PracticalDermatology

Background

Lipomas are common benign soft tissue tumors of mature adipocytes occurring in 1% of the population.1 While lipomas are benign in nature, individuals frequently request removal when a lipoma is bothersome or cosmetically disfiguring. The first-line treatment is usually surgical removal which has proven to be highly effective but will result in scarring. The risk of scarring may make a patient hesitant or unwilling to elect for surgical removal of lipoma in a cosmetically sensitive area. In 2015, intralesional deoxycholic acid was approved for lipolysis in the submental region. Few studies have been published regarding the off-label use of deoxycholic acid in the reduction of the size of large lipomas prior to surgical removal. While this is a promising advance in the treatment of lipomas, there is still potential for scarring during surgical removal. Other additional non-invasive treatment options that have been used for lipoma removal include liposuction and high-intensity focused ultrasound.

Bipolar radiofrequency microneedling has been of growing interest and is approved for the treatment of body cellulite and facial rhytides. Radiofrequency microneedling uses a temperature-controlled microneedling device which induces intradermal thermal damage resulting in deposition of collagen, elastin, and increased hyaluronic acid, while also leading to subcutaneous fat coagulation. The use of a bipolar electrode allows for more localized energy delivery to the tissue when compared to monopolar devices. The application of heat and microneedling alters fat density by upregulating local adipocyte metabolism, stimulating lipase-mediated degradation of triglycerides and adipocyte apoptosis, and increasing capillary blood flow to the area. Advantages include a controlled needle depth and the ability to target the dermis and subcutaneous fat without inducing epidermal damage. To our knowledge, the use of bipolar radiofrequency microneedling has not been published for the treatment of facial lipoma. A single case study of monopolar microneedling in the treatment of a facial lipoma was published in 2019.

Case Presentation

We report a case of a facial lipoma treated with a bipolar radiofrequency microneedling device. A 54-year-old Caucasian female presented for consultation regarding the treatment of a lipoma on the left medial lower forehead. She had been evaluated previously by a dermatologist outside of our practice who performed an ultrasound which confirmed the diagnosis of lipoma. The patient was offered surgical removal but declined due to risk of scarring on her face. The patient presented to our office for consultation regarding alternative treatment options. Non-surgical treatment options were discussed with the patient including deoxycholic acid injections or bipolar radiofrequency microneedling procedure. The possibility of deoxycholic acid injection requiring multiple treatments and concern for damage to the supraorbital nerve was discussed. Alternatively, it was explained that bipolar radiofrequency microneedling treatment has proven successful in the reduction of submental fat and cellulite. While treatment of lipoma is an off-label use for this device, this treatment modality reduces and remodels subcutaneous fat which may be applicable in the treatment of a lipoma. After discussion, the patient opted to proceed with radiofrequency microneedling.

Methods

Anesthesia was performed locally with 1% lidocaine with 1:100,000 epinephrine. A bipolar radiofrequency microneedling device was used. This device has two treatment handpieces: a dermal handpiece and a subcutaneous handpiece. The dermal handpiece extends to a depth of 1.5mm to provide optimal volume restoration and stimulation of collagen, elastin, and hyaluronic acid. The subcutaneous handpiece extends to a depth of 2.9-5.8mm which provides optimal subcutaneous fat reduction and remodeling. The goal of the procedure was to reduce lipoma size therefore a subcutaneous handpiece was used at a depth of 4mm. The microneedle tip was set at the controlled temperature setting of 67° Celsius. Within the diameter of the palpable lesion, a total of 34 microneedle insertions were performed at a rate of 1 every 0.4 seconds, each spaced 0.2mm apart.

Results

Figure 1 demonstrates the presentation of the patient before treatment. There was a visible and palpable subcutaneous nodule on the left medial lower forehead. The patient was reevaluated after 1 month of treatment, as demonstrated in Figure 2. There was a subjective decrease in lipoma size of 70%. No evidence of scarring or post-inflammatory pigmentary alteration was seen. Motor nerve function remained intact. She reported initial “tingling” sensation over the lesion, but this is resolving with time. The only other adverse effect reported was mild bruising, which resolved over a few days.

Figure 1. Images before treatment demonstrating a visible and palpable subcutaneous nodule on the left medial inferior forehead.

Figure 2. Re-evaluation of the patient 1 month after a single treatment with bipolar radiofrequency microneedling.

Summary

Bipolar radiofrequency microneedling is a temperature-controlled procedure that generates dermal skin tightening and subcutaneous fat reduction and remodeling through a non-surgical approach. This treatment method has been demonstrated to be safe in the treatment of pigmented individuals. Additionally, there have been no reports of interruption of lymphatic flow or vascular perfusion. This case demonstrates the successful use of this novel device as a non-surgical treatment for lipoma. Current treatments for lipoma involve invasive procedures with the risk of scarring. Bipolar radiofrequency microneedling provides a non-invasive and non-scarring option for the treatment of lipoma in cosmetically sensitive locations.

Dr. Clara Barranco is a PGYIII Dermatology Resident at the Orange Park Hospital/HCA Florida residency program.

Contents of this paper were presented in part at the Cosmetic Surgery Forum (Cosmetic SurgeryForum.com) in Nashville, in December 2022. This presentation was recognized as a top resident presentation at CSF 2022.

1. Charifa A, Azmat CE, Badri T. Lipoma Pathology. StatPearls. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Accessed November 14, 2023. PMID: 29493968

For Further Reading

Dubin et al. Intralesional deoxycholic acid as neoadjuvant treatment of a large lipoma. J Am Academ Dermatol. 2019;81(4):AB84.

Santiago-Vázquez M, Michelen-Gómez EA, Carrasquillo-Bonilla D, Carrasquillo OY, Cruz A. Intralesional deoxycholic acid: A potential therapeutic alternative for the treatment of lipomas arising in the face. JAAD Case Rep. 2021;13:112-114. Published 2021 May 26. doi:10.1016/j.jdcr.2021.04.037

Dayan et al. Adjustable depth fractional radiofrequency combined with bipolar radiofrequency: A minimally invasive combination treatment for skin laxity. Aesth Surg J. 2019 Apr; 39(Suppl 3): S112–S119.

Hong et al. Noninvasive size reduction of lipoma with an insulated monopolar radiofrequency microneedle device. Dermatol Ther. 2018;e12608.

Levy AS, Grant RT, Rothaus KO. Radiofrequency physics for minimally invasive aesthetic surgery. Clin Plast Surg. 2016;43(3):551-556. doi:10.1016/j.cps.2016.03.013

Dayan E, Theodorou S, Rohrich R, Jay Burns A. Aesthetic applications of radiofrequency: Lymphatic and perfusion assessment. Plastic and Reconstructive Surgery - Global Open. 2020;8 (10):e3193. doi: 10.1097/GOX.0000000000003193.