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JAMA Facial Plastic SurgeryJournal Club Slides:Lip Infantile Hemangiomas O TMJ, Scheuermann-Poley C, Tan M, Waner M. Distribution, clinical characteristics, and surgical treatment of lip infantile hemangiomas. JAMA Facial Plast Surg. Published online May 30, 2013. doi:10.1001/jamafacial.2013.883.
Introduction • Infantile hemangiomas (IHs) are the most common tumors of infancy. • Facial IHs are noted to occur at certain sites more commonly than other sites, showing a predilection for regions of embryologic fusion. • Lip IHs can be disfiguring and cause functional impairment in feeding and speech. • Lip IHs have a propensity to ulcerate with risk of pain, sepsis, and bleeding.
Purpose • To describe the patterns of occurrence of lip IHs. • To correlate these findings with patterns of anatomical distortion and predictable clinical outcomes. • To describe the surgical management of these lesions.
Relevance to Clinical Practice • IHs are the most common tumors of childhood. • We offer a treatment algorithm for lip IHs as well as illustrating surgical approaches.
Description of Evidence • Retrospective medical record review over an 8-year period at a tertiary medical practice specializing in the treatment of vascular anomalies. • Lip IHs were mapped onto a lip schematic drawing. • Frequencies of lesion characteristics, complicating functional and aesthetic factors, and airway obstruction were documented. The treatment course was noted. • Representative cases were used to illustrate the surgical approach.
Description of Evidence Facial schematic showing the location of focal lip IHs. A, Lip schematic. B, Focal map showing positions of the lesions (1-4). C, Segmental map. FN indicates frontonasal; V2, maxillary; and V3, mandibular.
Description of Evidence • There were 342 patients with 360 lip IHs. • 59.2% were focal lesions and 40.8% were segmental lesions. • Most common focal lesion: lower lip. • Most common segmental lesion: mandibular, V3. • Anatomical distortions: • 61.5% Vermiliocutaneous junction involved. • 28.7% Horizontal lengthening of the lip. • 31% Vertical lengthening of the lip. • Ulceration and scarring: 38.1%. • 40% of patients with mandibular segmental involvement had airway disease.
Description of Evidence Focal Lip Lesions of the Patients
Description of Evidence Segmental Lip Lesions of the Patients
Description of Evidence Distribution of focal (A) and segmental (B) lip IHs.
Description of Evidence A-C, Surgical approach to lower lip focal IH (position 4). A, Preoperative photograph: note ulceration of the left lower lip hemangioma. B, Surgical excision was performed at age 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). C C
Description of Evidence A-D, Surgical approach to lower lip mandibular (V3) segmental IH. A, Clinical presentation at age 6.5 months. B, The patient had undergone several pulsed dye laser treatments between ages 7 and 9 months. C, Excision of the lower lip segmental IH at age 12 months. The hemangioma was excised through a vermiliocutaneous incision. A second surgery at age 17 months was necessary to excise residual hemangioma and scar tissue of the lower lip. D, Postoperative stage at age 3 years. E, Placement of horizontal incisions among the vermiliocutaneous junction. A B D
Description of Evidence Surgical approach to upper lip focal IH (position 1). A, Patient 1, with a large upper lip focal hemangioma. B, Excision of the hemangioma along facial subunits. C, Patient received pulsed dye laser to prepare the skin flap, which remains after excision. D, Patient 2, with a large upper lip focal hemangioma. 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.
Description of Evidence • Treatment algorithm for lip IHs. Asterisk indicates may add PDL in segmental lesions.
Controversies and Consensus • Consensus • Corticosteroids have largely been replaced by propranolol for the medical treatment of IHs. • Segmental IHs are locally more aggressive and destructive and have a longer growth phase up to 2-3 years. Medical therapy with or without pulsed dye laser should be instituted early. • Ulcerated lesions can be painful, bleed, and be a site of infection. These are a clear indication for surgical intervention.
Controversies and Consensus • Controversies • Since all IHs involute, should we even bother treating them? • Propranolol is advocated by most practitioners as the first line of medical therapy for IHs, but propranolol can cause short-term memory loss in adults. Should this be more widely investigated before it is used so commonly in children? • These surgical procedures are performed in infants and young children. Will these have an effect on the growth patterns of these anatomical units?
Comment • Lip IHs are at risk for anatomical distortion and ulceration. • Medical therapy should be started early. If there is no response or inadequate response, surgery can offer excellent outcomes.
Conclusions • There are sites of predilection of lip IHs, and these sites seem to correlate with the embryologic development of the lip. • Lip IHs can be classified into focal and segmental patterns of tissue involvement. • When medical therapy is inadequate, laser and surgery are used to reconstitute the normal anatomy of the lip.
Contact Information • If you have questions, please contact the corresponding author: • Teresa Min-Jung O, MD, Vascular Birthmark Institute of New York, Lenox Hill Hospital and Manhattan Eye, Ear, and Throat Hospitals, 210 E 64th St, Seventh Floor, New York, NY 10065 (email@example.com). Conflict of Interest Disclosures • None reported.