Hemangioma excision





Definition

Hemangioma excision is the use of surgical techniques to remove benign tumors made up of blood vessels that are often located within the skin. Strawberry hemangiomas are often called strawberry birthmarks. Hemangioma surgery involves the removal of the abnormal growth in a way that minimizes both physical and psychological scarring of the patient.


Purpose

Almost all hemangiomas will undergo a long, slow regression, known as involution, without treatment. The end result of involution is potentially worse than the scarring that would occur with surgery. Thus, surgical intervention is commonly indicated only if the growth of the tumor is life threatening or highly problematic from a medical or psychosocial point of view. For example, tumor growths that affect the ability of the eye to see, the ear to hear, or the passage of air in and out of the lungs are frequently candidates for surgical treatment. Tumors that have ulcerated are also common candidates for surgical treatment. Surgery after involution can be used to remove remaining scar tissue.

Although controversial, some surgeons also recommend surgery before or during the involution process, in an attempt to minimize the final cosmetic deformity. Small lesions that are in areas that can be excised without cosmetic or functional risk are particularly well-suited to early surgical treatment.


Demographics

Hemangiomas are the most common tumor of infancy, occurring in approximately 10–12% of all white children and are nearly twice as common in premature infants. For unknown reasons, the occurrence in children of black or Asian background is much lower, approximately 0.8–1.4%. The tumors have been reported to be from two to six times more common in females than in males. The great majority of these tumors are located in the head and neck, with the remaining appearing throughout the body, including internally.

At present, an estimated 60% of patients with hemangiomas require some form of corrective surgery sometime during recovery from the tumor surgery. The remaining 40% rely on the spontaneous involution process to resolve the lesion, although complete return to normalcy is extremely rare.


Description

Hemangiomas undergo a characteristic set of stages during the tumor development. Approximately 30% are present at birth, with the remainder appearing within the first few weeks of life, often beginning as a well-demarcated pale spot that becomes more noticeable when the child cries. The tumors are highly variable in presentation and range from flat, reddish areas known as superficial hemangiomas, to those that are bluish in color and located further under the skin, and are known as deep hemangiomas.

During the first six to 18 months of life, hemangiomas undergo a stage where they grow at an excessive rate in size due to abnormal cell division. The final size of the tumors can range from tiny, hardly noticeable red areas to large, disfiguring growths. In almost all hemangiomas, a long, slow involution process that follows the proliferation stage can take years to complete. Among the first signs of the involution process is a deepening of the red color of the tumor, a graying of the surface, and the appearance of white spots. In general, 50% of all hemangiomas are completely involuted by age five, and 75–90% have completed the process by age seven.

Once a decision to treat a hemangionma with surgery is made, the exact technique to be utilized must also be determined. The most commonly used technique for small lesions is very straightforward and involves removing the abnormal vascular tissue with a lenticular, or lens-shaped excision, that results in a linear scar. Recently, some surgeons have been advocating the use of an elliptical, circular, or irregular incision shapes, followed by a purse-string-type closure. This technique does result in a scar having radial (starshaped) ridges that can take several weeks to flatten. However, the overall result is a shorter scar that can be followed up by removal, using the lenticular excision technique.

Larger, more extensive lesions may require angiography , a process that maps the path of the vessels feeding the lesion, and embolization, the deliberate blocking of these blood vessels using small particles of inert material. This process is followed by complete removal of the abnormal tissue.

Depending on the size and nature of the tumor, the excision surgery can be done on an outpatient or inpatient basis. For very small lesions, local anesthetic may be sufficient, but for the great majority, general anesthesia is necessary to keep the patient comfortable.


Diagnosis/Preparation

Initial correct diagnosis of the hemangioma is necessary for effective treatment. Generally, hemangiomas are

To remove a hemangioma that is very large or in a troublesome area (A), the surgeon makes an incision around the mark (B), then closes the skin around it (C). (Illustration by GGS Inc.)
To remove a hemangioma that is very large or in a troublesome area (A), the surgeon makes an incision around the mark (B), then closes the skin around it (C). (
Illustration by GGS Inc.
)
not present at birth; they proliferate during the first year of the patient's life, and then commonly begin an involution process. These clinical characteristics distinguish hemangiomas from another type of congenital vascular lesion called a vascular malformation. Vascular malformations are always present at birth, do not proliferate, and do not involute. Vascular malformations are developmental abnormalities and can involve veins, arteries, or lymphatic tissue. Because of the lack of rapid proliferation, the expectation for vascular malformations differs from those with a hemangioma, and so the precise type of lesion has a significant impact on treatment decisions.


