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IDEAS AND INNOVATIONS

Minimally Invasive Approach to Familial Multiple Lipomatosis

Ronan, Stephen J. M.D.; Broderick, Timothy M.D.

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Plastic and Reconstructive Surgery: September 2000 - Volume 106 - Issue 4 - p 878-880
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Lipomas are the most common type of soft-tissue tumor, with an incidence of 2.1 per 1000 people. 1 These tumors can develop anywhere in the body. However, the development of familial multiple lipomatosis—a syndrome of multiple encapsulated lipomas—is rare, with an incidence of 0.002 percent in the general population. A patient with this disease is likely to be male (2:1), have family members with the disease, and present in the third decade of life. The discrete, mobile, encapsulated tumors are distributed over the arms, thighs, and trunk, with sparing of the head, neck, and shoulders. 2

A consideration for cosmesis has prompted several investigators to approach multiple lipomas in a less deforming manner. 3–6 We employed a minimally invasive technique to remove 35 abdominal wall lipomas in one patient and achieved a successful result. The only specialized piece of equipment used was a lighted breast retractor. All palpable lipomas were completely excised. Cosmesis and patient satisfaction were high.

Technique

A diagnosis of familial multiple lipomatosis was given to a patient based on patient and family history, physical examination, and previous excision with pathologic diagnosis. All palpable lipomas on the abdominal wall, thighs, and extremities were marked preoperatively (Fig. 1, left, and Fig. 2, left).

Fig. 1
Fig. 1:
Preoperative (left) and 6-month postoperative (right) frontal views of a male patient with multiple familial lipomatosis.
Fig. 2
Fig. 2:
Preoperative (left) and 6-month postoperative (right) oblique views of the patient in Figure 1.

Under general anesthesia, two small, 2- to 3-cm, vertical midline incisions were made in the subxiphoid and supraumbilical areas. With the aid of a lighted breast retractor, the abdominal wall was dissected with cautery in a suprafascial plane. To preserve blood supply, care was taken not to dissect uninvolved tissue. All palpable abdominal wall35 lipomas were resected from this approach using cautery and digital manipulation (Fig. 3). Two 10-mm Jackson-Pratt flat drains were placed in the abdominal wound through separate stab incisions. These drains were removed 6 days after surgery. Five thigh lipomas were resected from the right anterior thigh through one 3-cm incision. A single upper extremity lesion was removed using traditional excision. All excised specimens were sent for routine histopathologic diagnosis and confirmed as lipomas. Surgical time for the abdominal portion of the procedure was 2 hours and 15 minutes. Postoperatively, the patient required one aspiration for a left abdominal seroma, but otherwise healed uneventfully. His cosmetic result was believed to be excellent (Fig. 1, right, and Fig. 2, right).

Fig. 3
Fig. 3:
Lipomas excised from the patient in Figure 1.

Discussion

Although lipomas are painless and pathologically benign, discomfort and disfigurement encourage patients to seek their removal. The traditional surgical method of removing each or a few lipomas through an incision can lead to countless incisions and significant disfigurement.

A consideration for cosmesis has prompted several investigators to approach lipomas in a less invasive way. Liposuction has been advocated as a way to treat lipomas without causing unsightly scars. 3,7 However, the use of liposuction has some major drawbacks. First, the surgeon is unable to visualize the tumor during excision. Second, the mass is fragmented before a benign pathologic diagnosis has been made. And third, fragmentation of the mass theoretically makes its complete removal impossible and may seed the cannula tracks with tumor.

The addition of an endoscope to liposuction does not negate the effect of lipoma fragmentation. 4 Endoscopy with an ultrasonic scalpel also has drawbacks of fragmentation and/or emulsification. 6 In addition, the use of an ultrasonic scalpel and/or endoscopy adds considerable cost to the procedure.

We employed the minimally invasive technique described herein to excise 35 abdominal wall lipomas from one patient; in doing so, we attempted to obtain the best cosmetic result possible, with complete tumor excision performed in a cost-effective manner. Our surgical approach allowed a complete excision of all the palpable lipomas under direct vision. The specimens were not fragmented or emulsified. The technique proved cost-effective because it could be performed on an outpatient basis with minimal specialized equipment necessary (i.e., a lighted retractor). The total operative time for the abdominal portion of the procedure was 2 hours and 15 minutes. Excision of the first 10 lipomas took twice as much time as the rest, suggesting that with additional experience the operative time will decrease further.

In our experience with this minimally invasive technique of multiple abdominal wall lipoma excision, its use resolved many of the stated problems of direct excision, liposuction, endoscopic, and ultrasonic scalpel-assisted procedures.

Summary

Thirty-five abdominal wall lipomas were removed from a patient with familial multiple lipomatosis using a minimally invasive approach in a cost-effective, reliable, and cosmetically pleasing manner. The surgical technique used is described in this case report. Clinical findings and prior excisions provided the preoperative diagnosis. The abdominal wall was dissected through two small, vertical midline incisions in the suprafascial plane with the aid of a lighted breast retractor. A complete excision of all palpable lipomas was achieved with this approach. The patient had excellent cosmetic results with minimal postoperative scarring.

REFERENCES

1. Roth, D., Widelec, J., Ramon, F., and Bellemans, M. Adipose tumors of soft tissues. J. Belge Radiol. 75: 321, 1992.
2. Leffell, D. J., and Braverman, I. M. Familial multiple lipomatosis. J. Am. Acad. Dermatol. 15: 275, 1986.
3. Carlin, M. C., and Ratz, J. L. Multiple symmetric lipomatosis: Treatment with liposuction. J. Am. Acad. Dermatol. 18: 359, 1988.
4. Hallock, G. G. Endoscope-assisted suction extraction of lipomas. Ann. Plast. Surg. 34: 32, 1995.
5. Sakai, Y., Okazaki, M., Kobayashi, S., and Ohmori, K. Endoscopic excision of large capsulated lipomas. Br. J. Plast. Surg. 49: 228, 1996.
6. Sawaizumi, M., Maruyama, Y., Onishi, K., et al. Endoscopic extraction of lipomas using an ultrasonic suction scalpel. Ann. Plast. Surg. 36: 124, 1996.
7. Hallock, G. G. Suction extraction of lipomas. Ann. Plast. Surg. 18: 517, 1987.
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