The lipoma is a benign tumor (neoplasm) of fatty tissue.
It may be moveable beneath the surface of
the mouth membrane and more superficial lesions have a yellow/white color. It is painless and
slowly enlarges, sometimes to become several inches across. It can occur at any age and will not
diminish on its own, hence, must be surgically removed. It has no potential for developing into a
cancer.
Introduction
The lipoma is a very common benign tumor of adipose tissue, but its presence in the oral and
oropharyngeal region is relatively uncommon, with a prevalence rate on only 1/5,000 adults (Table 1).
The first description of an oral lesion was provided in 1848 by Roux in a review of alveolar masses; he
referred to it as a "yellow epulis." While most lesions are developmental anomalies, those which occur in
the maxillofacial region usually arise late in life and are presumed to be neoplasms of adipocytes,
occasionally associated with trauma. As with all fatty tissue, a lipoma will float on the surface of formalin
rather than sink to the bottom of a biopsy specimen jar.
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Clinical Features
The lipoma is a slowly enlarging, soft, smooth-surfaced mass of the submucosal tissues (Figures 1 & 2).
When superficial, there is a yellow surface discoloration. When well-encapsulated, tumors are freely
movable beneath the mucosa, but less well-demarcated lesions are not movable. The lesion may be
pedunculated or sessile and occasional cases show surface bosselation. The tumor has a less dense and
more uniform appearance than surrounding fibrovascular tissues when it is transilluminated. MRI scans
are very useful in the clinical diagnosis; CT scans and ultrasound are less reliable.
Few oral or pharyngeal lesions occur before the third decade of life and there is no gender predilection.
Once present, a mucosal oral lipoma may increase to 5-6 cm. over a period of years, but most cases are
less than 3 cm. in greatest dimension at diagnosis. Rarely, a lipoma will occur within maxillary bones or
sinuses, but usually this entity is found in the buccal, lingual or oral floor regions. Multiple head and neck
lipomas have been observed in neurofibromatosis, Gardner syndrome, encephalocraniocutaneous
lipomatosis, multiple familial lipomatosis, and Proteus syndrome. Generalized lipomatosis has been
reported to contribute to unilateral facial enlargement in hemifacial hypertrophy.
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Pathology and Differential Diagnosis
The lipoma is composed predominantly of mature adipocytes, possibly admixed with collagenic streaks,
and is often well demarcated from the surrounding connective tissues (Figures 3 & 4). A thin fibrous
capsule may be seen and a distinct lobular pattern may be present. Quite often, however, lesional fat
cells are seen to "infiltrate" into surrounding tissues, perhaps producing long, thin extensions of fatty
tissue radiating from the central tumor mass (Figure 5). When located within striated muscle this
infiltrating variant is called intramuscular lipoma (infiltrating lipoma), but extensive involvement of a wide
area of fibrovascular or stromal tissues might best be termed lipomatosis.
Occasional lesions exhibit excessive fibrosis between the fat cells (fibrolipoma), excess numbers of small
vascular channels (angiolipoma), a myxoid background stroma (myxoid lipoma, myxolipoma), or areas
with uniform spindle-shaped cells interspersed between normal adipocytes (spindle cell lipoma, Figure 6).
When spindle cells appear somewhat dysplastic or mixed with pleomorphic giant cells with or without
hyperchromatic, enlarged nuclei, the term pleomorphic lipoma is applied. When the spindled cells are of
smooth muscle origin, the term myolipoma may be used, or angiomyolipoma when the smooth muscle
appears to be derived from the walls of arterioles.
Rarely, chondroid or osseous metaplasia may be seen in a lipoma (osteolipoma, ossifying lipoma,
chondroid lipoma, ossifying chondromyxoid lipoma). When bone marrow is present, the term myelolipoma
is used. Also on rare occasions, isolated ductal or tubular adnexal structures are scattered throughout fat
lobules, in which case the term adenolipoma is applied. Perineural lipoma has also been reported.
On occasion, lipoma of the buccal mucosa cannot be distinguished from a herniated buccal fat pad,
except by the lack of a history of sudden onset after trauma. Otherwise, lipoma of the oral and pharyngeal
region is not difficult to differentiate from other lesions, although spindle cell and pleomorphic types must
be distinguished from liposarcoma. When metaplastic calcified tissue is present, the lesion may be
confused with soft tissue chondroma or soft tissue osteoma.
