Lipomas are common, benign soft tissue tumors that occur on the body surface either sporadically or in association with inherited disorders of fat metabolism. They are typically painless and mobile and enlarge slowly. Histologically, they consist of enlarged adipocytes with uniform nuclei and are usually surrounded by a fibrous capsule [
Although there have been multiple reports of successful liposuction for lipoma removal, the technique is not widely embraced. Objectors argue that liposuction limits visualization of the tumor, fragments the specimen confounding histopathological examination for features of malignancy, and leaves residual lipomatous or capsular tissue that predisposes to recurrence [
We describe the largest series of lipomas removed through a combination of liposuction and direct excision and report patient outcomes over a decade to address concerns about recurrence and malignancy.
For 25 consecutive patients with superficial fat tumors typical of lipomas seeking excision, we offered two alternative techniques for removal: direct excision alone or a combination of liposuction and direct excision. Patients were advised that, should fluid accumulate following excision, serial aspiration might be required with either method. After discussion of the potential benefits, limitations, and risks of each technique, all patients chose the liposuction and excision combination approach.
The lipomatous mass was outlined in its entirety and infiltrated with a solution 1% xylocaine with epinephrine, 1 : 100,000 for local anesthesia and to promote hemostasis. A 3 mm sharp liposuction cannula was then inserted through a 1 cm incision made in the midportion of the surface of the mass with a #15 scalpel blade. The bulk of the lipoma was removed by aspiration before removing residual tissue and capsule by direct, sharp, and step-wide excision. All extracted specimens were submitted for histopathological examination to exclude liposarcoma or atypical cells. The wound was then irrigated and assessed for hemostasis. Closure was achieved with subcutaneous 5-0 Vicryl and Monocryl sutures without drain placement, Steri-strips were applied, and a bulky dressing was secured. After suctioning of lipomas from the back or abdomen, compressive garments were used to secure the bulkier dressings.
While drain insertion after removal of large lipomas is reasonable, serial aspiration avoids the need for additive drainage scars or elongation of the incision and is preferred to control postoperative fluid accumulation. The dressing was changed 1 week postoperatively and topical silicone gel and pigment-reducing cream were applied for several weeks to reduce scar thickening, retraction, or discoloration. The incision was evaluated postoperatively by the senior surgeon to assess healing and the aesthetic result.
Follow-up questionnaires were sent to all patients in 2013 (1–10 years postoperatively) to collect retrospective data about the quality and durability of the result, late complications, further treatment, or development of additional lipomas (see appendix).
Between 2003 and 2012, 48 lipomas were removed by combined liposuction and excision from 25 patients (17 women and 8 men), ranging in age from 19 to 77 years (mean 49.8 years). Six had multiple lipomas and 19 had solitary masses. Lipomas ranged in diameter from 1 to 15 cm (mean 5.4 cm); 7 were smaller than 3 cm. Two were located on the head or neck, 11 on the back, 2 on the abdomen, 31 on the extremities, and 2 on the groin (see Table
Summary of patients and lipomas.
Patient | Age (years) | Lesion diameter (cm) | Location | Initial follow-up (weeks) | Long-term follow-up (years) |
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(1) S. R. | 44 | 5 cm; 7 cm | RT shoulder; LT flank | 3 | 10 |
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(2) M. S. | 50 | 7 cm | LT shoulder | 1 | 10 |
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(3) C. T. | 55 | 5 cm | LT arm | 1 | 10 |
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(4) C. K. | 40 | 10 cm | RT back | 4 | 9 |
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(5) G. G. | 77 | 15 cm | Upper back | 8 | 8 |
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(6) A. C. | 65 | 10 cm | RT posterior knee | 1 | 8 |
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(7) P. T. | 24 | 6 cm | Back | 1 | 7 |
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(8) H. F. | 49 | 10 cm | Upper back | 3 | 7 |
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(9) A. T. | 19 | 10 cm | RT ankle | 52 | 7 |
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(10) D. S. | 52 | 7 cm | RT back | 4 | 7 |
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(11) R. M. | 46 | 7 cm | Upper back | none noted | N/A |
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(12) S. A. | 54 | 10 cm | Upper back | 2 | 7 |
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(13) R. T. | 59 | 2 cm | RT temple | 4 | 6 |
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(14) A. K. | 52 | 4 cm | LT mid back | 1 | 5 |
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(15) A. I. | 42 | 3 cm; 4 cm; 5 cm | RT upper back; RT lower back; LT jawline | 2 | N/A |
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(16) C. L. | 53 | 2–5 cm | RT lower lateral thigh; RT midlateral thigh; RT upper medial thigh; RT middle medial thigh; RT lower medial thigh; HIP; RT upper buttock; RT lower buttock; RT outer thigh | 6 | 5 |
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(17) N. P. | 46 | 13 cm | Upper back | 8 | 5 |
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(18) C. L. | 53 | 2–5 cm | LT buttock; LT infragluteal fold; LT midlateral exterior thigh; LT interior thigh; LT arm | 6 | 5 |
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(19) C. L. | 53 | 2–5 cm | LT upper forearm; LT lower forearm; LT inner thigh; LT upper outer thigh; LT medial thigh, LT lower thigh; LT upper anterior thigh; LT medial thigh; LT lower anterior thigh | 6 | 5 |
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(20) L. Q. | 42 | 10 cm | LT lower abdomen | 12 | 5 |
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(21) A. S. | 50 | 10 cm | RT rectal-vaginal | 5 | 5 |
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(22) J. Z. | 62 | 10 cm | RT arm | 1 | 3 |
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(23) S. I. | 60 | 7 cm | RT shoulder | 12 | 1 |
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(24) M. A. | 47 | 1.5 cm; 3 cm | RT upper elbow; LT groin | 1 | 1 |
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(25) A.D. | 80 | 15 cm | RT upper back | 4 | 1 |
All extracted and excised specimens submitted for histopathological evaluation were sufficient for analysis and had characteristics of benign lipomas; none contained morphologically dysplastic or malignant cells.