Aftercare

Aftercare for a hemangioma excision involves wound care and maintenance such as changing of bandages.


Risks

The greatest risk of hemangioma excision is bleeding during the operation, as these tumors are comprised of abnormal blood vessels. Surgeons often utilize special surgical tools to reduce this risk, including thermoscalpels (an electrically heated scapel) and electrocauteries (a tool that stops bleeding using an electrical charge).

A second risk of the surgery is recurrence of the tumor, that is, an incomplete excision of the abnormally growing tissue. Surgery may also result in scarring that is at least as noticeable as what would remain after involution, if not more so. Patients and their caregivers should carefully consider this possibility when deciding to undergo surgical treatment for hemangiomas.

Other risks of the surgery are very low, and include those that accompany any surgical procedure, such as reactions to anesthesia and possible infections of the incision.


Normal results

Completely normal appearance after surgery is very rare. However, for significantly disfiguring tumors or those that impact physical function, the surgical scar may be preferable to the presence of the tumor.

Morbidity and mortality rates

Morbidity and mortality resulting from this surgery is close to zero, particularly because of the new surgical techniques and tools that prevent intra-operative bleeding of the tumor.


Alternatives

Several alternatives to surgical excision include observation ("watchful waiting"), treatment with steroids during the proliferation stage to shrink the tumor and speed the involution process, and laser surgery techniques to alter the appearance of the tumor. Commonly, a combination of these treatment methods, including surgery, will be used to tailor a therapeutic approach for a patient's particular tumor.


Resources

BOOKS

DuFresne, Craig R. "The Management of Hemangiomas and Vascular Malformations of the Head and Neck." In Plastic Surgery: Indications, Operations, and Outcomes, Volume 2, edited by Craig A. Vander Kolk, et al. St. Louis, MO: Mosby, 2000.

Waner, Milton, and James Y. Suen. Hemangiomas and Vascular Malformations of the Head and Neck. New York: Wiley-Liss, 1999.

PERIODICALS

Mulliken, John B., Gary F. Rogers, and Jennifer J. Marler. "Circular Excision of Hemangioma and Purse-String Closure: The Smallest Possible Scar." Plastic and Reconstructive Surgery 109 (April 15, 2002): 1544.

ORGANIZATIONS

American Society of Plastic Surgeons. 444 E. Algonquin Rd. Arlington Heights, IL 60005. (800) 475-2784. http://www.plasticsurgery.org .

Vascular Birthmark Foundation. P.O. Box 106, Latham, NY 12110. (877) VBF-LOOK (daytime) and (877) VBF-4646 (evenings and weekends). http://www.birthmark.org .

OTHER

Sargent, Larry A. "Hemangiomas. " In Tennessee Craniofacial Center Monographs, 2000 [cited March 23, 2003] http://www.erlanger.org/craniofacial/book .


Michelle Johnson, MS,JD

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?


The procedure is generally performed by plastic surgeons and, except for extremely small lesions, is done on an inpatient basis in a hospital operating room .

QUESTIONS TO ASK THE DOCTOR


  • What is the predicted cosmetic outcome of the surgery and how does this compare to the outcome after involution?
  • What are the risks of the surgery and how does this compare with the risks of continuing to observe the tumor?
  • Is treatment of this hemangionma using steroids a possibility?
  • Are laser techniques a viable option for this tumor?

User Contributions:

Samir
Report this comment as inappropriate
Apr 5, 2008 @ 4:04 am
my baby (newly bron 1month & 8days) infected with hemangioma can u send me full details about this desease hemangioma......
mel harper
Report this comment as inappropriate
Nov 1, 2008 @ 8:20 pm
hi i am a new mother to a wonderful baby girl that has a hemangioma on her nose. i will see a derm soon but i would like to see after picture of the hem.. after surgery please help!!!!!!
Ben
Report this comment as inappropriate
Feb 9, 2010 @ 12:12 pm
My daughter was a premie 14 years ago and has two hemangiomas one about the size of a dime on her nose and the other much larger one on her lower right back As I said she has lived with these now for 14 years but now a teenager she wants the one on her nose removed . The doctor assumed it would go away on it's own but of course it has not.it is the same color as her skin now but still is raised up above the skin surface about a 1/16" and is noticable. I would like to know where to take her for a consult, a dermatologist or possibly a vascular surgeon? not sure if my insurance will pay for the surgery or consider it cosmetic? as it is in her line of vision Are there any topical treatments? I heard mentioned steroid creams; is that a viable option?
Is it better to have it removed as at her age? it has shrunk about as much as it's going to. It was about the size of a quarter and red until she was about 10 or 11 years old.
Report this comment as inappropriate
Dec 20, 2010 @ 6:18 pm
i have a little 3 month old baby w/ this birth mark it really worries me because she has it under her eye i check it everyday and it worrys me it might get infected so im taking her to get it removed i dont want to wait for it to cause her a vision problem before getting it removed but im still scared could u tell be the percentage of the outcomes of operations remonving the hemangioma mark..please and after pictures right now hers is about the size of a bean
Report this comment as inappropriate
Dec 29, 2010 @ 1:13 pm
Our son is about 18 months and has three hemangiomas: one near his left eye, one on the left nostil and one in the middle of his back. He has been on propanol (Beta Blocker) since he was 6 months. The mark on his eye and back have flattened out and even broken into smaller marks. The one on his nose is turning grayish and fading. This treatment takes a lot longer than we thought it would and it is given orally so after about two months of two shots a day we had to put it in his milk.

