Double Recurrence of Lipoma Following Liposuction: Highlighting the Potential for Cannular Seeding

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A 24-year-old healthy woman presented with a recurrent lipomatous mass on her upper back following 2 prior attempts at liposuction excision by an outside plastic surgeon. The patient reported that the current recurrence was larger than the previous one, and she now desired definitive surgical management. Magnetic resonance imaging (MRI) was obtained following initial evaluation and demonstrated a subcutaneous lipoma measuring 8.9 x 10.7 cm, located at the mid-thoracic level just right of the paraspinal region (Figure 1). The patient was taken to the operating room for wide local excision. Following excision, the wound cavity was palpated to ensure complete removal. Palpation revealed an additional segment of lipomatous tissue branching from the primary tumor. The tissue was excised and the cavity was once again palpated, which revealed another similar branch of lipomatous tissue. This sequence was repeated multiple times, ultimately revealing 5 additional discrete areas of mature adipose tissue with surrounding fibrosis adjacent to the primary mass, suggestive of peripheral seeding from prior liposuction attempts (Figure 2). Because these branches were adjoining and congruent, they were not distinguishable on preoperative MRI and, thus, the lipomas were interpreted as a single mass. All involved areas were submitted for histopathologic analysis. Final pathology confirmed mature adipose tissue without atypia and negative MDM2 staining by immunohistochemistry, consistent with a benign lipoma. Importantly, there has been no evidence of recurrence at 12 months postoperative (Figure 3).

Figure 1. Preoperative photograph of the lipomatous mass located in the patient's right upper parathoracic region prior to wide local excision.

Figure 2. Intraoperative photograph of the multiple discrete lipomatous specimens immediately following excision and prior to submission for histopathologic evaluation.

Figure 3. Longitudinal clinical photograph at the 12-month postoperative follow-up demonstrated no clinical evidence of recurrence.

This case presentation uniquely illustrates a rare presentation of iatrogenic lipoma recurrence likely due to peripheral seeding from prior liposuction, prompting critical reevaluation of surgical technique, recurrence patterns, and diagnostic vigilance in distinguishing benign from malignant soft tissue tumors.

Lipomas are the most common benign soft tissue mesenchymal neoplasms of the human body, with a prevalence of 2.1 per 1000 people.^1,2 They occur most frequently on the arm, shoulder, back, legs, forehead, and face.³ Most lipomas range from 1 to 10 cm, with lipomas greater than 10 cm classified as giant lipomas.⁴ The presence of multiple lipomas may be indicative of a variety of syndromes.⁴

Lipomas are generally painless, subcutaneous, well-circumscribed, mobile, soft, solitary, and slow-growing masses with the absence of epidermal change.^1,4 Histologically, lipomas are composed of mature, normal-appearing adipocytes with small eccentric nucleus—thus indistinguishable from adipocytes in the subcutaneous tissue.⁴ Histology is important in distinguishing a benign lipoma from liposarcomas, which are a malignant lipomatous neoplasm. The absence of vacuoles in irregularly shaped hyperchromatic nuclei and an increased cell size can be helpful in the differentiation between lipomas and liposarcomas.⁵ A differential diagnosis for a subcutaneous mass on a trunk can commonly include—but is not limited to—epidermoid cysts, hibernomas, angiolipomas, angiomyolipomas, and liposarcomas.^1,4 Epidermoid cysts frequently display a central punctum on the surface and are attached or fixed to the overlying skin.⁴ Hibernomas are rare, benign tumors composed of brown adipose tissue, most often located in the mediastinum or the interscapular region of the back, and generally present in adults as slow-growing masses measuring between 3 and 12 centimeters.⁴ Angiolipomas are characteristically painful, well-defined lesions typically less than 2 centimeters in diameter, and are most commonly found on the forearms of adolescents or young adults.⁴ Angiomyolipomas tend to arise in acral sites and are more frequently seen in adult males.⁴ Liposarcomas usually manifest as deep-seated tumors with a predilection for the retroperitoneum or, classically, the thigh.

A variety of techniques exist for lipoma removal, including injection lipolysis, liposuction, and open surgical excision. Patients commonly seek treatment because of aesthetic concerns, discomfort, compressive symptoms, or oncologic anxiety.⁶ Liposuction for lipoma removal was first popularized by Rubinstein et al in 1985 as a less invasive alternative associated with fewer complications.⁷ Early proponents of liposuction emphasized its cosmetic advantages, such as reduced scarring, decreased intraoperative bleeding, contouring capability, shorter operative times, cost-effectiveness, and the ability to address multiple lesions through fewer incisions.^8,9 However, its efficacy was initially met with skepticism by some.¹⁰ The decision to pursue liposuction vs open excision is largely guided by shared decision-making between the patient and surgeon. Liposuction is typically favored for well-circumscribed, suprafascial lesions—either solitary or multiple—that are moderate to large in size with a confirmed benign diagnosis.⁶ Given the inability to obtain a specimen with intact margins, preoperative evaluation to exclude malignancy is paramount. At minimum, fine needle aspiration and ultrasound imaging have been recommended to ensure diagnostic certainty prior to proceeding with liposuction.¹¹

