Management of hemangioma of infancy: review of 245 patients.

A retrospective study of patients treated from May of 1981 to April of 1994 was conducted. A total of 245 patients with 299 hemangiomas were studied, which represents the largest series reported to date. The study consisted of 173 females and 72 males ranging in age from 1 day to 59 years, with the average age being 4 years and 7 months. Twenty-six were premature neonates (14 females and 12 males). An interesting finding was a 1:1 sex ratio among this group in contrast to the 3:1 female-male ratio frequently reported in the literature. Onset was at birth in 170, within the first month in 43, and after the age of 1 month in 32 patients. Among the 245 patients, 175 hemangiomas were located on the head and neck, 62 on the trunk, 49 on the extremities, and 13 in the perineal area. Five groups of patients were defined based on clinical management. As a result, these groups are not similar. The five groups are as follows: group I (48), observation; group II (9), steroid treatment; group III (27), excision and reconstruction; group IV (88), laser therapy; and group V (73), combined therapy. The involved area of hemangioma was as follows: group 1, 0.5 x 0.5 to 20 x 8 cm; group II, 2 x 2 to 8 x 8 cm; group III, 0.4 x 0.8 to 7 x 7 cm; group IV, 0.5 x 0.5 to 20 x 9 cm; and group V, 1.5 x 1.5 to 25 x 25 cm. The complications of hemangioma seen at the time of consultation were obstruction (28.6 percent), ulceration (20.4 percent), bleeding (14.7 percent), infection (4.9 percent), and pain (0.4 percent). Treatment periods ranged from 1 month to 11 years, with the mean period in each group as follows: group I, 4 years and 9 months; group II, 2 years and 5 months; group III, 1 year and 1 month; group IV, 2 years and 1 month; and group V, 3 years. The outcomes of each patient were evaluated based on improvement of volume, color, and texture by the following scale: 1, poor (0 to 25 percent); 2, fair (26 to 50 percent); 3, good (51 to 75 percent); and 4, excellent (76 to 100 percent). Each of these parameters was summarized for each of the five groups. Statistical analysis by the Irwin-Fisher test was used for analysis and comparison of the final results between groups. Statistically significant differences in outcomes between treatment groups were demonstrated. Laser therapy was shown to be statistically superior to observation with regard to length of treatment and with regard to outcomes of volume and texture (p < 0.05).

Laser treatment of complicated head and neck hemangiomas in infancy.

A retrospective study of 73 patients treated for symptomatic hemangiomas of head and neck from May 1981 to April 1994 was conducted. Fifty-three females and 20 males ranging in age from 1 day of life to 11 years with the average age being 19 months were reviewed in the University of California, Irvine Medical Center. All patients were referred by pediatricians or family practitioners for evaluation and possible laser treatment. The lesions reported were particular troublesome because of obstruction of orifice(s), repeated ulceration, bleeding, subsequent pain or life threatening. Various lasers have been used for these patients including: CO2 laser [10], Argon laser/with intralesional steroid injection [33/14], Nd YAG laser [21], KTP laser [1] and Flashlamp-pumped pulsed dye laser (FPPDL)[8]. All treated lesions healed in 7 to 21 days (mean, 12 days). Complications associated with laser treatment, such as postoperative bleeding and infection were not seen. The symptoms were totally relieved from 7 days to 24 months (mean, 9 months). Combined with reconstructive surgery, the texture changes (7 patients) after laser treatment were corrected successfully. The outcome was graded by reduction in volume, improvement of color and texture of hemangioma as follow: Grade 1 - Poor (0-25%); Grade II - Fair (26-50%); Grade III - Good (51-75%); Grade IV - Excellent (76-100%). The final results of the patients are similar to what may be expected after spontaneous involution of a complicated hemangioma. In summary, complicated hemangiomas of head and neck in infancy have significant morbidity that can be efficiently avoided with the use of laser therapy.

Treatment of vitiligo with melanocytic grafting.

This case report documents the treatment of extensive vitiligo with melanocytic grafting using ultra-thin, split-thickness skin grafts. Results, limitations, and disadvantages are discussed.

Electrical burn injury to the upper extremity.

