Management of Capillary Malformations

3D imaging of vascular anomalies using raster-scanning optoacoustic mesoscopy

OBJECTIVES

Vascular anomalies such as capillary malformations (CMs) and infantile hemangiomas (IHs) are common pediatric vascular disorders that are treated with therapeutic laser. The treatment method, however, relies on subjective evaluation of clinical findings and can have unpredictable results. Raster-scanning optoacoustic mesoscopy (RSOM) is an innovative imaging technology using pulsed-light laser to excite hemoglobin, generating ultrasound waves that are converted into three-dimensional images of tissues. RSOM can provide objective information about superficial structures such as the microvasculature of vascular anomalies.

MATERIALS AND METHODS

In this study, we explore the clinical potential of RSOM to study vascular anomalies before and after laser treatment. We scanned nine patients with CM (n = 6) and IH (n = 3) who underwent laser treatment and calculated the blood vessel volume.

RESULTS

Overall, there was a posttreatment volume increase in CM, and a decrease in IH.

CONCLUSION

These findings support the possibility that RSOM may have a role in developing an objective method of evaluating these lesions, leading to a tailored treatment approach and avoidance of adverse outcomes.

Surgical correction for patients with port-wine stains and facial asymmetry

BACKGROUND

The refractory port-wine stains are often associated with soft and hard tissue hypertrophy leading to facial asymmetry and psychological problems.

AIMS

The authors describe and illustrate a surgical strategy for the treatment of both hard and soft tissue malformations in patients with port-wine stains to restore facial symmetry.

METHODS

The medical records, photographs of two patients with soft and hard tissue hypertrophy were reviewed. After physical examinations, 3-dimensional computed tomography was conducted to evaluate bony asymmetry. The surgical strategy was designed according to individual malformation and requests.

RESULTS

Both patients had congenital port-wine stains that were resistant to laser therapy. As they grew up, they developed both soft and hard tissue hypertrophy. Zygoma, maxilla, nose, and lips are involved, causing facial asymmetry, deviated nose, increased dental show and malocclusion. To correct bony malformation, orthognathic surgery, and facial bone contouring including zygomatic reduction, mandibular angles osteotomy and genioplasty were performed. After the correction of the bony factor, soft tissue symmetry was improved via resection, autologous fat grafting, liposuction, and rhinoplasty. Both patients were satisfied with the surgical result.

CONCLUSIONS

To acquire facial symmetry, surgical correction is inevitable for patients with port-wine stains associated with soft and hard tissue hypertrophy. The authors describe the successive correction of bony and soft tissue asymmetry to achieve harmonious surgical outcomes.

Wound-Healing Problems Associated with Combined Vascular Malformations in Klippel-Trenaunay Syndrome

Significance: In Klippel-Trenaunay syndrome (KTS), management of a wound in the affected limb can be difficult because of the underlying vascular malformations present. This review describes the characteristics of KTS with wound complications in light of the genetic and molecular mechanisms of the disease. Recent Advances: KTS is a slow-flow combined vascular malformation characterized by the triad of capillary malformation, venous malformation with or without lymphatic malformation, and limb overgrowth. KTS is encompassed within the phosphatidylinositol-4,5-bisphosphate3-kinase catalytic subunit alpha (PIK3CA)-related overgrowth spectrum (PROS), having recently been linked to activating mutations in the PIK3CA gene. This clearly has implications for both molecular diagnosis and potential treatment strategies for the disease. Critical Issues: KTS should be distinguished from Parkes Weber syndrome, a fast-flow-type combined vascular malformation with limb overgrowth. Individualized management is needed for KTS and should be focused on the treatment of symptoms. Future Directions: Targeted therapies that inhibit the phosphoinositide 3-kinase signaling pathway are a potential treatment option for PROS.

Reconstruction of Head and Neck Capillary Malformations With Free Perforator Flaps for Aesthetic Purposes

BACKGROUND

Capillary malformations (CMs) are composed of dilated capillaries and venules in the dermis layer. They appear as pink- or purple-colored lesions on the involved skin and usually follow a dermatomal distribution. Generally, laser treatment is considered the treatment of choice; however, in some patients, a surgical approach should be considered. This article presents the authors' experiences with free perforator flap transfer to the head and neck after resection of CMs for aesthetic purposes.

PATIENTS AND METHODS

A total of 5 patients with CMs on their head and neck underwent operations for aesthetic purposes. After lesion debulking, defect sizes were measured and precise flaps were designed. A primary flap-thinning procedure was needed in obese patients before flap inset. The donor site was closed primarily in 4 cases.

RESULTS

Thoracodorsal artery perforator free flaps were performed in all patients. The average size of harvested flaps was 146.8 cm. All flaps survived without recurrence of CM on the skin paddle of the transferred flap. Aesthetic restoration and high patient satisfaction were achieved after the surgery.

