Intralesional laser photocoagulation-steroids as an adjunct to surgery for massive hemangiomas and vascular malformations

Accident due to Incorrect Selection of Diode Laser Technique in the Treatment of Oral Venous Malformation

Venous malformation (VM) originates from a congenital venous network disorder, configuring about 40% of the vascular anomalies that occur in the head and neck region. The usage of diode lasers in the treatment of VM is associated with various advantages, such as short operating time and few postoperative complications. Nevertheless, for larger and deeper VM treatment, it may require more than one session for the complete resolution of the lesion. Laser surgery for oral VM may induce heat accumulation due to excessive irradiation causing adverse events postoperatively, including pain and ulcer formation with scarring. In this clinical case, it was recommended to use the leopard technique (LT) to reduce the lesion size, evaluate the remaining unhealed lesion, and apply different laser techniques to obtain the complete resolution of the lesion.

Successful Intralesional Laser Therapy for Sclerotherapy-resistant Huge Venous Malformation

Venous malformations (VMs) are compressible, blue-purple tumors that are present at birth, and are treated with either surgery or sclerotherapy, or a combination of both. Patients often experience recurrent hemorrhage, swelling, pain, or difficulty in daily life. Treatment of massive VMs can, therefore, be challenging. We applied intralesional laser photocoagulation (ILP) to a 19-year-old female patient with a huge VM who had shown resistance to sclerotherapy. It spanned from the dorsal area to the lateral chest. ILP is delivered directly into thick, deep lesions through a bare fiber delivery system. The effect on deep components is optimized without directly contacting the cutaneous or mucosal surfaces to minimize epithelial damage. We applied ILP to the lesion at 30 W in continuous mode (10 seconds) under ultrasound monitoring using an Nd:YAG laser of 1064-nm wavelength. In total, there have been 4 sessions of the same treatment; the lesion was treated with a combined 120 kJ of energy. Satisfactory regression of the huge VM was achieved by this ILP treatment. No significant complications (major bleeding, severe pain, post-perforation skin ulcer, and scar contraction) occurred during the treatment. ILP has been indicated for only sclerotherapy-resistant cases until now, but we suggest that it is a potentially safe and minimally-invasive resolution of VM without scarring or loss of normal shape, sensory feel, or function. ILP appears to be a safe and minimally-invasive resolution of VM. We propose that this technique could become a first-choice treatment modality for VM.

Retrospective Study on Laser Treatment of Oral Vascular Lesions Using the "Leopard Technique": The Multiple Spot Irradiation Technique with a Single-Pulsed Wave

OBJECTIVE

This study aimed to retrospectively evaluate the efficacy and safety of laser treatment of oral vascular lesions using the multiple spot irradiation technique with a single-pulsed wave.

BACKGROUND DATA

In laser therapy for vascular lesions, heat accumulation induced by excessive irradiation can cause adverse events postoperatively, including ulcer formation, resultant scarring, and severe pain. To prevent heat accumulation and side effects, we have applied a multiple pulsed spot irradiation technique, the so-called "leopard technique" (LT) to oral vascular lesions. This approach was originally proposed for laser treatment of nevi. It can avoid thermal concentration at the same spot and spare the epithelium, which promotes smooth healing. The goal of the study was to evaluate this procedure and treatment outcomes.

PATIENTS AND METHODS

The subjects were 46 patients with 47 oral vascular lesions treated with the LT using a Nd:YAG laser (1064 nm), including 24 thick lesions treated using a combination of the LT and intralesional photocoagulation.

RESULTS

All treatment outcomes were satisfactory without serious complications such as deep ulcer formation, scarring, bleeding, or severe swelling.

CONCLUSIONS

Laser therapy with the LT is a promising less-invasive treatment for oral vascular lesions.

Hemangioma: review of literature

Hemangiomas are tumors identifed by rapid endothelial cell proliferation in early infancy, followed by involution over time. All other abnormalities are malformations resulting from anomalous development of vascular plexuses. The malformations have a normal endothelial cell growth cycle that affects the veins, the capillaries or the lymphatics and they do not involute. Hemangiomas are the most common tumors of infancy and are characterized by a proliferating and involuting phase. They are seen more commonly in whites than in blacks, more in females than in males in a ratio of 3:1.

