An otherwise healthy 14-year-old white girl presented to our dermatologic laser clinic with a protruding tumor above the right nasolabial fold. The patient's parents reported that the patient had a fast-growing red tumor during the first months after birth in the same area. The lesion at that time was diagnosed as infantile hemangioma by the pediatrician, and no further intervention was carried out. The skin lesion spontaneously resolved over the following years leaving the residual skin changes. The skin lesion had remained unchanged for the last 4 years without further improvement in appearance.
Physical examination revealed a protruding subcutaneous tumor, abnormally lax overlying skin with several linear indentations, and a soft atrophic scarlike surface texture (Figure 1A and Figure 2A). Several telangiectasias were discernable within the skin lesion and in its immediate surrounding skin. The oral mucosa of the patient appeared to be free of any alterations. Findings of the general skin examination were unremarkable: no other similarly protruding skin lesions were found.
Close-up photographs taken at a 45° angled view to emphasize the rough surface structure before (A) and 4 weeks after (B) 5 fractional photothermolysis treatment sessions. The same photographic and flash setup was used for the before and after pictures, assuring constant light and photography angles.
Close-up photographs taken at 90° angled view (profile) to emphasize the herniation of the skin lesion before (A) and 4 weeks after (B) 5 fractional photothermolysis treatment sessions. The same photographic and flash setup was used for the before and after pictures, assuring constant light and photography angles.
The patient was referred for consideration of treatment alternatives to the proposed surgical intervention for the removal of the involuted facial infantile hemangioma. Of special concern for the patient was the irregular surface structure of the skin lesion rendering the application of make-up in an attempt to mask the lesion impossible. Invasive ablative procedures including traditional laser resurfacing were also deemed to be too aggressive and risky by the patient's parents. Less invasive procedures to improve the cosmetic appearance of the skin lesion were sought.
The patient consulted our department for treatment alternatives to surgical excision of the involuted facial infantile hemangioma. The patient and her parents agreed to a trial of nonablative fractional photothermolysis (nFP) as a first treatment because of its favorable adverse effect profile, its demonstrated efficacy in treating atrophic scar tissue,1- 4 and its reported improvement of telangiectasias.5- 7 We advised the parents that several nFP treatment sessions would likely be needed and that additional liposuction might be necessary to reduce the residual fibro-fatty mass.8- 10
For the nFP treatments, 2 different 1550-nm glass-fiber lasers were used (Fraxel 750 and Fraxel re:store; Reliant Technologies Inc, Clear View, California). The first 3 treatments were done with the Fraxel 750 device at a microbeam energy of 16 mJ per microthermal treatment zone (MTZ) and a final MTZ density of 1250 MTZ/cm2 delivered in 10 passes at 125 MTZ/cm2 per pass. Two subsequent treatments were executed with a Fraxel restore device, an upgraded instrument model from the same manufacturer, at a fluence of 35 and 40 mJ/MTZ, treatment level 8, and 8 passes. Local anesthesia was achieved by 60-minute incubation without occlusion of a custom-made topical anesthetic cream containing lidocaine, 23%, tetracaine hydrochloride, 3.5%, and tetracaine base, 3.5%. Furthermore, a forced-air cooling device (Zimmer Cooling Device; Medizin Systems, Irvine, California) was used on a setting of 3 during the laser exposure to reduce discomfort and the potential risk of bulk heating.
The patient tolerated each procedure with mild to moderate discomfort. Treatment intervals varied between 4 weeks and 4 months. Immediately after each treatment there was confluent erythema and edema typical for nFP treatments. A cold compress was applied to the area immediately after each laser treatment to reduce edema and patient discomfort, and the patient was instructed to continue to cool the treatment area to reduce posttreatment edema and erythema.
One month after the fifth treatment, the involuted hemangioma showed a clear improvement in the cutaneous texture and laxity and surprisingly an apparent reduction in volume of the lesion (Figure 1B and Figure 2B). The patient and her parents were very satisfied with the result. The patient herself was especially pleased with the ability to camouflage the lesion with make-up, which had been impossible before the nFP treatments.
Infantile hemangioma is a benign vascular proliferation showing some similarities to placental vasculature.11 With an incidence of approximately 10%, this is the most common neoplasia in childhood.12,13 Common infantile hemangiomas have a distinct evolution consisting of a proliferative phase during the first year of life, followed by gradual and often very slow regression with softening of the tumoral mass taking up to a decade or more.
During the time of rapid proliferation and growth, infantile hemangiomas can displace the surrounding tissue in a manner similar to that of a tissue expander. The normal dermal architecture is commonly destroyed resulting in an abnormal cutaneous laxity. The vascular tumor mass is frequently not entirely absorbed during involution, but is replaced partly by a loose fibro-fatty stroma with lobular architecture.14,15 This leads to a residual tumor in the affected area even after the vascular tumor has completely regressed (Figure 1A and Figure 2A).16,17 In addition, ulceration of the rapidly growing lesion occurs frequently and can lead to further scarring of the affected tissue.18 Remaining telangiectasias also contribute to the typical heterogeneous clinical presentation of involuted infantile hemangiomas. Hence, important disfigurement persists in approximately 25% of the cases even after the natural involution process of the infantile hemangiomas is completed.16
It has been clearly established that corticosteroids and/or pulsed-dye laser treatments can cause early involution of infantile hemangiomas. These early treatments might reduce the need for corrective procedures after natural involution has occurred.
