Early surgical treatment of Cyrano-nose haemangiomas with Rethi incision

Our experience in the treatment of hemangioma with intense pulsed light laser: A 10 year study in Albania

Laser treatment brought an innovation in the treatment of hemangiomas and vascular anomalies. The range of superficial vascular lesions that can be treated with laser continues to expand. In our country laser device date relatively late, since then these technologies have facilitated the treatment of many skin condition. The goal of laser therapy is to maximize vascular destruction while minimizing injury to surrounding healthy epidermis and dermal tissues. We present our experience with IPL as a first line therapy in the treatment of superficial hemangiomas. After institutional review, board approval we analyzed the medical records of 202 patients diagnosed with hemangioma and treated with the IPL laser during January 2009 to January 2019. The performed procedure consists of using impulses of light with wave length that varies from 590 to 595 nm, duration 1.5 ms, and fluency by 11 to 12 J/cm² . For each patient, four PDL sessions have been performed. We aim to evidence the efficacy and the good safety profile of (IPL) laser but with small adverse events that this treatment represent. The importance of proper patient selection, use of appropriate equipment settings, skin cooling mechanisms, and other safety measures minimize the occurrence of adverse events due to IPL treatment.

A Novel Approach in the Surgical Management of Nasal Tip Hemangiomas: A 26-Year Experience

Infantile hemangiomas are common benign tumors of infancy with a predilection for the face. Nasal-tip hemangiomas, termed the "Cyrano deformity," can have especially devastating psychological effects. The ideal surgical approach and timing for these patients is unclear, as numerous designs have been reported in the literature. The authors present a novel approach to nasal tip reconstruction involving an algorithmic approach to incision selection and leaving a thin rim of hemangioma tissue under the dermis after debulking to minimize skin envelope atrophy. Nineteen cases were treated with the senior author's preferred method, with a mean age of 3.3 years and follow-up of 2.5 years. At follow-up, 10 patients were deemed by the senior author to have a very good aesthetic result, and the remaining nine patients were deemed to have an excellent one. The results of this study suggest that surgical intervention as early as 3 to 4 years of age is safe and provides good aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Nasal Reconstruction and Repair of Secondary Nasal Deformities Following Treatment of Nasal Hemangiomas

BACKGROUND

Secondary nasal deformities and retardation of development due to treatment of nasal hemangioma during infancy are a challenge when it comes to nasal reconstruction. In order to evaluate nasal repair and reconstruction in these patients, the authors compared the ease and outcomes of using expanded forehead, nasolabial sulcus, and medial upper arm tube flaps.

METHODS

According to the deformities and patients' wishes, flaps were selected; using autogeneic rib cartilage, auricle cartilage, or silica gel as a scaffold or without framework; the inner lining were made by the residual scar tissue or the distal end of transferred flap. The esthetical and functional scores were recorded by the Nasal Appearance and Function Evaluation Questionnaire score to evaluate the effectiveness of the methods.

RESULTS

From January 2010 to December 2015, 34 patients were included. Postoperative follow-up went for 12 to 36 months. The expanded forehead flap was used in 28 patients, the nasolabial sulcus flap in 5 patients, and the medial upper arm tube flap in 1 patient. Regarding framework, 20 patients used rib cartilage, 8 patients used auricle cartilage, 1 patient used silicone, and 5 patients did not use any framework. All patients reported the increasing nasal appearance and function evaluation.

CONCLUSION

Repair of secondary nasal defects following treatment of hemangiomas in infants and young children using an expanded frontal flap and autogenous cartilage framework is a reliable method with great long-term esthetic results. The nasolabial sulcus flap is a relatively simple method, especially for patients with a unilateral nasal alar defect. Supporting structure is needed and appropriate overcorrection is necessary.

Modern Management of Nasal Hemangiomas

Importance

Current treatment approaches for infantile hemangiomas of the nose include observation, pharmacologic agents, surgery, and/or laser therapy. Because of the known functional, social, and cosmetic effect of nasal deformities, obtaining the best possible result is critical. Optimal timing, type, duration, and extent of therapy remain unclear.

