Can a lipoma be excised in an office visit?

Office-Based Lipoma Excision

Yes, most lipomas can be safely excised in an office setting using local anesthesia, but specific criteria must guide this decision. 1, 2

Appropriate Cases for Office Excision

Lipomas suitable for office removal include:

• Superficial lipomas <5 cm in diameter with typical clinical features (soft, mobile, painless masses) 2
• Slow-growing lesions without red flag features 2
• Lipomas in non-complex anatomical locations (avoiding retroorbital or deep-seated areas) 1, 3
• Lesions confirmed as benign by ultrasound showing hyperechoic appearance, well-circumscribed borders, and minimal internal vascularity 2

Mandatory Referral Criteria (NOT Office-Based)

Immediate referral to a sarcoma center or surgical oncologist is required for:

• Any lipoma >5 cm diameter - these are high-risk features requiring specialized management 1, 2
• Deep-seated masses (beneath muscle fascia) - higher suspicion for atypical lipomatous tumor 1, 2
• Retroperitoneal or intra-abdominal location - requires specialist sarcoma multidisciplinary team evaluation 2
• Rapid growth, pain, or firm consistency - red flags for potential malignancy 2
• Atypical MRI features including nodularity, thick septations, or concerning characteristics 2

The British Sarcoma Group emphasizes that deep or large lipomatous masses have high local recurrence rates if inadequately excised, and progressive dedifferentiation can occur with each recurrence. 2

Anesthetic Approach for Office Excision

Local infiltrative anesthesia is the standard approach:

• Lidocaine with epinephrine at maximum doses of 7 mg/kg is safe for standard infiltrative anesthesia 4
• Tumescent local anesthesia can be used for larger lipomas (up to 22 cm have been successfully removed in office settings) with lidocaine doses up to 55 mg/kg proven safe 4, 5
• Warm anesthetic solution and slow infiltration rate decrease patient discomfort during administration 4

Research demonstrates that large lipomas (10-22 cm) can be completely excised under tumescent local anesthesia in outpatient settings with excellent safety profiles, though this requires judicious patient selection. 5

Surgical Technique

Complete en-bloc excision with negative margins (R0) is the standard:

• Wide excision removing the tumor with a rim of normal tissue around it 4, 1
• The American College of Surgeons confirms that general surgeons with specific training in soft tissue tumor removal can perform standard lipoma excisions 1
• Plastic surgeons are preferred for cosmetically sensitive areas or when complex reconstruction is needed 1

Critical Pitfall to Avoid

Never excise a lipoma without proper imaging if ANY concerning features exist. MRI is mandatory when there is diagnostic uncertainty, as it can differentiate between benign lipomas and atypical lipomatous tumors in up to 69% of cases. 2 If suspicion of atypical lipomatous tumor exists, percutaneous core biopsy for MDM-2 amplification testing is mandatory before surgery, as this definitively distinguishes lipoma from atypical lipomatous tumor and fundamentally alters surgical planning. 2

Post-Excision Management

After successful office-based excision:

• Patients can be discharged to primary care after postoperative wound care 3
• Re-referral is only required if clinical suspicion of recurrence develops 3
• Recurrence rates are low with complete excision 1, 6