Approach
Lipomas can occur in a wide variety of sites. The position, size, likely differential and other characteristics of a lesion determine what treatments are feasible and appropriate. Since lipomas do not have malignant potential they do not necessarily have to be removed, but this course of action depends on a number of factors, the most notable being the likelihood that the lesion could be a liposarcoma.
Superficial cutaneous lipomas on trunk or extremity
Lipomas of this type are often removed for a number of reasons:[5][16]
For cosmetic appearance
If they are painful or bothersome
If they increase in size
If there is concern regarding a potential liposarcoma.
The traditional treatment of small, superficial lipomas has been surgical excision under local anaesthesia. If multiple lipomas require removal or if the lesion is large, then general anaesthesia may be more appropriate. The surgical site is prepped and draped sterilely to prevent infection.[40] The incision line is marked over the lipoma in a position that minimises scarring and optimises exposure. For lesions on the trunk, the incision line should follow Langer lines. For lesions on the extremities, the incision should follow Langer lines or the long axis of the extremity, depending on the precise location of the lesion.
Local anaesthetic is infiltrated into the skin and subcutaneous tissue around the lesion and along the line of incision.
Demonstration of injection techniques used to administer local anaesthetic, for allergy skin testing, and for tuberculin skin testing.
Once the skin is fully anaesthetised, the skin is incised through to the subcutaneous fat layer using a scalpel. Skin flaps are then raised to the borders of the lesion using electrocautery, taking care to avoid any nearby nerves or blood vessels. When the capsule of the lipoma is encountered, sharp or blunt dissection can be used to enucleate the lesion. Clamps can be attached to the tumour to provide traction for removal of the mass. Once it is freed from its surrounding tissue, the lipoma is delivered as a whole. The resultant cavity is palpated to ensure complete removal of the tumour. If margins are not fully removed or are 'positive', then the lipoma may recur.
Following removal of the tumour, haemostasis is achieved using electrocautery or suture ligation. The wound is then gently irrigated with normal saline. If the tumour and resultant cavity is large (e.g., a mass >5 cm), closed suction drains may have to be used. The skin is closed using buried, interrupted 2.0 or 3.0 vicryl sutures in the dermal layer. The skin is then approximated using 3.0 or 4.0 nylon vertical mattress suture vicryl sutures or monocryl as a running subcuticular suture. A pressure dressing is used to reduce the likelihood of haematoma formation. The patient is given routine wound care instructions, and the wound is checked in 5 to 10 days. Sutures are removed after 5 to 14 days, depending on the location of the tumour. Specimens are submitted for histological analysis.
Liposuction is generally not recommended as a treatment option for lipomas. Although it may result in less scarring due to a smaller incision, it may fail to remove the entire mass, making recurrence more likely.[44] Moreover, it will not provide adequate histopathology for confirmatory diagnosis. The injection of corticosteroids or phosphatidylcholine to trigger lipolysis is also not generally recommended, as elimination of the tumour is not achieved, recurrence is almost certain, and unpredictable scarring and fibrosis can occur.[45]
For patients with Dercum's disease, treatment includes symptom management, including excision of the most painful lipomas. Referral to a multidisciplinary team with expertise in chronic pain management is recommended.[12]
Gastrointestinal tract lipomas
If gastrointestinal tract lipomas are sufficiently large to be causing obstructive symptoms or significant bleeding, then surgical excision is indicated.[46] This may be achieved by laparoscopic or open segmental resection, depending on the exact location and characteristics of the lipoma.
Lipomas in atypical sites
Treatment of lipomas that arise in unusual sites such as the adrenal glands, parotid glands, parapharyngeal space, breast, mediastinum, pleura, airways, heart, superior vena cava, brain, and intraspinal areas are considered on a case-by-case basis. The general principle of treatment of such cases is close observation. However, if there is a concern that the lesion could potentially be a liposarcoma, surgical excision is indicated.
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