CONCLUSIONS

The authors used free flaps to improve aesthetic outcomes, which have been used for reconstruction after trauma and malignancy. Free perforator flap transfer should be considered a valuable option for head and neck CMs.

The assessment of pulsed dye laser treatment of port-wine stains with reflectance confocal microscopy

BACKGROUND

Reflectance confocal microscopy (RCM) is a noninvasive technique for evaluating cutaneous lesions with cellular level resolution close to conventional histopathology. The aim of this study is to observe the vascular changes in Port-wine (PWS) lesions and assess the clinical efficacy of Pulsed Dye Laser (PDL) treatment by examining vessel diameter and density with RCM.

MATERIALS AND METHODS

Eleven adult patients with PWS, each had four test patches carried out with different pulse durations (1.5, 3, 6, and 10 ms), respectively; fluences of 9-12 J/cm²; and a spot size of 7 mm. The PDL treatment was repeated 3-5 times at a 2-month interval. Photographs and measurements with RCM were taken before each treatment and 2 months after the last treatment.

RESULTS

The PDL treatment exhibited increasing clearance with reducing pulse durations. Vessel diameters and densities were significantly decreased in the same pulse-duration groups after treatment. There was significant difference between 1.5 ms pulse-duration group and other pulse-duration groups in reducing blood vessel diameter at the depth of 150 μm.

CONCLUSIONS

RCM can be used to assess the clinical efficacy of PDL treatment.

Complex vascular anomalies

The classification system for vascular anomalies now used by experts worldwide comprises two distinct disease entities that differ in their biologic and pathologic features: vascular tumors and vascular malformations. Vascular tumors include infantile and congenital hemangiomas, tufted angiomas, and kaposiform hemangioendotheliomas. Infantile hemangiomas, the most common vascular anomaly, generally have a predetermined life cycle (proliferation and subsequent involution). GLUT-1, a glucose transporter, is a marker for these specific lesions during all phases of development. Vascular malformations are classified according to their vascular tissue of origin and include capillary, venous, arteriovenous, lymphatic, and mixed malformations. Complex lymphatic malformations and complex mixed malformations, which may have most vascular components, are the most difficult vascular malformations to successfully treat. These lesions are present at birth and often expand or grow in response to trauma, infection, or hormonal changes. Imaging advancements have enabled more accurate assessments and improved management of vascular anomalies. In addition, many lesions are now being managed with targeted pharmacologic therapy. Propranolol and steroids are used for complex or disfiguring tumors, and new anti-angiogenesis inhibitors such as sirolimus are selectively used to treat lymphatic and venous lymphatic malformations that are poorly responsive to sclerotherapy, embolization, and surgical excision. Multimodal therapies are often essential for complex lesions and require the combined expertise of an interdisciplinary team.

Vascular anomalies - a practical approach

Vascular anomalies are common clinical problems (around 4.5% of all patients) in pediatric dermatology. A correct diagnosis is possible on clinical grounds in around 90% of cases; the remaining patients may require radiologic evaluations (duplex ultrasonography, MRI scan) and, rarely, histology. Vascular anomalies are divided into tumors and vascular malformations. This clear division reflects the different biological behaviors of these two groups. The infantile hemangioma represents by far the most common vascular tumor and is characterized by a typical growth cycle consisting of rapid proliferation, plateau phase, and finally slow regression. The discovery in 2008 of the efficacy of beta blockers in this disease is a therapeutic milestone. Vascular malformations can affect all types of vessels (capillaries, veins, arteries and lymphatic vessels). They usually manifest at birth and grow proportionally with the affected child. Some show marked progression especially during puberty. Considerable progress has been made with innovative interventional therapies in recent years, but surgery remains an important option. Basic knowledge of these diseases is important to every dermatologist in order to be able to counsel and manage affected patients correctly.

CM-AVM syndrome in a neonate: case report and treatment with a novel flow reduction strategy

Mutations in the RASA-1 gene underlie several related disorders of vasculogenesis. Capillary malformation-arteriovenous malformation (CM-AVM) is one such entity and was recently encountered in a neonate who demonstrated its clinical and radiologic features. A single mutation in the RASA-1 gene was detected.A novel flow reduction strategy was employed to a large AVM affecting the patient's upper limb. The imaging findings, surgical procedure and patient's improved post-operative state are described.

Vascular anomalies in children

The process of understanding and treating children with vascular anomalies has been hampered by confusing and occasionally incorrect terminology. The most important step when evaluating a maxillofacial vascular anomaly is to determine whether it is a tumor or a malformation. In most cases, this diagnosis can be made by history and physical examination. Selective radiographic imaging is helpful in differentiating vascular malformations or the extent of bony involvement and/or destruction. Children with vascular anomalies should be managed by an interdisciplinary team of trained providers who are committed to following, treating, and studying patients with these complex problems.