Assessment of Knowledge and Awareness Levels of Lipoma and Simple Surgical Excision Among Adults in Makkah Region, Saudi Arabia

Background Lipoma is a soft tissue tumor primarily composed of fat cells. These slow-growing, painless, subcutaneous nodules can occur in any place in the body where fat is present. Our study aims to assess the awareness, knowledge, and attitudes of Makkah region inhabitants regarding lipomas and the surgical excision method. Methodology This study used a cross-sectional methodology to evaluate the general public’s knowledge regarding lipomas and the surgical excision method using a self-administered questionnaire in the Makkah region from January to April 2024. Results A total of 367 participants were included, with the majority (56.10%) aged between 18 and 29 years. The survey revealed that 48.50% had heard about lipomas, 42.80% lacked any knowledge about them, and 26.70% acquired their information via social media. Furthermore, 31.60% believed it to affect both genders equally, 46.60% admitted uncertainty, 20.40% correctly identified that lipomas can occur at any age, and 39.80% were uncertain. Overall, 57.20% correctly identified lipomas as benign tumors composed of fat cells. Opinions diverged on whether lipomas cause pain, with 46.90% being uncertain. Moreover, 25.90% of respondents thought that surgery was the sole option for removing a lipoma, while 38.10% recognized the risk of lipoma recurrence after surgical removal. Overall, 85.60% reported never being diagnosed with a lipoma, while 4.10% had been diagnosed, predominantly with single lipomas 6.00%. There were significant differences in the participants’ marital status, with widowed people exhibiting the greatest awareness level, followed by single people. Conclusions Our study findings indicate a moderate level of awareness about lipomas among residents of the Makkah region. However, there are significant gaps in understanding various aspects of lipomas, including their characteristics, treatment options, and demographic distribution.


Introduction
Within the realm of dermatological mysteries, lipomas are a silent phenomenon filled with curiosity and questions among both patients and healthcare professionals about their origins, growth patterns, and potential impact on the surrounding structures.These benign soft tissue tumors are defined as subcutaneous tumors with predominant adipocytic (fat cells) contents, which emerge as soft, painless, encapsulated, slow-growing nodules.
The World Health Organization classified soft tissue tumors in 2020 as benign mesenchymal tumors [1], therefore, it is essential to distinguish common benign lipomas from liposarcoma, especially the welldifferentiated ones because of their similar characteristics [2].
Globally, lipomas are reported to affect 1% of the population, which means it affects 2.1 per 1,000 people annually [2].They are more common in men than women and can occur in any age group, but often occur between the fourth and sixth decades of life.
Although lipomas commonly occurs on the trunk, they can also develop in other parts of the body where soft fatty tissue is abundant.Furthermore, lipomas do not always appear as subcutaneous tumors.A few cases have shown various types of lipomas involving deep fascia, muscles, bones, nerves, and other cutaneous and noncutaneous sites.
Multiple causative factors have been reported including metabolic triggers such as obesity, diabetes, and hyperlipidemia.Moreover, lipoma cases are frequently seen after physical trauma [3].Additionally, some studies showed cases of patients where genetic factors likely contributed to lipoma formation, as 2-3% of patients with lipoma have multiple familial anomalies representing alterations of chromosomes 12 and 13 [4].
Lipoma can be diagnosed clinically or by other radiological imaging such as ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) in some atypical locations of lipoma.However, most subcutaneous lipomas do not require any further imaging studies, and after complete surgical excision, samples are sent for histopathological examination [5].
Several factors influence the decision to treat lipomas, including the size of the nodule as they commonly grow to 1-10 cm, with lipomas larger than 10 cm referred to as giant lipomas [6].Furthermore, anatomical locations, symptoms such as pain, compression on the surrounding structures, and cosmetic reasons play a role in treatment options.
A histopathological screening was performed at King Fahd Hospital at the University in Saudi Arabia from 1983 to 1989 to review the morphological spectrum of adipose tissue tumors.The study revealed that of the 1,093 cases of adipose tissue tumors, 579 patients were diagnosed with lipomas, and only 36 were greater than 10 cm in diameter [7].
Through our comprehensive review, we found global and local studies targeting lipoma from different aspects such as case reports, epidemiology, and histological features of case series.However, no study focused on understanding the public's knowledge and awareness regarding lipoma, specifically in regions such as Al-Qunfudhah.Therefore, there is a need to highlight the knowledge gaps to improve educational efforts and conduct future research.
Therefore, this study aims to assess the knowledge and awareness levels of lipomas and simple surgical excision by identifying the point of ignorance and misunderstanding among adults in the Makkah region.Moreover, we aim to increase awareness levels of various aspects of lipomas and improve the educational efforts to promote the public's understanding of lipomas.Additionally, this research serves as a database for future research.

