Plastic Surgery for Hemangioma

Plastic Surgery for Hemangioma

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Vascular lesions of the skin are divided into congenital and acquired lesions. A classification of vascular lesions is shown in the image below.

Acquired and congenital vascular lesions are described as follows:

Acquired vascular lesions: The most significant acquired vascular lesions of infancy are hemangiomas. [1, 2] The lesions are composed of proliferating blood vessels and, although benign, have a potentially destructive character. Hemangiomas undergo a proliferative and an involution stage. Pyogenic granuloma is another acquired vascular lesion that is frequently observed during childhood. It is of minor aesthetic significance compared to hemangiomas. [3] After infancy, acquired vascular lesions are associated with aging (senile angiomas), trauma (arteriovenous fistulas), systemic conditions (spider angioma), and malignancy (Kaposi sarcoma).

Congenital vascular lesions: The most common congenital vascular lesions are vascular malformations. Vascular malformations are the outcome of errors in vascular formation during embryonic life. They do not proliferate. The dilated blood vessels that build up these lesions gradually enlarge. Vascular malformations can be classified based on their type of blood flow into slow-flow lesions (capillary, venous, lymphatic), high-flow lesions (arterial), and lesions with a combined slow and fast blood flow (see the image below).

The nomenclature of vascular lesions is confusing, and one may find perplexing terms such as “capillary hemangiomas” in some textbooks. Terms such as “strawberry hemangiomas” for superficial lesions and “cavernous hemangiomas” for deep lesions are puzzling and probably should not be used. Instead, hemangiomas should be classified as superficial, deep, or mixed type, according to their location in the skin and subcutaneous tissue. The classification presented here is based on the type of blood vessel, type of flow, and clinical presentation of the lesion. [1] Exceptions are found to this classification; some hemangiomas are congenital, [4] and some vascular malformations are not present at birth. Congenital hemangiomas are discussed in the Outcome and Prognosis section.

Approximately 80% of hemangiomas grow as a single tumor, [5] and 20% proliferate in multiple sites. Hemangiomas are far more common in females than in males, with a female-to-male ratio of 3-5:1. The incidence in white infants is 10-12% and is 22% in preterm infants who weigh less than 1000 g. The incidence is lower in infants with darker skin. [5] Prenatal associations include older maternal age, placenta previa, and preeclampsia. [6]

Formation and remodeling of blood vessels are controlled generally by paracrine signals, many of which are protein ligands that bind and modulate transmembrane receptor tyrosine kinases. [7] Negative regulators include angiostatin, Endostatin, and thrombospondin. Among the positive regulators are vascular endothelial growth factor (VEGF), fibronectin, 5-integrin, vascular endothelial cadherin, and transforming growth factor-1 (TGF-1). [7, 8]

Several studies indicate that hemangiomas are the outcome of an angiogenic growth factor effect. [7, 9, 10] Basic fibroblast growth factor (bFGF) and VEGF messenger RNAs are up-regulated in proliferative hemangiomas. [11] TGF-β 1 messenger RNA remains low in both proliferative and involuted hemangiomas. [9] VEGF is localized predominantly in pericytes and endothelial cells during the proliferative phase. [10] bFGF is found in endothelial cells in both the proliferative and early involutional phases. [10] Other studies indicate that the angiogenic peptide, bFGF, is elevated in the urine of infants with proliferating hemangiomas. [5] Its levels subsequently diminish and return to normal during natural involution or during accelerated regression induced by antiangiogenic therapy. In contrast, in patients with vascular malformations, normal concentrations of bFGF are found in the urine. [5]

See Etiology.

Diagnosis of a vascular lesion is based on the medical history, physical examination, and imaging. The type of lesion can usually be determined based on the first 2 items. Imaging is mostly useful for confirming the clinical diagnosis, estimating the extent of the lesion, and determining the feasibility of surgical resection.

Medical history is described in the image below.

When obtaining the medical history, ask the following 4 questions:

Was the lesion present at birth?

Did proportional or disproportional growth of the lesion occur after birth?

Did a phase of involution occur?

Has an episodic enlargement occurred at any point?

Physical examination of a patient with a vascular lesion includes inspection, palpation, and transillumination.

