While multiple modalities have been used in the past to treat port-wine stains, pulsed-dye laser treatment, with its ability to selectively target blood vessels, currently offers the most effective treatment. Kristen M. Kelly, MD, and colleagues present the current treatment approaches for port-wine stains using pulsed-dye laser therapy. Skin-cooling methods are required to treat at higher radiant exposure with the pulsed-dye laser to decrease epidermal melanin absorption. Their study used current treatment protocols with higher pulsed-dye laser exposures (up to 16 J/cm2) and cryogen-spray cooling for the epidermis to determine if port-wine stain blanching was enhanced. They did not find improved blanching results with higher radiant exposures in this protocol. Pulsed-dye laser therapy remains the current standard of care, however, because it selectively and safely targets the involved vessels for destruction and results in at least some lightening in most patients. Resistant lesions may have only a minimal response, even after multiple treatments.
Rami K. Batniji, MD, and colleagues present an algorithmic approach to the management of facial hemangiomas. They review the natural course, classification, and history of treatment of these lesions throughout the past 100 years. As many as 25% to 40% of hemangiomas result in significant cosmetic deformities that may benefit from intervention. If a lesion is in the proliferative phase, the decision to treat is based on the rate of growth, the presence of ulceration, and likely aesthetic result. Serial observation may be used for stable lesions, but superficial lesions that are rapidly proliferating, ulcerating, or functionally limiting may require intervention with pulsed-dye laser therapy. Treatment with systemic or intralesional corticosteroids may be indicated for deep hemangiomas. Treatment for involuting hemangiomas is based on whether they involute early or late. Surgical treatment for “early involuters” is delayed until age 4 years, but for “late involuters” earlier therapy is indicated. The authors outline important surgical principles to consider during excision of a hemangioma, as well as a special emphasis on management of lesions of the periorbital region, nose, and lip.
Vascular malformations of the head and neck may cause not only significant cosmetic defects but also functional impairment of structures such as the eye, tongue, or throat. Traditionally, surgical treatment is recommended, but the benefits of surgery are limited when healthy structures are intimately involved with the lesion. John P. Deveikis, MD, presents a comprehensive study on the evaluation and treatment of patients with vascular malformations of the head and neck using percutaneous ethanol sclerotherapy. His technique of sclerotherapy is usually performed with the patient under general anesthesia because of the pain associated with ethanol injection. Imaging studies are helpful adjuncts for treatment planning. Contrast-enhanced imaging is performed to ensure that the needle is in the proper location, followed by injection of the sclerosing agent. The procedure may be repeated if the desired result is not obtained after the initial treatment.
Marcelo Hochman, MD, and Alfredo Mascareno, MD, report their extensive experience treating infantile hemangiomas involving the nose. They present a comprehensive review of the management of these lesions involving the nasal tip and lobule. Treatment involves a combination of serial observation, systemic corticosteroid therapy, pulsed-dye laser treatment, and surgical therapy. Guidelines for treatment are based on whether the phase of the lesion is proliferative or involutional. Systemic corticosteroid therapy is helpful only during proliferation. Serial pulsed-dye laser therapy effectively treats the superficial component of the lesion. Any surgery performed should include an emphasis on conservative skin resection with modification of traditional rhinoplasty incisions. Cartilage grafting is preferably delayed until nasal growth is complete but may be necessary earlier for patients with severe deformities.
Self-portrait by Elisabeth Louise Vigée-Le Brun (1755-1842).Article
This issue’s Highlights were written by Scott Roofe, MD.
Highlights of Archives of Facial Plastic Surgery. Arch Facial Plast Surg. 2005;7(5):285. doi:10.1001/archfaci.7.5.285