Materials And Methods
This cross-sectional study of adult Saudi citizens residing in the Makkah region in Saudi Arabia was conducted between January and April 2024.The study included individuals of both genders who were older than 18 years old.Participants who lived outside of the Makkah region and were younger than 18 years old were excluded.The minimum sample size needed was 367.An Arabic questionnaire was used to collect the data.
The questionnaire was a self-administered questionnaire developed by the authors and underwent validation to assess its accuracy.The questionnaire was disseminated via the social media of the selected sample.
The questionnaire was divided into nine sections.The first section included a study description and participant consent form.The second section included demographic data such as gender, age, marital status, education level, employment status, and residence.The third section included questions assessing the awareness, source of knowledge, and participants' satisfaction with the available information.The fourth section included questions assessing participants' general knowledge about lipoma.The fifth section included questions assessing the knowledge about the risk factors of lipoma.The sixth section included questions assessing the knowledge about the diagnostic approach of lipoma.The seventh section included questions assessing the knowledge about medical interventions for lipoma.The eighth section included questions assessing the barriers to not seeking medical attention.Finally, the ninth section included questions assessing participants' personal experiences.

Statistical analysis
The statistical analysis was performed using SPSS version 26 (IBM Corp., Armonk, NY, USA).The categorical data were presented as frequencies and percentages.The Mann-Whitney and Kruskal-Wallis tests were used to determine the association between the knowledge score and the sociodemographic data to present medians, interquartile ranges, and p-values.A p-value <0.05 indicated statistical significance.

Sociodemographic data
The study assessed the knowledge and awareness levels of lipoma and simple surgical excision among adults in the Makkah region, Saudi Arabia.A total of 367 participants were included in the study after excluding individuals who refused to participate and those aged less than 18 years.The majority of respondents fell within the age range of 18-29 years (N = 206, 56.10%).Regarding gender distribution, the sample comprised predominantly females (N = 272, 74.10%).Regarding marital status, a considerable proportion of participants were single (N = 188, 51.20%).Educational attainment varied, with the majority holding a bachelor's degree (N = 218, 59.40%).Employment status showed that a significant proportion were students (N = 149, 40.60%).Geographically, the highest number of participants resided in Qunfudhah (N = 129, 35.10%) (Table 1).Data are expressed as n and %.

General knowledge and awareness about lipoma
As shown in Table 2, 48.50% (N = 178) of respondents had heard about lipomas, while 42.80% (N = 157) did not possess knowledge about lipomas.Regarding satisfaction with available information, responses varied, with 31.10%(N = 114) expressing the lowest satisfaction (rating 1).In terms of factual understanding, a majority (N = 210, 57.20%) correctly identified lipomas as benign tumors composed of fat cells.On the contrary, when asked about growth characteristics, responses were more divided, with 24.00% (N = 88) believing lipomas are fast-growing tumors and 52.60% (N = 193) being unsure.Similarly, opinions diverged on whether lipomas cause pain, with 46.90% (N = 172) being uncertain.A significant proportion (N = 171, 46.60%) acknowledged that lipomas may compress surrounding nerves and structures causing discomfort.Additionally, 46.30% (N = 170) were unsure if lipomas were typically hard and firm or not.Similarly, 49.60% (N = 182) were unsure if lipomas typically move freely under the skin or not.Furthermore, 190 (51.80%) participants acknowledged that lipomas can develop anywhere on the body.Finally, when asked about the understanding of the exact cause of lipomas, 64.00% (N = 235) remained uncertain about the exact etiology.As shown in Figure 1, 45.50% (N = 167) of the participants did not know anything about lipomas while 26.70% (N = 98) reported using social media as a source of knowledge about lipomas.Data are expressed as percentages.