Conventional open excision is often regarded as the gold standard for lipoma removal, as it allows for complete en bloc resection and histopathologic evaluation.¹² The surgical approach varies depending on the size and location of the lesion. For small, superficial lipomas, techniques such as punch excision, linear incision, or elliptical excision are commonly employed.^13-16 In contrast, larger lipomas may necessitate more advanced planning to optimize exposure while minimizing incision length and visible scarring. Reported approaches for larger lesions include extended linear incisions, large elliptical excisions, Z-plasty techniques, and one-third incisions, each tailored to achieve adequate exposure and aesthetic outcomes.^12,16-18

As with any surgical intervention, lipoma management carries the risk of complications, which vary depending on the chosen technique. Critics of liposuction argue that the approach limits direct visualization, fragments the specimen—complicating histopathologic evaluation—and may leave behind residual lipomatous or capsular tissue, increasing the risk of recurrence.^19-21 In addition to common postoperative issues such as seroma and hematoma formation, delayed complications including contour irregularities and cutaneous depressions have also been reported.⁶ Notably, similar complications can occur following open excision, including seroma, hematoma, nerve injury, and residual mass due to incomplete resection.^17,18

Histologically, well-differentiated liposarcoma (WDLS) is characterized by mature adipocytes interspersed with varying numbers of hyperchromatic, spindle-shaped cells and multivacuolated lipoblasts.²² Immunohistochemical analysis often reveals CDK4 positivity, present in approximately 62% of cases.²² Despite concerns about malignant transformation, true recurrence of a benign lipoma as a liposarcoma is exceedingly rare, with only isolated case reports documented in the literature.^23,24 Notably, both reported cases of recurrent WDLS shared certain risk factors, including large (≥5 cm) or giant lipomas and atypical tumor locations.²³ These findings underscore the importance of thorough preoperative assessment. Sonographic features such as deep location, septations, irregular borders, hyperechogenicity, vascularity, and large size should prompt further evaluation.²⁵ In such cases, MRI is the gold standard for advanced imaging.²³ Additionally, recent studies suggest that the combination of p16 immunohistochemistry with MDM2 fluorescence in situ hybridization staining enhances diagnostic accuracy in distinguishing WDLS from deep-seated benign lipomas.²⁶

The recurrence rate following open lipectomy has been reported to be approximately 2%.²⁷ Unfortunately, recurrence rates following liposuction alone are infrequently cited in the literature. When outcomes are reported, liposuction is often performed in conjunction with surgical excision, which limits applicability to cases managed with liposuction as a standalone technique. One study from 1992 noted an “unacceptably high recurrence rate” following isolated liposuction.¹⁰ Proposed reasons for recurrence after liposuction include limited visualization, incomplete removal of lipomatous or capsular tissue, deep-seated or giant lipomas, septated architecture, tissue fragmentation with possible seeding, and failure to excise the capsule—each of which may predispose to residual disease and recurrence.^6,28,29 It is important to note that tissue fragmentation with potential seeding has been identified as a risk factor for recurrence.²⁹ Additionally, the fragmentation inherent to liposuction may compromise the integrity of the specimen, limiting the ability to perform accurate histopathologic evaluation—particularly in cases where there is clinical concern for malignancy.⁶

In conclusion, we present the unique case of a 24-year-old woman with a recurrent truncal lipoma following 2 unsuccessful attempts at removal via liposuction alone. Definitive management was ultimately achieved through wide local excision, with no evidence of recurrence at 12 months postoperative. This case is notable given the paucity of literature reporting recurrence rates following liposuction alone and, to our knowledge, there are no previously documented cases of multiple recurrences after isolated liposuction. Intraoperatively, 5 discrete lipomatous masses were identified, highlighting a potential complication of liposuction—namely, tissue fragmentation with possible seeding—an outcome that has been theorized but rarely demonstrated in the literature. These findings suggest that the recurrence pattern in this patient may have resulted from iatrogenic dissemination. Additionally, this case underscores the importance of comprehensive preoperative evaluation, particularly when liposuction is considered. Inadequate oncologic control due to failure to excise the capsule, coupled with an inaccurate benign diagnosis, could theoretically permit malignant transformation or residual disease. Ultimately, this case emphasizes the need for careful selection of treatment modality and reinforces the real risk of recurrence when liposuction is used as the sole method of lipoma removal.