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This manuscript is a compilation of clinical lessons learned from 30 years of treating hemangiomas. We review relevant clinical anatomy, the role of lasers and medications, timing of surgery, and operative judgment, as it pertains to the treatment of hemangiomas.

Hemangiomas often leave contour deformities and scarring after involution. Surgical resection leaves permanent scars and may distort adjacent anatomy. Circular excision with purse-string closure results in the smallest possible scar and minimal distortion. Thirty-six patients with varying stages of hemangiomas underwent resection with purse-string closure. The dimensions of each hemangioma were measured at the time of excision. Dimensions of the scar at follow-up office visits were recorded. The final scar was calculated as a percentage of the original size of the lesion. Thirty-six patients underwent circular excision and purse-string closure of 39 hemangiomas. Thirty (83.3%) were girls and 6 (16.7%) were boys. The ages of the patients ranged from 5 months to 13 years, with a median age of 2.08. The most common locations were: scalp 9 (23.1%), cheek 9 (23.1%), forehead 5 (12.8%), and eyebrow 4 (10.3%). The median area of the hemangiomas was 491 mm (range: 113-2826 mm2). Follow-up measurements were available for 25 patients with 33 hemangiomas. Follow-up ranged from 1 to 22 months (median follow-up, 3 months). The median area of the purse-string scar was 70.7 mm (range: 3.925-706.5 mm2). The median percentage reduction in area of involvement was 80.6% (range: 24.2%-99.1%). When the hemangiomas were stratified into "large" and "small" hemangiomas, the median percentage reduction in the areas were 84.1% and 79.2%, respectively. There were 3 complications: 1 patient scratched open her incision (ultimately 76% of original size), and 1 toddler scraped her scalp against the carpet and dehisced the purse-string closure (final size, 43% of original size), and a second toddler fell and dehisced a scalp hemangioma (final size, 80% of original size). Traditional lenticular excision of hemangiomas results in increased scar length as compared with the original lesion. Circular excision and purse-string closure of defects results in a scar smaller than the original lesion. It is well tolerated and can be considered the default method in most anatomic locations.

Mucous membrane hemangiomas of the lip are common benign vascular tumors of infancy. This clinical study evaluated the efficacy and safety of liquid nitrogen cryotherapy of mucous membrane hemangiomas of the lip in early infancy. It was a retrospective review of 127 pediatric patients with hemangiomas involving the lips who underwent liquid nitrogen cryotherapy under inhalation general anesthesia with sevoflurane. Forty-one males and 86 females were treated. The overall median age at diagnosis of the mucous membrane hemangiomas was 3.6 months (range, 7 days to 18 months). The oral mucous membrane hemangioma involved the vermilion of the lower lip in 78 cases (61.4%), the vermilion of the upper lip in 40 cases (31.5%), and both vermilions in 9 cases (7.1%). No complications because of anesthesia occurred. The mean follow-up was 10 months, with a range of 8 to 14 months; 94 lesions (74.0%) were completely involuted, 22 lesions (17.3%) were mostly involuted, 11 lesions (8.7%) were partially involuted, and no lesion showed a small amount of involution. Liquid nitrogen cryotherapy is an effective, simple, and safe treatment for mucous membrane hemangiomas of the lip in early infancy.

Despite the fact that cyanoacrylates, a group of rapidly polymerizing adhesives, are used widely in general surgery, neuroradiology, otolaryngology, and plastic surgery, scientific data on histopathological changes resulting from the deposition of -butyl-2-cyanoacrylate (NBCA), a new-generation cyanoacrylate derivative, in human tissues is based largely on experimental observations in animals and sporadic postmortem studies in humans. The authors report the consecutive pathological findings of a patient who underwent surgery for facial hemangioma after percutaneous injection of NBCA for devascularization of a lesion, and underwent additional surgery 1 and 6 months after the initial operation for the removal of the residual NBCA cast from the injection site. Acute inflammatory findings after injection of NBCA and the development of a chronic granulomatous foreign body reaction support the histological findings of experimental animal studies and postmortem examinations on humans. Additionally, their findings support the proposed hypothetical sequence of events for the recanalization of cyanoacrylate-embolized vascular structures.