The benign neoplasm of brown fat, hibernoma, has been reported in the oral/pharyngeal region only
rarely. This childhood tumor is comprised of lobules of highly vascular stroma admixed with three types of
adipocytes: a large, univacuolated fat cell with a peripheral nucleus; a moderate-sized multivacuolated fat
cell with scanty granular, eosinophilic cytoplasm and a centrally located rounded nucleus; and a smaller
cell with the same cytoplasm but with only small circular spaces representing fat microvacuoles.
A fat tumor comprised of a central core of mature adipocytes and a peripheral envelope of cells
containing variably sized fat vacuoles is called lipoblastoma (Figure 7). Affected cells are smaller than
normal, with 1-4 vacuoles, perhaps with a light, wispy cytoplasm between vacuoles. Some cells have
nuclei centrally located, as seen in the moderately-sized cells of hibernoma, while others show the
nucleus to be pushed toward the cytoplasmic membrane (signet-ring cell). Mitotic activity is extremely
rare and fibrous septa separate fat lobules in this tumor. An abnormality of the long arm of chromosome
8q11-13 is a rather consistent finding in the lesional cells.
Definition
A lipoma is a slow-growing, fatty lump that's most often situated between your skin and the
underlying muscle layer. Often a lipoma is easy to identify because it moves readily with slight
finger pressure. It's doughy to touch and usually not tender. You may have more than one
lipoma. Lipomas can occur at any age, but they're most often detected during middle age.
A lipoma isn't cancer and is usually harmless. Treatment generally isn't necessary, but if the
lipoma is in a location that bothers you, is painful or is growing, you may want to have it
removed.
Symptoms
Lipomas are:
• Located just under your skin. They commonly occur in the neck, shoulders, back,
abdomen, arms and thighs.
• Soft and doughy to the touch. They also move easily with slight finger pressure.
• Generally small. Lipomas are typically less than 2 inches (5 centimeters) in diameter,
but they can grow larger.
• Sometimes painful. Lipomas can be painful if they grow and press on nearby nerves, or
if they contain many blood vessels.
When to see a doctor
A lipoma is rarely a serious medical condition. But if you notice a lump or swelling anywhere on
your body, have it checked by your doctor.
Causes
The exact cause of lipomas is unknown. Lipomas tend to run in families, so genetic factors likely
play a role in their development.
Risk factors
Several factors may increase your risk of developing a lipoma, including:
• Being between 40 and 60 years old. Although lipomas can occur at any age, they're
most common in this age group. Lipomas are rare in children.
• Having certain other disorders. People with other disorders, including adiposis
dolorosa, Madelung disease, Bannayan-Riley-Ruvalcaba syndrome, Cowden syndrome
and Gardner syndrome have an increased risk of multiple lipomas.
Preparing for your appointment
You're likely to start by first seeing your family doctor or a general practitioner. However, you
may then be referred to a doctor who specializes in skin disorders (dermatologist).
Here's some information to help you get ready for your appointment, and what to expect from
your doctor.
What you can do
• Write down any symptoms you're experiencing, including any that may seem
unrelated to the reason for which you scheduled the appointment.
• Make a list of all medications, as well as any vitamins or supplements, that you're
taking.
• Write down questions to ask your doctor.
Preparing a list of questions can help you make the most of your time with your doctor. For
lipoma, some basic questions to ask your doctor include:
• What caused this growth?
• Is it cancer?
• Do I need any tests to be sure?
• Will this lump always be there?
• Can I have it removed?
• What's involved in having it removed? Are there any risks?
• Are there any brochures or other printed material that I can take home with me? What
Web sites do you recommend?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask
questions during your appointment any time you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you questions too. Being ready to answer them may reserve time to
go over any points you want to spend more time on. Your doctor may ask:
• When did you first notice the lump?
• Have you noticed if it's grown at all?
• Have you had similar growths in the past?
• Is the lump painful?
Tests and diagnosis
To diagnose a lipoma, your doctor may give you:
• A physical exam
• A tissue sample removal (biopsy) for lab examination
• An ultrasound or other imaging test, such as an MRI or CT scan, if the lipoma is large,
has unusual features or appears to be deeper than the fatty tissue
There's a very small chance that a lump resembling a lipoma may actually be a form of cancer
called liposarcoma. Liposarcomas — cancerous tumors in fatty tissues — grow rapidly, don't
move under the skin and are usually painful. A biopsy, MRI or CT scan is typically done if your
doctor suspects liposarcoma.
