BACKGROUND: Lipomas are common benign soft tissue neoplasms but they are found very rarely in the deep lobe of parotid gland. Surgical intervention in these tumors is challenging because of the proximity of the facial nerve, and thus knowledge of the anatomy and meticulous surgical technique are essential. CASE PRESENTATION: A 71-year-old female presented with a large asymptomatic mass, which had occupied the left facial area for over the past fifteen years, and she requested surgical excision for a cosmetically better facial appearance. The computed tomography (CT) scan showed a well-defined giant lipoma arising from the left deep parotid gland. The lipoma was successfully enucleated after full exposure and mobilization of the overlying facial nerve branches. The surgical specimen measured 9 × 6 cm in size, and histopathology revealed fibrolipoma. The patient experienced an uneventful recovery, with a satisfying facial contour and intact facial nerve function. CONCLUSION: Giant lipomas involving the deep parotid lobe are extremely rare. The high-resolution CT scan provides an accurate and cost-effective preoperative investigative method. Surgical management of deep lobe lipoma should be performed by experienced surgeons due to the need for meticulous dissection of the facial nerve branches. Superficial parotidectomy before deep lobe lipoma removal may be unnecessary in selected cases because preservation of the superficial lobe may contribute to a better aesthetic and functional result

Chan, Leong-Perng

Chi, Hung-Pin

Chiang, Feng-Yu

Hsu, Ying-Che

Kuo, Wen-Rei

Wu, Che-Wei

English

PubMed

Che-Wei Wu

Hung-Pin Chi

Feng-Yu Chiang

Ying-Che Hsu

Leong-Perng Chan

Wen-Rei Kuo

Springer - Publisher Connector

BioMed Central
World Journal of Surgical Oncology
ssOpen AcceCase report
Giant lipoma arising from deep lobe of the parotid gland
Che-Wei Wu1, Hung-Pin Chi1, Feng-Yu Chiang1,2, Ying-Che Hsu1, Leong-
Perng Chan1 and Wen-Rei Kuo*1,2
Address: 1Department of Otolaryngology – Head and Neck Surgery, Kaohsiung Medical University Hospital, Taiwan and 2Department of 
Otolaryngology – Head and Neck Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Taiwan
Email: Che-Wei Wu - smalljjdog@hotmail.com; Hung-Pin Chi - chenjjd@hotmail.com; Feng-Yu Chiang - d740009@cc.kmu.edu.tw; Ying-
Che Hsu - kart001.tw@yahoo.com.tw; Leong-Perng Chan - oleon24@yahoo.com.tw; Wen-Rei Kuo* - kmuent@yahoo.com.tw
* Corresponding author    
Abstract
Background: Lipomas are common benign soft tissue neoplasms but they are found very rarely
in the deep lobe of parotid gland. Surgical intervention in these tumors is challenging because of the
proximity of the facial nerve, and thus knowledge of the anatomy and meticulous surgical technique
are essential.
Case presentation: A 71-year-old female presented with a large asymptomatic mass, which had
occupied the left facial area for over the past fifteen years, and she requested surgical excision for
a cosmetically better facial appearance. The computed tomography (CT) scan showed a well-
defined giant lipoma arising from the left deep parotid gland. The lipoma was successfully
enucleated after full exposure and mobilization of the overlying facial nerve branches. The surgical
specimen measured 9 × 6 cm in size, and histopathology revealed fibrolipoma. The patient
experienced an uneventful recovery, with a satisfying facial contour and intact facial nerve function.
Conclusion: Giant lipomas involving the deep parotid lobe are extremely rare. The high-
resolution CT scan provides an accurate and cost-effective preoperative investigative method.
Surgical management of deep lobe lipoma should be performed by experienced surgeons due to
the need for meticulous dissection of the facial nerve branches. Superficial parotidectomy before
deep lobe lipoma removal may be unnecessary in selected cases because preservation of the
superficial lobe may contribute to a better aesthetic and functional result.
Background
Lipomas are the most commonly encountered benign
mesenchymal tumors, arising in any location where fat is
normally present. Their occurrence in the head and neck
is relatively rare [1], most commonly presenting in the
posterior subcutaneous neck [2,3]. However, lipomas
involving the deep parotid lobe are extremely rare. The
first case of lipoma involving the deep lobe of parotid
gland was reported by Janecka et al., in 1977 [4], and few
additional cases of deep lobe parotid lipomas have been
reported in the surgical literature since then [2,5-9], Surgi-
cal intervention in these tumors is challenging because of
the proximity of the facial nerve, and thus knowledge of
the anatomy and meticulous surgical technique are essen-
tial. Here, we describe a rare case of giant lipoma arising
from deep lobe of the parotid gland that was successfully
managed by surgery.
Published: 02 June 2006
World Journal of Surgical Oncology 2006, 4:28 doi:10.1186/1477-7819-4-28
Received: 20 December 2005
Accepted: 02 June 2006
This article is available from: http://www.wjso.com/content/4/1/28
© 2006 Wu et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 5
(page number not for citation purposes)
World Journal of Surgical Oncology 2006, 4:28 http://www.wjso.com/content/4/1/28Case presentation
A 71-year-old female presented in our clinic with a large
left facial mass requesting surgical excision for a cosmeti-
cally better facial appearance. She had been aware of the
slow-growing, painless swelling for over the past fifteen
years. She had sought medical advice ten years before, but