The treatment of nasal hemangiomas continues to be controversial. The authors' experience with early surgical treatment of nasal hemangiomas is presented. This retrospective study includes 11 patients. Surgical intervention consisted of excision of the nasal hemangioma and reconstruction by local tissue transfer or rearrangement. Age at surgery ranged from 10 months to 6.5 years (mean age, 2.2 years). All patients have acceptable nasal contour and have demonstrated excellent nasal growth. The authors' experience demonstrates that early surgical intervention is an acceptable alternative for the management of nasal hemangiomas.

Verrucous hemangiomas are a distinct subset of vascular malformations that have not been described extensively in the plastic surgery literature. They are characterized by reactive epidermal acanthosis, papillomatosis, hyperkeratosis, and extension into the subcutaneous tissues. In response to injury, infection, or subtotal resection, they enlarge and become increasingly keratotic. In light of contemporary definitions of hemangiomas and malformations, the authors recommended that these lesions be renamed verrucous malformations. The authors review their evaluation and treatment of 6 patients with this lesion and offer an algorithm that emphasizes excision over ablative therapy. Of the 6 patients, 3 patients had failed either cryotherapy or laser removal by a nonsurgeon, with a consequent increase in lesion size and discomfort. The lesions were all subsequently excised. Because of the size and location of the verrucous malformations, staged removal was required in 3 patients. Patients have been followed for as long as 7 years. A single recurrence was controlled with reexcision. Excision of verrucous malformations, rather than laser ablation or cryosurgery, is supported by the authors' favorable results.

The sliding door flap raised on the surface of the vermilion to the oral mucosa has been used for reconstruction of soft-tissue defects of the lower lip. The blood supply to this flap comes from the bilateral inferior labial artery. Utilizing both sides of the arteries, bilateral flaps allow for safe and easy transfer of the vermilion tissue to partial defects of the red lip. These flaps have been used in cases of lower lip defects with complete survival. The sliding door flap has increased mobility by at least 1 cm more than by the other style of flap reported by Goldstein. Moreover, this flap contributes to excellent cosmetic results. Our technique and clinical experiences are presented.

The application of the Mitek Anchor System for bony fixation of the flap in the cheek area is described. The cervicofacial rotation-advancement flap is fixated to the malar bone using Mini Anchors for the purpose of diminishing the downward traction on the lower eyelid. They reduced the tension in the distal part of the flap and avoided distal-edge necrosis and ectropion. In another patient the free vascularized musculocutaneous flap, which had been grafted previously for a surgical defect in the cheek and resulted in ectropion of the lower eyelid, was fixated to the malar bone, and the ectropion was corrected. The Mitek Anchor System is useful in flap fixation to the bone because it provides a simple, fast, and reliable method for flap fixation with minimal dissection and precise placement.

A cohort of 118 twin pairs with infantile hemangioma was reviewed to determine clinical characteristics and to estimate the relative contribution of hereditary and/or environmental factors to pathogenesis. Questionnaires were sent to parents of twins in Massachusetts and Australia. Zygosity was determined by clinical questions. Accuracy of ascertainment was based on clinical and anatomic criteria. Race, gender ratio, topographic distribution, number of lesions, age of onset, and complications were all consistent with demographic data from other studies of infantile hemangioma. Of the 118 pairs, 40 were monozygotic twins (32 like-sex females and 8 like-sex males, and 78 were dizygotic (30 like-sex females, 17 like-sex males) and 31 unlike sex). The concordances in monozygotic and dizygotic female twins were 32% and 20%, respectively (p = 0.5). In like-sex male monozygotic and dizygotic pairs, the concordances were 25% and 12%, respectively (p = 0.4). These differences were not statistically significant. This study suggests that hereditary factors are not paramount in causing hemangioma. However, being female, fair-skinned, Caucasian, and having a positive family history presumably lowers the threshold for hemangiogenesis wherein extragenetic factors can trigger the appearance of this most common tumor of infancy.

