PLASTIC SURGERY RECONSTRUCTIVE

Dr. Francesca Ughi in collaboration with:

Current possibilities for treatment of sequelae of facial hemangiomas cervico

C. AZZOLINI – F. UGHI – A. AZZOLINI

Professor of plastic and reconstructive surgery at the University of Pavia
Director: Prof. Giorgio Boggio Robutti

 

SUMMARY

Current surgical treatment of the sequelae of cervico-facial hemangiomas.

The Authors, after considering morphogenetics, hemodynamic, arteriographic and evolutive aspects of the hamangiomas, present their terapeutic approach to theese lesions, referring particularly to their sequelae.

They in discordance with the diffuse attitude of therapeutic abstension in consideration of the spontaneous involution of the hemangioma, recommend to begin as soon as possible a general and/or intralesional corticotherapy to prevent the proliferative phase of the hemangioma rather than to cure a settled lesion.

Early surgery is limited to particular cases. The surgical treatment is general addressed to the correction of the sequelae of the hemangiomas which are often rather typical depending on the area of the lesion. the Authors present a systematic approach to their treatment in the various facial regions.

The surgical treatment is generally performed before school-age to avoid psychological problems of the patient, due to an alterated body image. Bigger procedures with large extensions flaps, undermining and skin expansion are performed around the tenth year of age.

Following this therapeutic approach and the described techniques, it is possible to achieve satisfactory results also in the most severe cases.

ABSTRACT

The Authors, after considering the aspect morphogenetic, emodinamici, arteriography, and evolutionary angiomas, expose their therapeutic approach to this type of injury, with particular reference to their outcomes.

The Authors, unlike many doctors and pediatricians who maintain an attitude of abstention therapeutic founded on the notion that hemangiomas undergo spontaneous and slow resorption, emphasize the need to establish as soon as possible a cortisone treatment for general and / or intralesional whose purpose is to prevent the initial development POUSSE dell'angioma.

Early surgical therapy is limited to particularly serious cases.

Typically it is directed to the correction of sequelae of angiomas, which are often quite typical in relation to site of injury. The authors present a systematization of the treatment in the various regions facial.

Generalmente gli interventi si realizzano tra i 3 and the 5 years of age, ie before school to avoid psychological damages resulting from a distorted image of their body. Interventions vast, che obbligano a ricorrere a scollamenti estesi e soprattutto all’espansione cutanea devono essere realizzati intorno ai 10 year old.

Following the therapeutic approach and the techniques, is generally possible to achieve a satisfactory morphological normalization also in more serious cases.

The angiomas are characterized by the morphogenetic perspective from a primary core cell angioblastiche type immature proliferative activity which tends to form clusters of vessels of capillary type.

The increase in size of these lesions depends on the initial extension of the nest or nests angioblastici, the lesser or greater liveliness of their reproductive activity and the stimulus hemodynamic angectasizzante that blood flow is to exercise the newly formed capillaries.

Azzolini and Coll. (³) already in 1971 had demonstrated with a study angiocardiografico, run on hemangiomas of various anatomical regions and in different developmental stage, that immature hemangiomas are typically covered by a very rapid flow.

A case of hemangioma of the parotid gland, which is reproduced here courtesy of Authors, serves to demonstrate this fact very well hemodynamic (fig. 1a, b, c).

Fig.1- a) Angioma of the parotid region; b) left: Early visualization of the arteries afferent, dell'angioma and simultaneous visualization of the venous drainage from the contrast made by 2 large branches from the right carotid. Right: the image immediately after arteriography shows, than the other side, the enormous global expansion of the internal jugular vein with a venous stagnation that affects up breast crosswise, also intensely opacato; c) Risultato della terapia steroidea

 

From the comparison with the opposite side, made possible dall'angiocardiografia, appare infatti evidente il precoce riempimento della massa angiomatosa da parte del contrasto e la contemporaneità dello scarico venoso (fig. 1b). In the following phase, always very early, can be observed in the impregnation of the internal jugular veins of which the one on the affected side appears more contrasted and greatly expanded for all its extension.

L’immissione di sangue ad alta pressione crea infatti una barriera emodinamica al deflusso venoso cerebrale che si rende responsabile di una ectasia venosa che si ripercuote fino ai sensi della fossa cranica posteriore dei quali quello traverso appare maggiormente dilatato (fig. 1b right).

Questi rilievi testimoniano l’intensità dell’attività emodinamica della lesione angiomatosa che azzolini e Coll. have also detected in all 14 cases they studied (³).

Well, despite the speed of the flow that runs through them, gli angiomi vanno incontro a spontaneo e lento riassorbimento; resorption, however, that can be greatly accelerated by steroid therapy which can also, if instituted early, is able to prevent the evolutionary POUSSE.

The notion that hemangiomas undergo spontaneous and slow resorption led for decades and still causes the majority of doctors and especially pediatricians to an attitude of therapeutic abstention because time is in their opinion the best therapy. The damage that the strict application of this propensity abstainer has determined can be very important when it concerns large lesions, Fast growing and placed in critical areas.

