.
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 tin can be attached to the tumor to provide traction for removal of the balance of the growth. Once information technology is freed, the lipoma is delivered as a whole (Figure four). The surrounding tissue in the hole can be palpated to ensure complete removal of the tumor. Table 2 lists possible complications of excision.
Effigy 4.
Once freed, the lipoma is delivered equally a whole, and hemostasis is accomplished.
Tabular array ii
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 corrective deformity or contracture |
| Muscle injury/irritation |
| Fat embolus |
| Periostitis/osteomyelitis |
| Seroma |
Acceptable hemostasis is achieved following the removal of the lipoma using hemostats or suture ligation. The dead space is airtight beneath the pare using buried, interrupted three-0 or four-0 Vicryl sutures (Figure 5). Occasionally drains may have to be placed to prevent fluid accumulation, simply this should be avoided if possible. The peel is and 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 intendance 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 assay.
FIGURE 5.
Interrupted iii-0 or four-0 Vicryl sutures are used to partially shut the dead space.
Figures i and two were provided past Thomas Zuber, K.D., Department of Family and Community Medicine, Emory University School of Medicine, Atlanta
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REFERENCES
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1. Anders KH, Ackerman AB. Neoplasms of the subcutaneous fat. In: Freedberg IM, Eisen AZ, Wolff One thousand, Austen KF, Goldsmith LA, Katz SI, et al., eds. Fitzpatrick's Dermatology in general medicine. 5th ed. New York: McGraw-Colina, 1999:1292–1300. ...
2. Koh HK, Bhawan J. Tumors of the peel. In: Moschella SL, Hurley HJ, eds. Dermatology. 3d ed. Philadelphia: Saunders, 1992:1721–1808.
3. Bigelow DC, Eisen MD, Smith PG, Yousem DM, Levine RS, Jackler RK, et al. Lipomas of the internal auditory canal and cerebellopontine angle. Laryngoscope. 1998;108:1459–69.
4. Zimmermann G, Kellermann Southward, Gerlach R, Seifert 5. Cerebellopontine angle lipoma. Acta Neurochir. 1999;141:1347–51.
5. Enzinger FM, Weiss SW. Soft tissue tumors. 3d ed. St. Louis: Mosby, 1995:381–430.
6. Lellouch-Tubiana A, Zerah M, Catala M, Brousse N, Kahn AP. Congenital intraspinal lipomas. Pediatr Dev Pathol. 1999;ii:346–52.
7. Signorini Grand, Campiglio GL. Posttraumatic lipomas: where do they really come from?. Plast Reconstr Surg. 1998;101:699–705.
viii. Zuber TJ. Skin biopsy, excision, and repair techniques. In: Soft tissue surgery for the family medico (illustrated manuals, videotapes, and CD-ROMs of soft tissue surgery techniques). Kansas City, Mo.: American Academy of Family Physicians, 1998:100–half dozen. Retrieved September 2001, fromhttps://world wide web.aafp.org.
ix. Enzi One thousand. Multiple symmetric lipomatosis: an updated clinical report. Medicine. 1984;63:56–64.
10. Uhlin SR. Benign symmetric lipomatosis. Arch Dermatol. 1979;115:94–5.
eleven. Austin RM, Mack GR, Townsend CM, Lack EE. Infiltrating (intramuscular) lipomas and angiolipomas. A clinicopathologic written report of 6 cases. Arch Surg. 1980;115:281–4.
12. Lerosey Y, Choussy O, Gruyer X, Francois A, Marie JP, Dehesdin D, et al. Infiltrating lipoma of the head and cervix. Int J Pediatr Otorhinolaryngol. 1999;47:91–5.
13. Digregorio F, Barr RJ, Fretzin DF. Pleomorphic lipoma. Instance reports and review of the literature. J Dermatol Surg Oncol. 1992;xviii:197–202.
14. Fanburg-Smith JC, Devaney KO, Miettinen M, Weiss SW. Multiple spindle cell lipomas: a study of 7 familial and 11 nonfamilial cases. Am J Surg Pathol. 1998;22:xl–8.
15. Brody HJ, Meltzer HD, Someren A. Spindle jail cell lipoma. An unusual dermatologic presentation. Arch Dermatol. 1978;114:1065–6.
16. Matsumoto K, Hukuda S, Ishizawa M, Chano T, Okabe H. MRI findings in intramuscular lipomas. Skeletal Radiol. 1999;28:145–52.
17. Einarsdottir H, Soderlund V, Larson O, Jenner M, Bauer HC. MR imaging of lipoma and liposarcoma. Acta Radiol. 1999;40:64–8.
18. Wilhelmi BJ, Blackwell SJ, Mancoll JS, Phillips LG. Some other indication for liposuction: small facial lipomas. Plast Reconstr Surg. 1999;103:1864–seven.
This article is ane in a series of "Office Procedures" articles coordinated by Thomas J. Zuber, M.D., Assistant Professor, Department of Family and Community Medicine, Emory University Schoolhouse of Medicine, Atlanta.
Copyright © 2002 by the American Academy of Family Physicians.
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