Is early surgical management appropriate in select focal infantile hemangiomas?
In this case series of 5 children, tissue expansion effect of select focal infantile hemangiomas permitted primary closure without incurring significant functional or aesthetic deformity. This procedure also shortened the time needed to treat these patients with medication and observation.
Select focal infantile hemangiomas may be treated with surgery, taking advantage of the tissue expansion effect of the lesion itself to close the defect without significant aesthetic or functional deformity.
The current standard of treatment for infantile hemangiomas (IHs) involves initial observation for regression throughout infancy and childhood, with or without medical management with β-blocker medications. Approximately 50% of the lesions respond almost completely to this regimen. However, the remaining 50% of the lesions, especially established focal IHs of the lip, nose, eyelids, forehead, cheek, and scalp, do not regress completely with this regimen or do so leaving a deformity; among these lesions, early surgical management may result in a superior aesthetic and functional outcome.
To identify select focal head and neck lesions of IH that will likely not completely involute with medical management and that are ideal for a 1-stage surgical excision.
Design, Setting, and Participants
In this case series, records of infants and children presenting to a tertiary care vascular anomalies center for management of IHs by the senior author were reviewed. Representative examples of focal IHs of the lips, nose, eyelids, cheek, and glabella demonstrating the tissue expansion effect were selected for presentation. Expert opinion based on more than 20 years of experience of the senior surgeon treating more than 2000 patients with focal IH and long-term clinical follow-up is also provided.
Main Outcomes and Measures
Eradication of the IH while restoring aesthetic form and function to the face.
Five examples of patients with focal IHs of the lip, nose, eyelid, cheek, and glabella demonstrating the tissue expander effect who were successfully treated with surgery are presented. The 5 patients with these lesions ranged in age from 3 months to 5 years old, and all of them were female. One of these patients was treated with β-blockers, and another with steroids, with incomplete response to treatment prior to undergoing surgery. The tissue expander effect of a focal IH on adjacent, unaffected tissue facilitated excision of the lesion and primary closure without distortion of anatomical subunits in all 5 of these cases. Improved cosmesis with either improved or unaffected function was demonstrated.
Conclusions and Relevance
Clinicians should consider early surgical intervention in infants with select focal infantile hemangiomas in lieu of prolonged observation or medical management. The psychological benefit of early removal of these disfiguring lesions has not been quantified, but is subjectively apparent to clinicians and the families of patients. Furthermore, the costs and unknown long-term sequelae of β-blocker medication, which is the current standard of treatment for IHs along with observation for regression, have not yet been quantified but will gain increasing salience in the current medical climate.
Level of Evidence
Brennan TE, Waner M, O TM. The Tissue Expander Effect in Early Surgical Management of Select Focal Infantile Hemangiomas. JAMA Facial Plast Surg. Published online February 02, 2017. doi:10.1001/jamafacial.2016.1991