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 for 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.

Endoscopic Therapy

Nonoperative 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.^[23]Otherwise, surgical removal is indicated.

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.^[24]

Subcutaneous lipomas are removed for cosmetic reasons, and hence, a cosmetically pleasing incision should be used.^[25]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.^{[26, 27, 28, 29]}The lesion may also be approached by means of advanced minimal-access tissue dissection methods, with the use of a dissecting balloon.^[30]These 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.^{[26, 27, 28, 29]}

Lipoma formation has been reported as an unusual complication of liposuction and has also been found to occur following trauma.^{[9, 31]}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.^[32]

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.

Questions

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Media Gallery

Upper gastrointestinal series shows duodenal lipoma with central ulceration where the overlying mucosa has thinned, ulcerated, and bled.
Duodenal lipoma resected through a duodenotomy. Overlying mucosa with central ulceration removed and lobulated fatty tumor shelled out intact with capsule. The mucosa was then sutured closed, and the duodenotomy closed. The stitch was placed to orient the specimen for pathologic examination.

of 2

Author

Todd A Nickloes, DO, FACOS Associate Professor, Department of Surgery, Division of Trauma/Critical Care, University of Tennessee Medical Center-Knoxville

Todd A Nickloes, DO, FACOS is a member of the following medical societies: American Medical Association, American Osteopathic Association, Association for Academic Surgery, Society of Critical Care Medicine, Society of Laparoscopic and Robotic Surgeons, Southeastern Surgical Congress, Southern Medical Association, Eastern Association for the Surgery of Trauma, American College of Osteopathic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Daniel D Sutphin, MD, FACS Attending Plastic and Reconstructive Surgeon, Yuma Regional Medical Center

Daniel D Sutphin, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: Received none from RFA Medical for director; Received none from MRC Biotec for director.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Juan B Ochoa, MD Assistant Professor, Department of Surgery, University of Pittsburgh School of Medicine; Medical and Scientific Director, HCN, Nestle Healthcare Nutrition

Disclosure: Nothing to disclose.

Acknowledgements

Klaus Radebold, MD, PhD Former Research Associate, Department of Surgery, Yale University School of Medicine

Disclosure: Nothing to disclose.

Carol E H Scott-Conner, MD, PhD Professor, Department of Surgery, University of Iowa College of Medicine

Disclosure: Nothing to disclose.