A complete body examination should be performed to exclude syndromes that include skin hemangiomas. One such syndrome is neonatal hemangiomatosis, which refers to infants with multiple cutaneous hemangiomas. Such patients may have intrahepatic hemangiomas that can cause congestive heart failure (CHF), hepatomegaly, and anemia. [5]

Hemangiomas may be associated with other underlying conditions; lumbosacral hemangiomas may be overlying an occult spinal dysraphism as a tethered cord, lipomeningocele, and diastematomyelia. Facial hemangioma may be associated with posterior fossa abnormality, malformations of great arteries, and ocular abnormalities. PHACE syndrome is the association of Posterior fossa malformations, Hemangiomas, Arterial abnormalities, Coarctation of the aorta, and Eye abnormalitieS. [12] Subglottic hemangioma should be suspected in an infant with a facial hemangioma who presents with dyspnea and stridor.

Hemangiomas may be confused with deep lymphatic or venous vascular malformations. The presence of the lesion at birth supports a diagnosis of a vascular malformation, although congenital hemangiomas are observed at birth. MRI can help distinguish between a vascular malformation and a hemangioma. The differential diagnosis also includes gliomas and other benign and malignant tumors. The first image below shows a 1-year-old girl who presented with a 3-month history of a right facial lump. The lesion was initially managed as a hemangioma. However, MRI indicated that this was not a vascular lesion, and excisional biopsy through an upper buccal incision disclosed nodular fasciitis. The second image below shows the differential diagnosis of orbital hemangioma.

Pyogenic granuloma, which is also one of the most common acquired vascular lesions of childhood, has a typical history of a nonhealing and occasionally bleeding wound. It has a growth phase similar to that of hemangiomas but is usually much smaller and may appear after the first year of life. [3]

Most hemangiomas do not require treatment. They regress spontaneously by the time the individual is aged 10-12 years. [5]

Indications for early intervention are primarily functional, such as obscuration of vision or breathing difficulties.

Uncontrolled bleeding and pain caused by an ulcerated hemangioma may also be an indication for intervention (see the images below). Facial hemangiomas, especially aggressive, rapidly spreading hemangiomas, may necessitate early pharmacologic or surgical intervention to decrease the long-term aesthetic deformity (see the first image below). Very large hemangiomas may be associated with platelet trapping, thus requiring early intervention.

Parental concerns and psychosocial effects of the deformity on the growing child should also be taken into consideration and may warrant earlier treatment. The indications for treatment and a regional approach to the management of facial hemangiomas are presented in Surgical therapy.

Hemangiomas are composed of abnormal vessels located at the skin and/or subcutaneous tissue. The lesion can extend far beyond the skin and invade adjacent structures such as the floor of the mouth and the cheek muscles. The image below shows a lower lip hemangioma in an infant aged 6 months (upper left) and following proliferation at age 16 months (lower left). MRI shows extension of the lesion into the floor of the mouth and cheek.

Surgical therapy may be contraindicated in several circumstances, including the following:

Intraoperative and postoperative bleeding cannot be controlled.

Surgery places an organ at risk (eg, injury to the eye or facial nerve).

Expected aesthetic and/or functional outcome of the procedure is similar or inferior to the aesthetic outcome of spontaneous involution.

Aesthetic and/or functional outcome of the procedure is similar to the predicted outcome of spontaneous involution and the psychosocial effect on the child living through childhood with a disfiguring deformity is not significant.

Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg. 1982 Mar. 69(3):412-22. [Medline].

Marler JJ, Mulliken JB. Current management of hemangiomas and vascular malformations. Clin Plastic Surg. 2005. 32:99-116. [Medline].

Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): a clinicopathologic study of 178 cases. Pediatr Dermatol. 1991 Dec. 8(4):267-76. [Medline].

Boon LM, Enjolras O, Mulliken JB. Congenital hemangioma: evidence of accelerated involution. J Pediatr. 1996 Mar. 128(3):329-35. [Medline].

Mulliken JB. Vascular anomalies. Aston SJ, Beasley RW, Thorne CHM, eds. Grabb and Smith Plastic Surgery. 5th ed. NY: Lippincott Raven Publishers; 1997.

Hemangioma Investigator Group, Haggstrom AN, Drolet BA, Baselga E, Chamlin SL, Garzon MC, et al. Prospective study of infantile hemangiomas: demographic, prenatal, and perinatal characteristics. J Pediatr. 2007 Mar. 150(3):291-4. [Medline].

Breugem CC, van Der Horst CM, Hennekam RC. Progress toward understanding vascular malformations. Plast Reconstr Surg. 2001 May. 107(6):1509-23. [Medline].

Boon LM, Ballieux F, Vikkula M. Pathogenesis of vascular anomalies. Clin Plast Surg. 2011 Jan. 38(1):7-19. [Medline]. [Full Text].

