Early Surgical Intervention for Proliferating Hemagiomas of the Scalp -- An Article Review

 Updated 3/2017--photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

First I want to repost this information on hemangiomas from last July. It was included in a post on Vascular Birthmarks.

Hemangiomas.

Hemangiomas are classified as superficial when they appear on the surface of the skin ("strawberry marks") and cavernous when found deeper below the skin's surface. They can be slightly raised and bright red and sometimes aren't visible until a few days or weeks after a baby is born. Cavernous, deep hemangiomas may be bluish because they involve blood vessels in deeper layers of the skin. Hemangiomas grow rapidly during the first 6 months or so of life, but usually shrink back and disappear by the time a child is 5 to 9 years old. Some, particularly larger ones, may leave a scar as they regress that can be corrected by minor plastic surgery. Most are on the head or neck, although they can be anywhere on the body, and can cause complications if their location interferes with sight, feeding, breathing, or other body functions.

Approximately 30% of all hemangiomas are visible at birth. The remaining 70% become visible within one to four weeks after birth. They affect approximately one in 10 to 20 Caucasian children, with a 3:1 predilection for the female sex. The incidence in non-Caucasian infants is lower.

Hemangiomas are endothelial neoplasms. To date, there is no universally accepted model for the etiology of hemangiomas. There is general consensus on the importance of endothelial cells, but the source of the endothelial cells is speculative and there is no consensus on the possible mechanisms by which the hemangioma endothelium interacts with surrounding cells. There is a scientific debate on whether they are of mutational or placental origin or fit in a developmental field disruption. In the past hemangiomas were once thought to be due to maternal behavior or thoughts during pregnancy. The term vascular birthmark itself implies a connection between birth and a vascular lesion. The term strawberry nevus indicates that the mother's intake of red fruits (strawberries) was once thought to cause birthmarks. It is important for the family to remember that the cause of hemangiomas has not been determined, and neither parent should bear guilt over the occurrence or appearance of one of these birthmarks. Approximately 83% percent occur on the head and neck area. The remaining 17% appear throughout the rest of the body (both externally and internally).

At birth, a precursor lesion may be present as an erythematous patch or a telangiectasia. Within weeks the lesion expands rapidly. Hemangiomas can grow for up to 18 months and then begin a long slow regression known as involution. This involution can last from 3- 10 years. This dramatic/fast growth of a hemangioma may seem alarming, but usually no treatment is indicated. This is because this rapid growth phase is followed by a gradual involution (regression) in the following years. At the age of 5 years, 50 percent of the hemangiomas have involuted, and at the age of 9 years 90 percent have.

The ones that do need treatment are the ones that ulcerate, obstruct the airway, or cause visual deficits or cardiovascular symptoms. Current treatment may include intralesional or systemic corticosteroid treatment, systemic interferon treatment, local bleomycin treatment, and surgery. Early intervention has been shown to reduce the need for corrective surgery after "involution" has occurred; or to, at least, minimize extensive corrective surgeries in the future. Psycho-social scarring which occurs when a child has been forced to live with a facial deformity until "involution" has been completed can be avoided by early, aggressive intervention.

Now, I want to review the information in the first reference below (photo to the right from that article). It is basically a report of six cases and how they were treated. Their conclusions are:

Although patience may be virtuous for many hemangiomas, we feel that large hemangiomas of the scalp deserve special scrutiny.

Besides the commonly accepted reasons for surgical intervention (e.g., ulceration, hemodynamic instability, airway obstruction), large (and even not so large) hemangiomas of the scalp may invite a more aggressive surgical approach for the following reasons.

First, even if a hemangioma undergoes complete involution, the remaining fibrofatty skin is often atrophic. The dermal layer is extremely thin and devoid of normal skin appendages. This can lead to large alopecic areas and/or derangement of the natural hairline..........

Second, hemangiomas of the parietal scalp may impinge on the ear. Because of the well-known pliability of the neonatal ear, thought to be secondary to the effects of maternal estrogens, extrinsic deforming forces may result in a permanent deformity. Thus, there is an opportunity to both remove the deforming force and reshape the ear within an early postpartum window of opportunity. As demonstrated in cases 4 through 6, permanent ear deformity was avoided by early removal of the deforming hemangioma.

Finally and perhaps most importantly, the scalp of a newborn infant possesses significant elasticity because of a relative tissue excess and an inherent pliability resulting from the absence of a thick fibrous galeal layer. As the infant ages, this considerable redundancy of scalp tissue dissipates, which may limit the possibility of primary closure (with or without scalp rotation flaps) without the need for tissue expansion. It should be noted that in the case of neonates born prematurely, the optimal timing for surgical intervention needs to be considered individually, as the relative operative risk will vary with the degree of prematurity.

One reason for traditionally waiting (other than that most will regress) is the concern that excision of hemangiomas in infants can be associated with life-threatening bleeding. They offer three important technical points are emphasized to minimize this risk.

First, all excisions are performed only after infiltrating the lesion and surrounding tissues with a tumescent solution of dilute epinephrine.

Second, hemostatic polypropylene sutures may be placed around the hemangioma to limit inflow to the lesion.

Third, the plane of dissection is outside of the lesion in the avascular galeal layer. Although bleeding of any amount in an infant is potentially dangerous, application of these simple principles will reduce the chance of a potentially disastrous hemorrhage.

I would encourage pediatrician and family doctors to go ahead and make the referral to a plastic or ENT surgeon if the hemangioma is large and in the head/scalp region. The surgeon may choose to watch with you, but the patient will already be in the pipeline if something needs to be done early.

REFERENCES:

Early Surgical Intervention for Proliferating Hemangiomas of the Scalp: Indications and Outcomes; Plastic and Reconstructive Surgery:Volume 122(2)August 2008pp 457-462; Spector, Jason A. M.D.; Blei, Francine M.D.; Zide, Barry M. D.M.D., M.D.

Hemangiomas and Vascular Malformations in Infants and Children: A Classification Based on Endothelial Characteristics; The Pathogenesis of Hemangiomas: A Review; Plastic and Reconstructive Surgery:Volume 117(2)February 2006; Bauland, Constantijn G. M.D.; van Steensel, Maurice A. M. M.D., Ph.D.; Steijlen, Peter M. M.D., Ph.D.; Rieu, Paul N. M. A. M.D., Ph.D.; Spauwen, Paul H. M. M.D., Ph.D.

Progress to ward Understanding Vascular Malformations [Special Topic]; Plastic and Reconstructive Surgery:Volume 107(6)May 2001; Breugem, Corstiaan C. M.B.Ch.B.; van der Horst, Chantal M. A. M. M.D., Ph.D., and; Hennekam, Raoul C. M. M.D., Ph.D

Vascular Birthmarks: Hemangioma and Malformations. by Mulliken, John B. MD; Young, Anthony E. MD; Textbook--W.B. Saunder, Philadelphia, PA, 1988.

Hemangiomas and Vascular Malformations of the Head and Neck edited by Milton Waner, MD and James Suen, MD--Wiley-Liss, NY 1999