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Original Investigation | Journal Club

Distribution, Clinical Characteristics, and Surgical Treatment of Lip Infantile Hemangiomas

Teresa Min-Jung O, MD, M Arch1,2; Catharina Scheuermann-Poley, MD1,2,3; Melin Tan, MD4; Milton Waner, MD, FCS(SA)1,2
[+] Author Affiliations
1Vascular Birthmark Institute of New York, New York
2Department of Otolaryngology, Lenox Hill Hospital and Manhattan Eye, Ear, and Throat Hospitals,, New York, New York
3Charité Universitätsmedizin Berlin, Berlin, Germany
4Department of Otorhinolaryngology, Head and Neck Surgery, Montefiore Medical Center, Bronx, New York
JAMA Facial Plast Surg. 2013;15(4):292-304. doi:10.1001/jamafacial.2013.883.
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Published online

Importance  Infantile hemangiomas (IHs) are the most common tumors of infancy.

Objectives  To describe the patterns of occurrence of lip IHs and correlate these findings with patterns of anatomical distortion and predictable clinical outcomes and to describe the surgical management of these lesions.

Design  A retrospective medical record review of patients diagnosed as having facial IH of the upper or lower lips during an 8-year period (January 1, 2004, through December 31, 2011). Using clinical photographs and patient records, we mapped the 360 IHs of 342 patients on a lip schematic. Each lesion was encoded with a number reflective of its location, and this number was shared by other lesions found at the same site. Frequencies of lesion characteristics, complicating functional and aesthetic factors, and airway obstruction were documented. The treatment course was noted.

Setting  Tertiary care hospital and practice specializing in the care of congenital pediatric vascular anomalies of the head and neck.

Participants  Three hundred forty-two patients with 360 IHs.

Results  A total of 1916 IHs were diagnosed. Of these, lip IHs were found in 342 patients. We reviewed those patients’ medical records. Of the lesions, 59.2% were focal and 40.8% were segmental. A nonrandom distribution of lip IHs was found. The most common focal lesion occurred at the lower lip (98 of 213 lesions [46.0%]). The most common segmental lesion involved the mandibular segment (75 of 147 [51.0%]). Of the 75 patients, 30 (40.0%) had airway involvement. The most common anatomical distortions of the lip involved the vermiliocutaneous junction in 216 (61.5%). Horizontal and vertical lengthening of the lip was evident in 28.7% and 31.0% of patients, respectively. Ulceration and scarring were common findings in 137 patients overall (38.1%), with segmental mandibular IHs associated with the highest percentage (46 of 137 [33.6%]), followed by focal IHs of the lower lip (35 of 137 [25.5%]). Using previously described surgical procedures, we developed a problem-oriented solution for each of these zones.

Conclusions and Relevance  The nonrandom distribution of facial hemangiomas has been documented with focal and segmental patterns of growth. Distinct anatomical patterns of occurrence for lip IHs are described. The distribution seems to be related to the embryologic development of the upper and lower lips. These anatomical patterns allow for the prediction of anatomical location, structural distortion, and possible clinical outcomes. This information is relevant when planning medical and surgical treatment for these children.

Level of Evidence  NA.

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Figures

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Figure 1.
Facial Schematic Showing the Location of Focal Lip Infantile Hemangiomas

A, Lip schematic. B, Focal map showing positions of the lesions (1-4). C, Segmental map. FN indicates frontonasal; V2, maxillary; and V3, mandibular.

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Figure 2.
Distribution of Lip Infantile Hemangioma

A, Focal. B, Segmental.

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Figure 3.
Upper Lip Focal Infantile Hemangiomas (Position 1)

A through E, Examples at various stages of growth. F, Focal pattern.

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Figure 4.
Surgical Approach to Upper Lip Focal Infantile Hemangioma (Position 1) (Patients 1 and 2)

A, Patient 1. Large upper lip focal hemangioma. Note the increase in length of both the vertical and horizontal dimensions of the upper lip and the medial displacement of the philtrum. B, Excision of the hemangioma along facial subunits. C, Patient received pulsed dye laser (PDL) to prepare the skin flap, which remains after excision. The child will receive further PDL treatment until all erythematous staining has disappeared. Fractional carbon dioxide laser dermabrasion is used to treat any residual atrophic scarring. D, Patient 2. A large upper lip focal hemangioma. Note the complete distortion of the upper lip. E, After excision of the hemangioma. The incision was placed along the left border of the philtrum. F, Surgical planning. The incision is placed along boundaries of facial subunits (solid line). A second incision (dashed line) is made parallel to the first and its position is determined by the degree of horizontal lip length and vertical lip height adjustment required to reestablish symmetry.