A retrospective study of 245 patients with 299 hemangiomas treated from May 1981 to April 1994 was done. A subset of 175 of these patients (58.5%) had hemangiomas of the head and neck. Six of the 175 (3%) required reconstruction following laser therapy. Tissue expansion was chosen for each of these reconstructions. Five females and 1 male underwent tissue expansion. The age of the patients at the time of tissue expansion ranged from 2.5 to 12 years, with an average of 6 years. Tissue expander sizes were 50 cc and 100 cc. Infection was seen during the course of expansion in 1 patient. Satisfactory results were achieved after reconstruction in all cases. Tissue expansion is the treatment of choice for reconstruction of head and neck hemangioma deformities following laser or other surgical procedures as well as involution.

Although the advent of endoscopic technology is expanding the fields of reconstructive and aesthetic surgery in adults, there have been to date no reports of its use in the pediatric population. Because of its minimally invasive nature, yet wide range of exposure, endoscopic techniques have much appeal in this age group. Herein we present our initial experience with endoscopic pediatric plastic surgery. From February 1995 to December 1995, 41 patients were treated utilizing 5-mm and 10-mm endoscopes at Scottish Rite Children's Medical Center, Atlanta, GA. There were 19 males and 22 females. The mean age at surgery was 5.6 years (range, 7 months-15 years). The most common types of procedures performed were insertion of tissue expanders (N = 19), excision of facial dermoids (N = 7), torticollis release (N = 5), and excision of vascular lesions (N = 4). The remaining 6 patients underwent a variety of reconstructive procedures. The complication rate in the tissue expander group was 3 out of 39 expanders inserted (9.5%), and consisted of infection (N = 2) and rupture (N = 1). In the dermoid group, complications consisted of wound infection requiring reoperation (N = 1), and transient frontal paresis (N = 1). One patient in the hemangioma group had an incomplete resection necessitating open excision. The remaining patients all had satisfactory outcomes with no complications. The majority of the procedures were done on an outpatient basis. These results suggest that endoscopic techniques are eminently applicable in the pediatric population, providing the benefits of small and remote incisional wounds with complication rates that are comparable to those of conventional surgical treatment.

The approach to a rapidly growing vascular tumor is determined by a number of objective and subjective factors. As a rule, treatment of a hemangioma in an infant is usually delayed, in the expectation that involution will be complete. While most hemangiomas are harmless vascular marks, some may grow to become large, infiltrating masses. Local factors that influence treatment decision making include volume, ulceration, secondary infection, and bleeding of the tumor. Hemangiomas situated on the nose are distinguished from other locations by a few but important aspects and may demand a more aggressive position from the surgeon. An important consideration is the potential for aplasia of the delicate nasal cartilages that are undergoing development, due to the mass effect of the tumor. Nasal tip hemangiomas are slow to regress, and contour deformities result from the fibrofatty tissue that invariably remains even after total involution. More importantly, hemangiomas of the nasal region are particularly prone to causing great social distress to the parents, who will request prompt treatment for such a visible, deforming lesion. A definite solution that ensures removal of affected tissue and preservation of anatomy seems to be the best treatment for these tumors. In this article, the experience of the senior author (IP) in treating hemangiomas located on the nose is reviewed. The elliptical midline incision over the nasal dorsum described in the text was developed to address three important aspects: an expedient procedure to treat a highly disfiguring disease; an open access to allow for complete resection and, at the same time, allow for the correction of underlying cartilaginous disruption; and placement of a scar in an anatomic location proven to be very satisfactory aesthetically, permitting access for secondary procedures for better definition of nasal contour. Careful patient selection for this surgical procedure is emphasized.

A patient with Wolf-Hirschhorn syndrome had multiple congenital anomalies and a right cleft lip. Hemangioma involved the full thickness of the upper medial lip segment at the age of 2 months, which caused lip repair to be very difficult. The first attempt at adhesion cheiloplasty resulted in complete separation. The tumor did not respond to steroid treatment. A subsequent trial of lip repair with the assistance of a tension-relieving suture tied to the nasal septum was successful. This type of tension suture is helpful to prevent dehiscence when security of lip closure is questionable or cannot be achieved.