she had been unwilling to undergo surgery due to the fear
of the postoperative morbidity. Clinical examination
revealed a mobile, soft, and non-tender mass measuring
10 × 7 cm in size over the region of the left parotid and
upper lateral neck area (Figure 1). The surface of the mass
was smooth and the overlying skin was normal without
any signs of discoloration or tumor-adhesion. The facial
nerve function was intact and the remainder of the head
and neck examination was unremarkable.
The high-resolution CT scan showed an adipose tissue sig-
nal density mass arising from the left deep-lobe parotid
gland that protruded inferiorly to the upper lateral neck
(Figures 2A, B). A classic parotidectomy incision was
made and the main trunk of facial nerve identified at the
stylomastoid foramen. From the main trunk of the facial
nerve, each branch in continuity is dissected away from
the overlying superficial parotid lobe. Then a glistening
yellow mass was identified in the deep lobe, closely asso-
ciated with the lower branches of the facial nerve (Figure
3A). The tumor was well encapsulated and easily and
totally enucleated after mobilization of the overlying
facial nerve branches. Then the raised superficial parotid
lobe was repositioned to cover the facial nerves before
wound closure (Figure 3B). The surgical specimen was
well encapsulated measuring 9 × 6 cm (Figure 4). The his-
topathology examination revealed fibrolipoma, a histo-
logical variant of lipoma. The patient had an uneventful
recovery, with a satisfying facial contour and intact facial
nerve function (assessed as House-Brackmann Grade 1)
(Figure 5). Neither tumor recurrence nor Frey's syndrome
was observed 9 months after surgery.
Discussion
Lipomas are the most commonly encountered benign
mesenchymal tumors that are histologically similar to
mature adipose tissue, but the presence of a fibrous cap-
sule helps to differentiate them from simple fat aggrega-
tions [10]. Onlyapproximately 25% of lipomas and their
variants arise in the head and neck region [1] and most of
these occursubcutaneously in the posterior neck [2,3].
Rarely, they can develop in the parotid gland with
reported incidence ranges from 0.6 to 4.4% among
parotid tumors, and they appear most frequently in the
fifth and sixth decades of life with a definite male predom-
inance [11].
Lipomas involving the deep parotid lobe are extremely
rare. Similar to lipomas in other part of body, they tend to
grow insidiously and give rise to few symptoms other than
the effect of a localized mass or cosmetic concerns [9]. The
same was true of this case, who had been aware of the
slow-growing, painless swelling for the past fifteen years
and sought medical advice only on cosmetic grounds.
As they grow, deep lobe parotid lipomas tend to extend
into adjacent loose connective tissues of the neck with var-
ious shapes. They may extend posteromedially between
the sternocleidomastoid and digastric muscles causing an
asymptomatic soft lump on the upper lateral neck, as pre-
sented in this case. In addition, they may also extend
medially into the parapharyngeal space, causing medial
displacement of the lateral pharyngeal wall and/or ton-
sil[12]. Facial paralysis [13] and pain [11] in the presence
of parotid lipoma are uncommon and have been
described rarely. Probably because of the slow and flexible
growth pattern of the tumor, there was neither facial
paralysis nor pain on presentation even though severe
tenting of the facial nerve branches was observed during
operation in this case.
Clinical examination alone is insufficient to identify the
nature and location of deep parotid lipomas. Hence,
Photograph of a 71-year-old female patient who presented with a 15-year history of s ow-growing swelling of th  left parotid nd upper lat ral neck a eaFigure 1
Photograph of a 71-year-old female patient who presented 
with a 15-year history of slow-growing swelling of the left 
parotid and upper lateral neck area.Page 2 of 5
(page number not for citation purposes)
World Journal of Surgical Oncology 2006, 4:28 http://www.wjso.com/content/4/1/28imaging examination such as ultrasonography, CT or
magnetic resonance imaging (MRI) may be helpful in fur-
ther assessment and diagnosis. Ultrasonography has been
used as an initial imaging study in cases suspected to have
head and neck lipomas [14,15]. Compared with CT and
MRI, ultrasonography is quick, easy, less costly, and with
the use of high-frequency transducers, more suitable for
imaging superficial structures. However, the soft tissue
characterization is less specific with ultrasonography than
with CT or MRI.
On CT scans, lipomas have the typical characteristics of
homogeneous masses with few septations, a specific range
of CT Hounsfield Unit (HU) values (usually between -50
and -150 HU), and they show no contrast enhancement
[5,15,16]. MRI can also accurately diagnose lipomas pre-
operatively by comparison of signal intensity on T1-and
T2-weighted images [5,16]. Moreover, the margin of a
lipoma is clearly defined by MRI as a 'black-rim', enabling
lipomas to be distinguished from surrounding adipose
tissue, a distinction that cannot be made from CT images
[8].
In this reported case, however, the high-resolution CT
scan provided enough information with respect to the
preoperative planning and contributed to the diagnosis.
Although MRI may prove to be a better diagnostic tool
regarding tumor margin characteristics, this did not
change our surgical strategy and it was not necessary to