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Figure 5.
Focal Lip Infantile Hemangiomas Limited to the Red Portion of the Lip

A through E. Surgical approach. A and B, Position 1. C and E, Position 3. A and C, Note that only the vermilion is involved and the lesion is bulky and elevated. B and D, Surgical intervention. Excision of upper lip hemangioma. E, Postoperative with restored symmetry. F, Incision is placed along the wet-dry margin of the lip.

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Figure 6.
Upper Lip Focal Infantile Hemangioma (Position 2)

A through D, Examples. E, Focal pattern.

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Figure 7.
Upper Lip Focal Infantile Hemangioma (Position 2)

A through F, Surgical approach. A, Initial presentation at age 3 months. B, After pretreatment with 2 corticosteroid injections. (Note that today this patient would have been treated with oral propranolol, which accomplishes a similar effect.) C, Stage 1 surgical excision. The bulk is reduced through an elliptical horizontal incision centered along the wet-dry margin of the upper lip. Although some orbicularis oris muscle is invariably removed, the integrity of the muscle is preserved. Pulse dye laser treatment of the upper lip and the vermillion is performed. D, Stage 2 surgical excision 4 months later. A through-and-through vertical wedge (skin, muscle, and mucosa) excision is performed along with pulsed dye laser. The procedure is followed by fractional carbon dioxide laser treatment of atrophic scarring secondary to hemangioma. F, Postoperative presentation at age 2 1/2 years taken 1 year after surgery. G, Surgical placement of incision to approach upper lip focal hemangioma (position 2).

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Figure 8.
Upper Lip Focal Infantile Hemangioma (Position 3)

A through D, Examples. E, Focal pattern.

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Figure 9.
Upper Lip Focal Infantile Hemangioma (Position 3)

A through D, Surgical approach. A, Three-month-old presents after intralesional corticosteroid injection. (Note that today this patient would have been treated with oral propranolol, which accomplishes a similar effect.) Pulsed dye laser treatment is performed at 3, 5, and 7 months of age to prepare the skin flap for surgery. B, Stage 1 surgical excision at age 10 months: direct elliptical excision of right nasolabial-commissure hemangioma with intraoperative facial nerve monitoring. Surgery was followed by suture removal and pulsed dye laser treatment to the right cheek. C, A large intraoral component remained after this surgery, producing a mass effect that displaced the commissure inferiorly and anteriorly. An attempt was made to reduce this effect with an intralesional steroid injection, which unfortunately failed. Pulsed dye laser treatments were performed to reduce the superficial cutaneous component left behind from the resection. D, The patient will undergo further pulsed dye laser treatment and fractional carbon dioxide laser treatment to reduce any residual cutaneous hemangioma and atrophic scarring. E, Surgical incision for focal pattern (position 3).

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Figure 10.
Lower Lip Focal Infantile Hemangioma (Position 4)

A through E, Examples. F, Focal pattern.

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Figure 11.
Lower Lip Focal Infantile Hemangioma (Position 4)

A through C, Surgical approach. A, Preoperative photograph: note ulceration of the left lower lip hemangioma. B, Surgical excision was performed at the age of 9.5 months. A wedge incision was made along the outlines of the hemangioma centered to a base just above the labiomental crease. C, Postoperative photograph 7 days after surgery. D, Wedge incision for focal pattern (position 4).

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Figure 12.
Frontonasal (FN) Segmental Lip Infantile Hemangioma

A through E, Examples. F, Segmental pattern. V2 indicates maxillary; V3, mandibular.

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Figure 13.
Frontonasal (FN) Segmental Lip Infantile Hemangioma

A through E, Surgical approach. A, A 3-month-old boy presented with an ulcerated, proliferating hemangioma and required a staged surgical approach to treatment. He had been treated with multiple laser treatments and corticosteroid injections. B and C, Surgical excision at 12 months: modified Weber-Ferguson excision of upper lip and paranasal hemangioma. D, Patient at 13 months. Further pulsed dye laser is performed. E, Patient at 2 years. Two-stage surgical excisions were performed (1) excision of nasal tip hemangioma and (2) perialar wedge excision to elevate the upper lip and vermillion wedge excision of the upper lip. F, Surgical incisions for segmental pattern (FN).