Treatment strategies for large oral venous malformations using intralesional laser photocoagulation

We report two treatment strategies using intralesional laser photocoagulation (ILP) for large venous malformations (VMs) in the oral cavity. ILP is considered to be an effective technique for massive vascular lesion. The satisfactory results could have been obtained, since we started ILP for the treatment of large VMs. Recently, to improve the safety, reliability, and effectiveness of the treatment, we developed modifications of ILP that include a combination of ILP and transmucosal irradiation; and compartmentalization and serial step irradiation. In the former, ILP is performed for a deep layer lesion and transmucosal irradiation with multiple spots fashioned using a single pulse is added for the superficial layer in the same session, to increase the efficacy of regression. In the latter, the lesion is divided by virtual compartment and each area will be sequentially treated by ILP. The irradiated area and total energy in a session should be limited to avoid severe reactions and excessive thermal destruction of surrounding tissue. All treatment outcomes by each technique were satisfactory without serious complications, such as deep ulcer formation, bleeding, or severe swelling developing obstruction. Both treatment strategies improve the safety, reliability, and effectiveness of ILP and make the method less traumatic for patients.

Ultrasound-guided intralesional laser treatment of venous malformation in the oral cavity

An ultrasound-guided intralesional photocoagulation (ILP) technique using a laser is described for treatment of deep venous malformations in the oral cavity. ILP is basically a blind operation and has a risk of unintended destruction of surrounding normal tissue, therefore the authors now routinely use guidance by ultrasonography using a mini-probe to improve the safety and reliability of ILP. This approach enables safe fibre insertion, appropriate laser irradiation, and intraoperative assessment of coagulation. The use of this technique is described in 8 patients. The authors conclude that ultrasound-guided ILP with a laser is a promising technique for less-invasive treatment of a vascular malformation in the oral cavity.

Long term follow-up of intralesional laser photocoagulation (ILP) for hemangioma patients

BACKGROUND AND OBJECTIVES

Hemangiomas remain a challenge for patients and plastic surgeons. Promising results have been reported using intralesional photocoagulation (ILP) for treatment. The objective of our study is to review the long term results of a large series of hemangiomas in patients treated by ILP. Materials (Subjects) and Methods: A retrospective review of 684 hemangiomas in patients were treated by ILP with an Nd:YAG (neodymium-yttrium-aluminium-garnet) (1064 nm) laser over a period of 10 years (January 1996-January 2005). Patients' ages ranged from one month to 11 years 5 months (mean, 1 year 10 months). The patient group consisted of 474 females and 210 males.

RESULTS

Patients were treated with an Nd:YAG laser delivered through a 600 m optical fiber. Laser power was set at 7 to 15 watts (W) and delivered with pulse duration of 7 to 15 seconds (s). The results showed 603 (88.6%) patients had more than 50% reduction of the volume in hemangiomas at 3 months after one treatment; and 663 (96.9%) patients had more than 50% reduction of the volume at 3 months after two treatments. Patients who had continuous ILP achieved excellent results.

CONCLUSIONS

Postoperative complications have been related to photocoagulation that has been delivered too extensively or superficially, with resultant ulceration, infection, bleeding, and scarring. These complications can be avoided if this potential for harm is kept in mind.

Intralesional laser treatment of voluminous vascular lesions in the oral cavity

OBJECTIVE

In laser treatment of voluminous vascular lesions, there are many cases in which submucosally located angioma remnants cannot be reached by noncontact superficial laser application. To diminish these remnants we used intralesional photocoagulation (ILP) in treatment of oral vascular lesions, because this approach is effective in treatment of voluminous vascular lesions of the skin.

STUDY DESIGN

Four cases of voluminous vascular malformation in the oral cavity were treated by ILP using a potassium-titanyl-phosphate (KTP) laser. In 1 case, treatment was carried out under ultrasound and manual control.

RESULTS

All lesions showed more than 70% regression after the first ILP session, and the treatment outcome was satisfactory. There were no serious complications, such as bleeding or invasive infection. Ultrasonography was useful for guiding laser treatment in the oral cavity.