We are of the opinion that the therapeutic abstention can be justified only in the presence of small lesions, showing no tendency to grow and to be placed in areas of the body covered.

Fig. 2. – a) most extensive hemangioma of the upper limb and shoulder, due to heart failure; b) Result distance after resorption dell'angioma obtained by simple elastic bandage compression that has quickly corrected even heart failure.

In tutti gli altri casi è opportuno istituire il più presto possibile un trattamento steroideo per via generale o in certi casi intralesionale la cui finalità a nostro avviso dovrebbe anzi essere spostata da quella terapeutica a quella preventiva della poussè iniziale di sviluppo. More precisely the reasons for our interventionism are the following:

1) lesions initially very limited can grow rapidly and unpredictably during the first months of life, reaching a considerable size and sometimes aspects of real monstrosity;

2) very extensive injuries to particular locations such as perioral regions, nasal, ear and eyelid may require minor repairs not simple; in reference to the location of the eyelid then the functional deficit resulting from a possible visual deprivation can lead to problems of amblyopia;

3) locally the perpetuation of a situation of hypervascularity can cause a hypertrophy tissue that most often occurs at the nasal, labial, auricolo-parotid and genieno;

4) similar effects may occur on the morphology of the bone, typically by compression, especially noticeable at the level of the maxilla and mandible;

5) Finally are particularly feared complications of ulcerative and hemorrhagic type that can mark every moment of the natural history of an angioma immature.

Fig. 3 – a) Angioma front-orbit-palpebrale; b) Result remote 12 years of surgery, and steroid therapy for general and intralesional

 

Negli angiomi la necessità di realizzare interventi chirurgici molto precoci è eccezionale e essenzialmente limitata a 4 types of lesions:

1) angiomas extremely extended, usually associated with hepatic hemangiomas that are due to an arteriovenous shunt so important to determine severe heart failure. In these cases it is sometimes necessary to drill a superselective embolization and sometimes a ligation of the hepatic artery or, in the presence of hepatic rupture, una epatectomia parziale.

Exceptionally heart failure caused by venous shunt can also occur for hemangiomas interesting all of a limb, but in these cases an elastic bandage compression has been shown to, as in a case of our observation, both reduce the shunt and to normalize the heart function, which cause rapid resorption dell'angioma (fig. 2a,b).

2) Angioma extended upper airway which cause severe respiratory failure.

These birthmarks in urgency they exceptionally required a tracheotomy and an emptying of the neck. Otherwise may be indicated embolization.

Fig. 5 – a) Angioma lip-genieno; b) Excess skin and fibro-adipose buccal; c) Result of modeling surgery performed at the age of 11 year old.

 

3) Angioma orbitofrontal eyelid where the swelling of the upper eyelid causes, as we mentioned before, una ostruzione dell’asse ottico e per mancata stimolazione simmetrica degli emisferi occipitali una degenerazione dei neuroni della vita ottica con instaurazione di una ambliopia ex anopsia. Since this very serious complication may also occur for obstructions of the duration of one or two months, in the presence of an angioma orbitofrontal eyelid is necessary to establish a cortisone therapy systemically to a full dose and, if this does not get in the space of 1 the 2 weeks a unblocking of the optical axis, it is necessary to intervene surgically (fig 3a, b; 4a, b, c, d, and, f).

4) Angioma extended associated with thrombocytopenic purpura (Syndrome Kasabach Merit). Se questa non può essere controllata dalla terapia medica una embolizzazione o un intervento chirurgico di exeresi sono necessari.

Fig. 6 – a) Excess skin and fibro-adipose lateronasale; b) Result of modeling.

 

A parte queste evenienze la terapia chirurgica è in genere rivolta alla correzione degli esiti degli angiomi; in fact the 50% degli angiomi regredisce in modo perfetto, but in the remaining 50% sequelae may remain more or less important and often quite typical in relation to the site of the lesions.

Il trattamento delle sequele deve avvenire quando l’attività angiopoietica è cessata e l’angioma si afflosciato e scolorato. interventions are made usually between 3 and the 5 years and that is before school to avoid psychological damages arising from the perception of a distorted image of their body.

La più modesta delle sequele che si possono incontrare è costituita dalla presenza di arborizzazioni capillari e di ectasie venulari che possono essere migliorate per mezzo di iniezioni sclerosanti.

In genere è possibile infatti reperire un capillare o una venula di calibro sufficiente all’introduzione di un ago che consente di diffondere il liquido sclerosante in un’area abbastanza vasta.

Treatment should be repeated as long as they meet pots caliber sufficient introduction of the needle.

The end result can be completed with the Microcoagulation or with laser therapy of the smallest capillaries residues.

More often because of local hypervascularity that lasts for the entire process of resorption dell'angioma determines a ipertrophization localized adipose tissue with the formation of a mass fibroangiolipomatosa. Spesso la massa può essere asportata con una piccola incisione praticata finché possibile in una plica naturale.

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