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inant condition also found most frequently inmen, is characterized by widespread symmet-ric lipomas appearing most often over theextremities and trunk2,9 (Figure 1). Lipomato-sis may also be associated with Gardner’s syn-drome, an autosomal dominant conditioninvolving intestinal polyposis, cysts, and osteo-mas.8 The term Madelung’s disease, or benignsymmetric lipomatosis, refers to lipomatosis ofthe head, neck, shoulders, and proximal upperextremities. Persons with Madelung’s disease,often men who consume alcohol, may presentwith the characteristic “horse collar” cervical

Lipomas are slow-growing, nearlyalways benign, adipose tumorsthat are most often found in thesubcutaneous tissues.1 Most lipo-mas are asymptomatic, can be

diagnosed with clinical examination (Table 1)and do not require treatment. These tumorsmay also be found in deeper tissues such as theintermuscular septa, the abdominal organs, theoral cavity, the internal auditory canal, thecerebellopontine angle and the thorax.2-4 Lipo-mas have been identified in all age groups butusually first appear between 40 and 60 years ofage.5 Congenital lipomas have been observedin children.6 Some lipomas are believed to havedeveloped following blunt trauma.7

While solitary lipomas are more common inwomen, multiple tumors (referred to as lipo-matosis) are more common in men.2,8 Heredi-tary multiple lipomatosis, an autosomal dom-

Lipomas are adipose tumors that are often located in the subcutaneous tissues of thehead, neck, shoulders, and back. Lipomas have been identified in all age groups butusually first appear between 40 and 60 years of age. These slow-growing, nearlyalways benign, tumors usually present as nonpainful, round, mobile masses with acharacteristic soft, doughy feel. Rarely, lipomas can be associated with syndromes suchas hereditary multiple lipomatosis, adiposis dolorosa, Gardner’s syndrome, andMadelung’s disease. There are also variants such as angiolipomas, neomorphic lipo-mas, spindle cell lipomas, and adenolipomas. Most lipomas are best left alone, butrapidly growing or painful lipomas can be treated with a variety of procedures rang-ing from steroid injections to excision of the tumor. Lipomas must be distinguishedfrom liposarcoma, which can have a similar appearance. (Am Fam Physician 2002;65:901-4,905. Copyright© 2002 American Academy of Family Physicians.)

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

OFFICE PROCEDURES

O A patient informa-tion handout aboutlipomas, written bythe author, is providedon page 905.

This article is one in aseries of “Office Proce-dures” articles coordi-nated by Thomas J.Zuber, M.D., Assistant Professor, Departmentof Family and Commu-nity Medicine, EmoryUniversity School of Medicine, Atlanta.

TABLE 1

Differential Diagnosis of Lipoma

Epidermoid cystSubcutaneous tumorsNodular fasciitisLiposarcomaMetastatic diseaseErythema nodosumNodular subcutaneous fat necrosis

Weber-Christian panniculitisVasculitic nodulesRheumatic nodulesSarcoidosisInfections (e.g., onchocerciasis,

loiasis)Hematoma FIGURE 1. Multiple lipomatosis of the trunk

(hereditary multiple lipomatosis).

appearance.2,10 Rarely, these patients experi-ence swallowing difficulties, respiratory ob-struction, and even sudden death.1,2

EvaluationLipomas usually present as nonpainful,

round, mobile masses, with a characteristicsoft, doughy feel. The overlying skin appearsnormal. Lipomas can usually be correctlydiagnosed by their clinical appearance alone.

Microscopically, lipomas are composed ofmature adipocytes arranged in lobules, manyof which are surrounded by a fibrous capsule.Occasionally, a nonencapsulated lipoma infil-trates into muscle, in which case it is referredto as an infiltrating lipoma.5,11,12

Four other types of lipomas may be notedon a biopsy specimen. Angiolipomas are avariant form with co-existing vascular prolif-eration.2,11 Angiolipomas may be painful andusually arise shortly after puberty. Pleomor-phic lipomas are another variant in whichbizarre, multinucleated giant cells areadmixed with normal adipocytes.1,13 Pleo-morphic lipomas’ presentation is similar tothat of other lipomas, but they occur predom-inantly in men 50 to 70 years of age. A thirdvariant, spindle cell lipomas, has slender spin-dle cells admixed in a localized portion of reg-ular-appearing adipocytes.14,15 A newlydescribed variant of superficial lipoma, ade-nolipoma, is characterized by the presence ofeccrine sweat glands in the fatty tumor; thistype is often located on the proximal parts ofthe limbs.1

A rare clinical consideration is Dercum’sdisease, or adiposis dolorosa, which is charac-terized by the presence of irregular painfullipomas most often found on the trunk, shoul-ders, arms, forearms, and legs.8 Dercum’s dis-ease is five times more common in women, is

often found in middle age, and has astheniaand psychic disturbances as other prominentfeatures.

