Hemangiomas - Surgery

Surgical Management

Surgical resection of hemangiomas is possible. It is important to realize that there is no text describing these procedures. The experience and past results of the surgeon are important. Since hemangiomas are vascular tumors, the risk of severe blood loss is a possibility but in experienced hands, this risk is negligible. Surgical resection should be reserved for lesions that are unlikely to involute (shrink) spontaneously and the experience of the surgeon is of paramount importance.

Whether or not surgery is indicated will depend on a number of factors. In general, if there is a complication best treated with surgery or if it is likely that the outcome of spontaneous regression or medical management is not likely to leave a satisfactory outcome, then surgery should be considered. The scope of this narrative does not permit a complete discussion of all of the indications for surgery but we will attempt to cover the most common.

Hemangioma Complications

There are a number of complications that can be treated surgically. These include:

Eyelid Hemangiomas

Hemangiomas of the eyelid are serious enough to warrant special consideration. The cornea of the eye is partly responsible for focusing an image on the retina of a child's eye. The presence of a hemangioma on one or other of the eyelids can interfere with this. As the hemangioma expands, it can deform the cornea by virtue of its weight. This will cause an image to be focused on multiple planes and the result is an out-of-focus image. This is known as astigmatism. Astigmatism in both eyes is usually not a problem, but if it affects only one eye, the child's developing brain will ignore the out of focus eye and a "lazy" eye will develop. This can result in blindness of that eye. It is therefore imperative that the child be seen by a pediatric ophthalmologist. We have been able to remove these hemangiomas very successfully and if this is done early enough (before 8 months of age) the astigmatism will reverse. Both Propranolol and steroid injections have also been used to treat these hemangiomas, but we may not have the luxury of waiting several months to see the results of treatment. In our experience, surgical resection can completely eliminate the hemangioma as well as the astigmatism (if done early) (See Fig. 1).

Ulceration

Ulceration refers to a loss of skin covering the hemangioma. The cause for this is not known. Ulceration can occur in both focal and segmental hemangiomas. In general, ulceration is extremely painful and the degree of pain seems to be out of proportion to the degree of ulceration. Ulceration usually persists for many weeks or even months. An ulcerated hemangioma can bleed and at times, these bleeds can be severe. Surgery can be used to remove a focal hemangioma and this will dramatically reduce the degree of pain experienced by the child. Hemangiomas that have ulcerated almost always leave a scar and this can be surgically corrected. Hemangiomas of the nose almost always require surgical intervention. Hemangiomas of the upper or lower lip will often require surgical correction.

(Example of tissue loss from an ulcerated upper lip and nose hemangioma. See Fig. 3)

(Example of same patient after surgical reconstruction of the nose and surgical correction of the upper lip. See Fig. 4)

Airway Obstruction

A hemangioma can also involve the airway and this can lead to obstruction of the child's airway. This can occur in the presence of a beard distribution segmental hemangioma or with a focal hemangioma. The early sign of this is noisy breathing. If this is suspected, the child should be seen by a specialist in this field. We usually recommend an Ear Nose and Throat Surgeon. In some cases, surgery may be necessary to overcome the obstruction.

All hemangiomas involute. Involution simply means shrink. This process may or may not result in a satisfactory outcome. It is important to realize that involution may take many years and the process may be complete by 10 to 12 years of age. If it is likely that the outcome of involution will not leave a satisfactory result or if the process is taking too long, then surgery can be considered. We prefer to have the child looking as normal as possible by two and half to three years of age since this is the age of awareness and self-esteem. Early surgery has the advantage of healing with less scarring and this should always be taken into consideration.

There are no hard and fast rules regarding the treatment of hemangiomas. It is therefore advisable for the parents to seek expert opinion. This may mean several opinions and unfortunately, these may differ.