Lipomas are adipose tumors that are often located in the subcutaneous tissues of the head, neck,
shoulders, and back. Lipomas have been identified in all age groups but usually first appear
between 40 and 60 years of age. These slow-growing, nearly always benign, tumors usually
present as nonpainful, round, mobile masses with a characteristic soft, doughy feel. Rarely,
lipomas can be associated with syndromes such as hereditary multiple lipomatosis, adiposis
dolorosa, Gardner's syndrome, and Madelung's disease. There are also variants such as
angiolipomas, neomorphic lipomas, spindle cell lipomas, and adenolipomas. Most lipomas are
best left alone, but rapidly growing or painful lipomas can be treated with a variety of procedures
ranging from steroid injections to excision of the tumor. Lipomas must be distinguished from
liposarcoma, which can have a similar appearance.
Lipomas are slow-growing, nearly always benign, adipose tumors that are most often found in
the subcutaneous tissues.1� Most lipomas are asymptomatic, can be diagnosed with clinical
examination (Table 1) and do not require treatment. These tumors may also be found in deeper
tissues such as the intermuscular septa, the abdominal organs, the oral cavity, the internal
auditory canal, the cerebellopontine angle and the thorax.2–4 Lipomas have been identified in all
age groups but usually first appear between 40 and 60 years of age.5 Congenital lipomas have
been observed in children.6 Some lipomas are believed to have developed following blunt
trauma.7
TABLE 1
Differential Diagnosis of Lipoma
Epidermoid cyst
Subcutaneous tumors
Nodular fasciitis
Liposarcoma
Metastatic disease
Erythema nodosum
Nodular subcutaneous fat necrosis
Weber-Christian panniculitis
Vasculitic nodules
Rheumatic nodules
Sarcoidosis
Infections (e.g., onchocerciasis, loiasis)
Hematoma
While solitary lipomas are more common in women, multiple tumors (referred to as lipomatosis)
are more common in men.2,8 Hereditary multiple lipomatosis, an autosomal dominant condition
also found most frequently in men, is characterized by widespread symmetric lipomas appearing
most often over the extremities and trunk2,9 (Figure 1). Lipomatosis may also be associated with
Gardner's syndrome, an autosomal dominant condition involving intestinal polyposis, cysts, and
osteomas.8 The term Madelung's disease, or benign symmetric lipomatosis, refers to lipomatosis
of the head, neck, shoulders, and proximal upper extremities. Persons with Madelung's disease,
often men who consume alcohol, may present with the characteristic “horse collar” cervical
appearance.2,10 Rarely, these patients experience swallowing difficulties, respiratory
obstruction, and even sudden death.1,2
FIGURE 1.
Multiple lipomatosis of the trunk (hereditary multiple lipomatosis).
Evaluation
Lipomas usually present as nonpainful, round, mobile masses, with a characteristic soft, doughy
feel. The overlying skin appears normal. Lipomas can usually be correctly diagnosed by their
clinical appearance alone.
Microscopically, lipomas are composed of mature adipocytes arranged in lobules, many of which
are surrounded by a fibrous capsule. Occasionally, a nonencapsulated lipoma infiltrates into
muscle, in which case it is referred to as an infiltrating lipoma.5,11,12
Four other types of lipomas may be noted on a biopsy specimen. Angiolipomas are a variant
form with co-existing vascular proliferation.2,11 Angiolipomas may be painful and usually arise
shortly after puberty. Pleomorphic lipomas are another variant in which bizarre, multinucleated
giant cells are admixed with normal adipocytes.1,13 Pleomorphic lipomas' presentation is similar
to that of other lipomas, but they occur predominantly in men 50 to 70 years of age. A third
variant, spindle cell lipomas, has slender spindle cells admixed in a localized portion of regular-
appearing adipocytes.14,15 A newly described variant of superficial lipoma, adenolipoma, is
characterized by the presence of eccrine sweat glands in the fatty tumor; this type is often located
on the proximal parts of the limbs.1
A rare clinical consideration is Dercum's disease, or adiposis dolorosa, which is characterized by
the presence of irregular painful lipomas most often found on the trunk, shoulders, arms,
forearms, and legs.8 Dercum's disease is five times more common in women, is often found in
middle age, and has asthenia and psychic disturbances as other prominent features.
Malignancy is rare but can be found in a lesion with the clinical appearance of a lipoma.
Liposarcoma presents in a fashion similar to that of a lipoma and appears to be more common in
the retroperitoneum, and on the shoulders and lower extremities.8 Some surgeons recommend
complete excision of all clinical evidence of a lipoma to exclude a possible liposarcoma,
especially in fast-growing lesions.8 Recently, magnetic resonance imaging has been used with
some success to differentiate lipomas and liposarcomas.16,17
Treatment
NONEXCISIONAL TECHNIQUES
Nonexcisional treatment of lipomas, which is now common, includes steroid injections and
liposuction.