Malignancy is rare but can be found in alesion with the clinical appearance of alipoma. Liposarcoma presents in a fashionsimilar to that of a lipoma and appears to bemore common in the retroperitoneum, andon the shoulders and lower extremities.8 Somesurgeons recommend complete excision of allclinical evidence of a lipoma to exclude a pos-sible liposarcoma, especially in fast-growinglesions.8 Recently, magnetic resonance imag-ing has been used with some success to differ-entiate lipomas and liposarcomas.16,17

Treatment NONEXCISIONAL TECHNIQUES

Nonexcisional treatment of lipomas, whichis now common, includes steroid injectionsand liposuction.

Steroid injections result in local fat atrophy,thus shrinking (or, rarely, eliminating) thelipoma. Injections are best performed on lipo-mas less than 1 inch in diameter. A one-to-onemixture of 1 percent lidocaine (Xylocaine)and triamcinolone acetonide (Kenalog), in adosage of 10 mg per mL, is injected into thecenter of the lesion; this procedure may berepeated several times at monthly intervals.8

The volume of steroid depends on the size ofthe lipoma, with an average of 1 to 3 mL of

902 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 65, NUMBER 5 / MARCH 1, 2002

FIGURE 2. Proposed incision removing skinover the lipoma. The palpable borders of thelipoma are marked to aid the surgeon in com-plete removal.

FIGURE 3. The skin inside the incision graspedwith a hemostat to provide traction. Thelipoma is dissected from the surrounding tis-sue using scissors or a scalpel.

ILLU

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total volume administered. The number ofinjections depends on the response, which isexpected to occur within three to four weeks.Complications, which are rare, are the resultof the medication or the procedure, and canbe prevented by injecting the smallest totalamount possible and by positioning the nee-dle so that it is in the center of the lipoma.

Liposuction can be used to remove small orlarge lipomatous growths, particularly thosein locations where large scars should beavoided. Complete elimination of the growthis difficult to achieve with liposuction.8,18

Office procedures using a 16-gauge needleand a large syringe may be safer than large-cannula liposuction. Diluted lidocaine usu-ally provides adequate anesthesia for officeliposuction.

PREPARATION FOR EXCISION

Surgical excision of lipomas often results ina cure. Before the surgery, it is often helpful todraw an outline of the lipoma and a plannedskin excision with a marker on the skin sur-face (Figure 2). The outline of the tumor oftenhelps to delineate margins, which can beobscured after administration of the anes-thetic. Excision of some skin helps to elimi-nate redundancy at closure.

The skin is then cleansed with povidoneiodine (Betadine) or chlorhexidine (Betasept)solution, making sure to avoid wiping awaythe skin markings. The area is draped withsterile towels. Local anesthesia is administeredwith 1 or 2 percent lidocaine with epineph-rine, usually as a field block. Infiltrating theanesthetic in the subcutaneous area surround-ing the operative field creates a field block.

ENUCLEATION

Small lipomas can be removed by enucle-ation. A 3-mm to 4-mm incision is made overthe lipoma. A curette is placed inside thewound and used to free the lipoma from thesurrounding tissue. Once freed, the tumor isenucleated through the incision using thecurette. Sutures generally are not needed, and

a pressure dressing is applied to preventhematoma formation.

EXCISION

Larger lipomas are best removed throughincisions made in the skin overlying thelipoma. The incisions are configured like afusiform excision following the skin tensionlines and are smaller than the underlyingtumor. The central island of skin to beexcised is grasped with a hemostat, or Allisclamp, which is used to provide traction forthe removal of the tumor (Figure 3). Dissec-tion is then performed beneath the subcuta-neous fat to the tumor. Any tissue cutting isperformed under direct visualization using ano. 15 scalpel or scissors around the lipoma.Care must be taken to avoid nerves or bloodvessels that may lie just beneath the tumor.