This is a very recent discovery so ask your doctor about it or do a search with beta blockers to see some of the results.
Daniel
Report this comment as inappropriate
Jan 28, 2011 @ 10:10 am
My 2 year old daughter developed a hemangioma at the base of her neck when she was just a few months old. It grew quickly until it literally touched her ear. After visiting one dermatologist who would swore by steroid cream, we had no results except growing fine hair near the area. We were referred to another derm. who put my daughter on propranolol. In 8 months the heman. involuted until it is almost flat. She will have surgery to remove the loose skin next month. If you desire results, ask your dermatologist about propranolol. If they won't try it, find a doctor that will. Traditionally a blood pressure medicine, this old drug has found a new use. We could not be more pleased with the results.
Harriet
Report this comment as inappropriate
Jul 27, 2011 @ 3:15 pm
I am 16, and I have finally decided to have surgery for my strawberry hemangioma. It came up a few hours after I was born, and was bright red, and raised quite high, right in the middle of my lower forehead. My mum and dad were told it would disappear by the time I was 5, and as it was not affecting my health, they decided to leave it to disappear. As they said age 5 it would disappear, my parents probably didn't consider how I would be treated at school. My the time I was 5 it had faded to skin colour but was still raised and noticible, I was always stared at and one of my friends told my other friends I must be an alien because I had it. It sounds silly now but it really hurt me at the time. When I finished primary school everyone was used to it, I had good friends and people liked me. I went into high school and had to go through the whole staring thing, and the comments as there was so many more students there. It has always affected my confidence and I have decided I just want to at least try and have surgery even if I get a scar because it has really affected my confidence. Other people might be able to deal with it as its not even that big, but I am so shy anyway it affects me trying to speak to new people. Its really the parents decision at birth but there is a 50% chance your child will want surgery when they are older anyway, so it is just what you think is best.
Report this comment as inappropriate
Sep 15, 2011 @ 9:21 pm
i ask what is the most perfect how to remove the strawberry hemangioma because my daugther have that..she's 5months old..what is the best medicine for my daugther..
Selvakumar
Report this comment as inappropriate
Oct 12, 2011 @ 5:05 am
My daughter is 4 months old...She is having the strawberry hemangioma in her side of leg just below the knee of size around 1 1/2 inches in diamater and also in her upper eye lid. I was very much worried with the one in her upper eyelid which may cause visibilty problems. Please kindly suggest me the correct treatment to rescue her from psycological problems which may occur in future
Report this comment as inappropriate
Nov 5, 2011 @ 3:03 am
Thanks for the awesome post. I liked it a lot. Great work, keep it up.
Rachel H
Report this comment as inappropriate
Nov 26, 2011 @ 8:20 pm
My Daughter is now 18 months she has had a hemangioma since she was 2 months she just under went surgery 2 weeks ago she looks wonderful the day of surgery she came home and played i was so scared and worried that she would be in pain but she wasnt and as far as with the "bump" i had people look stare and ask about it made me mad some of the things that were said by nasty nay sayers but rememebr hold you head high you didnt cause it and smile because you have a beautiful child with a "mark". Its made me understand things differnt i wish you all luck and happy ending for your little one!
K.B.Vishweswaran
Report this comment as inappropriate
Dec 28, 2011 @ 7:07 am
My daughter is 9 months old now. She has strawberry hemangioma in right hand (very big) and back side of neck (2 big dots). Both these marks looks very visible. But nowadays she gets irritation in those areas since she has see the right hand comfortably she started rubbing the marks. What will happen will it disappear when she grows or not. Also after bath small pieces (similar to dots) are coming away sometimes. Is it a good sign by disappearing by itself, Can you suggest please.
D. Anderson
Report this comment as inappropriate
Mar 1, 2012 @ 12:12 pm
I am 23 years old and when I was 21 I started having terrible migranes and my blood pressure went up and was started on blood pressure pills. I got an mri done and my doctor told me that I have an Hemangioma in my head. He said that it would be ok if it didnt grow or change in any kind of way, that I would not have to have surgery. But I resently went to my obgyn because I was looking into having a child. And the dotor told me that it would be in my best intrest not to try and have kids. It hurt to hear him say that because he said it could cause a stroke or even kill me. I want to have kids, What would be the best thing to do, have the surgery to remove it or just leave it alone? I read that it can only come in infants and babies. How did I get it? Where do they come from?
S. Ramroop
Report this comment as inappropriate
Jul 16, 2012 @ 6:18 pm
I am 23 years old, for 2 weeks now i have something what resembles hemangioma i went to an ENT specialist and he said i have to surgically remove it, it is on my face (left cheek) but that's where all the the clustered blood vessels are and will bleed a lot. I'm not white, black or asian and I'm not an infant this just happen within 2 to 3 weeks started out as a small pimple. This is crazy just like that this happened? is it really heamangioma or something else misdiagnosed?
Cathy
Report this comment as inappropriate
Jul 31, 2012 @ 11:23 pm
I am 46 yrs old I have a hemagomia tumor on my liver the size of a baseball. I have seen 4 doctors and none will remove it. It is in the worst place it could be. The risk of removing it and surviving the surgery is slim to none. I'm in constant pain and the several pain pills given to me all make me sick in one way or another. I don't know what to do. Take the risk on the operating table or deal with the pain for the rest of my life.
Wanda
Report this comment as inappropriate
Sep 27, 2012 @ 9:09 am
I have a 2 1/2 month old who has a segmental facial hemangioma including one on his eyelid which grew very quickly to the point where he could not open his eye all with in a month from birth. Our pediatrician referred us to the Vascualar Birthmark Institue in NY. Dr.Blei has been absolutely amazing. She started him on propranolol and it has gotten alot better and its only been a month and a half since he's been on it..
jess
Report this comment as inappropriate
Sep 27, 2012 @ 4:16 pm
Hi, i'm jess, i actually had a hemangioma tumor of the blood vessels myself.
I was born with the tumor itself but my mum always said it was never really noticeable until i was about 2 years old... I was on steroids which was supposed to control the tumor, but didn't actually work so i went into surgery.
I got it removed when i was 6 years old at Great Ormand Street Hospital, they helped me through so much.
I'm 16 years old now but still always get sharp pains and throbbing in my neck and cheek area where the tumor was, i mean its bearable because it happens several times throughout the day, but it is very painful for me and i'm not sure what to do? Advice would be nice. Thank you
Report this comment as inappropriate
Oct 15, 2012 @ 3:03 am
My baby is 2 month & 5 days old and is infected with strawberry hemangioma on right side of the neck. It is approximately 2 inch in size.

Can u send me full details about this disease and the SPECIAL CARE to be taken, treatments,etc.
christina
Report this comment as inappropriate
Jan 18, 2013 @ 11:11 am
Hi im 35 and ive recently been diagnosed with a hemangioma on my lower spine. i was told by gp that they do not cause pain, but ive been suffering severe acute pain all over my back. which is now getting that bad that it is generating round into my stomach and then up into my chest :( please can someone tell me do they are dont they cause pain ? all i have been given.is physiotherepy does anyone no if this is advisable as i start next week ? any help and advice will be much appreciated thankyou.
mamta
Report this comment as inappropriate
Mar 29, 2013 @ 6:06 am
Hi,
i have a 1 year old baby she has an hemongioma on her right face near eye.
how can we cure pls help. hope we will get a positive response.