Seventy-six patients (51 females, 25 males) with port-wine stains (PWS) were treated with the flashlamp-pumped pulsed dye laser (585 nm, 450 microseconds). The patients ranged in age from 1 month to 71 years (average, 14 yr). Forty-nine percent of all patients under study had a 90% or better (average, 94.6%) lightening response after an average of 9.0 (range, 4-15) laser treatment. Overall, there was a 79% clinical improvement seen after an average of 9.1 (range, 2-19) laser treatments. In contrast to previous studies, the number of treatments necessary to obtain PWS clearing in older children (9-15 yr) and adults (> 16 yr) was not significantly greater than the number required to treat PWS in infants (0-2 yr) and younger children (3-8 yr). In fact, PWS in children aged 3 to 8 years required the greatest number of laser treatments, which may be due to continued abnormal growth of the ectatic blood vessels comprising the lesion during the growth of the child. In addition, there did not appear to be a significant difference in the number of laser treatments necessary to obtain clearing of PWS in different body locations. While the 585 nm pulsed dye laser continues to be the treatment of choice for removal of PWS in children and adults, the number of treatments necessary to obtain lesional clearing in all age groups in greater than previously reported.

The argon-pumped tunable dye laser (APTDL) is useful in the treatment of a wide variety of superficial vascular and melanocytic lesions. Safety is enhanced by the use of a computerized scanning device--the Hexascan. Over a 1-year period, 140 patients (33 patients under the age of 21, and 21 patients from 0 to 10 years of age) were treated. Facial rosacea/telangiectasia was the most frequently treated lesion, followed by port-wine stain. Although multiple treatments were often necessary, fading was successfully achieved in most patients without scarring or other complications.

Lips may need to be repaired because of congenital malformations, benign or malignant tumors, or trauma. When a large portion of the lip is involved in the defect, or when this portion is cosmetically relevant, the repair may be particularly challenging and requires a perfect technique. We devised a surgical technique for the reconstruction of the vermilion that involves the use of a large portion of the mucosa vestibularis and of the underlying musculus orbicularis. The mucosa and muscle are taken from one lip and are rotated to cover the quantitative and qualitative defect of the opposite prolabium. Two stages are required in this procedure.

Diagnostic criteria of vascular lesions in the face were studied in a series of 57 patients investigated and treated during the years 1980 to 1990. Twenty-eight had hemangiomas and malformations, and 29 had telangiectasia. At present, the histological diagnoses are most commonly used to describe vascular lesions, but unfortunately this gives little idea of the actual appearance of the lesion. In the present study, the clinical appearance was compared and correlated with the findings at the time of surgery, with the angiographs, and with the histological diagnosis. An attempt was undertaken to coordinate the accepted clinical, microscopic, and angiographic classifications with our own results. Based on the modern concepts of pathology of angiogenesis and the conclusions drawn from our present investigation, the "new," unifying classification of vascular lesions was compiled. This classification is presented in the form of a diagram.

Eight patients treated with dermal-fat grafts and 8 patients treated with vascularized tissue transfer were retrospectively reviewed to determine the efficacy of the two methods in the treatment of the soft-tissue defects in Romberg's disease, clefting syndromes including hemifacial microsomia, and traumatic defects. Follow-up averaged 4 years and ranged from 1 to 9 years for the vascularized transfers and 1.5 to 11 years for the dermal-fat grafts. Both techniques were able to provide enduring augmentation. The vascularized transfers were able to provide a greater amount of augmentation. We conclude that dermal-fat grafting is a satisfactory technique for mild to moderate defects, but that vascularized transfers are required for moderate to severe defects.

A new technique is presented for the treatment of deep vascular lesions. A potassium-titanyl-phosphate (KTP), argon, or Nd:YAG laser is attached to a fiberoptic wand, which is passed percutaneously. The laser is activated and coagulates the lesion without direct injury to the skin. Eleven hemangiomas and two lymphangiomas have been treated using this technique. A reduction in size of the lesions was obtained in all patients. Repeat treatments were done to improve results in six patients. Conventional transcutaneous laser therapy was used as an adjunct in four patients. Average patient follow-up was 29 months. No major complications have been noted in this series. Percutaneous fiberoptic photocoagulation has been found to be a safe, long-lasting technique for the treatment of deep vascular lesions.

Gardner's syndrome is a hereditary disease manifested by multiple colonic polyps that progress to malignancy at an early patient age and also manifested by multiple lesions of the different germ layers including sebaceous cysts, lipomas, fibromas, and osteomas of the facial bones. The plastic surgeon often is asked to treat these patients for the more mundane manifestations of the disease such as inclusion cysts or lipomas. At times, however, the plastic surgeon may be faced with an unusual presentation. Two such unusual cases are presented here, the first being a hemangioma of the hand, which has never been described in a patient with Gardner's syndrome, and the second being a fibroma of the left cheek requiring excision by an intraoral approach.

