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.
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.
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.
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