Risk factors, diagnosis, and medical interventions related to lipoma
The study assessed various aspects of knowledge and perceptions regarding lipomas and their management among participants.Data are expressed as n and %.

Personal experiences and barriers to seeking medical intervention regarding lipoma
The study examined the limitations and barriers hindering individuals from seeking medical attention for lipoma presentations, with the majority citing unawareness and lack of knowledge about lipomas and surgical excision (N = 201, 54.80%) as a significant obstacle.Regarding personal experiences with lipomas, a vast majority (N = 314, 85.60%) reported never being diagnosed with one, while a small percentage (N = 15, 4.10%) had been diagnosed, predominantly with single lipomas (N = 22, 6.00%).The most common site of lipomas reported among those diagnosed was the upper extremity (N = 17, 4.60%).Pain or discomfort (N = 32, 8.70%) was the most commonly mentioned characteristic of lipoma.Furthermore, 46.00% (N = 169) of participants did not know if there were known cases of lipoma among close relatives.Among those with diagnosed lipomas, only a fraction sought medical attention (N = 15, 4.10%), with reasons for not seeking treatment including fear of diagnosis or surgery (N = 24, 10.40%).Simple excision procedures were uncommon (N = 10, 2.70%), and recurrence rates were low (N = 9, 2.50%).However, among those who experienced recurrence, new lipomas were commonly located in different areas (N = 10, 3.20%) (Table 4).If yes, where are they located?

Parameter
In the same place as the previous one 1.60% In another location 3.20% I have never had a lipoma before 95.10%

TABLE 4: Personal experiences and barriers to seeking medical intervention regarding lipoma (n = 367).
Data are expressed as n and %.

The association of sociodemographic data with the knowledge level of lipoma
The analysis of demographic factors and their association with median levels of awareness about lipomas and simple surgical excision revealed some notable trends.There were significant differences concerning marital status (p = 0.019).Specifically, individuals who were widowed exhibited the highest median awareness level, with a median score of 9.0 (IQR = 2.0-10.0),followed by single participants with a median score of 8.0 (IQR = 2.0-11.0).Age, gender, educational level, employment status, and residence did not show significant differences in median awareness levels (p > 0.05).These findings suggest that marital status may influence awareness levels about lipomas and simple surgical excision, warranting further investigation (Table 5).

The association of different sociodemographic variables with risk factors for lipoma
The analysis of demographic factors and their association with median levels of risk factors for lipoma revealed several significant findings.Age was found to have a significant impact on satisfaction levels (p = 0.019), with individuals aged 18-29 years exhibiting the highest median score of 2.0 (IQR = 0.0-3.0).Marital status also showed significant differences (p = 0.014), with single individuals reporting the highest median level of 2.0 (IQR = 0.0-3.0).Employment status demonstrated significant differences (p = 0.006), with students reporting the highest median level of 2.0 (IQR = 0.0-3.0).No significant differences were observed based on gender, educational level, or residence (Table 6).

