466 Journal of Maxillofacial & Oral Surgery 2008 Vol. 7 : No.

Case Reports - Cysts & Tumours

Lipoma in the
Suhas Godhi1, Sonia Goyal 2, Manish
Pandit3

1
Professor

Submandibular Region: A
2
Associate Professor
3
PG student

Case Report
Department of Oral and Maxillofacial
Surgery, I.T.S Centre for Dental Studies
and Research

Address for Correspondence:

Suhas Godhi, Sonia Goyal, Manish Pandit Suhas Godhi

Department of Oral & Maxillofacial
Abstract: Lipomas in the submandibular region are relatively rare. This case Surgery
report presents a case of lipoma in submandibular region in a 35 year old Indian I.T.S Centre for Dental Studies &
male. Lipomas and its variants are common soft tissue tumors but are not Research, Muradnagar
commonly are in the oral and maxillofacial region. Lipoma of the oral and Delhi-Meerut Road
maxillofacial region occurs most commonly in the parotid region, followed closely Ghaziabad – 201 206, Uttar Pradesh
Ph: 09899450488
by buccal mucosa. It is composed of adult fat cells that are subdivided into lobule
E-mail: drgodhi@yahoo.com
by septae of fibrous connective tissue. Surgical excision is the treatment of choice
with recurrence not expected. Received for publication August 2008
Accepted after peer review December 2008
Keywords: Lipoma and submandibular. Available online Dec. 2008 at www.jmosi.com