To avoid psychosocial functional impairment, additional treatment of these residual lesions is often carried out. More than 80% of these common tumors are located in the head and neck region.19 Of 100 cases of parotidal hemangioma retrospectively studied by Greene et al,17 66% were deemed to need reconstructive surgery after natural regression had occurred. Ninety-two percent of these patients underwent preauricular excision of redundant skin and/or fibrofatty tissue, and 37% of patients needed auricular revision. Surgical excision of excess tissue and/or local tissue flaps and grafts often result in an extra wide scar. The classic surgical approach of elliptical excision has been improved by Mulliken et al20 and Vlahovic et al,21 who proposed a circular excision and purse-string closure technique. With this technique, the residual scar size is approximately 70% the size of the scar resulting from standard lenticular excisions. Another advantage of the purse-string closure technique is minimal distortion of surrounding structures.20,21
However, even this improved technique results in a significant residual surgical scarring and might not be applicable in cases with a larger affected area. Surgical procedures are also associated with all the risks of general anesthesia and common surgical adverse effects of infection, tissue necrosis, and nerve damage. Another less invasive technique to change the appearance of the involuted lesion is the volumetric reduction of the fibro-fatty tissue mass by different liposuction techniques.8- 10 Although beneficial in volumetric reduction, this method does not resolve the overlying dermal and epidermal changes.
Traditional ablative laser resurfacing or dermabrasion can be used,22,23 but these techniques cause wounds with the risk of permanent hypopigmentation, infection, and scarring. The potential for these adverse effects was strictly rejected by our patient and her parents. We therefore decided to use nFP.
The principle behind the nFP technique is to create an array of small thermal lesions within the skin called MTZs using focused laser microbeams.3 The tissue within those MTZs is completely denatured, but the skin can recruit the surrounding unharmed tissue to regenerate very quickly, thus reducing adverse effects significantly.5 In addition, nFP has been shown to improve the appearance of atrophic acne scars as well as surgical scars.1,4,6,24,25 Facial telangiectasias and postinflammatory erythema have also been reported to respond to treatment with nFP.6,7,26Figure 1B and Figure 2B demonstrate improvement of the involuted infantile hemangioma after nFP.
Changes in skin surface structure due to nFP treatment were expected and can be explained by a dermal remodeling process.5,27 However, the apparent volumetric changes of the involuted skin lesion were surprising and to our knowledge have not been described previously. A likely explanation for these 3-dimensional changes is an increase in dermal strength and elasticity due to the laser treatment. This dermal “tissue tightening” then could decrease the apparent herniation of the protruding fibro-fatty tissue.
Treatment depth of nFP is presently limited to 1.5 mm, and the MTZ depth varies with micropulse energy. We observed good improvement after the first 3 treatments and much greater apparent amelioration after the fourth and fifth treatments. This was also reflected by the observation of the patient herself, suggesting that an energy response study for these lesions is warranted.
Nonablative fractional photothermolysis appears to be an effective treatment technique for involuted facial infantile hemangiomas. It is a valid alternative to surgical excision and other more invasive procedures.
Clinicians, residents, and fellows are invited to submit cases of challenges in management and therapeutics to this section. Cases should follow the established pattern. Manuscripts should be prepared double-spaced with right margins nonjustified. Pages should be numbered consecutively with the title page separated from the text (see Instructions for Authors [http://archderm.ama-assn.org/misc/ifora.dtl] for information about preparation of the title page). Clinical photographs, photomicrographs, and illustrations must be sharply focused and submitted as separate JPG files with each file numbered with the figure number. Material must be accompanied by the required copyright transfer statement (see authorship form [http://archderm.ama-assn.org/misc/auinst_crit.pdf]). Preliminary inquiries regarding submissions for this feature may be submitted to George J. Hruza, MD (firstname.lastname@example.org). Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archdermatol.com).
Correspondence: Hans-Joachim Laubach, MD, Massachusetts General Hospital, Wellman Center for Photomedicine, BAR No. 305, 50 Blossom St, Boston, MA 02114 (email@example.com).
Accepted for Publication: June 21, 2008.
Author Contributions: Dr Laubach had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Laubach and Manstein. Acquisition of data: Laubach. Analysis and interpretation of data: Laubach, Anderson, Luger, and Manstein. Drafting of the manuscript: Laubach and Manstein. Critical revision of the manuscript for important intellectual content: Anderson and Luger. Obtained funding: Laubach and Manstein. Administrative, technical, and material support: Luger and Manstein. Study supervision: Anderson and Luger.
Financial Disclosure: Dr Laubach has received travel expenses and research funding from Reliant Technologies Inc; Dr Manstein has received honoraria, research funding, and royalties from Reliant Technologies Inc; Dr Luger has received research funding from Reliant Technologies Inc; Dr Anderson has received honoraria, research funding, and royalties from Reliant Technologies Inc.
Funding/Support: Reliant Technologies Inc provided a consumable part of their laser device free of cost for this study.
Additional Contributions: The professional photographers Jutta Bueckmann and Peter Wissel assisted with the acquisition of the patient photographs.
Laubach H, Anderson RR, Luger T, Manstein D. Fractional Photothermolysis for Involuted Infantile Hemangioma. Arch Dermatol. 2009;145(7):748-750. doi:10.1001/archdermatol.2009.114