Observations

Results of a review of 86 patients (64 females and 22 males; mean age, 4.8 months [range, 2 days-23 years]) with infantile hemangiomas of the nose treated from January 1, 1999, to December 31, 2015, and a review of the literature are presented to gain insight into the preferred approach to the treatment of these lesions. Patients underwent single-modality and multimodality treatment with pulsed-dye laser (n = 73), oral corticosteroids (n = 11), intralesional corticosteroids (n = 2), propranolol hydrochloride (n = 30), and surgery (n = 50). The treatment decision algorithms and outcomes based on tumor phase and infantile hemangioma subtype are reviewed in detail. Nine articles met the criteria to be included in the literature review. Literature from the era before the approval of propranolol advocates for early use of oral or intralesional corticosteroids followed by surgery or pulsed-dye laser in cases of unacceptable outcomes. Literature from the era after the approval of propranolol supports early initiation of oral β-blockers until proliferation ceases or until additional intervention is necessary.

Conclusions and Relevance

Despite a lack of higher levels of evidence, there exists a general consensus between the literature and clinical experience advocating for early multimodality treatment to achieve the best result possible by the time the children reach certain sociodevelopmental milestones.

Diagnosis and Management of Infantile Hemangioma

Infantile hemangiomas (IHs) are the most common tumors of childhood. Unlike other tumors, they have the unique ability to involute after proliferation, often leading primary care providers to assume they will resolve without intervention or consequence. Unfortunately, a subset of IHs rapidly develop complications, resulting in pain, functional impairment, or permanent disfigurement. As a result, the primary clinician has the task of determining which lesions require early consultation with a specialist. Although several recent reviews have been published, this clinical report is the first based on input from individuals representing the many specialties involved in the treatment of IH. Its purpose is to update the pediatric community regarding recent discoveries in IH pathogenesis, treatment, and clinical associations and to provide a basis for clinical decision-making in the management of IH.

Cervicofacial hemangiomas: pattern, clinical management, and treatment outcomes

OBJECTIVE

The aim of this study was to evaluate treatment outcomes following various managements of hemangiomas.

STUDY DESIGN

Sixty-two patients were included and retrospective review conducted. Based on clinical management, each patient was assigned different treatment groups: steroid, sclerotherapy, surgical, and combined therapy. Treatment outcomes were evaluated based on improvement in size, color, and texture by a blinded panel of 4 raters including 3 doctors and 1 patient or patient's parents. Finally, comparison of outcomes between groups was analyzed.

RESULTS

The results revealed that there was reduction in size and improvement in color and texture following intervention in each group. No significant difference in outcome was observed between groups regarding change in size and texture. However, color change was better in combined and surgical treatment groups.

CONCLUSIONS

A favorable outcome can be achieved following appropriate intervention during all stages of development of hemangiomas.

Rhinoplasty for cleft and hemangioma-related nasal deformities

PURPOSE OF REVIEW

To provide a concise review of recent articles on rhinoplasty approaches for cleft nasal deformity and nasal hemangiomas published in 2008-2010.

RECENT FINDINGS

Cleft nasal deformity rhinoplasty approaches have undergone further refinements as well as new development in techniques and surgical principles to minimize recurrent cleft nasal deformities. There is a paucity of studies addressing cleft septal deformity although there appears to be a greater emphasis on functional outcome in cleft rhinoplasty. Complications from primary cleft rhinoplasty and presurgical nasoalveolar molding were also reported. Similarly, nasal hemangioma rhinoplasty approaches have undergone further modifications with open rhinoplasty and subunit approaches gaining wider acceptance.

SUMMARY

There are several new studies that compare different rhinoplasty techniques to determine which approaches offer superior surgical outcomes; however, there needs to be a greater acceptance of objective measurements when assessing surgical results to identify a uniform surgical protocol and technique for both cleft rhinoplasty and nasal hemangiomas.

Infantile haemangioma: part II. Risks, complications and treatment

Because of their spontaneous involution, most infantile haemangiomas (IH) do not require therapeutic intervention. However, in 10 to 15% of cases such as segmental and multifocal IH, locations in the periocular, airway and perineal areas, or complications of ulceration, treatment is necessary. Moreover, the risk of permanent scarring and disfigurement associated with IH, even if involution is complete, has been increasingly recognized as a rationale for treatment. Treatments for IH currently include topical, intralesional, systemic therapies, laser and surgical modalities depending on the clinical scenario. However, clinicians must carefully weigh the risks and benefits for each treatment. Recently, the efficacy of propranolol, a non-cardioselective beta-blocker, was reported and has been revolutionary in the management of IH.

Hemangiomas of the nasal tip: an approach to a therapeutic challenge

OBJECTIVE

Hemangiomas of the nasal tip (HNT) are commonly described as "Cyrano" or "Pinocchio nose". They may cause significant aesthetic and functional impairment. It is still controversial how and when HNT should be treated. The risk of severe complications like irreversible contour deformities, growth disturbance, ulcerations, and nasal obstruction may obligate a therapeutic intervention. The aim of this study is to overview and to analyze different therapeutic approaches which were practiced over the last decade in two specialized centers.