Chang J, Most D, Bresnick S, Mehrara B, Steinbrech DS, Reinisch J, et al. Proliferative hemangiomas: analysis of cytokine gene expression and angiogenesis. Plast Reconstr Surg. 1999 Jan. 103(1):1-9; discussion 10. [Medline].

Tan ST, Velickovic M, Ruger BM, Davis PF. Cellular and extracellular markers of hemangioma. Plast Reconstr Surg. 2000 Sep. 106(3):529-38. [Medline].

Wang F, Xu R, Xu Q, Cao Y, Lin L, Dang W. Effect of laser therapy on plasma expression of VEGF and bFGF in infants with cutaneous hemangioma. Oncol Lett. 2017 Mar. 13 (3):1861-5. [Medline]. [Full Text].

Metry DW, Hawrot A, Altman C, Freiden IJ. Association of solitary, segmental hemangiomas of the skin with visceral hemangiomatosis. Arch Dermatol. 2004 May. 140(5):591-6. [Medline].

Armstrong DC, ter Brugge K. Selected interventional procedures for pediatric head and neck vascular lesions. Neuroimaging Clin N Am. 2000 Feb. 10(1):271-92, x. [Medline].

Ylmaz KB, Canter HI, Vargel I, Ormeci T, Can U, Turk A, et al. Use of three-dimensional MRI-angiography in preoperative evaluation and postoperative management of hemangiomas of head and neck region. J Craniofac Surg. 2011 Sep. 22(5):1814-8. [Medline].

Li M, Liu J, Valeska M, Luo D, Zhou B. Clinical Evaluation of Color Doppler Ultrasound in Selecting the Optimal Treatment Modality for Infantile Hemangioma. Chin Med Sci J. 2017 Jun 10. 32 (2):100-6. [Medline].

Takahashi K, Mulliken JB, Kozakewich HP, Rogers RA, Folkman J, Ezekowitz RA. Cellular markers that distinguish the phases of hemangioma during infancy and childhood. J Clin Invest. 1994 Jun. 93(6):2357-64. [Medline]. [Full Text].

Organek A, Cohen M, Zuker R. Interactive information kiosk improves patient knowledge and satisfaction in a busy pediatric plastic surgery clinic. Can J Plast Surg. 2000. 8(3):105.

Bonifazi E, Mileti F. Images in clinical medicine. Congenital hemangioma. N Engl J Med. 1999 Apr 8. 340(14):1080. [Medline].

Drolet BA, Frommelt PC, Chamlin SL, Haggstrom A, Bauman NM, Chiu YE, et al. Initiation and use of propranolol for infantile hemangioma: report of a consensus conference. Pediatrics. 2013 Jan. 131(1):128-40. [Medline]. [Full Text].

Li P, Guo Z, Gao Y, et al. Propranolol represses infantile hemangioma cell growth through the ß2-adrenergic receptor in a HIF-1a-dependent manner. Oncol Rep. 2015 Apr 14. [Medline].

Sloan GM, Reinisch JF, Nichter LS, Saber WL, Lew K, Morwood DT. Intralesional corticosteroid therapy for infantile hemangiomas. Plast Reconstr Surg. 1989 Mar. 83(3):459-67. [Medline].

Tan BH, Leadbitter PH, Aburn NH, Tan ST. Steroid therapy for problematic proliferating haemangioma. N Z Med J. 2011 Feb 11. 124(1329):57-65. [Medline].

Pope E, Krafchik BR, Macarthur C, Stempak D, Stephens D, Weinstein M, et al. Oral versus high-dose pulse corticosteroids for problematic infantile hemangiomas: a randomized, controlled trial. Pediatrics. 2007 Jun. 119(6):e1239-47. [Medline].

Boon LM, MacDonald DM, Mulliken JB. Complications of systemic corticosteroid therapy for problematic hemangioma. Plast Reconstr Surg. 1999 Nov. 104(6):1616-23. [Medline].

Ezekowitz RA, Mulliken JB, Folkman J. Interferon alfa-2a therapy for life-threatening hemangiomas of infancy. N Engl J Med. 1992 May 28. 326(22):1456-63. [Medline].

Fawcett SL, Grant I, Hall PN, Kelsall AW, Nicholson JC. Vincristine as a treatment for a large haemangioma threatening vital functions. Br J Plast Surg. 2004 Mar. 57(2):168-71. [Medline].

Scheepers JH, Quaba AA. Does the pulsed tunable dye laser have a role in the management of infantile hemangiomas? Observations based on 3 years’ experience. Plast Reconstr Surg. 1995 Feb. 95(2):305-12. [Medline].

Achauer BM, Celikoz B, VanderKam VM. Intralesional bare fiber laser treatment of hemangioma of infancy. Plast Reconstr Surg. 1998 Apr. 101(5):1212-7. [Medline].

