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Contemporary Review |

Current Knowledge and Management of Vascular Anomalies:  I. Hemangiomas

Marcelo Hochman, MD; Denise M. Adams, MD; Travis D. Reeves, MD
Arch Facial Plast Surg. 2011;13(3):145-151. doi:10.1001/archfacial.2011.33.
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Published online

Objective  To present current information on the diagnosis, pathogenesis, natural history, and treatment of infantile hemangiomas.

Methods  Literature review.

Results  Infantile hemangiomas are the most common vascular tumors of childhood. They are thought to be derived from embolized placental progenitor cells that lodge in privileged sites of the developing embryo. They exhibit a characteristic postnatal course with defined periods of growth and regression.

Conclusions  Multimodality intervention involving observation, medical therapy, laser photocoagulation, and surgery is the accepted modern approach. Timing of the intervention to obtain the best possible results in concert with developmental milestones is the goal. “Leave it alone—it will go away” is no longer universally acceptable advice for infantile hemangiomas.

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Figure 1

. Examples of misdiagnosed and mistreated vascular anomalies. A, This patient was correctly diagnosed as having a hemangioma but was told, “Leave it alone—it will go away,” with an outcome unlikely to be acceptable. B, This patient's “hemangioma” was treated with vincristine chemotherapy, which had no effect on her venous malformation.

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Figure 2.

Histologic and clinical correlates of infantile hemangioma (IH) proliferation and involution. A, Histopathologic appearance of a proliferating IH showing a well-circumscribed, homogeneous lesion with plump endothelial cells and pericytes, mitotic figures, and a few small vessels. B, Clinical specimen of a proliferating IH showing the “solid” nature of the tumor. C and D, An IH during early and late involution showing flattening of endothelial cells, enlargement of lumina, and an increase in fibrofatty stroma. E, Clinical specimen in early involution showing a softer, less vascular tumor.

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Figure 3.

Clinical appearance of proliferating infantile hemangiomas (IHs). A, A superficial proliferating IH. B, A proliferating deep IH. C, A compound IH in early involution.

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Figure 4.

Glucose transporter protein 1 immunostaining of involuting infantile hemangioma endothelial cells. Glucose transporter protein 1 reactivity is pervasive throughout the proliferating and involutional stages.

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Figure 5.

Examples of acceptable and unacceptable involution of infantile hemangiomas. A, Acceptable result after involution of superficial infantile hemangiomas of the forehead and cheek by 2 years of age. B, Unacceptable result of full involution after 4 years, with expanded, telangiectatic skin.

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Figure 6.

Propranolol therapy (2 mg/kg/d divided into 3 doses) for a proliferating, compound hemangioma of the glabella. A, Pretreatment photograph. B, There is clear diminution in volume of the deep component and improvement of the superficial component. These changes occurred over a short period at an age (2-4 months) when most infantile hemangiomas are still proliferating. Whether the changes are coincidental or causal to the treatment is unclear, but they are the basis for the widespread interest in, and use of, this drug.

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Figure 7.

Compound involuting infantile hemangioma of the upper lip treated with surgery. A, An involuting compound infantile hemangioma of the upper lip that is not expected to involute to an acceptable result. The normal lip subunits are carefully marked, and measurements are transferred to the affected side. The tumor was resected in 1 stage, preserving normal skin and features. B, In 1 operation, more progress was made in alleviating this patient's facial difference than if years of continued involution were allowed to pass and a similar operation would likely have had to be performed.

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Figure 8.

Operative sequence of resection of compound infantile hemangioma in early involution. A-C, The superficial component was treated with the pulsed-dye laser while we were waiting for the child to achieve an adequate weight for elective anesthesia. Incisions are marked along the columellar edge, circumventing the soft-tissue triangles, and onto the alar grooves. D-G, A plane is developed between the deep component of the tumor and the skin, and the tumor is resected from the underlying lower lateral cartilages. An interdomal suture is used to approximate the cartilages without altering their shape. H-J, The expanded skin is redraped and, in this case, resected, while respecting the nasal subunits (ie, tip and ala). In some cases, the expanded soft-tissue envelope requires incisions that may involve crossing the subunits of the nose, a reality that is recognized by many articles in the literature (eg, references 31 and 32).

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