One hundred six cutaneous vascular abnormalities were treated over a 3-year period by the argon laser. Absorption of light energy causes heat coagulation of the hemangioma with sparing of the overlying skin and secondary skin appendages. Patients with port wine hemangiomas, capillary/cavernous hemangiomas, and telangiectasia showed good response to argon laser treatment. Superficial varicosities of the lower extremity proved to be relatively insensitive to laser treatment. The argon laser shows promise as an effective clinical tool in the treatment of hemangiomas; however, further clinical and laboratory investigation will be necessary to establish the laser as the modality of choice in the treatment of such lesions.

Hemangioma of the zygomatic bone is an extreme rarity. Six cases have been reported in the English literature. These reports and the 2 new patients presented here constitute the basis for our data. Clinical, histopathological, therapeutic, and reconstructive considerations are discussed.

We report unsatisfactory results of electrothrombosis for the treatment of venous angiomas. After we reviewed a report of successful use of electrothrombosis for treating cirsoid angiomas of the face and scalp and varices of the leg, a clinical trial was begun with 6 patients in whom previous conventional surgery was relatively unsuccessful and in whom further surgery had not been recommended owing to the high risk or probability of unsatisfactory results. Two patients had objective clinical improvement, resulting in no further treatment in 1 patient and allowing secondary surgical correction in the other. Four patients had no significant improvement. We now recommend and will continue further laboratory research with electrothrombosis for the treatment of angiomas before treating additional clinical cases.

Hemangiomas are the most common benign tumors of infancy and childhood. Most involve skin and subcutaneous tissues and are readily visible. Intramuscular hemangiomas are very uncommon, and rarely appear in the musculature of the head and neck. A 59-year-old woman who had had a lipoma excised from her left temporal region many years earlier underwent excision of a hemangioma of the left temporalis muscle. Intramuscular hemangiomas do not spontaneously involute and should be removed as soon as they are diagnosed, in order to obviate later destruction of the involved muscle and adjacent tissues. Preoperative embolization of the hemangioma may reduce intraoperative hemorrhaging.

Pathophysiological effects of the argon and carbon dioxide lasers are discussed in detail in reference to pediatric hemangioma problems. Capillary/cavernous hemangioma excision by lasers is illustrated by case examples. Benefits as well as indications for laser usage in the pediatric age group are reviewed. Relatively bloodless excision of hemangiomas by the laser renders this modality particularly valuable for pediatric patients.

The Nd:YAG laser is well suited for the treatment of cutaneous vascular lesions. The characteristic properties of the Nd:YAG laser emissions in tissue are a high degree of penetration with low absorption by unpigmented tissue. The result is a coagulative effect on tissue containing hemoglobin with relative skin sparing. The Nd:YAG laser was used to treat 116 patients with a variety of cutaneous vascular lesions. Good to excellent results were obtained with a low complication rate for deep cavernous and capillary lesions, port wine stains, and minor vascular ectasias above the lower extremities. Minor venous ectasias and varicosities located on the lower extremities responded poorly. The Nd:YAG laser represents an efficacious tool for the treatment of difficult vascular lesions, with the exception of venous lesions of the lower extremities.

In the natural color system (NCS) the notations are based on psychometric experiments and give a cognitive description of color appearance. It is shown by clinical examples that the NCS is a useful method for evaluating laser treatment results, and that NCS also makes it possible to express the results in numerical values in 2 ways.

A microsurgical dissection technique for residual strawberry marks applied to patients 6 years of age or older (a total of 7 cases) resulted in minimal bleeding during the operations. Therefore, the same technique was used for patients aged 4 months through 3 years and 4 months. The latter 8 patients had a minimal amount of intraoperative bleeding (no tourniquet was applied to the upper arm case), direct skin closure of the wound, and no postoperative complications. The procedure is tedious but makes dissection of the hemangioma easier because of the watery subcutaneous structure in the infant; it also is less traumatic than the usual surgical dissection technique. We found this procedure to be valuable for complete removal of the unwanted strawberry mark with subcutaneous hemangioma in infants.

