Abstract

---

Lipomas are adipose tumours which are one of the commonest and most benign of all tumors. They are composed of fat cells of adult type. Most favoured site of lipomas in the head and neck region is cheek followed by the tongue, floor of the mouth, buccal sulcus, vestibule, lip, palate and gingiva. Lipomas have been identified in all age groups but they usually appear between 40 and 60 years of age. Solitary lipomas are more common in women and multiple tumours (referred to as lipomatosis) are more common in men. A case of giant subcutaneous solitary lipoma, with a rapid growth rate in the neck region (greater than 4 cm) is presented in a 55 year old man. The excision produced excellent cosmetic results and no functional impairment.

Introduction

---

Lipomas are adipose tumours usually present subcutaneously. They are one of the most common mesenchymal and benign of all tumors. They are composed of fat cells of adult type .They can occur anywhere in the body where there is accumulation of fat cells, thus they are often called as a “universal tumor” or a “ubiquitous tumor”[1,2]. Cheek is the most favoured site in head and neck region followed by the tongue, floor of the mouth, buccal sulcus, vestibule, lip, palate and gingiva[3].Lipomas are classified as subcutaneous type, subfascial type or intermuscular type. Lipomas have been identified in all age groups but usually appear between 40 and 60 years of age [4].Solitary lipomas are more common in women and multiple tumours (referred to as lipomatosis) are more common in men.

Treatment   modalities for lipomas range from liposuction, steroid injection to surgical excisions [5]. We report a case of giant subcutaneous lipoma in the anterior neck region and present the clinical and histopathological findings along with the review of literature.

Case Report

---

A 55 year old male was referred with a chief complaint of swelling in the anterior region of the lower jaw since 4 years.  No treatment was undertaken as the growth was slow and painless. The swelling showed rapid growth since  last 5 months. There was no history of trauma to the area. Patient did not have any complaint of pain, dyspnea and dysphagia. There was no history of weight loss or fever. On clinical examination, the mass was 4 × 5 cm in size with smooth surface and diffuse margins. The mass was unattached to the overlying skin and the overlying skin was stretched without signs of inflammation or prominent veins. The mass was non tender, soft and movable.  The patient had no lymphadenopathy or any other palpable mass. Laboratory findings were within normal limits. On radiographic examination, panoramic image showed no bony changes in the symphyseal region and teeth in the area were vital and normal (illustration -1). Fine needle aspiration cytology was not productive. To facilitate the diagnosis of a lipoma, specific imaging such as ultrasound or magnetic resonance imaging (MRI) is needed but the  patient came from a poor and rural area and could not afford expensive diagnositic techniques.So, an OPG was taken to rule out any dental /oral pathology.

 Before the surgery, the incision was outlined with a marker on skin surface in submental region (illustration - 2).

A 4 mm incision was made over the lipoma. Blunt dissection with dissecting scissors was done subcutaneously to free the lipoma from the surrounding tissue. Once dissected free, lipoma was delivered as a whole (illustartion -3).

Primary closure was   done in   layers and pressure packing was given to prevent hematoma formation. Specimen was submitted for histopathological analysis (illustartion- 4).  Post operative recovery was uneventful.

Histopathological Examination

---

Histopathological examination of specimen showed lobules of mature fat cells, enclosed in a thin fibrous capsule( illustration 5) which was characterized by empty cytoplasm with an eccentrically placed nucleus(illustration 6). These lobules were separated by variable amount of connective tissue but no epithelium. There was presence of collagen fiber bundles and fibroblasts. The blood vessels also were seen which were dilated and engorged at a few places. Histopathologically the lesion was confirmed to be a lipoma.   