IQR = interquartile range
The analysis examining the association between demographic factors and risk factors for lipoma revealed several noteworthy findings.Age groups ranging from 18-29 to 50-59 years demonstrated positive beta coefficients, indicating a positive association with risk factors for lipoma, although none reached statistical significance (p > 0.05).Similarly, across marital status categories, including single, married, divorced, and widowed, positive beta coefficients were observed, suggesting a potential positive association with risk factors for lipoma, albeit without statistical significance (p > 0.05).Employment status categories, including student, employed, not employed, and retired, showed mixed results, with some categories displaying negative beta coefficients, indicating a negative association with risk factors for lipoma, but none of these associations were statistically significant (p > 0.05).These findings suggest that while there may be trends indicating associations between demographic factors and satisfaction levels, further investigation with larger sample sizes may be necessary to establish significant relationships.The multivariable generalized linear regression analysis assessed the independent predictors of knowledge regarding lipomas using the significantly associated variables as independent variables, and the dependent variable was the percent knowledge score.Results were presented as beta coefficients and 95% confidence intervals.Statistical significance was set at p-values <0.05 (Table 7).

Discussion
This study aimed to evaluate lipoma awareness and surgical excision knowledge among residents in the Makkah region.The results provided insights into lipoma from different aspects, including sociodemographic data, general knowledge about lipomas, and their risk factors, diagnosis, and medical management related to these soft tissue tumors.
Additionally, the study investigated the respondents' personal experiences and the barriers to not seeking medical attention.It showed the association of sociodemographic data with knowledge and risk factors of lipomas.
In terms of sociodemographic data, the majority of the participants were 18-29 years old (56.10%), predominantly female (74.10%), and mostly held a bachelor's degree (59.40%), and a large proportion of the respondents were students (40.60%).Therefore, these findings highlighted that people with higher educational backgrounds were well represented, which indicates that education could be a fundamental solution to improve awareness and knowledge on various topics.
The study showed that while 42.80% of respondents were ignorant of lipomas, 48.50% had heard of them.However, there was uncertainty and misconceptions regarding various aspects, such as growth characteristics, risk factors, associated pain and symptoms, and management options.Therefore, it highlights the need to correct these misconceptions to improve public understanding.
Of the participants, 45.50% had no awareness of lipomas, whereas 26.70% of the respondents obtained their information about lipomas via social media platforms, highlighting the importance of social media platforms in improving health-related knowledge.Regarding management, 25.90% of participants thought that surgery was the only way to remove the tumor, and 38.10% were aware that there was a chance that lipoma may return after surgery.
Badhiya et al. in a study published in 2022 found no relationship between the rate of lipoma recurrence and the patient's age, sex, or size and site of lipoma [8].Although the marginal excision of lipoma has been a standard, Kooby et al. reported a higher risk of local recurrence after the marginal excision of lipomas [9].In another study, Sommerville et al. reported a local recurrence rate of 8% after the marginal excision of lipoma [10], similar to the study by Bassett et al. which also recommended the marginal excision of lipoma because of the low risk of local recurrence of lipomas [11].
Furthermore, 49.30% of participants reported having the lowest level of awareness about simple surgical excision.Regarding personal experiences with lipomas, a vast majority (85.60%) reported never being diagnosed with one, while a small percentage (4.10%)had been diagnosed, predominantly with single lipomas (6.00%).The upper extremity (4.60%) was the most often reported site of lipomas among the diagnosed individuals.Merely 4.10% of individuals with lipomas sought medical attention, and 10.40% of the respondents cited fear of the diagnosis or surgery as their reason for not seeking treatment.Simple excision procedure was rare (2.70%).
One study discussed seeking medical attention for lipomas.The study identified a crucial factor associated with the clinical incidence of seeking medical care.Hence, many people with lipomas might not have had their diagnosis noted when they saw their doctors for other conditions.The study then showed that the true number of lipomas may be more than the number recorded in medical records and may even be roughly twice as high as the number of lipomas that were microscopic examined for histological analysis [12].
In a study by Ezike et al., the most common site for lipomas was the head and neck, followed by the trunk, accounting for 75.52% of cases.Additionally, 30.15% of lipomas affected the forearm [13].In our study, respondents reported experiencing lipomas most commonly in the upper extremities, followed by the trunk.Moreover, multiple subcutaneous lipomas were reported in 22 (17.46%)patients.However, lipomas can also appear in significantly rare sites, as in a case of lingual lipoma reported from Makkah in 2020.
The first reported case of lipoma of the tongue was from Saudi Arabia [14].Another case was reported in Jeddah in 2022 of a vulvar lipoma in a 29-year-old female, which was removed by surgical excision [15].
Regarding the association between sociodemographic data and the knowledge level of lipoma, there were significant differences related to marital status (p = 0.019).Specifically, respondents who were widowed demonstrated the highest median awareness level, followed by single participants.These results suggest that marital status potentially impacts awareness levels about lipomas and simple surgical excision, indicating the need for additional investigation.
Although this research provides valuable insights into lipomas, it is important to address certain limitations of our study, such as the sparse literature on lipoma awareness due to the limited number of previous studies on this topic.Our study is a cross-sectional online survey that limits our ability to examine cause-effect relationships, which may have restricted the perception of illiterate individuals.Additionally, the study was restricted to residents of the Makkah region, with the majority of participants recruited from Al-Qunfudhah and the Holy Capital.Third, the sample size was relatively limited.Furthermore, results may be skewed due to the large proportion of people who have never had lipoma.