METHODS

This is a retrospective study which includes the analysis of demographic parameters, extent of the lesion, therapeutic interventions, outcome, and follow-up interventions. The analysis includes a blinded evaluation of photographic series for evaluation of the extension at the time of presentation and of the final outcome.

RESULTS

Twenty-three children with HNT were analyzed who presented from 04/01/1998 to 03/31/2009. The age at presentation ranged from 1 to 63 months. On 6 patients (26%) conventional surgery was performed, 6 (26%) were treated with Nd:YAG laser, 6 (26%) were only observed, in 3 cases (13%) cryotherapy and in 2 patients (9%) treatment with Propranolol was performed. The results were evaluated between 9 months and 10.5 years after treatment (mean: 35.5 months). Limited lesions which were only observed showed a good tendency of regression. Significant wound healing disturbance and scar formation was observed after Nd:YAG laser therapy. Secondary rhinoplasty in adulthood was recommended to two patients.

CONCLUSION

Limited lesions do not require therapy. The results with Propranolol are encouraging. Laser- and cryo-therapy have to be critically reevaluated. Treatment of choice for lesions that are not suitable for beta blockers and residual disease is conventional surgery.

Current management of infantile hemangiomas

During the past several years, there have been new advancements in the management of infantile hemangiomas (IHs). In many patients, no treatment is ever necessary--because IHs are well known for their natural history of spontaneous involution. However, a significant minority of hemangiomas do require treatment. Moreover, they are very heterogeneous, making the decision of when, how, and why to intervene quite variable. The least common but most important rationale for intervention is the presence of a life- or function-threatening complication, where prompt therapeutic intervention is a necessity. A much more common scenario is ulceration, where appropriate management is needed to expedite healing and control pain. Increasingly, the life-altering aspects of hemangioma are being recognized as a rationale for treatment because permanent scarring and disfigurement can result even if involution is complete. Treatments for IHs currently include topical, intralesional, and systemic therapies. Laser and surgical modalities are also sometimes used depending on the clinical scenario. In the absence of rigorous evidence-based studies, clinicians must carefully weigh the risks and benefits of medical or surgical treatments versus observation alone in tailoring management to the specific clinical situation at hand.

[Infantile hemangioma]

Infantile hemangioma is the most common tumor in children, but its pathophysiology is still not well understood. Infantile hemangioma develops during the first weeks of life, usually builds up over 3 to 6 months, and then regresses very slowly over a period of 3 to 7 years. Three quarters of these hemangiomas are lobular and are not associated with malformations. On the other hand, the hemangiomas referred to as segmental may be associated with developmental abnormalities (PHACES and PELVIS/SACRAL syndromes). Because of their spontaneous involution, most infantile hemangiomas do not require therapeutic intervention. In 10 to 15 % of cases, treatment is necessary because of complications when life or physiological functioning is threatened, or there are local complications or the long-term esthetic risk is too high. Until now, the standard first-line treatment has been general corticosteroid therapy. The usual choice for second-line treatment is interferon or vincristine. The efficacy of propranolol, a non-cardioselective beta-blocker, was recently reported.

Treatment of nasal hemangiomas

Hemangiomas are the most common soft tissue tumors of infancy. Almost 60% of these tumors develop in the head and neck region. Nasal hemangiomas, distort human physiognomy and leave long lasting psychological sequelae. Conservative approach (intralesional corticosteroids, laser) may accelerate involution. Proponents of an early surgery suggest that aesthetic improvement during a critical period in child development can be achieved. Fourteen patients with nasal hemangioma were treated during 5-year period (2003-2007) with intralesional corticosteroids, lenticular excision, open rhinoplasty excision, and circular excision with "purse string suture". The first line of treatment for large nasal hemangiomas is intralesional corticosteroids. Excision is indicated for small hemangiomas, while subtotal excision is preferable for large nasal hemangiomas. Circular excision and "purse string suture" is appropriate for prominent hemangiomas with predominant deep component. In our opinion surgery with maximal care for nasal architecture is the treatment option for nasal hemangioma.

Hemangiomas of the nose: surgical management using a modified subunit approach

OBJECTIVES

To study a new surgical approach to pediatric nasal hemangiomas and the need for early surgical intervention. Childhood hemangiomas are most common in the head and neck area. They can result in life-altering situations by causing airway obstruction, disfigurement, ulceration, and other adverse effects.