Wu X, Mao W, He P, Wei C. Curative effect of chemotherapy, KTP lasers, and CO2 lasers combined with chemotherapy in the treatment of adult laryngeal hemangioma. Acta Otolaryngol. 2018 Jan 8. 1-7. [Medline].

Achauer BM, Chang CJ, VanderKam VM, Boyko A. Intralesional photocoagulation of periorbital hemangiomas. Plast Reconstr Surg. 1999 Jan. 103(1):11-6; discussion 17-9. [Medline].

Yanes DA, Pearson GD, Witman PM. Infantile Hemangiomas of the Lip: Patterns, Outcomes, and Implications. Pediatr Dermatol. 2016 Sep. 33 (5):511-7. [Medline].

Chang CS, Wong A, Rohde CH, Ascherman JA, Wu JK. Management of lip hemangiomas: Minimizing peri-oral scars. J Plast Reconstr Aesthet Surg. 2011 Sep 19. [Medline].

Silfen R, Amir A, Regev D, Hauben DJ. Tumescence: a valuable adjunct for the excision of facial hemangiomas. Plast Reconstr Surg. 2000 Jul. 106(1):217-8. [Medline].

Enjolras O, Mulliken JB, Boon LM, Wassef M, Kozakewich HP, Burrows PE. Noninvoluting congenital hemangioma: a rare cutaneous vascular anomaly. Plast Reconstr Surg. 2001 Jun. 107(7):1647-54. [Medline].

Zuker MR, Cohen M. Congenital hand anomalies (discussion). Goldwyn RM, Cohen MN, eds. The Unfavorable Result in Plastic Surgery Avoidance and Treatment. 3rd ed. Philadelphia: Lippincott Williams and Wilkins; 2000. 710-13.

Rialon KL, Murillo R, Fevurly RD, et al. Risk factors for mortality in patients with multifocal and diffuse hepatic hemangiomas. J Pediatr Surg. 2015 May. 50(5):837-41. [Medline].

Meir Cohen, MD, MPS Consulting Staff, Department of Plastic Surgery, Schneider Children’s Medical Center of Israel, Tel Aviv University Sackler Faculty of Medicine, Israel

Meir Cohen, MD, MPS is a member of the following medical societies: American Cleft Palate-Craniofacial Association, Plastic Surgery Research Council

Disclosure: Nothing to disclose.

Eyal Raveh, MD Consulting Staff, Department of Otolaryngology, Rabin Medical Center, Israel

Disclosure: Nothing to disclose.

Dan Ben-Amitai, MD Head of Pediatric Dermatology Service, Lecturer, Schneider Children’s Medical Center of Israel

Dan Ben-Amitai, MD is a member of the following medical societies: Israeli Medical Association

Disclosure: Nothing to disclose.

Benjamin Shalev, MD Consulting Staff, Ophthalmology Unit, Schneider Children’s Medical Center of Israel

Disclosure: Nothing to disclose.

Moshe Lapidoth, MD, MPH Dermatologist, Head of the Laser Unit, Dermatology Department, Rabin Medical Center, Israel

Moshe Lapidoth, MD, MPH is a member of the following medical societies: European Society for Laser Dermatology

Disclosure: Nothing to disclose.

Eric Bensimon, MD, FRCSC Assistant Professor, Department of Surgery, University of Montreal Faculty of Medicine, Canada

Eric Bensimon, MD, FRCSC is a member of the following medical societies: American Society of Plastic Surgeons, Canadian Society of Plastic Surgeons, Quebec Medical Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Wayne Karl Stadelmann, MD Stadelmann Plastic Surgery, PC

Wayne Karl Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Plastic Surgeons, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, Phi Beta Kappa

Disclosure: Nothing to disclose.

Gregory Gary Caputy, MD, PhD, FICS Wound Healing Consultant, Advantage Surgical and Wound Care

Gregory Gary Caputy, MD, PhD, FICS is a member of the following medical societies: American Society for Laser Medicine and Surgery, International College of Surgeons, International College of Surgeons US Section, Wound Healing Society

Disclosure: Nothing to disclose.

Shahin Javaheri, MD Chief, Department of Plastic Surgery, Martinez Veterans Affairs Outpatient Clinic; Consulting Staff, Advanced Aesthetic Plastic & Reconstructive Surgery

Shahin Javaheri, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Shimon Maimon, MD Head of Invasive Radiology Unit, Beilinson Campus, Rabin Medical Center, Israel

Disclosure: Nothing to disclose.

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