Review of literature

---

Adlair et al (1932) [6], Geschickter et al (1934) [7] and Bick (1936) [8] reviewed that lipomas were uncommon in children. They were usually smaller than 5 cm on the trunk, shoulder, upper arm and the hand. They were commonly reported in females.  Howard & Helwing (1960) [9] found greater frequency of multiple lipomas in females than males. Berendes (1974) [10] found an autosomal dominant mode of inheritance with low penetrance and suggested that this condition  should be considered as a specific entity unrelated to solitary lipoma. Dixon et al (1981) [11] reported proportions of angiolipomas in patients with multiple lipomas.  Chanlaouni et al (1981) [12] concluded that the lipomas were semi-liquid at room temperature, change in shape occur depending upon the external forces acting upon them. Berg (1983) [13] concluded that solitary lipomas of the lower arms were more frequent in young patients and males had more lipomas and located on the chest .some of these patients probably had or were developing multiple lipomas. The sex difference for lipomas location might be due to differences in the distribution of subcutaneous fat. Enzi G (1984) [14] reviewed that solitary lipomas were common in women; multiple tumors (referred to a lipomatosis) were more common in men. Field LM (1984) [15] and Rubenstein R (1985) [16] concluded that liposuction could be better for small or larger lipomatous growths, particularly those locations where large scars should be avoided. Som (1985) [17] concluded lipomas to be the most common neoplasm of mesenchymal origin. Only 13% of them arise from head and neck region, most them occur in the posterior neck. Rarely can they develop in anterior neck, infratemporal fossa and in or around the oral cavity, pharynx, larynx and parotid gland .Sharma P (1991) [18] showed that complete elimination of the lipoma was difficult with liposuction. Bataineh A (1991) [19] advocated excellent results of squeeze delivery of subcutaneous lipomas. Medina C (2007) [5] preferred surgical excision for removal of lipomas.

Discussion

---

Lipomas are usually hamartomatous proliferation of mature fat cells [20]. They are benign adipose tumours   of the mesenchymal origin [21]. Approximately 25% of lipomas and their variants arise in the head and neck region and most of these occur subcutaneously in the posterior neck [22]. Rarely can they develop subcutaneously in the anterior neck [23] whereas in this case it has developed in the anterior neck region. Sometimes lipomas are associated with syndromes like multiple lipomatosis[24](lipoma over extremities and trunk),Gardner’s syndrome(intestinal polyposis,cysts,osteomas),Dercum’s disease(multiple painful subcutaneous lipomas)[25],Madelung’s disease(lipomatosis of the neck,head,shoulders and proximal extremities)[26]. A peak incidence of lipoma formation is noted in 5^th and 6^th decade of life [27]. Lipomas   are most common in obese patient but we found it in an average built patient. Solitary lesions are most common in females (80%) and our patient is male. Cheek is the most favoured site in head and neck region followed by the tongue, floor of the mouth, buccal sulcus, vestibule, lip, palate and gingiva but we found it in anterior neck region.  Intraoperatively lipomas are soft, yellow, shiny, smooth, mobile encapsulated and occasionally lobulated subcutaneous masses. Clinical features vary greatly depending upon the lesion’s size, location and rate of growth. Most benign tumours present as a painless, mobile, palpable masses which are often overlooked by patients till they become an appreciable mass [28]. Histopathologicaly, lipomas show lobular growth of mature fat cells, enclosed in thin fibrous capsule, which are characterized by empty cytoplasm with an eccentrically placed nucleus [29]. If lipomas infiltrates into the surrounding muscles then it is termed as an infiltrating lipoma [30]. Lipomas usually do not show any familial occurrence. Conventional lipomas have characteristic chromosomal abnormalities. For example conventional lipomas often show chromosomal rearrangements of 12q14-15,6p and 13q9 [31].  Treatment modalities for lipomas can be divided into nonexcisional (steroidal therapy) and excisional therapy [27]. Complications after excision of a lipoma are hematoma formation, surgical infection/cellulitis/fasciitis, ecchymosis, and injury to nearby nerves with permanent paraesthesiae/anesthesia, injury to nearby vessels /vascular compromise, seroma, fat embolus and muscle injury irritation [4],but careful execution of surgery ,knowledge of regional anatomy ,subcutaneous locations are an aid to uneventful recovery.

Conclusion

---

Lipomas are the most commonly encountered benign mesenchymal tumors. There is a paucity of published analogous cases   in our literature, hence conclusively we propose to include lipomas in the differential diagnosis of swellings of the neck and for a clinician it is pertinent to know this entity which sometimes may be a diagnostic dilemma nevertheless simple to understand and manage.

References

---

1. Russell RCG, Williams N, Bulstrode CJK : Bailey & Love short practice of surgery,London : Arnold publishers 2004; 1151-1153.