During early follow-up 1 to 12 weeks postoperatively, repeated aspiration was required in 18 cases with eventual resolution, including one hematoma after removal of a 10 cm abdominal lipoma and one seroma after removal of a 15 cm lipoma from the back (see Figure
Pre- and 1-month postoperative photographs of an 80-year-old woman with 15 × 13 cm lipoma. (a) Back view and (b) right lateral view.
Later outcomes were assessed by written responses to a survey, to which 23 patients responded (92%) 4 months to 10 years postoperatively (mean 7 years; median 6.5 years); two patients did not respond. None of the respondents identified complications of the procedure or recurrence of lipoma, appearance of new lipomas, hyperpigmentation, scarring, or clinical evidence of malignant transformation.
Since its introduction in 1975 by Fischer, followed by Illouz’s “wet technique” in 1977 [
The combined liposuction and excision technique facilitates complete removal of lipomas through small incisions. Fibrous lipomas and angiolipomas are less amenable to liposuction; others have indistinct borders or transitions to nonlipomatous adipose tissue. While these require greater direct excision of the fibrous components, initial liposuction aided debulking and facilitated removal through smaller incisions. Early postoperative fluid accumulation developed in over a third of cases (incidence 37.5%) but responded to percutaneous aspiration without residua. Postoperative hematoma or seroma might have been avoided by placement of conventional drains, which would entail additional scarring, as discussed with patients preoperatively. There was no clinical recurrence among the 23 patients we queried after a median postoperative interval of 6.5 years. The local recurrence rate of lipomas after surgical excision has been reported as 1-2% over an indefinite period [
None of the lesions in this series had clinical features suggestive of liposarcoma, hibernoma, or lipoblastoma. Liposarcomas typically occur between the 5th and 7th decades of life in the deeper soft tissues of the extremities [
This study is limited by sample size, which is insufficient to identify recurrence rates less than about 2 percent. None of the lipomas had malignant features, and we caution clinicians to carefully assess soft tissue tumors for atypical clinical features before employing the intervention we describe. Despite these limitations, our observations suggest that the combination of liposuction and excision is a safe option for removal of subcutaneous lipomas that yields successful results. Outcomes could differ for submuscular lipomas. While a questionnaire is not entirely sufficient for evaluating recurrence, it provides a subjective method of assessing whether the patient detects recurrence. The outcomes in the two patients who failed to respond to the survey could not be determined.
Since the management of lipomas is inherently conservative, excision is recommended only when the tumors are symptomatic because of their size or location, have suspicious clinical features, or are cosmetically unacceptable to the patient, and the incidence of malignancy is low; we believe that removal by combined liposuction and direct excision is a reasonable alternative to direct, open excision.
The use of liposuction permits a smaller incision and favorable aesthetic results, without exposing patients to recurrence or compromising pathological analysis in the vast majority of cases. A randomized trial comparing liposuction with conventional direct excision is necessary to more conclusively compare the outcomes of these techniques.
Did your lipoma return or did you need to seek further treatment for your lipoma? yes or no If so, what year? Did you have any postoperative bruising or skin dimpling at the surgical site? yes or no Have you had other lipomas removed before or after this one? yes or no If so, what year and how did your postoperative recovery compare (pain, bruising, etc.)? Do you have a history of cancer? yes or no Do you have any other concerns about the procedure or your recovery?
The authors declare that there is no conflict of interests regarding the publication of this paper.