Our experience with a group of 22 patients with electrical injuries to the hand is reported. Some guidelines in management are formulated.

Treatment of traumatic tattoos by Q-switched ruby laser.

The Q-switched ruby laser is currently used in the treatment of amateur and professional decorative tattoos. The present study documents the clinical management and follow-up of 12 subjects with traumatic tattoos treated with the Q-switched ruby laser. The results of this study indicate that an excellent clinical outcome can be achieved with substantial removal of the targeted foreign pigmented matter while potential adverse effects are significantly reduced. Hypopigmentation, which occurred in four patients (33.3 percent), was temporary and resolved spontaneously in all subjects within 6 months of laser exposure. There was no hypertrophic scarring, atrophy, or induration seen in any of the subjects treated with the Q-switched ruby laser.

Management of vascular and premalignant nevi in the pediatric population.

Successful management of the pediatric patient is a challenge to plastic surgery nurses as they work in tandem with surgeons to guide the family through the treatment process. This article will discuss the treatment of a number of congenital birthmarks, specifically congenital vascular birthmarks and congenital nevi, which have a potential for malignant transformation.

Clinical experience with the tunable pulsed-dye laser (585 nm) in the treatment of capillary vascular malformations.

A retrospective review of 134 patients who received laser therapy with the pulsed-dye laser at the 585-nm wavelength for capillary vascular malformations was conducted. These patients were treated over a 5-year period with a minimum follow-up of 2 years. Ninety-five patients were available for evaluation of results. Thirty-nine were lost to follow-up. Each birthmark was described before and after treatment under a classification system developed by the authors. Results were reported by classification, age, anatomic location, and race. Excellent or good results were obtained in the majority of patients in all age groups and regardless of the color of the birthmark. All anatomic areas and all ethnic groups responded to treatment with varying degrees of success. A range of up to eight treatments was required to achieve resolution. Scarring was an infrequent complication (1.1 percent) of treatment. Hypopigmentation was seen in 3.2 percent of treated patients. The pulsed-dye laser (585 nm) offers promise to patients of all ages and hope to those who previously were not candidates for laser therapy.

Vascular lesions.

Most cutaneous vascular abnormalities can be successfully, and in fact preferentially, treated with lasers. The field is evolving rapidly. It is important that the appropriate laser be used. In addition, many of the early references in this field are quite out of date. We are treating lesions at a much earlier age and our expectations are much higher. We expect the result to be virtually normal-looking skin with complete resolution of the problem. Capillary vascular malformations (port wine stain) are the most frequent indication for laser treatment in both children and adults. With the advent of the flashlamp pumped pulsed dye laser, these lesions can be treated in infancy and early childhood. This represents a significant breakthrough, because unlike with previous lasers, scarring is a rare side effect of treatment with yellow light lasers. The psychologic trauma of growing up with a facial deformity can be minimized with early treatment. It is hoped that the hypertrophy and permanent deformity associated with these lesions can be mitigated. The various lasers currently available to the plastic surgeon provide treatment options not previously available. Lasers are expected to play an increasing role in cutaneous abnormalities in the field of plastic surgery.

Results of a survey of cleft palate teams concerning the use of nasendoscopy.

A national survey was conducted concerning methods used for the evaluation of velopharyngeal function with emphasis on the role of nasendoscopy. Forty-five percent of questionnaires were returned. Ninety percent of the responding teams indicated that nasendoscopy was available. Sixty-one percent agreed that endoscopy was an important clinical tool and not solely a research tool. The majority (59%) considered 3 to 5 years of age to be the youngest, appropriate age for referral. Ninety percent agreed that nasendoscopy was indicated for difficult diagnostic problems and 41% reported endoscopic studies were appropriate for all patients for whom secondary palatal management is planned. The results of this survey suggest that endoscopic assessment of velopharyngeal function is used routinely as an adjunct to the perceptual evaluation of speech and has become the standard of care among cleft palate teams for difficult diagnostic cases. However, the data also indicate that increased availability does not necessarily assure optimal use.

Strawberry hemangioma of infancy: early definitive treatment with an argon laser.

