Lipomas Treatment & Management

Updated: Jun 08, 2017
  • Author: Todd A Nickloes, DO, FACOS; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Treatment

Approach Considerations

Lipomas are removed for the following reasons:

  • Cosmetic reasons
  • To evaluate their histology, particularly when liposarcomas must be ruled out
  • When they cause symptoms
  • When they grow and become larger than 5 cm

Obtain biopsies of large lipomas or of those tethered to fascia to rule out a liposarcoma.

No contraindications to removing a lipoma exist, unless the patient is unfit for surgery or anatomic location makes removal unfeasible (as in the case, for example, of an intraspinal lipoma). Benign lipomas are simply "shelled out," with complete removal of the capsule in an extracapsular plane. This is an inadequate operation for a liposarcoma, and hence, performing an initial biopsy to exclude this lesion may be considered for large fatty tumors or for those in the retroperitoneum or the intramuscular spaces.

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Endoscopic Therapy

Nonsurgical therapy includes endoscopic excision of tumors in the upper gastrointestinal (GI) tract (ie, esophagus, stomach, or duodenum) or the colon. Colonoscopic snare removal has been described but may be associated with perforation if the base is broad. Japanese authors reported a safe technique in which a bipolar snare was used and the mucosa of the defective region was clipped. [22] Otherwise, surgical removal is indicated.

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Surgical Therapy

Complete surgical excision with the capsule is advocated to prevent local recurrence, whether the lipoma in question is subcutaneous or intracardiac in origin. These lesions may be lobulated, and it is essential that all lobules be removed.

Specific therapy depends on the location of the tumor. [23]

Subcutaneous lipomas are removed for cosmetic reasons, and hence, a cosmetically pleasing incision should be used. [24] The incision is usually placed directly over the mass and is oriented to lie in a line of skin tension. Liposuction is an alternative that allows removal of the lipoma through a very small incision, the location of which may be remote from the actual tumor. [25, 26, 27, 28] The lesion may also be approached by means of advanced, minimal-access tissue dissection methods, with the use of a dissecting balloon. [29] The latter two methods allow the incision to be placed in an inconspicuous location. For example, axillary incisions may be used to remove lipomas from the back.

Liposuction may be employed more often in small facial lipomas, because favorable aesthetic results have been obtained through strategically placed incisions. Liposuction is indicated for the treatment of medium-sized (4-10 cm) and large (>10 cm) lipomas; in small lipomas, no advantage has been reported, because these tumors can be extracted through small incisions. [25, 26, 27, 28]

Lipoma formation has been reported as an unusual complication of liposuction and has also been found to occur following trauma. [9, 30] The mechanism in these cases is unknown. Research on genetic markers of atypical lipomatous tumors and liposarcomas is ongoing. These tumors have been shown to express receptors for leptin. [31]

For more unusual locations, the method of removal must be tailored to the site and may require the expertise of a consultant, as follows:

  • Local removal is indicated in intestinal lipomas causing obstruction or hemorrhage; uncertainty of diagnosis for an intramural intestinal mass also warrants resection, because liposarcomatous disease of the bowel has been described
  • If esophageal lipomas cannot be endoscopically removed, surgical excision is indicated, whether by a transhiatal or a transthoracic approach
  • Lipoma-related narrowing of the major airways warrants removal of the instigating mass; likewise, intraparenchymal lipomas of the lung may require thoracotomy and the expertise of a thoracic surgeon
  • Breast lipomas are excised if their nature is in doubt, whether by means of wire or ultrasonographic localization or by means of direct palpation
  • Vulvar lipomas may be locally excised
  • Lipomas in critical locations, such as the heart, may require a more physiologically and technically demanding procedure for removal, including median sternotomy with bypass
  • Intraosseous lipomas may be removed by means of endoscopy in combination with orthopedic expertise

Tumors can usually be enucleated. They may recur if not properly removed, which should include removal of the capsule. Hibernomas tend to be highly vascular. Lipomas in other locations may present unique difficulties during removal; for example, in a person presenting with a frontalis-associated subfascial lipoma as a protruding mass on the lateral forehead, the lipoma may be difficult to dissect because of the highly vascular muscle that invests it. Lipomas of the GI tract can frequently be shelled out of their submucosal location.

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