LAS VEGAS — Telling parents that an infant's facial hemangioma will go away and doesn't need follow-up is no longer acceptable, Dr. Edward D. Buckingham said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.
Older studies that support the leave-it-alone approach defined “acceptable” cosmetic outcomes in ways that don't meet today's higher standards, said Dr. Buckingham of Austin, Tex.
Hemangiomas are benign tumors that evolve from an initial proliferative phase to a second phase of involution, in which the tumor gradually disappears. Complications can include scars from ulcerations, epidermal atrophy from thinning of the skin as the tumor grows, cosmetic distortion of facial features, residual telangiectasias, redundant skin after involution, or cartilage destruction by some hemangiomas around the ear or nose.
In the half of children with hemangiomas who show significant (“early”) involution before age 5, 38% had “imperfect” cosmetic outcomes, one 1983 study found. In the other half of children whose hemangiomas did not show significant (“late”) involution by 5 years of age, 80% had imperfect cosmetic outcomes, he noted. Once the hemangioma stops proliferating, the rate of involution can give a sense of the likelihood of an acceptable cosmetic outcome without medical or surgical treatment.
Observation alone may be adequate management for small hemangiomas in clinically insignificant cosmetic areas, but this does not mean forgetting about the lesion.
All birthmarks that develop during the first month of life should be evaluated by a specialist and followed through serial evaluations, Dr. Buckingham said.
There are reasons to treat many hemangiomas during the proliferative or involution phases with the goals of preventing the lesion from getting larger than it needs to be and achieving the best cosmetic results by age 2 or 3 years, when children begin to form a self-image, he said.
Evaluation by a specialist also is key to proper diagnosis of hemangiomas, which commonly are confused with port wine stains, said Dr. Marcelo Hochman. Port wine stains are venous malformations, not tumors, and require different and more difficult treatment.
Hemangiomas occur in 4%–10% of white newborns, with girls four times more likely than boys to develop the lesions. Most hemangiomas develop on the head or neck. Diagnosis is made by history and physical exam; ultrasound imaging should be performed if more than three hemangiomas are present to check for involvement of the liver or spleen, said Dr. Hochman of Charleston, S.C.
Dr. Buckingham warned that hemangiomas on the upper or lower eyelid can endanger vision permanently and deserve referral to a pediatric ophthalmologist.
There is no consensus on treating hemangiomas. Photodynamic therapy (PDT), steroids, and surgery are the main treatment options. Treat superficial or rapidly proliferating hemangiomas every 4–8 weeks with PDT, a safe option with very little risk of scarring, he said.
PDT on the area around an ulcerated hemangioma can help heal the ulcer, data show. Retreat every 4–6 weeks if needed, Dr. Buckingham suggested. PDT also cleans up residual telangiectasias.
For deep hemangiomas, inject steroids into the lesion or try a 10-week course of oral steroids during proliferation; expect a 30%–90% response. Combine steroids and photodynamic therapy for compound lesions. Refer children on oral steroids to an endocrinologist for weekly evaluation.
Reserve surgical debulking for cleanup during involution, or during the proliferative phase for hemangiomas that don't respond to steroids or that threaten vision.
Lesion Myths And Realities
Confusion about the differences between vascular malformations and hemangiomas abound. Many physicians entertain the following common misconceptions about hemangiomas, Dr. Hochman said:
Myth: Hemangiomas are big bags of blood, so surgical resection carries a big risk of bleeding.
Reality: Hemangiomas are solid tumors. Surgical removal is relatively simple.
Myth: There are numerous and tortuous feeder vessels in hemangiomas that require embolization.
Reality: Hemangiomas typically have one feeder vessel that's easily isolated. “This is very low-tech surgery,” Dr. Hochman said.
Myth: Hemangiomas infiltrate surrounding tissues and are difficult to remove.
Reality: Hemangiomas can push tissue out of the way, giving the impression of infiltration, but there is always a plane between the tumor and surrounding normal tissues. Dissection is relatively easy in discrete planes that occur naturally and can be created between the superficial and deep components of the hemangioma, or in the deep component, or within the fibrofatty residuum of skin and scar tissue.
Dr. Hochman cautioned that although these myths don't apply to hemangiomas, they may sometimes apply to malformations like port wine stains.