Facial musculature is divided into masticatory muscles, i.e. M. masseter and M. 
buccalis, with bony insertions and smaller facial muscles involved in facial 
expression, which insert into bone and skin. There are four fixed osteocutaneous 
points of the face, i.e. zygomatic (Mac Gregor), mandibular (Furnas), orbital 
(Psillakis), and masseteric with an antigravitational effect and functional role 
in facial expression (1,2). In other body parts, the direct insertion of muscle 
fibers into skin has not been reported. In the neck-shoulder region, direct 
insertion of skeletal muscles into the skin can be observed during surgery in 
this area. We observed this phenomenon in 3 adult male patients (51-65 years 
old) during lipoma surgery. In our case series, lipomas were of the superficial 
subcutaneous type. After local anesthesia with 1% ropivacain, a fusiform skin 
incision was followed by en bloc resection of the lipoma. During resection, we 
became aware that muscle fibers of M. levator scapulae inserted into the back 
skin (Figure 1). This has practical implications for surgery because of possible 
pain when these fibers need to be cut to deliver a lipoma or other subcutaneous 
tumors. Lipomas are a common benign tumor of the subcutaneous adipose tissue, 
known as the superficial type. However, lipomas may occur intramuscularly, 
intermuscularly, parostealy and intra-osseously (3). In the deep subtypes of 
lipoma, pain and discomfort may be a leading clinical symptom whereas 
superficial lipomas often are asymptomatic (4,5). Surgery is the treatment of 
choice, while liposuction and laser-lipolysis are alternatives (6). During 
surgery of lipomas of the shoulder/neck region, direct insertion of muscle 
fibers of M. levator scapulae into skin was noted - an observation possibly 
underreported in surgical literature.