2. Yaknbu A, Edino S, Mohammed A. Giant and complicated subcutaneous lipoma of the neck. WAJM 2008; 27:44-46.
3. Ayasaka N, Chino T, Anoth M. Infiltrating lipoma of the mental region: report of a case. British Journal of Oral and Maxillofacial Surgery1993; 31:388-390.
4. Salam G. Lipoma excision. Am Fam Physician 2002; 65:901-905.
5. Medina C, Schneider S. Giant submental lipoma: case report and review of literature. Can J Plast Surg 2007; 15:219-222.
6. Adair F E, Pack G T. & Farrior J H. Lipomas. Am. J. Cancer 1932; 16:1104-1120.
7. Geschickter C F.  Lipoid tumors. Am. J. Cancer 1934; 21:617-641.
8. Bick E.  Lipoma of the extremities. Ann. Surg 1936; 104:139-143.
9. Howard W R. & Helwing E B. Angiolipoma. Arch. Dermatol.1960; 82: 924-931.
10. Berendes O. Multiple tumours of the skin: clinical, histopathological and genetic features. Hum.Genet.1974; 22:181-210.
11. Dixon AY, McGregor D H. & Lee S H.  Angiolipomas: An ultrastructural and clinicopathological study. Hum Pathol 1981; 12: 739-747.
12. Chahlaoui J, Sylvestre J, Durdsault R G.  Inspirationexpiration films for mediastinal fatty tumours. Journal of the Canadian Association of Radiologists1981; 32:88-90.
13. Berg N O, Rydholm A, Akerman M. Size, site and clinical incidence of lipoma-factors in the differential diagnosis of lipoma and sarcoma . Acta Orthop Scand 1983; 54:929-934.
14. Enzi G. Multiple symmetric lipomatosis: an updated clinical report. Medicine 1984; 63:56-64.
15. Field LM. Lipo-suction surgery: A review. J Dermatol Surg Oncol 1984; 10:530-538.
16. Rubenstein R, Roenigk HH, Garden JM, Goldberg NS, Pinski JB. Liposuction for lipomas. J Dermatol Surg Oncol 1985; 11:1070-1074.
17. Som P M, Scherl M P, Rao V M. and Biller H F. Rare presentations of ordinary lipomas of the head and neck—a review. American Journal of Neuroradiology1986; 7: 657-664.
18. Sharma PK, Janninger CK, Schwartz RA, Rauscher GE, Lambert WC. The treatment of atypical lipoma with liposuction. J Dermatol Surg Oncol 1991; 17:332-334.
19. Bataineh AB, Mansour MJ, Abalkhail A.Oral infilterating lipomas. Br J Oral Maxillofac Surg 1996; 34:520-523.
20. Marx R, Stern D. Oral and maxillofacial pathology: A rationale for diagnosis and treatment, Quintessence Publishing Co,Inc 2003:404-405.
21. Greenberg M, Glick M. Burket’s Oral Medicine,Diagnosis & Treatment. Hamilton ,Ontario :BC Decker2003; 138-194.
22. Wu Wei C, Chi H. Case report giant lipoma arising from deep lobe of the parotid gland. World journal of Surgical Oncology2006; 4:28-32.
23. Ramakantan R, Shah P. Anterior neck lipoma masquerading as an external laryngocoele. J Laryngol Otol 1989; 103:1087-1088.
24. Kenawi MM. ‘Squeeze delivery’ excision of subcutaneous lipoma related to anatomic site. Br J Surg 1995; 82:1649-1650.
25. Brody HJ, Meltzer HD, Someren A. Spindle cell lipoma. An unusual dermatologic presentation. Arch Dermatol 1978; 114:1065-1066.
26. Austin R,Mack G . Infiltrating (intramuscular)lipoma and angiolipoma  -A clinicopathologic study of six cases. Arch Surg 1980; 115:281-284.
27. Truhan AP, Garden JM, Caro WA, Roenigk HH Jr. Facial and scalp lipomas: Case reports and study of prevalence. J Dermatol Surg Oncol 1985; 11:981-984.
28. Del Agua C, Felipo F. Adenolipoma of the skin. Dermatol Online J 2004; 10:9- 15.
29. Salvatore C,Antonio B,Lanza A. Giant infiltrating lipoma of the face:CT and MR imaging findings.Am J Neuroradiol 2003;24:283-286.
30. Altug H,Sahin S. Non infiltrating angiolipoma of the cheek:a case report and review of the literature. J Oral Sci 2009; 51:137-139.
31. Austin R,Mack G . Infiltrating (intramuscular) lipoma and angiolipoma  -A clinicopathologic study of six cases. Arch Surg 1980; 115:281-284.

Source(s) of Funding

---

none

Competing Interests

---

none

Disclaimer

---

This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.