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| Dr. Joel Aronowitz |
Dr. Joel Aronowitz: “We're going to remove a septentaneous mass under local anesthesia today, and if you look carefully, you can see it protruding. This is in the upper posterior thigh. Okay, Richard, we're ready for prime time. Now, did you anesthetize this already? Okay, let's just make sure that the deep area is numb. This is lidocaine, a local anesthetic. Richard is a professional opera singer, so you can see how the skin relaxed skin tension lines are going in this direction as opposed to this direction. So we want to make our incision in that direction, and it's hard to tell, but there may be a little pore there. So we'll make a little skin excision here. And our patient is under local anesthesia, but he doesn't feel anything because of the local anesthetic. Basically, it renders the local sensory nerves inoperable temporarily. We'll talk about local anesthetic later and how it works.”
Assistant: “That's amazing.”
Dr. Joel Aronowitz: “Local anesthetic?”
Assistant: “I have no idea what that is deep.”
Dr. Joel Aronowitz: “Yeah, it goes pretty deep. Now you can see as I put a little pressure, I haven't even dissected. That mass has its own. That means that it doesn't have a real capsule around it. It actually has just the surrounding tissue that's gotten a little bit thick and fibrous. And you can see the different lobules, if you will, of fatty tissue, and here's the loose connective tissue that connects it to the normal fat. Here's normal fat right here. So here's the normal subcutaneous fat, and this fat is different. It's what's called a lipoma. It's a benign growth of fatty tissue, and there you can see it. And this is the tissue that I'm describing as a pseudo capsule. It's basically just that loose connective tissue that's been forced to condense at the edges of the lipoma. You're probably wondering why can I cut into this tissue and it doesn't bleed very much, and that's because Bridget has anesthetized it with some lidocaine with epinephrine. And the epinephrine causes the small blood vessels to constrict. So even though it's not bleeding now, once that epinephrine wears off after a while, it can start bleeding. So we need to make sure that there's nothing oozing. Here's some of the loose connective tissue. Here's the lipoma itself, and you can see how it's well encapsulated. And here's the skin that I've removed. So you can see the whole structure. And this will present as a palpable mass under the skin. And how can you tell externally that it's not malignant? Well, first of all, you can feel it and tell that it's not hard, it's soft. You can tell that it's mobile. In other words, when you palpate it, it will move around a little bit. It's not fixed to the surrounding tissue, and it's not fixed to the underlying layer. For example, the muscle fascia at the very back of the thigh here, the buttock. This kind of tumor is typically non-tender. But when there's a lot of blood vessels in it, you can have a variation of this called an angiolipoma, which typically is tender. And those we don't see as often. They're also benign. The type of tumor like this that's malignant is a liposarcoma. Liposarcoma, there's some others, epithelioid sarcoma, some other more rare sarcomas. These are highly malignant and they require much more extensive surgery to remove them.”
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