modify the operation based on the MRI differing from CT
findings. In addition, the cost of MRI is nearly three times
that of CT and so we believe that although MRI is highly
useful, the CT scan with specific radiodensity recording is
the preferred preoperative investigation.
Fine needle aspiration biopsy (FNAB) requires an experi-
enced cytologist, but it still has a significant false negative
rate in salivary gland tumors. It has also proved to be
unreliable in diagnosing parotid lipomas [8,9,17]. Fur-
thermore, fibrosis or adhesion between the facial nerve
branches and the lipoma capsule following FNAB may be
encountered, and this may increase the risk of facial nerve
injury during surgery. Therefore, we did not perform
FNAB for preoperative cytological diagnosis of parotid
lipoma in this case.
Conservative follow-up might be a valid option for
patients with clinically static deep parotid lipomas, since
lipomas can now be confidently recognized by CT and
MRI. Surgical intervention in these tumors is challenging
and may be reserved for patients with cosmetic or pressure
effects. Possible postoperative morbidities, such as facial
nerve dysfunction, facial scar or asymmetric contour, and
Frey's syndrome must be explained to the patient before
operation. During surgery, most surgeons recommend
superficial parotidectomy with facial nerve dissection
before removal of the deep lobe parotid lesions [6-9,12].
Transient or temporal facial nerve dysfunction may be
encountered after surgery in the case of deep lobe parotid
lipoma, so full exposure of the facial nerve [9] and also
High-resolution post-contrast CT scans shows a spherical, well marginated, lower attenuation giant lipoma arising from left deep par tid lobeFi ur  2
High-resolution post-contrast CT scans shows a spherical, well marginated, lower attenuation giant lipoma arising from left 
deep parotid lobe. (A) Axial view, the lipoma with rim of parotid gland overlaying lateral margin. (B) Reformatted coronal view, 
the lipoma is clearly defined from adjacent structures.Page 3 of 5
(page number not for citation purposes)
World Journal of Surgical Oncology 2006, 4:28 http://www.wjso.com/content/4/1/28facial monitoring [8,9] are advised for prevention of that
morbidity.
In our surgical experience of this case, because the lipoma
was mainly associated with the lower branches of the
facial nerve, we exposed these branches from the main
trunk by meticulously dissecting its overlaying superficial
parotid lobe instead of performing a formal superficial
parotidectomy. Then we reposited the raised superficial
parotid lobe to its original site after tumor removal. We
find the procedure with preservation of the superficial
parotid lobe may have the following advantages: it helps
to maintain better facial contour, and the need of resec-
tion of the redundant skin can be avoided. In addition,
the incidence of postoperative Frey's syndrome is reduced.
Conclusion
Giant lipomas involving the deep parotid lobe are
extremely rare. Although MRI may provide better tumor
margin characteristics, the CT scan with specific radioden-
sity recording is the preferred preoperative investigation.
Surgical management of deep lobe lipoma is challenging
and should be performed by experienced surgeons due to
the need for meticulous dissection of the facial nerve
branches. The postoperative aesthetic and functional
results should be the major concerns. Therefore, a formal
superficial parotidectomy may be unnecessary in selected
cases, especially when the tumor only involves the lower
branches of the facial nerve. Reposition and preservation
of the raised superficial parotid lobe may contribute to a
better postoperative aesthetic and functional result.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
CWW, HPC: Took part in the care of the patient, organised
clinical photographs and wrote first draft of the manu-
script. FYC: study conception and design. YCH: Performed
literature search, retrieved articles and helped with manu-
script preparation. LPC: Examined surgical specimen,
took the photograph of the specimen and helped with
manuscript preparation. WRK: Critical revision and
supervision.
All authors read and approved the final manuscript.
Funding source
None
The resected well encapsulated lipoma measured 6 × 9 cm in sizFigure 4
The resected well encapsulated lipoma measured 6 × 9 cm in 
size.
(A) The skin flaps and superficial parotid lobe (p) have been raised and a gi nt lipoma (l) seated on deep parotid lobe is clearly seen under the cervical (c), man ibular (m) nd uc-l(b) branches of the facial n rv which were dissectedfrom the main trunk (*)Figure 3
(A) The skin flaps and superficial parotid lobe (p) have been 
raised and a giant lipoma (l) seated on deep parotid lobe is 
clearly seen under the cervical (c), mandibular (m) and buc-
cal(b) branches of the facial nerve, which were dissected 
from the main trunk (*). (B) Reposition of the raised superfi-
cial parotid lobe (p) after tumor removal.Page 4 of 5
(page number not for citation purposes)
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Acknowledgements
Patients' written consent was obtained for publication of her case record 
and photographs.
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Postoperative photograph of the patient with a satisfying facial contour and intact facial n rve fu ctionFigure 5
Postoperative photograph of the patient with a satisfying 
facial contour and intact facial nerve function.Page 5 of 5
(page number not for citation purposes)


