• ”Excellence is never an accident; it is the

result of high intention, sincere effort,

intelligent direction, skillful execution,
and the vision to see obstacles as
opportunities.”
 “Sweet lips”

A Case of Lower Lip Hemangioma

Amante, Justin Brian Wilby G.
 Case Data
• EP
• 52 year old/female
• Filipino
• Pandacan, Manila
• CC: Lower Lip mass
Case Data
52 years PTC

• noted lower lip mass, flat, violaceous, no

ulcerations noted, approximately 1
fingerbreadth in size

• no medications taken, no consult done

Case Data
20 years PTC

• persistence of lower lip mass, now with

increase in size of the mass, now
approximately 2 fingerbreadths, no
ulcerations, no bleeding
• no consult done
Case Data
1 week PTC

• persistence of lower lip mass, no other

symptoms, no increase in size, no changes in
color,

• consult done with a private MD for cosmetic

reasons:
• IMP: lower lip mass t/c hemangioma
• advised surgery
• not amenable due to financial constraints
• referred to our OPD
Past Medical History

• No Asthma
• No DM
• No Hypertension
• No Allergies
• No previous operations
Family History

• (+) Hypertension - paternal

• No Diabetes Mellitus
• No Asthma
• No Myocardial Infarction
• No Cancer
 Review of Systems
Skin: (-) rashes (-) pruritus Hematologic: (-) easy
bruisability, (-) bleeding
tendencies
HEENT: (-) headache, (-) dizziness, (-)
blurring of vision, (-) hearing loss, (-)
postnasal drip, (-) epistaxis, (-)
bleeding gums, (-) mouth sores Genitourinary: (-) dysuria, (-)
hematuria, (-) incontinence,
(-) nocturia
Pulmonology: (-) cough, (-) colds, (-)
dyspnea, (-) hemoptysis

Cardiology: (-) chest pain (-) paroxysmal

nocturnal dyspnea (-) orthopnea (-)
easy fatigability
Physical Examination

Awake, ambulatory, coherent, not in cardiorespiratory

distress

Vital Signs:

BP 110/70
HR 72
RR 18
Temp 36.4C
Physical Examination

HEENT: Pink palpebral conjunctivae, anicteric sclerae,

(-) cervical lymphadenopathies

Chest and Lungs: Symmetrical chest expansion, no

retractions, clear breath sounds, (+) good air entry.

Heart: Adynamic precordium, normal rate, regular

rhythm, no murmur

Abdomen: Flat, NABS, soft, nontender

Physical Examination

(+) lower lip mass, left lateral aspect

violaceous, no bleeding noted,
no ulcerations, 4x3cm
Salient Features

• 52/Female
• Lower lip mass since birth flat, violaceous, no ulcerations
noted, approximately 1 fingerbreadth in size since birth,
no changes until after 30 years- increase size to 2
fingerbreadths
• No ulcerations
• No bleeding
• No xerostomias
Oral cavity lesion:
History & PE
Associated symptoms
Risks for malignancy
Formulate initial impression,
Diagnosis is probable:
Estimate likelihood of
malignancy
Approach Algorithm for Oral Cavity
lesions and Differential Diagnoses
Diagnosis is uncertain:
Investigate further with culture,
imaging or lab tests, refer to
dermatologist or hematologist
as appropriate. Perform biopsy
if malignancy is possible
Index of suspicion Approach Algorithm for Oral Cavity
for malignancy is lesions and Differential Diagnoses
high:
Perform Biopsy

1. Minor Salivary gland malignancy

2. Mucosal Melanoma
3. Squamous cell carcinoma
4. Kaposi sarcoma- consider referral to
oncologist or infectious disease
specialist

Assess and stage with CT MRI or PET

-Wide local excision
-Possibility of neck dissection for positive neck or selective
neck dissection for negative neck
-postoperative irradiation
 Index of suspicion for
malignancy is low: Approach Algorithm for
Can be generally Oral Cavity lesions and
managed with Differential Diagnoses
observation,
symptomatic treatment