thanka
mamta
Britt
Report this comment as inappropriate
May 8, 2013 @ 4:16 pm
My son will be 2 next month. He has had a hemangioma on his head just behind the hairline above his forehead, since he was a week old. It started out very light in color but over time grew to be about 1.5 inches in diameter and protruded over .5 inches. Luckily it did not affect him in any way except for the comments people would make about his "boo-boo" because they did not know any better. At the time his pediatrician encouraged us to wait and said it would eventually go away and not affect him at all. We had changed pediatrician at one point and were advised to consult a plastic surgeon at All Children's Hospital. The plastic surgeon was surprised that we had not come sooner as the results from surgery young are often much more desirable than the results after involution. Once he was in daycare I did not want him to feel different and for kids to poke at his head. He has had the surgery, it took about an hour and he went under general anesthesia. They managed to get all the red stain out and close it. The incision ended up being about 4 inches long but was done in such a way that the scar would be entirely in a hairline. I know when he is older that he will appreciate not having the stigma and I am happy that we have done it.
Jamilah
Report this comment as inappropriate
May 21, 2013 @ 2:14 pm
My daughter is 1 years old with a strawberry hemangioma. At the age of 3 weeks, we started to see it appear. At first, it looked like a bruise but soon and rapidly turned in to a huge bump. My daughters PCP said "It will disappear and it will look worst before better". So allowed it to continue to grow to about 3cm high and 2cm across. At this point, it began to bleed. So I seeked other advice. She started to visit Children's Hospital in Washington DC. There she become a monthly patient in there Vascular Clinic. Her first treatment was steriod injections for 2 months. Results- There was no change but my child reactions where accessive sweating. The doctors changed her treatment finally to propanolol. I thought I was going to be finally happy. We immediately saw changes. It was shrinking and the color changed. She was on the medicine for 4 months. I still was not as happy because I was under the impression that it will disappear. She has a appointment at the end of May and I'm seeking SURGERY!
abby
Report this comment as inappropriate
Jun 26, 2013 @ 5:17 pm
the tumors may vary in size and severity. i have had a hemangioma since birth right on my lip under my nose. as a baby it was huge and finally it went down a lot at about age 7 . i now have some loose skin and it looks like three scar marks there. it has been annoying and i have been made fun of. i feel that i am not as confident as i would be if i hadnt had this on my face all my life but for the most part im good . at least it wasnt on my insides as that can be dangerous. if given the choice at birth i wouldnt mind trying the surgery because i have a scar anyways where the tumor stretched my skin.
naveed khan
Report this comment as inappropriate
Jul 4, 2013 @ 8:08 am
Hello I got hypoechoic / heterogeneous swelling of about 26×6mm
In my right side of neck side so please suggest
Me what to do
amit gupta
Report this comment as inappropriate
Jul 29, 2013 @ 9:09 am
my baby girl is 18 months old. she has a hemangioma in her upper back. i have consulted many doctors of india and they suggested me that no need to take any medicine or surgery, let it be smaller and then go for surgery or laser treatment. they also suggest me that it will be done after 4 years of my child. kindly help me and suggest what to do now.
sammy
Report this comment as inappropriate
Oct 28, 2013 @ 7:07 am
My son just had a synovial hemangioma removed from his knee joint. He has had a sore knee for years and we had been told each time it came up that it was just growing pains that sometimes boys get. Every year it would be brought up at his physical, and every year we would be told the same thing. Finally it had been hurting every day and starting to swell, so we took him back. They finally after about 5 years did an mri and discovered the tumor. It is now 6 days after surgery and healing has been slow, but finally there is hope that he will finally be able to walk normally without pain once the healing is over. I only wish they had listened to us more sooner. No regrets. He at 16 years of age was so anxious to get this thing out of him. His mood has improved since it is no longer this mystery pain that he thought he would have to live with for the rest of his life!
GEORGIA
Report this comment as inappropriate
Apr 14, 2014 @ 1:13 pm
my daughter has had a hemangioma on her eye lid from 2 months old and was sent to a optomologist for treatment we were told to wait 6 months and then revisit she is now 11months and we have changed pediatric doctors due to her vision has been damaged and no plan to correct has been made the new doctor could not believe we had not seen a dermatologist and from the first visit each specialist has been surprised that no action had been made to this point. we are now starting propranolol and have surgery as a two week backup. suggestion if location of hemangioma is compromising a function of your child do not listen to "it will go away with time".

Comment about this article, ask questions, or add new information about this topic:

CAPTCHA


Hemangioma Excision forum