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Figure 14.
Maxillary (V2) Segmental Lip Infantile Hemangioma

A through E, Examples. F, Segmental pattern (V2, maxillary). FN indicates frontonasal; V3, mandibular.

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Figure 15.
Upper Lip Maxillary (V2) Segmental Infantile Hemangioma

A through E, Surgical approach (example 1). A, Preinterventional state. Note the right paranasal V2 segmental hemangioma involving the right paranasal area, the dorsum of the nose, and the upper lip. B, First surgical intervention: pulsed dye laser treatments to the right paranasal and upper lip segmental hemangioma at the age of 12, 13, and 14 months. C, Second surgical intervention: excision of right upper lip hemangioma. A horizontal wedge incision was made along the wet-dry margin of the right upper lip. Surgery was directly followed by pulsed dye laser to the right paranasal hemangioma. D, Postoperative presentation. The patient will need pulsed dye laser treatment and fractionated laser treatment for the scarring. E, Presentation after the third surgery in which the following was performed: excision of residual hemangioma of paranasal area, cheek advancement and correction of upper lip dimensions, and pulsed dye laser fractionated carbon dioxide laser treatment to right paranasal area. F, Placement of incisions for segmental pattern (V2, maxillary).

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Figure 16.
Upper Lip Maxillary (V2) Segmental Infantile Hemangioma

A through C. Surgical approach (example 2). A, Patient presents with a history of left upper lip and paranasal segmental infantile hemangioma. There is asymmetry in the face and cutaneous staining in the left paranasal area. The left upper lip is inferiorly displaced and elongated. There is some mucosal staining with the hemangioma and scarring (from ulceration) along the left nasolabial line with distortion of the corner of the mouth. B, Patient had undergone surgery with debulking of hemangioma tissue along the left hemilip and left lateral philtrum and laser treatment in the past. C, Postoperative stage 2 ½ weeks after surgery. The left upper lip area shows decreased bulkiness and symmetry. Carbon dioxide fractional laser treatment of the nasolabial scarring area will be performed.

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Figure 17.
Mandibular (V3) Segmental Lip Infantile Hemangioma

A through H, Examples. I, Segmental pattern (V3, mandibular). FN indicates frontonasal; V2, maxillary.

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Figure 18.
Lower Lip Mandibular (V3) Segmental Infantile Hemangioma

A through D, Surgical approach. A, Clinical presentation at age 6.5 months. B, The patient had undergone several pulsed dye laser treatments between the ages of 7 and 9 months. C, Excision of lower lip segmental infantile hemangioma at the age of 12 months. The hemangioma was excised through a vermiliocutaneous incision. A second surgery at the age of 17 months was necessary to excise residual hemangioma and scar tissue of the lower lip. D, Postoperative stage at age 3 years. In the future, the patient might need another debulking operation of the lower lip and the special sulcus reconstruction technique that we developed, which is further described in the next case. E, Placement of horizontal incisions along vermiliocutaneous junction.

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Figure 19.
Lower Lip Segmental Mandibular (V3) Infantile Hemangioma

A through S, Surgical approach and technique of sulcus reconstruction. A, Patient at initial presentation. Note the bilateral lower lip and neck involvement. B and C, Preoperative presentation at age 21 months. D, An incision is created along the vermiliocutaneous junction of the lower lip. A horizontal wedge of excessive tissue is removed with a Colorado tip bovie cautery. A subcuticular flap is elevated to the limits of the mass. E and F, An 18-gauge needle is passed anterior to posterior through all tissue layers. F through H, A polyglactin 910 absorbable (Vicryl) suture is then passed posterior to anterior through the needle shaft. I through M, The needle is then retracted anteriorly up to the subcuticular plane. The needle tip ensnares a small segment of dermis and is then advanced back through all of the layers to a position adjacent to its previous one. The suture is then withdrawn from the needle and the needle is then withdrawn completely. N and O, As many of these stitches may be placed as deemed necessary. P, The suture is then tied on the mucosal surface. Q and R, The flap has been secured. The dead space has been reduced and the vermiliocutaneous junction is now everted. S, The patient 4 months postoperatively. T, Placement of incisions for sulcus reconstruction.

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Figure 20.
Treatment Algorithm for Lip Infantile Hemangiomas (IHs)

Asterisk indicates may add PDL in segmental lesions.

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