This report documents the successful treatment of a hemangioma (strawberry hemangioma) at 5 weeks of age with the argon laser. The natural course of strawberry hemangioma of infancy is well known. It begins as a very small spot and develops very rapidly within the first few weeks of life. Many grow to a very large size and produce significant morbidity. It is logical to assume that if these were ablated early, the life cycle could be aborted. The patient of this case study developed two spots that appeared to be typical evolving hemangiomas. One was treated and disappeared. The other was not treated and evolved into a typical strawberry hemangioma that eventually involuted. This would indicate that early treatment holds some promise.

Ulcerated anogenital hemangioma of infancy.

Ten female infants were referred for symptomatic hemangiomas in the anogenital area. (One had had steroid treatment prior to consultation.) The natural history of these lesions is well known. Virtually all will spontaneously involute over a period of years. However, the lesions reported were particularly troublesome because of repeated ulcerations and subsequent pain. Prior treatment had been local wound care with antibiotic ointment and Telfa-type dressings. After referral from a family practitioner or pediatrician, argon laser treatment was performed in an outpatient setting. Eight of the 10 patients were treated with local anesthesia, and 2 had general anesthesia. All lesions healed in 1 to 5 weeks. No patients referred during this period were excluded from this series. All who received treatment were included. All the lesions involuted following treatment. In our estimation, the final result is identical to what may be expected after spontaneous involution of an ulcerated or infected hemangioma. The major difference is that involution occurred in a few weeks in laser-treated patients rather than a period of months or years. Ulcerated hemangiomas of the anogenital area have significant morbidity that can be efficiently avoided with the use of argon laser therapy. Lesions of the anogenital area have a strong predilection for females.

Clinical experience with the pulsed-dye laser in the treatment of capillary malformations (port-wine stains): a preliminary report.

This preliminary report reviews a series of 70 patients treated with tunable-dye laser therapy for congenital capillary malformations (port-wine stains). Results were reviewed according to age and ethnic group of patients and color and anatomical location of malformations. Red birthmarks were most responsive to treatment in all age groups in all anatomical locations. Purple birthmarks were generally less responsive to laser treatment except in children, who responded well. Scarring and hypopigmentation were minimal (5.7% and 1%, respectively), even in nonwhite patients. Recommendations emerging from this study include testing of infants, as results may vary. Detrimental side effects are rare. A major goal in treating port-wine stains is to avoid both the progression of these lesions through life and the psychological complications that occur during early socialization years in childhood. Pulsed-dye laser treatment offers much promise in these areas.

Capillary hemangioma (strawberry mark) of infancy: comparison of argon and Nd:YAG laser treatment.

Capillary hemangioma of infancy (strawberry mark) is a self-limiting problem, and conservative treatment is recommended. These birthmarks can be associated with a great deal of morbidity. There is definitely a role for a palliative form of treatment without systemic complications or destruction of adjacent tissue. In a 6-year period, 55 patients received 57 Nd:YAG or argon laser treatments. Thirty patients received 31 argon treatments, and 25 patients received 26 Nd:YAG treatments; and 2 received first argon with subsequent Nd:YAG treatments. Although more dramatic successes were noted in the Nd:YAG laser, complications were more frequent and severe. Complications included delayed healing, postoperative bleeding, and some hypertrophic scarring. Complications were seen in 12 percent of all patients, 9 percent of these associated with the Nd:YAG laser.

Treatment of extensive adenoma sebaceum with a carbon dioxide laser.

This case report documents the successful removal of a sizable and symptomatic adenoma sebaceum from the face, nose, and palate with the carbon dioxide laser.

Argon laser treatment of telangiectasia of the face and neck: 5 years' experience.

This study documents the treatment and long-term follow-up of telangiectasias of the face and neck with the argon laser. This study concurs with other examiners that treatment is effective with minimal complications and satisfactory long-term results.

Argon laser treatment of strawberry hemangioma in infancy.

Argon laser therapy is effective for removing port-wine stains and for reducing cutaneous vascular and pigmented lesions. Strawberry hemangiomas, being much thicker lesions than port-wine stains, were considered not appropriate for argon laser treatment. Using argon laser therapy in 13 cases of strawberry hemangioma, we achieved poor to dramatic results.