CONCLUSION

Intralesional photocoagulation treatment with a KTP laser is effective and safe for treatment of a vascular lesion in the oral cavity.

Intramuscular vascular malformation of the masseter muscle presenting with turkey wattle sign

Intramuscular vascular malformations are unusual tumors in the head and neck region. Less than 1% of vasoformative tumors throughout the body occur in skeletal muscle; 15% of them arise in head and neck musculature. Masseter muscle is the most frequent site for such vascular malformations; it accounts for approximately 5% of all intramuscular vascular malformations in the head and neck region. A case of unusual intramuscular vascular malformation of masseter muscle is described and the diagnosis and management of these tumors is discussed.

Laser Treatment of Venous Malformations

Venous malformations (VM) are developmental errors comprised of enlarged dysplastic blood vessels. Clinically they manifest as either a faint blue patch or a soft blue vascular mass. Treatment options include a sclerosing agent (such as alcohol or ethiblock), surgery or laser therapy. A review of the literature concerning VM and laser treatment yielded a few sporadic reports describing series of 3 to 46 cases. In this retrospective study we reviewed the files of the relevant cases. The data included the extent of the lesion, the different anatomical sites, age of patient and the extent of clearance of the lesion as the treatment's end point. This study includes 56 cases which makes it the largest series presented. The success rate of laser treatment was 92.8%. The immediate complication rate was very low (approximately 3.57%) including minimal scarring and deformity. No long term complications were noted. Our study concludes that treatment of VM is a difficult task due to the nature of the lesions. Laser treatment of these lesions enables one to obtain good results with a very low incidence of complications. Surgery and other treatment modalities are not always satisfactory, yield similar or less efficient results and have a higher complication rate. Laser treatment can play an important role in the treatment of VM and in fact may be the treatment of choice in some settings.

Management of low-flow vascular malformations of upper aero digestive system—role of N-butyl cyanoacrylate in peroperative devascularization

OBJECTIVES

Low-flow vascular malformations of upper aero digestive system may cause difficulty in swallowing and/or breathing and bleeding from these lesions may even threaten the life of patient due to risk of aspiration. These lesions may require surgical resection with prior devascularization to minimize blood loss during surgery.

METHODS

Peroperative devascularization of vascular malformations was carried in patients of our study group by injecting N-butyl cyanoacrylate (NBCA) into vascular malformations using direct puncture technique. This was followed by surgical resection of lesion in the same sitting.

RESULTS

Successful devascularization of vascular malformations in all patients in our study group was achieved by injection of NBCA into the lesion by direct puncture technique. There was retraction of malformation due to devascularization, good plane of cleavage was found during subsequent surgical resection and blood loss was minimal.

CONCLUSIONS

Low-flow vascular malformations of upper aero digestive system can be treated with surgical resection after peroperative devascularization. Direct puncture of NBCA into lesion under fluoroscopy control is an effective, safe and inexpensive method of devascularization which can be carried out by the surgeon in a single sitting.

Ultrasound-guided Endovenous Diode Laser in the Treatment of Congenital Venous Malformations: Preliminary Experience

The authors present their experience in treating congenital venous malformations with ultrasound (US)-guided endovenous diode laser. Six patients underwent treatment of eight venous malformations for complaints including pain, activity limitation, or cosmetic defect. At a mean follow-up interval of 14.5 months, all had either resolution of (five patients) or marked decrease in (one patient) pain, allowing them to resume previously limited activities. There were no instances of nerve damage or skin necrosis. One patient had a self-limited mucosal tongue base ulcer. In this small series of patients, endovenous laser treatment of venous malformations was effective during short-term follow-up.

Endovenous laser photocoagulation (EVLP) for varicose veins

BACKGROUND AND OBJECTIVES

Untreated varicose veins have significant morbidity and potential mortality. Treatment aims to relieve symptoms, improve appearance, and to prevent deterioration. Current therapeutic options include graduated compression stockings, sclerotherapy, ambulatory phlebectomy, surgical ligation, and stripping. Results of laser photocoagulation of vascular anomalies have been encouraging. Applying these concepts of laser-tissue interactions, we developed a new method of treatment for varicose veins of the lower extremities.