Patients with large and small port-wine stains have been studied using an intensive interview technique. Those with large defects were shown to have reality problems in common. In addition, their experiences were found to be tempered by individual life events and personality dynamics. Those with small port-wine stains who sought treatment showed no reality problems but experienced great individual psychological problems, which in this study are proved to be the same type. The implications of these findings for prophylaxis against mental illness as well as factors to take into consideration when treating these patients are discussed.

Lipomas constitute the most common soft-tissue tumors [11] and may occur sporadically or as one of several inherited disorders. Benign fatty tumors can be classified into three major categories: solitary lipomas, familial multiple lipomatosis, and congenital diffuse lipomatosis [4]. The latter has also been referred to as multiple symmetric lipomatosis, Madelung's disease, or Launois-Bensaude syndrome. Within the categories a more vascular varient of the lipoma, the angiolipoma, has been described separately by some authors, but in many reports it is not distinguished from a lipoma. Liposuction has been used for the treatment of solitary lipomas, but to our knowledge liposuction has not previously been reported for excision of angiolipomas or in familial cases involving multiple lipomas as described here.

Thirteen patients with capillary/cavernous hemangiomas of infancy have been treated with a combination of neodymium: YAG laser photocoagulation plus direct local instillation of steroids. In all cases, rapid growth immediately ceased and blanching started. Shrinkage of the lesions then occurred spontaneously over the ensuing months; any plateau in shrinkage was retreated. Five of 13 patients experienced dramatic blanching and shrinkage with one treatment. Six experienced mild to moderate shrinkage. Complications occurred in 2 patients.

Telespectrophotometric reflectance measurements are shown to give objective values of spectral changes in the port-wine stain skin after argon laser therapy. There are, however, many circumstances influencing the measurements and other factors to consider when evaluating the curves, which are hard to translate into human visual experience. Natural color system notations based on psychometric experiments, which give a cognitive description of color appearance, seem to have more value for qualitative judgement of the color change after treatment.

Using three different instruments, cryolesions were made in the skin of experimental animals (pigs) and the extent of necrosis was determined after one week. The most efficient device was a probe using liquid nitrogen; the amount of tissue killed varied directly with contact time. With all the instruments, a freeze of three minutes consistently led to full-thickness necrosis of the skin. The freeze-thaw-refreeze technique did not produce as much necrosis as a single continuous freeze of the same duration. Cryosurgery was used on 65 benign skin tumors in patients. Pain was minimal and the cosmetic results were excellent. The only difficulty with the method was that it occasionally failed to kill the lesion. For that reason, at present cryosurgery is recommended only for benign lesions. If one suspects that a tumor might be cancerous, it should be biopsied before freezing. If it proves to be malignant, further treatment (excisional or x-ray) should be considered strongly.

The present study documents the treatment and follow-up of 25 patients treated for four different types of superficial facial vascular lesions with the continuous wave, mechanically pulsed, yellow (577-nm wavelength) tunable dye laser using a 100-mu spot diameter handpiece and pulse durations of 0.05 to 0.10 s. When absorbed, this wavelength generates heat specifically within superficial blood vessels and, if delivered in a brief, intense pulse to a small, focused spot, can cause selective damage without destruction of the adjacent epidermis or surrounding dermis. The results indicate that the physician can attain an excellent clinical outcome while significantly reducing potential adverse side effects seen in treating these lesions with more conventional laser systems.

The indications for and limitations of cryosurgery for various types of hemangiomas on the body surface or in the intraoral region are reported based on our clinical experience. In our opinion, cryosurgery is not the method of choice in the management of hemangiomas but is useful under certain conditions, as with a localized cavernous under certain conditions, as with a localized cavernous hemangioma in the facial or intraoral region. It is also valuable for strawberry marks with bleeding or infection and may be acceptable for small port-wine stains; in the treatment of extensive port-wine stains, a resulting hypertrophic scar or depigmentation may present difficulties.

The principle and the many technical details of surgical treatment for large facial port-wine stains are outlined. The treatment consists of subtotal excision of the port-wine stain, retaining the dermal base and covering the defects with carefully selected full-thickness skin grafts. Complications and results are discussed.