Injection lipolysis in subcutaneous Lipoma- Tips and tricks

A lipoma is a benign tumor composed of adipose tissue (body fat). It is the most common benign form of soft tissue tumor. Lipomas are soft to the touch, usually movable, and are generally painless. The patient presents to physician for removal of lipoma for cosmetic reasons.

Surgical excision and Liposuction are two most common methods of treatment of lipomas in accessible areas. Surgical excision though preferred leaves a scar and undesirable results like hypertrophic scar and keloid may rarely develop. Liposuction though reduces scar the fact that it is a surgical procedure can deter patient who are anxious about surgery or surgically unfit.

With popularity of non invasive methods for all cosmetic procedures. Injection lipolysis is has gained popularity as a treatment for localized fat deposits in body. The need of hour is a non surgical treatment modality for the most common soft tissue tumor  “Lipoma”.

 

Injection Lipolysis

New methods under development are supposed to remove the lipomas without scarring. One is removal by injecting compounds that trigger lipolysis, such as steroids or phosphatidylcholine.Phosphatidylcholine has been used since very long time inmanagement of fat embolism and end stage liver diseases. The clinical safety of phosphatidylcholine for lipolysis has been established in various studies.

Phosphatidyl  choline  (PDC)  is  a  cell  membrane component  that  is  prepared  as  a  solubilized,  injectable formulation given with deoxycholate (DC), a bile acid.Prior to  its  experimental  use  in  treating  lipomas,  PDC/DC preparations had been used for cosmetic reductions of local fat deposits. Due to the similar composition between these fatty  tissues,  injection  therapy was experimentally applied to the management of lipomas.

PDC  injected  in  adipose  was  found  to  induce  the formation of liposomes from fat molecules contained within local  adipocytes, with DC  forming micelles. The micelles could subsequently be cleared from the body with the end effect of  localized fat reduction. It has also been proposed that PDC acts as both an emulsifier and as a stimulator of lipase.

Mechanism of action

When  injected  into  lipomas in vivo, PDC/DC causes fat necrosis. Histological evaluation of patients’ tissue at various points  in  time  after  receiving  injections  with  PDC/DC demonstrated  various  cellular  changes. Four  hours following injection into the lipoma, the adipocyte was found to decrease in size and alter its shape focally around injected areas.  Additionally,  the  tissue  demonstrated  supparative panniculitis,  which  progressed  to  a  predominantly neutrophilic inflammation over the course of 48 hours with an  ultimate  progression  toward  an  inflammation characterized  by  lymphocytes  and macrophages.  After  10 days  following  injection  into  the  lipoma,  lipophages  were found  to be present within  the  tissue. Thirty  and 60 days removed  from  the  injection,  the  tissue  was  devoid  of neutrophils, but still exhibited a  lymphocytic  inflammation with  large  lipophages.    Additionally,  the  lipoma  was observed to exhibit a broadened capsule, which reportedly improved the surgeons’ ability to resect the mass.

Besides PDC/DC, β2 adrenergic agonists combined with corticosteroids have been shown in a study to be efficacious at  reducing  the  size  of  lipomas. Isoproterenol,  a  non-selective  β  adrenergic  agonist  given  as  a  subcutaneous injection, was found to cause localized fat reduction without causing  systemic  toxicity,  likely  by  stimulating  lipolysis. Subsequent downregulation of  the β2 adrenergic receptor, however,  causes  decreased  lipid  breakdown  products, suggesting the β2 receptor’s more dominant role in this fat reduction. Corticosteroids,  in  addition  to  their  ability  to  directly induce  lipolysis, have  been  found  to  prevent  the downregulation of β2 adrenergic receptors by increasing the total quantity of receptors When  injected  into a  lipoma, subsequent  size  reduction  was  found  to  average  50 percent.Thus, while this therapy appears limited in its ability to prevent surgery, it can serve as a preoperative treatment to reduce the surgical incision size, especially due to  the  lack of  fibrosis  and  cellular  changes  caused by  this.

Side effects

There are more side effects when used for large area lipolysis and when maximum dose of 2500mg are exceeded. The most common complaint patients have is pain at injection site edema, diarrhea and  dizziness. When given superficially into dermis it may cause bruising  and rarely skin necrosis. In lipomas  bruising, erythema, edema, and pruritis at the treated sites are common.

 

Tips

1. Choose lipomas in subcutaneous plane and away from important structures like vessels, tendons and muscles. As Sodium deoxycholate has non specific cytolytic effect may damade underlying structures.
2. Prefer pure Phosphotidyl choline injections to PPC/DC combinations.
3. User lower concentrations of DC/PPC limit to 1% to avoid side effects.
4. Limit volume of injections to 1/3 the volume of lesion or ½ the largest diameter of lesion in cm.
5. When injecting multimple lipomas restrict total dose to 2500mg to avoid systemic side effects like dizziness, diarrhea hypotension etc.
6. Inject in center of lesion for small lipomas, for larger lipomas inject at every 1 cm distance about 1 ml or in a fan shape. Avoid injecting close to dermis as may cause bruising and rarely skin necrosis.
7. Combine xylocaine as per manufacturer instruction to reduce pain and also add steroid to reduce inflammation and fibrosis.
8. Inform patient about the normal course of mild burning sensation for 24hrs, erythema for upto 5 days, mild swelling and tenderness upto 2wks. And prescribe an analgesic.
9. Limit the number of injection sitting to 5 in non responders.
10. In case of lower limb lipoma prefer to excise the lesion as there are more chances of turning to liposarcoma.

 

 

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