STUDY DESIGN/MATERIALS AND METHODS

One hundred and forty-nine patients with 252 varicose greater saphenous veins underwent endovenous laser photocoagulation (EVLP) from January 1996 to January 2000. Subject's age ranged between 23 years 9 months and 80 years 7 months with a mean age of 50 years 8 months. There were 122 females and 27 males. Only patients with primary varicose veins and saphenofemoral reflux documented by Duplex ultrasound were treated. All patients received surgical ligation of the saphenofemoral junction (SFJ). EVLP was performed using the neodymium:yttrium-aluminium-garnet (Nd:YAG) (1,064 nm) laser, delivered with a 600 microm optical fiber. Laser power was set at 10 or 15 W, delivered with a pulse duration of 10 seconds. The outcome was compared before and after EVLP, based on the score of severity of the varicose veins by Hach's classification.

RESULTS

The range of total delivered energy is from 9,200 to 20,100 J. The entire procedure was completed in 95-175 minutes (mean 122.33 minutes) for bilateral procedures, and 65-100 minutes (mean 81.07 minutes) for unilateral procedures. The follow-up period ranged from 12 to 28 months with a mean of 19 months. One hundred and forty-one patients with 244 legs involved (96.8%) demonstrated remarkable improvement (P < 0.05). Common early complications of EVLP are: local paraesthesia of the treated area in 92 legs (36.5%), ecchymosis and dyschromia in 58 legs (23.0%), superficial burn injury in 12 legs (4.8%), superficial phlebitis in four legs (1.6%), and localized hematoma in two legs (0.8%) at 3 weeks post-operatively. The final outcome showed no significant morbidity or mortality. All patients recovered completely.

CONCLUSIONS

EVLP is a simple effective treatment modality for varicose veins. This less invasive method can minimize the complications of conventional surgery.

Potential complications of intralesional laser photocoagulation for extensive vascular malformations

Vascular anomalies remain a challenge for both patients and plastic surgeons. Recently, promising results have been reported using intralesional photocoagulation (ILP) to treat extensive vascular lesions. At the authors' center, they have treated more than 300 patients with vascular anomalies in different parts of the body between 1996 and 1999. They describe their operative techniques of ILP. Laser pulses of a 1,064-nm wavelength from the Nd:YAG laser were delivered to the target tissues with a 600-microm optical fiber. They report 2 patients who developed complications after a single session of ILP therapy for their extensive vascular malformations. The first patient had Klippel-Trenaunay syndrome (capillary-lymphaticovenous malformations) with widespread involvement of her buttocks and left lower limb. She had severe leukocytosis, thrombocytosis, and hyperkalemia that resolved with intravenous hydration, antibiotics, and sodium bicarbonate. In their second patient, the entire left upper limb was affected. Her total red cell count diminished by a quarter and her hemoglobin concentration dropped by more than 3 g%. This was corrected gradually with supplemental oral hematinics. Although these complications resolved uneventfully in their patients, they hope that their possible development will caution anyone who may wish to attempt this new method of therapy.

Cryogen spray cooling and pulsed dye laser treatment of cutaneous hemangiomas

When a cryogen spurt is applied to the skin surface for tens of milliseconds, cooling remains localized in the epidermis, leaving the temperature of deeper hemangioma vessels unchanged. The objective of this study was to compare the efficacy and safety of noncooled laser treatment (NC-LT) vs. cryogen spray cooling plus laser treatment (CSC-LT) for cutaneous hemangiomas in a large series of patients. A retrospective review was conducted of 164 patients treated with the pulsed dye laser (lambda = 585 nm; taurho = 450 microsec) over an 8-year period. Eighty-two patients received NC-LT using light doses of 5.5 to 8 J per square centimeter. Subsequently, 82 patients received CSC-LT using light doses of 9 to 10 J per square centimeter. The primary efficacy measure was quantitative assessment of improvements in lesional volume, texture, and color. Safety was evaluated for each treatment group by monitoring for adverse effects. Based on chi-squared analysis, there were clinical and significant differences in the number of treatments (p = 0.001), and improvement in volume (p = 0.008) and texture (p = 0.001) of the CSC-LT group compared with the NC-LT group. Permanent adverse effects were not observed in either group. In conclusion, CSC permitted the use of higher incident light doses for treatment of cutaneous hemangiomas, resulting in fewer treatments required and better improvement in lesional volume and texture.

