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Osteolipoma is a very rare condition, and only a few cases affecting the head were found in the literature. None can be compared with the giant lesion of the side of the head developing in the left temporo-parietal region of an 8-year-old boy from Central Africa. Under a huge lipoma, an irregular bony mass was found. Contouring resection was performed with an uneventful recovery. Technique and pathology are discussed.
An 8-year-old boy from Central Africa presented with a tumor of the skull whose size equaled that of the head. Under a huge lipoma, a bony proliferation was discovered. Contouring resection was performed uneventfully, with a satisfactory result. Examination of the specimen revealed an ossifying lipoma. This is a very rare benign condition.
1. Case history
After a normal birth in November, 1993, in Chad, a small soft tumor appeared two weeks later on the left side of the head of the male infant. It was growing slowly. At two years of age, an incision was performed and an off-white tissue was removed, without subsequent pathology examination. It healed rapidly, but the tumor continued to grow, at first slowly, and then, more rapidly. Between January and July of 2001, it doubled in volume. A transfer of the patient to our unit was then organised and the now 8-year-old child arrived in October 2001. His general condition was good; all blood tests and routine examinations were normal. He presented with the head tilted to the right because of the weight of the tumor located on the left temporo-pareital area (Fig. 1) , which at that point exceeded the head in size. The tumor was round and soft, and was covered with normal-looking hairy scalp, in the area adjacent to the head. Above the left ear, there was an extensive area of glabrous skin with dilated pores. Upon palpation, the softness of the tumor suggested a lipoma, but one could feel at the center of the tumor a hard and irregular mass of bony consistence. The left ear was pushed down and everted by the tumor but was of normal appearance. Hearing was not affected. The child complained only of the weight of the tumor, but felt no pain.
Figure 1Osteolipoma in an 8-year-old male from Central Africa, slow-growing since infancy. Note the displacement of the left ear.
The CT-scan showed a considerable increase of the thickness of the bone of the left temporo-pareital area, with an irregular external cortex (Fig. 2) . The inner cortex of the skull was not distorted. The MRI did not show any cerebral anomaly and confirmed the lipoma-like appearance of the soft mass located above the bony growth (Fig. 3) .
Figure 2CT-scan shows the bony mass inside the giant tumor adjacent to the left parietal area.
A biopsy was undertaken and the specimen was sent to the pathologist who confirmed that it was composed of benign fibro-lipomatous tissue.
After measurement of the quantity of scalp required for the final closure, an ellipse of scalp tissue 20 cm long and 15 mm wide was marked (Fig. 4) . Underneath, a typical giant lipoma was separated from the scalp edges and removed with electrocautery. Bleeding was minimal. Under the lipoma an irregular bony proliferation was found (Fig. 5) . The consistency was that of cancellous bone. It was removed gradually with oscillating saws and chisel until a contour close to normal was obtained. Bleeding was controlled with bone wax (Fig. 6) . Removal of a large block of proliferating osteoma allowed the left ear to come back to normal position. The temporal muscle was separated and reinserted in its normal position by several absorbable 2/0 sutures. Closure was easily performed by joining the edges of the remaining scalp in an L-shaped line, with a long suture line starting above the left ear and finishing in the occipital area. Suturing was done in two layers: interrupted absorbable 3/0 at the galea level and a running rapidly absorbable 3/0 suture on the scalp level, over a continuous suction drain.
Figure 4The lipoma is removed with a wide ellipse of skin (A), calculated to leave enough scalp tissue to allow final closure. The lipoma is exposed (B), and the bone as well (C).
Recovery was uneventful. The patient rapidly straightened his head position and adjusted to his new head balance (Fig. 7) . The post-op X-rays (Fig. 8) showed that the contour appeared symmetrical compared to the opposite side, even if the bone was still thicker than on the normal side.
Figure 7Two weeks after surgery: the contour of the head is satisfactory, the ear is close to normal position, and the L-shaped scar is hidden in the scalp.
The pathology report of the specimen showed that the major part of the tumor was fatty lobules separated by fibrous septa formed by very thick fibrous bands or nodules. Part of the tumor showed osseous cancellous tissue, containing hematopoetic marrow, suggesting an ossifying lipoma.
The patient returned home to Chad two weeks after surgery. The local doctor confirmed that he did well, has a normal appearance, and is well integrated in his community. No such case is known in the family or the area.
2. Discussion
Though lipomas are very frequent, their association with osteolipoma is extremely rare. Even if lipoma represents the most common mesenchymal neoplasm, osseous metaplasia is rare and is mainly encountered in lipomata of large size and long duration.
, published in 1982 by Shuangshotis et al described a tumor of the forehead in a 27-year-old woman. The bulging of this tumor measured 3 cm. It was firm. Other locations were found around the orbit and in the mandibular area. This tumor had existed since birth and had grown very slowly without symptoms, other than a decreased sense of hearing by involvement of the auditory canal. A contouring resection was performed, with difficulty because the radio-opaque tumor was very hard. Upon pathological analyses, areas of lipoma were found inside the specimen and the diagnosis of osteolipoma was made.
, published in 2001 by Hazanika et al from India, was an osteolipoma of the skull base in a 17-year-old girl.
This case is the first presented in the plastic surgery literature. This impressive benign tumor essentially raises a problem designing the excision and closure to obtain a good morphological correction.
The prognosis and extent of resection are to be discussed. The lipoma was removed in totality, but not the osseous proliferation. There was no clear limit between the hypertrophic bone and the normal bone.
One could have decided to remove the full-thickness of the cranial vault in the affected area. This would have created a defect of 14 cm×14 cm. A titanium or acrylic implant was not ideal for a boy living in Central Africa, and a repair with autologous bone, at this young age when calvarial splitting is difficult, would have represented a significant enterprise. We felt that this bony proliferation was a consequence of the lipoma, and that recurrence was not certain.
For all these reasons, we decided to contour the excess bone instead of doing a complete, full-thickness removal.
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