Conclusions
The study aimed to assess the awareness of lipoma and surgical excision knowledge among residents from the Makkah region.The study findings indicated a moderate level of awareness of lipoma (48.5%).However, 31.1% were dissatisfied with the lipoma information that is currently available, and there was a lack of knowledge regarding surgical excision of lipoma and the risk of recurrence.There is still scope for improvement in terms of knowledge on this topic.Healthcare professionals play the most significant role in informing the public about lipoma and how it differs from other skin conditions.These efforts could help address misconceptions, improve treatment decision-making, and, ultimately, contribute to better health outcomes for individuals affected by lipomas.-In another location -I have never had a lipoma before

FIGURE 1 :
FIGURE 1: Stack bar chart showing the sources of knowledge about lipoma.

Appendices 2024 3 - 4 - 5 - 6 - 5 2024 7 -never had a lipoma before 9 -
Taha et al.Cureus 16(5): e59727.DOI 10.7759/cureus.59727Questionnaire 1-Are imaging tests like ultrasound and MRI always necessary to diagnose lipomas?Can larger or symptomatic lipomas be treated differently than smaller ones?Is it common to only monitor the growth of a lipoma before recommending treatment?Is there a risk for lipoma recurrence after surgical removal?On a scale of 1 to 5, how well are you aware of the simple surgical excision of lipomas?Taha et al.Cureus 16(5): e59727.DOI 10.7759/cureus.59727Eighth section: Barriers to not seeking medical attention.1-In your opinion, what are the limitations and barriers that prevent patients from seeking medical attention for lipoma presentation in some cases?-Cosmetic concerns -Fear of medical procedures -Risk of complications -Risk of recurrence -Difficulty in the reach of medical centers ( rural areas, cost, transportation, etc.) -Unawareness and lack of knowledge about lipomas and surgical excision -Other?Ninth section: Personal experiences.1-Have you ever been diagnosed with lipoma?never had a lipoma before 2024 Taha et al.Cureus 16(5): e59727.DOI 10.7759/cureus.597275-Are there any known cases of lipoma among your close relatives?If the answer is no, why? -It was small and asymptomatic -I was not aware of the nature of it and the simple excision procedure -Fear of diagnosis or surgery -Other?8-Did you undergo a simple excision procedure for the lipoma?Have you ever developed any additional lipomas after undergoing the simple excision?never had a lipoma before 10-If yes, where are they located?-In the same place as the previous one.

TABLE 2 : General knowledge and awareness about lipoma (n = 367).
Data are expressed as n and %.

TABLE 6 : Association of different sociodemographic variables with risk factors for lipoma.
*: p < 0.05.

TABLE 7 : Linear regression showing the relationship of the statistically significant sociodemographic variables with risk factors for lipoma.
CI = confidence interval; LB = lower bound; UB = upper bound