Abstract Background Lipomas are common benign soft tissue neoplasms but they are found very rarely in the deep lobe of parotid gland. Surgical intervention in these tumors is challenging because of the proximity of the facial nerve, and thus knowledge of the anatomy and meticulous surgical technique are essential. Case presentation A 71-year-old female presented with a large asymptomatic mass, which had occupied the left facial area for over the past fifteen years, and she requested surgical excision for a cosmetically better facial appearance. The computed tomography (CT) scan showed a well-defined giant lipoma arising from the left deep parotid gland. The lipoma was successfully enucleated after full exposure and mobilization of the overlying facial nerve branches. The surgical specimen measured 9 × 6 cm in size, and histopathology revealed fibrolipoma. The patient experienced an uneventful recovery, with a satisfying facial contour and intact facial nerve function. Conclusion Giant lipomas involving the deep parotid lobe are extremely rare. The high-resolution CT scan provides an accurate and cost-effective preoperative investigative method. Surgical management of deep lobe lipoma should be performed by experienced surgeons due to the need for meticulous dissection of the facial nerve branches. Superficial parotidectomy before deep lobe lipoma removal may be unnecessary in selected cases because preservation of the superficial lobe may contribute to a better aesthetic and functional result.</p

Hsu Ying-Che

Chiang Feng-Yu

Chi Hung-Pin

Wu Che-Wei

Chan Leong-Perng

Kuo Wen-Rei

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