Once a portion of lipoma has been dis-sected from the surrounding tissue, hemostatsor clamps can be attached to the tumor toprovide traction for removal of the remainderof the growth. Once it is freed, the lipoma isdelivered as a whole (Figure 4). The surround-ing tissue in the hole can be palpated to ensurecomplete removal of the tumor. Table 2 listspossible complications of excision.

Lipoma

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

TABLE 2

Complications of Lipoma Excision

Surgical infection/cellulitis/fasciitisEcchymosisHematoma formationInjury to nearby nerves with permanent

paresthesia/anesthesiaInjury to nearby vessels/vascular

compromise

Permanent deformity secondaryto removal of a large lesion

Excessive scarring with cosmetic deformity or contracture

Muscle injury/irritationFat embolusPeriostitis/osteomyelitisSeroma

Lipoma

Adequate hemostasis is achieved followingthe removal of the lipoma using hemostatsor suture ligation. The dead space is closedbeneath the skin using buried, interrupted3-0 or 4-0 Vicryl sutures (Figure 5). Occa-sionally drains may have to be placed to pre-vent fluid accumulation, but this should beavoided if possible. The skin is then closedwith interrupted 4-0 or 5-0 nylon sutures. Apressure dressing is placed to reduce theincidence of hematoma formation. Thepatient is given routine wound care instruc-tions, and the wound is checked in two toseven days. The sutures are removed afterseven to 21 days, depending on the bodylocation. Specimens should be submitted forhistologic analysis.

The author indicates that he does not have any con-flicts of interest. Sources of funding: none reported.

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

REFERENCES

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

2. Koh HK, Bhawan J. Tumors of the skin. 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 internalauditory canal and cerebellopontine angle. Laryn-goscope 1998;108:1459-69.

4. Zimmermann M, Kellermann S, Gerlach R, SeifertV. Cerebellopontine angle lipoma. Acta Neurochir1999;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. PediatrDev Pathol 1999;2:346-52.

7. Signorini M, Campiglio GL. Posttraumatic lipomas:where do they really come from? Plast ReconstrSurg 1998;101:699-705.

8. Zuber TJ. Skin biopsy, excision, and repair tech-niques. In: Soft tissue surgery for the family physi-cian (illustrated manuals, videotapes, and CD-ROMs of soft tissue surgery techniques). KansasCity, Mo.: American Academy of Family Physicians,1998:100-6. Retrieved September 2001, fromhttp://www.aafp.org.

9. Enzi G. Multiple symmetric lipomatosis: anupdated clinical report. Medicine 1984;63:56-64.

10. Uhlin SR. Benign symmetric lipomatosis. Arch Der-matol 1979;115:94-5.

11. Austin RM, Mack GR, Townsend CM, Lack EE. Infil-trating (intramuscular) lipomas and angiolipomas.A clinicopathologic study of six cases. Arch Surg1980;115:281-4.

12. Lerosey Y, Choussy O, Gruyer X, Francois A, Marie JP,Dehesdin D, et al. Infiltrating lipoma of the head andneck. Int J Pediatr Otorhinolaryngol 1999;47:91-5.

13. Digregorio F, Barr RJ, Fretzin DF. Pleomorphiclipoma. Case reports and review of the literature. JDermatol Surg Oncol 1992;18:197-202.

14. Fanburg-Smith JC, Devaney KO, Miettinen M,Weiss SW. Multiple spindle cell lipomas: a report of7 familial and 11 nonfamilial cases. Am J SurgPathol 1998;22:40-8.

15. Brody HJ, Meltzer HD, Someren A. Spindle celllipoma. 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 G,Bauer HC. MR imaging of lipoma and liposarcoma.Acta Radiol 1999;40:64-8.

18. Wilhelmi BJ, Blackwell SJ, Mancoll JS, Phillips LG.Another indication for liposuction: small facial lipo-mas. Plast Reconstr Surg 1999;103:1864-7.

904 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 65, NUMBER 5 / MARCH 1, 2002

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

The Author

GOHAR A. SALAM, M.D., D.O., is assistant director in the family practice residencyprogram at Saginaw Cooperative Hospitals in Saginaw, Mich., where he completed aresidency in family practice. He is also assistant professor of family practice at Michi-gan 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.

Address correspondence to Gohar Salam, M.D., D.O., Saginaw Cooperative Hospitals, Inc.,1000 Houghton Ave., Saginaw, MI 48602. Reprints are not available from the author.