Surgical Treatment of Head and Neck Port-Wine Stains by Means of a Staged Zonal Approach:

Surgery for Port-Wine Stains: A Systematic Review

BACKGROUND

Port-wine stains (PWS) are congenital low-flow vascular malformations of the skin. PWS tend to become thicker and darker with time. Laser therapy is the gold standard and the first-line therapy for treating PWS. However, some resistant PWS, or PWS that have tissue hypertrophy, do not respond to this therapy. Our aim is to evaluate the role of surgery in the treatment of PWS birthmarks.

METHODS

A literature search was performed in PubMed, Scopus, Web of Science (WOS) and Google Scholar for all papers dealing with surgery for port-wine stains, from January 2010 to December 2020 using the search strings: (capillary vascular malformation OR port-wine stains OR Sturge Weber Syndrome OR sws OR pws) AND (surgical OR surgery).

RESULTS

Ten articles were identified and used for analysis. They were almost all case series with a short follow up period and lacked an objective-systematic score of evaluation.

CONCLUSIONS

Delay in treatment of port wine stains may result in soft tissue and bone hypertrophy or nodules with disfiguring or destructive characteristics. The correction of PWS-related facial asymmetry often requires bone surgery followed by soft tissue corrections to achieve a more harmonious, predictable result.

A Simple Surgical Solution for Functional Improvement of Deforming Vascular Malformations with Lip Involvement

The management of large, deforming facial arteriovenous malformations (AVMs) can be a daunting clinical challenge for patients and surgeons. Many patients delay treatment due to fear of surgical intervention and concern for unfavorable cosmetic outcomes. Delaying treatment can lead to soft-tissue hypertrophy. Occasionally, facial AVMs can also present with lip involvement, necessitating surgical intervention. A major potential issue regarding AVMs managed with surgical excision is excessive bleeding due to the enlarged dermal vascular plexus. Here, we present a simple surgical technique used to manage deforming AVMs involving the lips. A 32-year-old man with Sturge-Weber syndrome and a 72-year-old man with AVMs of the left face presented to clinic for management. The malformations involved the lips in both patients. Both patients had constant drooling and difficulty eating and talking, in addition to aesthetic concerns. They both underwent surgical excision of the redundant tissue with minimal undermining, advancement flaps, and layered closure. Minimal undermining allowed successful removal of the AVMs and redundant tissue without excessive blood loss and allowed healing without complications. Both patients had significant improvement in eating and talking without drooling. Aesthetically, satisfactory outcomes were maintained at 1-year follow-up appointments. Removal of AVMs while minimizing blood loss can be a challenging endeavor. Here, we have presented a successful, effective technique for restoring both form and function in patients with AVMs involving the lips, with good long-term results.

Imaging and Pathological Characteristics of Port-Wine Stain Patients with Tissue Hypertrophy Before Laser Therapy: Retrospective Data

Background: Port-wine stain (PWS) patients may simultaneously have accompanied soft tissue hypertrophy. The outcome of laser therapy can be poor. Objective: To study the imaging and histopathological characteristics of PWS patients with facial overgrowth. Materials and methods: We retrospectively assessed the effect of therapy on a subset of PWS patients with facial overgrowth. The degree of hypertrophy and the density of enhanced signals on T1-weighted magnetic resonance imaging (MRI) were independently graded by two radiologists using a quartile scale. Biopsies/resection of tissue deep to the facial muscle was reviewed and compared with flat PWS. Results: Thirty-two PWS patients with facial hypertrophy and 15 patients with flat PWS were included. MRI revealed a statistically significant correlation between the degree of hypertrophy and the density of enhanced signals (3.02 ± 0.92 vs. 2.47 ± 0.69; p < 0.01). Histological features of a subset of patients showed that vascular malformations existed in the dermis and also in the subcutaneous fat and muscle with much larger vessel diameters (fat, 0.048 vs. 0.020; muscle, 0.035 vs. 0.017) and thicker vessel walls (fat, 0.014 vs. 0.006; muscle, 0.010 vs. 0.006) (both p < 0.05). Conclusions: The imaging and pathological findings indicate that capillary malformation in subcutaneous tissue might be a major cause of poor therapeutic effect of laser therapy for PWS. Clinical trial registration no.: ChiCTR1800014278.