Introduction
Lipoma is a common, slow growing,
benign, encapsulated tumor of fatty tissue
that is rare in the oral cavity. It was first
reported in 1887 by Grosch.1 Lipomas are
the most common soft tissue mesenchymal
neoplasms, with 15 to 20% of the cases
involving the head and neck region and 1%
to 4% affecting the oral cavity. 2
Geschickter3 found only three oral tumors
in a series of 440 lipomas.
The lipoma represents 0.1% to 5% of
all benign tumors of the mouth. They are
usually found as long standing soft nodular
asymptomatic swellings covered by normal
mucosa. Oral lipomas affect predominantly
the buccal mucosa, floor of mouth, tongue
and lips.4
Histologically, they can be classified
as simple lipomas or its variants such as
fibrolipomas, Spindle Cell Lipomas
(SCL), intramuscular lipomas,
angiolipomas, salivary gland lipomas,
plemorphic lipomas, myxoid lipomas and
atypical lipomas. Angiolipomas and
infiltrating lipomas are rarely found in the
oral cavity. 4
According to Furlong et al lipoma of
the oral and maxillofacial region occur most
commonly in adult male in the parotid
region, followed closely by buccal mucosa.
This entity is rare in children.5
Case report
A 35 year old male patient presented
with a painless,gradually increasing, well
defined, oval shaped extraoral swelling
measuring, approximately 6x4 cm in left
submandibular region with 13 years
duration. On palpation, a soft rubbery mass
could be felt and slipping sign was present.
The transillumination test was negative.
Medical history was noncontributory. The
ultrasonograph revealed an elliptical mass
in right submandibular region that was
hyper-echoic relative to the adjacent
muscle. Based upon the classical sign of
slipping edge and ultrasonography the
diagnosis of lipoma was made. The patient
was admitted for excision of the mass under
general anesthesia. Routine preoperative
investigations were within normal limits.
A submandibular incision was made,
and a yellowish, soft encapsulated mass was
removed by blunt dissection. The mass
shelled out easily with no adhesion to
adjacent structures. Postoperative recovery
was uneventful. The patient was under
followup for 22 months and showed no
recurrence.
Histological investigation showed the
lesion to be macroscopically solid and
consisting entirely of microscopically
encapsulated fatty tissue with areas of
fibrosis. The adipocytes are loosely
arranged in large areas which show
presence of empty cytoplasm and small
nuclei.
Discussion
Lipoma presents clinically as a sessile
or pedunculated mass which is slow
growing, freely mobile, and may or may
not have a yellow hue, depending on depth
of localization and degree of fibrosis.6
De Visscher et al studied the clinical
and histological characteristics of lipomas
and fibrolipomas of the oral cavity. The
male-female ratio for lipomas was 1.5:1,
and for fibrolipomas 1:1.3. In most cases
the only symptom was a painless, palpable
tumour. The cheek was the most favoured
site, followed by the tongue, floor of mouth
and buccal sulcus and vestibule equally, lip,
palate, gingiva and retromolar area. 7
The benign fatty tumor, the lipoma, is
composed of adult fat cells that are
Journal of Maxillofacial & Oral Surgery 2008 Vol. 7 : No. 4
Fig. 1: Preoperative frontal view of the patient
photograph
Fig. 4: Specimen
subdivided into lobules by septae of fibrous
connective tissue. It appears frequently in
the subcutis of adults and is histologically
indistinguishable from normal adipose
tissue. The metabolism of lipoma differs
from that of normal adipose tissue. 8
Various variants of lipoma such as
chondrolipoma9, osteolipoma10, infiltrating
lipoma 11 and spindle cell lipoma12-15 are
reported in the literature. Lipomas in the
submandibular region are relatively rare.
Masaaki et al reported a case of lipoma in
submandibular region in 67 year old male.16
Dattilo et al also reported lipomas in
submandibular space. 17
Sialolipoma is a new variant of salivary
gland lipoma first described in 2001. Ramer
et al presented 2 cases of sialolipoma
involving the soft palate and buccal mucosa
of 2 female patients.18
Spindle cell lipoma is a distinct
histological variant of lipoma. Clinically,
it appears as a solitary, subcutaneous,
circumscribed lesion. Spindle cell lipoma
accounts for about 1.5% of all adipocytic
tumours. Very few cases of intraoral SCL
were found to be reported in literature. 13
According to Piattelli et al Spindle cell
lipoma is a benign tumour composed by:
(1) mature fat cells; (2) spindle cells; (3) a
myxoid matrix separated by thick bands of
birefringent collagen. Agoff et al reported
the first case of intramuscular Spindle-cell
Fig. 2: Exposure of the lesion
Fig. 5: Lipoma Photomicrograph
lipoma of the oral cavity. Oral SCLs are
rare, and only four cases of intramuscular
SCL exist in the literature. 14
According to Billings et al; Spindle
cell lipoma is typically seen in the neck/
trunk region of middle aged and older
men. Billings et al also described the
largest series of oral spindle cell lipoma
involving the tongue, buccal mucosa, floor
of mouth, and lip. The patients (3M; 4F)
ranged from 31 to 88 years of age.
Immunohistochemical stains for CD34
highlighted the bland spindle cells in all
cases. Spindle cell lipoma should be
considered in the differential diagnosis of
oral cavity mesenchymal tumors.15
Oliveros et al reported a case of a big
oral fibrolipoma in a 72 year old woman.
After surgery, a mass of 13 x 8 x 6 cm was
obtained. The tumor had an implantation
pedicle of 1 cm on the floor of the mouth.
The microscopic evaluation showed the
presence of polygonal cells grouped into
nests and separated by fibrous connective
tissue septa. 19
Lipomatous lesions of the parotid gland
are rare. Lipomatous lesions accounted for
only 1.3% of parotid tumors and occurred
more frequently in males, at a ratio of 3:1.
The most common presentation was that of
a slowly enlarging, painless mass.20
Kindblom et al reported 21 cases of
atypical lipoma. The tumors were mainly
467
Fig. 3: Excision of lesion
composed of univacuolated fat cells
without cellular or nuclear atypia, but also
showed univacuolated fat cells with
enlarged, moderately polymorphic, dark
nuclei. In two of the tumors a few
multivacuolated fat cells with scalloped
nuclei were found. Small multinucleated
cells with overlapping, peripherally
arranged nuclei, reminiscent of so called
floret-like cells as in pleomorphic lipoma,
could occasionally be seen. Areas of
generally delicate linear or patchy fibrosis
with atypical nuclei were a common
finding. 21
To facilitate the diagnosis of a lipoma,
specific imaging such as ultrasound or
Magnetic Resonance Imaging (MRI) is
needed. According to Ahuja et al the
characteristic sonographic appearance of
head and neck lipomas is that of an elliptical
mass parallel to the skin surface that is
hyperechoic relative to adjacent muscle.22,23
CT scan shows a density from 83-143
Hamsfield units with well or bad defined
margins depending on capsule. With MRI,
it is possible to confirm the diagnosis by
visualization of fat equivalent intensity
values.24
Solitary lipomas and familial multiple
lipomatosis are very well encapsulated.
They are very slow growing and have the
potential for recurrence if incompletely
excised and a very remote chance for
malignant changes. These can be freed from
surrounding tissue without difficulty, but
because of the fibrous nature of the capsule,
its violation is more likely to occur with
the suction technique. This may result in
an inadequate resection, possibly leading
to recurrence. Al-basti and El-Khatib
reported the treatment of moderate (>4-10
cm) and large (>10 cm) lipomas with
liposuction-assisted surgical extraction of
the capsule via the same wound (1 cm in
length).25 This capsule extraction was aimed
at avoiding recurrence and evaluating the
468
histopathological nature of these swellings.
There has been no recorded recurrence in
six years postoperative followup.
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