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HEMANGIOMA

Tommy. R
Sub.Bag. Bedah Plastik
FKUP / RSHS
Bandung
• Hemangiomas & lymphomas the most
common benign tumors in the skin and
deeper tissue of the neonate.
• Represent sequestra of fetal tissue that
consist primarily of endothelial cells.
• Before birth (congenital) or within at the
first 4 weeks of life (neonatal).
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
CLASSIFICATION OF HEMANGIOMA
Capillary hemangioma






Capillary –cavernous hemangioma
Cavernous hemangioma
Other hemangiomas

Wild-fire
Ulcerated
Spontaneous regression
Port-wine stain
Strawberry





Salmon patch
Campbell de Morgan
Telangiectasia
Pyogenic granuloma
Verrucous
Keratotic
Venous

by THOMSON
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• Most hemangiomas and lympangiomas 
small, localized, superficial sequestra that
are inconspicuosly located on the body.
• Emergent treatment for any of these
problem lesions is varied and depends on
the type, size, location, stage of
development, clinical course, and degree
of psychological impairment.
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
Classification of Vascular
Hamartomas
• No uniformity in the classification of
vascular hamartromas  great variation &
overlap in clinical and histopathologic
appearance.
• Mulliken and Glowacki and Pasyk et al,
proposed a classification based on cellular
dynamic / adynamic lesions of vascular
hamartomas.
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
Classification of Vascular
Hamartomas (Pasyk et.al)

Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
Cellular dynamic lesions :
• Possess definite proliverative & regressive phases
• Proliverative phase  H-thymidine uptake
• Presence of tumor angiogenesis factors
• Mast cell activity
• Syncytial cell formation

Cellular adynamic lesions
• Have no proliferation or regression phase

Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• Most common birthmarks (4%-5%),
present at birth or a few weeks during
neonatal period (70%), ↑ 25% in
premature infant.
• ♀ : ♂ = 2-3 : 1
• Head & neck region (56%), trunk (23%),
extremities (19%), genitalia (2%).
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• Grow rapidly in the first 5 to 8 month of
life, reach a plateau between 6 to 12
months, and regress within 12 to 18
months.
• Regression begins by the appearance of
central blanching and coalescence of blue-
gray areas of wrinkled skin that spread out
peripherally over the lession.
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• Partial / complete regression &
replacement fibrosis with fatty infiltration
occurs later.
• Various authors have indicated the
percentage of regression within 5 years:

Wallace (97%) Simpson (55%) Bowers (98%) Walter (96%)
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
INDICATIONS FOR EARLY
MANAGEMENT
1. Severe progressive tissue destruction &
distortion
2. Obstructs small luminal structures
3. Obstruction of the visual axis
4. Bleeding & thrombocytopenia
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
INDICATION FOR LATE
MANAGEMENT
• Hemangiomas that have incompletely
resolved.
• The remaining deformity may have
produced contour or color discrepancies or
may have distorted or destroyed facial
features such as the nose, lips, and
eyelids.
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
MANAGEMENT ALTERNATIVES
• The first principle in the management of
strawberry hemangiomas is to refrain from
emergency therapy.
• The second principle, in the absence of
factors that support active treatment,
nothing is lost by attentive monitoring of
the patient until at least 5 years of age.
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
MANAGEMENT ALTERNATIVES
• Grabb et al. (1991) ; listed various
treatments, in order of importance, as:
1. Observation
2. Short course of alternate-day
corticosteroid therapy.
3. Compression
4. Surgery
5. Other modalities
laser cryosurgery Sclerosing agents
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• During the period of attentive observation,
90 percent of these lessions either have
involuted or are in the process of
involution.
• An opaque cosmetic cream that is tinted to
match the patient’s skin color is useful
during this period.
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• Systemic & local corticosteroid  to
correct thrombocytopenia and prevent
further bleeding diatheses in patients with
giant hemangiomas (Kassabach-Meritt
syndr)
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• Compression treatment of hemangiomas
is believed to cause more rapid regression
of selected hemangiomas.
• Miller (1997) indicated that this therapy is
safe, noninvasive, and efficacious.
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• The best modality in most cases is surgery
(before or after the patient is 5 y.o)
• Small hemangiomas  excised electively
• In diffuse cavernous hemangioma
underneath the mucosa of the lip, multiple
chromic laigatures placed deep into the
substance of the hemangioma and then
tied may produce premature involution.
• Large lession  pedicle flap or skin graft.
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• Use argon laser
• Some success in reducing strawberry
hemangiomas
• Surgery  to removed contracted lession
• More success with the superficial capillary
hemangiomas (e.g: port-wine stain) than
the deeper cavernous lessions.
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• In larger dosage the regression is more
rapid, but the danger permanent radiation
dermatitis, late malignant degeneration, or
suppression of dental, epiphyseal, breast,
or gonadal.

Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• Achieved through liquid air, CO2 snow, dry
Ice sticks, ethyl chloride or freon 
superficial lessions.
• May have some applications for intraoral
or deeply invasive hemangiomas & loss of
blood can be minimized.
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• Located in the subcutaneous tissues and
presents as a soft, deep blue, cystic,
diffuse swelling frequently in the head and
neck.
• It involves a more mature endothelial cell
organization, and its growth &
development are more subtle than those
of strawberry hemangioma.
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• 60-70 %  regression with these lessions
by the age 8 to 12 years of age
• Other therapy is frequently needed when
the lession partially progresess, as in the
lower lip
• Emergencies arising from severe or
reccurent bleeding, ulceration, infection,
pain, intraluminal obstruction, bleeding
due to thrombocytopenia.
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• The use of steroid therapy and
compression dressing are not effective
means for reducing the tumor bulk.
• Cryosurgery, laser, and radiation therapy
remain controversial treatments for these
deep lessions  produce unnecessary
scarring & the morbidity associated with
radiation exposure.
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• Management is by palliative, and often
subtotal, excision.
• If excision is indicated, intraoperative
bleeding can be minimized by
preoperative embolization of vessels
supplying the hemangioma.
SCHWARTZ, Principles of SURGERY, 8
Th
ed,2005
• One the most difficult variant of
hemangiomas to treat.
• Intradermal lession composed of myriad
capillaries located at various levels of the
dermis.
• Present at birth & persist into adult life with
no tendency to regression.
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• Occasionally are mixed  cavernous
elements.
• Port-wine stains may be of any hue from
scarlet to reddish blue and located on the
head & neck.
• Posterior aspect of the neck  salmon
patches  involute spontaneously
• Resistant to the effects of steroids and
radiation therapy.
Grabb and Smith’s, Plastic Surgery, 4
th
ed.1991
• Do not resolve spontanously and are
present at birth.
• Treatment is by excision, laser
cauterization, tattooing, and application of
cosmetics
SCHWARTZ, Principles of SURGERY, 8
Th
ed,2005