Steroid injections result in local fat atrophy, thus shrinking (or, rarely, eliminating) the lipoma.
Injections are best performed on lipomas less than 1 inch in diameter. A one-to-one mixture of 1
percent lidocaine (Xylocaine) and triamcinolone acetonide (Kenalog), in a dosage of 10 mg per
mL, is injected into the center of the lesion; this procedure may be repeated several times at
monthly intervals.8 The volume of steroid depends on the size of the lipoma, with an average of
1 to 3 mL of total volume administered. The number of injections depends on the response,
which is expected to occur within three to four weeks. Complications, which are rare, are the
result of the medication or the procedure, and can be prevented by injecting the smallest total
amount possible and by positioning the needle so that it is in the center of the lipoma.
Liposuction can be used to remove small or large lipomatous growths, particularly those in
locations where large scars should be avoided. Complete elimination of the growth is difficult to
achieve with liposuction.8,18 Office procedures using a 16-gauge needle and a large syringe may
be safer than large-cannula liposuction. Diluted lidocaine usually provides adequate anesthesia
for office liposuction.
PREPARATION FOR EXCISION
Surgical excision of lipomas often results in a cure. Before the surgery, it is often helpful to draw
an outline of the lipoma and a planned skin excision with a marker on the skin surface (Figure 2).
The outline of the tumor often helps to delineate margins, which can be obscured after
administration of the anesthetic. Excision of some skin helps to eliminate redundancy at closure.
FIGURE 2.
Proposed incision removing skin over the lipoma. The palpable borders of the lipoma are marked
to aid the surgeon in complete removal.
The skin is then cleansed with povidone iodine (Betadine) or chlorhexidine (Betasept) solution,
making sure to avoid wiping away the skin markings. The area is draped with sterile towels.
Local anesthesia is administered with 1 or 2 percent lidocaine with epinephrine, usually as a field
block. Infiltrating the anesthetic in the subcutaneous area surrounding the operative field creates
a field block.
ENUCLEATION
Small lipomas can be removed by enucleation. A 3-mm to 4-mm incision is made over the
lipoma. A curette is placed inside the wound and used to free the lipoma from the surrounding
tissue. Once freed, the tumor is enucleated through the incision using the curette. Sutures
generally are not needed, and a pressure dressing is applied to prevent hematoma formation.
EXCISION
Larger lipomas are best removed through incisions made in the skin overlying the lipoma. The
incisions are configured like a fusiform excision following the skin tension lines and are smaller
than the underlying tumor. The central island of skin to be excised is grasped with a hemostat, or
Allis clamp, which is used to provide traction for the removal of the tumor (Figure 3). Dissection
is then performed beneath the subcutaneous fat to the tumor. Any tissue cutting is performed
under direct visualization using a no. 15 scalpel or scissors around the lipoma. Care must be
taken to avoid nerves or blood vessels that may lie just beneath the tumor.
FIGURE 3.
The skin inside the incision grasped with a hemostat to provide traction. The lipoma is dissected
from the surrounding tissue using scissors or a scalpel.
Once a portion of lipoma has been dissected from the surrounding tissue, hemostats or clamps
can be attached to the tumor to provide traction for removal of the remainder of the growth. Once
it is freed, the lipoma is delivered as a whole (Figure 4). The surrounding tissue in the hole can
be palpated to ensure complete removal of the tumor. Table 2 lists possible complications of
excision.
FIGURE 4.
Once freed, the lipoma is delivered as a whole, and hemostasis is achieved.
TABLE 2
Complications of Lipoma Excision
Surgical infection/cellulitis/fasciitis
Ecchymosis
Hematoma formation
Injury to nearby nerves with permanent paresthesia/anesthesia
Injury to nearby vessels/vascular compromise
Permanent deformity secondary to removal of a large lesion
Excessive scarring with cosmetic deformity or contracture
Muscle injury/irritation
Fat embolus
Periostitis/osteomyelitis
Seroma
Adequate hemostasis is achieved following the removal of the lipoma using hemostats or suture
ligation. The dead space is closed beneath the skin using buried, interrupted 3-0 or 4-0 Vicryl
sutures (Figure 5). Occasionally drains may have to be placed to prevent fluid accumulation, but
this should be avoided if possible. The skin is then closed with interrupted 4-0 or 5-0 nylon
sutures. A pressure dressing is placed to reduce the incidence of hematoma formation. The
patient is given routine wound care instructions, and the wound is checked in two to seven days.
The sutures are removed after seven to 21 days, depending on the body location. Specimens
should be submitted for histologic analysis.