Pulsed 1064-nm Nd:YAG laser therapy for noninvasive treatment of a massive hemangioma: case report

OBJECTIVE

The author determined whether cutaneous Nd:YAG laser therapy is a viable treatment option for a massive hemangioma located in the musculus soleus muscle of a patient's left leg.

SUMMARY BACKGROUND DATA

Giant hemangiomas generally require aggressive medical or surgical therapy to address complications. Because of the size of the lesions, there are risks inherent with conventional treatment options. In selected patients, Nd:YAG laser therapy is a noninvasive approach to treating large, subcutaneous hemangiomas.

METHODS

A 59-year-old female patient, who was diagnosed with a large, venous-type hemangioma in the musculus soleus muscle of the left leg, was treated during two treatment sessions with Nd:YAG laser therapy. A Plexiglas ring was placed on the leg, over the hemangioma, to force the hemangioma closer to the surface and laser irradiation was applied to the skin.

RESULTS

At 6-month follow-up after the second treatment, magnetic resonance imaging (MRI) demonstrated 75%-80% reduction in lesion size. There were no permanent adverse effects encountered with the treatment method.

CONCLUSIONS

The author concludes that in carefully selected cases Nd:YAG laser therapy can be used to treat large hemangiomas whose size poses risks with surgical and other treatments.

Lasers in plastic surgery: current practice

A wide variety of lasers provides the plastic surgeon with treatment options that were not available previously. Appropriate, safe use of lasers complements the many therapeutic treatment options available to plastic surgeons. Lasers have introduced a new therapeutic modality. Because of the ways the skin and its defects may be altered with lasers, they will be an increasingly important part of plastic surgery.

Management of hemangioma of infancy: review of 245 patients

A retrospective study of patients treated from May of 1981 to April of 1994 was conducted. A total of 245 patients with 299 hemangiomas were studied, which represents the largest series reported to date. The study consisted of 173 females and 72 males ranging in age from 1 day to 59 years, with the average age being 4 years and 7 months. Twenty-six were premature neonates (14 females and 12 males). An interesting finding was a 1:1 sex ratio among this group in contrast to the 3:1 female-male ratio frequently reported in the literature. Onset was at birth in 170, within the first month in 43, and after the age of 1 month in 32 patients. Among the 245 patients, 175 hemangiomas were located on the head and neck, 62 on the trunk, 49 on the extremities, and 13 in the perineal area. Five groups of patients were defined based on clinical management. As a result, these groups are not similar. The five groups are as follows: group I (48), observation; group II (9), steroid treatment; group III (27), excision and reconstruction; group IV (88), laser therapy; and group V (73), combined therapy. The involved area of hemangioma was as follows: group 1, 0.5 x 0.5 to 20 x 8 cm; group II, 2 x 2 to 8 x 8 cm; group III, 0.4 x 0.8 to 7 x 7 cm; group IV, 0.5 x 0.5 to 20 x 9 cm; and group V, 1.5 x 1.5 to 25 x 25 cm. The complications of hemangioma seen at the time of consultation were obstruction (28.6 percent), ulceration (20.4 percent), bleeding (14.7 percent), infection (4.9 percent), and pain (0.4 percent). Treatment periods ranged from 1 month to 11 years, with the mean period in each group as follows: group I, 4 years and 9 months; group II, 2 years and 5 months; group III, 1 year and 1 month; group IV, 2 years and 1 month; and group V, 3 years. The outcomes of each patient were evaluated based on improvement of volume, color, and texture by the following scale: 1, poor (0 to 25 percent); 2, fair (26 to 50 percent); 3, good (51 to 75 percent); and 4, excellent (76 to 100 percent). Each of these parameters was summarized for each of the five groups. Statistical analysis by the Irwin-Fisher test was used for analysis and comparison of the final results between groups. Statistically significant differences in outcomes between treatment groups were demonstrated. Laser therapy was shown to be statistically superior to observation with regard to length of treatment and with regard to outcomes of volume and texture (p < 0.05).