Minimally invasive removal procedure

http://www.aafp.org/afp/20021015/letters.html

Techniques and Tips for Lipoma Excision

TO THE EDITOR: I would like to compliment Dr. Salam on his lucid article, "Lipoma Excision."1 I would add a few minor facts and modifications in surgical techniques that I have found useful.

Before excising a lipoma, it is important to delineate the plane of the tumor (subcutaneous, subfascial). Once that is defined, it is useful to incise through all the overlying tissues right to the pseudocapsule before attempting to dissect the tumor from the surrounding tissues. Also, as in other soft tissue tumors, I have found it easier to get to one edge of the swelling, free the base from the deeper tissues, and then tilt the tumor out of the wound. This minimizes dissection and trauma, hematoma formation, and surgical time.

Lipomas at the nape of the neck are better left alone, unless they are a significant problem. In general, lipomas of the neck and back are more poorly defined than in other areas and there is no clear delineation between the subcutaneous fat and the tumor.

I prefer not to excise the overlying skin initially as Dr. Salam has indicated; rather, I would save this step until redundancy is demonstrated at the end of the procedure. By tucking one edge of the skin over the other, the exact extent of excess skin can be defined and excised.

I would also like to mention a few techniques that may be advantageous. One is the "squeeze technique," in which a small incision is made over the tumor, which is literally squeezed out through the incision.2 Fat, being fluid at body temperature, allows itself to be manipulated in this fashion. If multiple tumors need to be excised in one sitting, this is a useful technique to master. The other is the "pot-lid" technique, which is useful in cosmetically challenging areas such as the face.3 Using a punch to remove a circular piece of skin overlying the tumor, the lipoma is extruded through the hole. The piece of skin is then positioned over the defect and acts as a graft and minimizes scarring. Pereira and Schonauer4 suggest passing a gynecologic forceps through an incision placed in an aesthetically advantageous site to remove these fatty tumors to minimize unsightly scarring.

Dumbbell extensions (one tumor connected to another in a deeper plane through a defect in the deep fascia) are not uncommon in lipomas and should be actively sought to avoid incomplete excision and "recurrence."

KALYANAKRISHNAN RAMAKRISHNAN, M.D.
Family Medicine Clinic
900 NE 10th St.
Oklahoma City, OK 73104