DESIGN

A retrospective study of 44 consecutive patients with hemangiomas treated in our clinic during the last 9 years. The clinical characteristics of these hemangiomas are assessed and the outcome after surgery is discussed with respect to different surgical approaches. A new modified subunit approach is introduced.

RESULTS

Based on the subunit principle, the incision line was modified to allow better access to all nasal subunits. The results using this technique were superior to the results using conventional incisions with respect to accessibility of the tumor, ability to trim excess skin after tumor removal, and aesthetic outcome. In contrast to reports in the literature, early surgical intervention is advocated as a result of this study.

CONCLUSIONS

This modified surgical technique shows superior results to the techniques used in earlier years. We strongly advocate early surgical intervention.

Classification des tumeurs et malformations vasculaires: fondement de la classification et intérêt clinique

Vascular anomalies are a complex pathological group. They are especially difficult to study because of confusion in the terminology used. The classification developed by the ISSVA (International Society for the Study of Vascular Anomalies) now allows using a common scientific language. The classification is based on clinical, radiological, hemodynamic, and histological arguments. There are two groups of lesions: vascular tumors and vascular malformations. Vascular tumors are associated to vascular proliferation. They are called hemangioma and can be infantile or congenital. Vascular malformations are associated to vessels with morphologic anomalies. They are classified according to the distorted vessel type, capillary, venous, lymphatic, and arteriovenous). Such a classification has many implications. It is a guide for the orientation of radiological exams and treatment of vascular anomalies. The management of these anomalies is still difficult and must involve an interdisciplinary approach.

[Early surgical treatment of cutaneous hemangiomas]

Infantile hemangioma appears after the birth as a vascular tumor, which is known for its characteristic evolution in 3 phases: rapid augmentation then stabilization and involution on several years with in the best cases, classical "restitutio ad integrum". Usual surgical attitude is abstention and surgery is proposed only in order to treat sequel. But some particular situations require early surgery for life-threatening lesions or in case of functional impairment. Surgery consists in these cases in a simple volumetric diminution of the tumor with no aim for esthetic improvement. Other kinds of hemangiomas require an early surgical treatment before their complete involution. In some particular locations, deformation or growth delay can occur due to the lesion's development. In some cases, hemangiomas present a delayed involution with minor regression capacity; these are mainly located on the median part of the face and have principally a subcutaneous development. Early surgery can be proposed in order to avoid definitive deformation or growth impairment of adjacent structures. It should be performed before school age and before occurrence of psychological difficulties. Surgery is indicated in a perspective of esthetic improvement. Surgical procedure consists first in modeling excision followed by simple repair technique as linear suture or purse string closure; complex surgical procedures inducing their own sequels are usually inappropriate.

Prospective study of infantile hemangiomas: clinical characteristics predicting complications and treatment

OBJECTIVES

Infantile hemangiomas are the most common tumor of infancy. Risk factors for complications and need for treatment have not been studied previously in a large prospective study. This study aims to identify clinical characteristics associated with complications and the need for therapeutic intervention.

PATIENTS AND METHODS

We conducted a prospective cohort study at 7 US pediatric dermatology clinics with a consecutive sample of 1058 children, aged < or = 12 years, with infantile hemangiomas enrolled between September 2002 and October 2003. A standardized questionnaire was used to collect data on each patient and each hemangioma, including clinical characteristics, complications, and treatment.

RESULTS

Twenty-four percent of patients experienced complications related to their hemangioma(s), and 38% of our patients received some form of treatment during the study period. Hemangiomas that had complications and required treatment were larger and more likely to be located on the face. Segmental hemangiomas were 11 times more likely to experience complications and 8 times more likely to receive treatment than localized hemangiomas, even when controlled for size.

CONCLUSIONS

Large size, facial location, and/or segmental morphology are the most important predictors of poor short-term outcomes as measured by complication and treatment rates.

Place de la chirurgie dans les hémangiomes au stade des séquelles

The cure without after-effect of an hemangioma is classic but sometimes the spontaneous involution, a premature surgical treatment or an evolutionary complication can be at the origin of a definitive after-effect. In these cases, the treatment of the hemangioma, often multidisciplinary, will be begun in a late way during the late childhood or the adolescence. Surgical excision of an excess tissue or of a wide scar, lipoaspiration of a fat remainder, lasertherapy and fat tissue reinjection are simple and mostly sufficient procedures. In the most complex cases, notably at the facial site, a surgery heavier as a rhinoplasty, a resection of lip, a local flap or orthognatic surgery can be necessary.