Contemporary Management of Vascular Anomalies of the Head and Neck-Part 1: Vascular Malformations: A Review

Importance

Vascular anomalies of the head and neck are relatively rare lesions. Management is challenging because of the high likelihood of involvement of functionally critical structures. Multiple modalities of treatment exist for vascular anomalies of the head and neck, including medical therapies, sclerotherapy and embolization procedures, and surgery. This review focuses on the accurate diagnosis and the relative roles of the various therapeutic options.

Observations

Vascular anomalies are classified by the International Society for the Study of Vascular Anomalies into 2 major groups: vascular tumors and vascular malformations. Vascular tumors encompass proliferative lesions ranging from infantile and congenital hemangiomas to kaposiform hemangioendothelioma. Alternatively, vascular malformations are embryologic errors in vasculogenesis. This article focuses on the management of vascular malformations. The 3 primary vascular malformation subclassifications are lymphatic, venous, and arteriovenous. The burden of disease, diagnosis, and current management options are discussed in detail for each subtype.

Conclusions and Relevance

Most vascular malformations of the head and neck require a multidisciplinary approach. Available medical, interventional radiologic, and surgical interventions are constantly evolving. Optimization of function and cosmesis must be balanced with minimization of treatment-associated morbidity. Otolaryngologists-head and neck surgeons must remain up to date regarding options for diagnosis and management of these lesions.

Surgical Management of Facial Port-Wine Stain in Sturge Weber Syndrome

Sturge Weber Syndrome is characterized by the classic triad of a facial port-wine stain, leptomeningeal angiomatosis, and glaucoma. The resultant facial vascular anomaly can lead to soft tissue and bone irregularities, causing psychosocial distress and mental health morbidity. When severe, patients can opt for multi-staged surgical intervention by reconstructive surgeons to restore normal symmetry and improve the aesthetic appearance of the face. This study reports a case of surgical correction for severe facial vascular malformation resulting in poor outcomes due to the associated mental comorbidities seen in Sturge Weber Syndrome. A 37-year-old male with previously diagnosed Sturge Weber Syndrome presented to the outpatient craniofacial clinic for surgical evaluation of a large facial tuberous hemangioma. The patient underwent multiple operations for facial reconstruction including a staged full-thickness skin graft, facial recontouring, and extracranial correction of vertical orbital dystopia. The case was complicated by the patient's poorly controlled seizure disorder and psychosocial illness, resulting in self-mutilation of the repair and poor follow-up. Over the span of 10 years, the patient's mental illness caused him to fail numerous attempts at facial restoration and ultimately led to a poor final result. The psychosocial distress seen in patients with Sturge Weber Syndrome can adversely affect surgical outcomes. Physicians should be mindful of the possible complications that can arise in these patients and have the clinical means to address them.

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.

Surgical correction of hypertrophic upper lip in vascular malformations

Capillary malformations (CMs) and Lymphatic malformations (LMs) are vascular malformations that share a common tendency to cause soft and hard tissue hypertrophy, expressed in the three dimensions of the space. The middle third of the face is the most commonly involved area, with a predominance of the upper lip. To our knowledge, no paper has previously focused on the surgical technique to correct such deformities. We propose and illustrate a surgical protocol, consisting in merging an asymmetric bikini upper lip reduction and a unilateral bull horn resection technique, that allowed to reduce the overall volume of the hypertrophied lip thus restoring lip symmetry. We adopted this technique in 2 patients affected by CMs and 4 patients with LMs, with satisfactory results.

Vascular Malformation of the Face: a Rare Case with Follow-up of 18 Years

Objective

Vascular malformations are structural anomalies in the blood vessels. They are present at birth and persist throughout life. These malformations can be classified according to the type of vessel involved. A port-wine stain is a vascular malformation characterized by an increased number of ectatic vessels in the dermal vascular plexus, which can be found in any part of the body, including the head and neck region. Over time, most of these stains result in soft tissue hypertrophy and this growth can cause severe facial deformity.

Materials and Methods

This study describes a rare case of a giant proliferative vascular anomaly arising from a port-wine stain on the face.

Results

The report highlights the continuous and proliferative growth of the malformation observed after follow-up of 18 years, as well as the difficulty in establishing the diagnosis due to the complexity and dimension of the lesion and the conditions related to the patient’s low socioeconomic status.

Conclusions

We have described a rare and unusual case report of a giant proliferative vascular malformation arising from a Port-wine stain on the face.