Inflammatory lesions: Tumorlike Lesions Benign Neoplasm:

Infectious: Torus: Intervention only Hemangioma
Viral: Symptomatic if denture fit affected Nevus
treatment Papilloma
Bacterial: antibiotics Cyst: observation or Mucocoele
Fungal: antifungals excision
Oral hairy leukoplakia or
unusual infx: rule out HIV Fibroma: observation or Treat with local
and refer excision excision

Non infectious: Odontogenic cyst:

Apthuous ulcer: Excision or debridement
symptomatic treatment
 Diagnosis

Lower lip mass, probably Hemangioma

 Plan

• Excision of lower lip Hemangioma with possible

flap reconstruction
 Admitting Orders
• Scheduled for procedure
• NPO at midnight
• D5LR at 8 hours once on NPO
• Therapeutics:
– Cefuroxime 1.5g/iv 1hr prior to procedure
• CP cleared as outpatient
• Cleared by anesthesia as outpatient
• Referred to AROD for anesthesia
 Post Op

• S> Comfortable, good pain control, no

nausea/vomiting, no febrile episodes
• O> Dressings dry and intact, wound dry and
well coaptated, flap viable,
VS: 110/70, HR 72, RR18, afebrile

• Discharged same day

Post Op
 Final Histopath
HP-2019-2560
Consistent with Hemangioma
 Discussion

• Hemangiomas
– benign vascular
neoplasm
– mitotically active
endothelial cells
surrounding several
confluent blood-filled
spaces
– may enlarge
significantly, 90% will
involute over time
 Discussion
• Treatment
– interferes with function
• airway vision and feeding
• recommended in
situations of irritation
• Hemorrhage
– Cosmesis
 Discussion
• Treatment options
– Pulsed-dye laser ablation
– Cryotherapy
– Excision
– Sclerotherapy
 Goals of Lip Reconstruction

• Preservation of function
• Reconstitution of orbicularis oris
• Three-layered closure
• Accurate alignment of vermillion
• Maintenance of relationship between upper and
lower lips
• Optimization of cosmesis
 Goals of Lip Reconstruction

• Small defects can be closed by direct

repair:
• defects up to 25% of the width of the
upper lip can be closed; and
• defects up to 30% of the width of the
lower lip can be closed.
Operative Techniques
 Defect-Specific Reconstruction of
the Lip
• Use remaining lip segment
– Best option: perfect match in terms of color,
thickness, composition
– Defects of the upper lip of less than 25% can be
closed by direct approximation. For the lower lip, a
slightly larger defect, up to 30%, can be closed
directly.
 Defect-Specific Reconstruction of
the Lip
• Through-and-through defects
– Next choice is opposite lip
– Tissue from adjacent cheek, nasolabial region, or
neck
– Sub-mental region
– Extreme defects: regional or distant or free flaps
 Small Full-Thickness Defects

• V-shaped wedge design - smaller defects

• W-plasty placed at the base of the V - larger
defects
– To keep the scar above
the mental crease
 Small Full-Thickness Defects

• Wedge Resection of the Lip:

• Up to 25% of the upper lip can be resected and
repaired directly
• Up to 30% of the lower lip can be resected and
repaired directly
• Careful approximation of the muscle layer
ensures a functional repair
 Intermediate Full-Thickness
Defects
• Lip Switch Flaps
• Width of the flap should be half of the width of
the defect
• Height of the flap should be the same as height
of the defect
• Pedicle of Abbe flap should be placed at the
midpoint of the defect
• Pedicle division at 14-21 days
 Intermediate Full-Thickness
Defects
• Estlander flap
– Abbe flap that is
brought around the
commissure
– No pedicle division is
necessary
– Disadvantage : blunting
of the commisure
• The OPPOSITE of success is not failure,
it is MEDIOCRITY! Failure is actually part
of the process of success!”
THANK YOU