Vascular malformations occur during development in the womb. In a child’s developing body, there are connections between the arteries (blood being pumped from the heart), veins (blood flowing back to the heart) and lymphatic vessels (carrying fluid that leaks out from the arteries and veins). Masses can grow at the area of connections. Depending on the vessels that are connected, these masses can grow over time, causing surrounding tissues to change as well.
Vascular birthmarks come in several forms. Those that can be potentially problematic are hemangiomas, of which there are two varieties. The most common and “classic” kind occurs when the mark appears after the child’s birth, usually several weeks later. These hemangiomas can grow quickly and, depending on where they are located, might require quick treatment. Some hemangiomas might exist at birth, however, and determining the difference between these and vascular malformations can be difficult.
The sizes of these masses can range from being almost unnoticeable to extremely large and disfiguring. They can affect any part of the body and can grow over time; they can even pulsate. In regard to lymphatic malformations, colds and/or coughs can cause additional swelling. Sometimes infection can occur, requiring antibiotics.
These are often described as appearing “bright” or crimson red. They also tend to occur on the surface of the skin, however they can also have a large, deeper portion that can appear bluish and dark. When pressure is applied, hemangiomas feel full or firm, compared to the softer vascular malformations.
Although these malformations can accompany certain syndromes, there is no known cause. There are some ideas as to why they occur on the cellular level, however there is no clinical evidence to support a definite cause.
Treatment of vascular malformations depends on the size and location and the extent to which it disturbs the child. Treatment options vary from trying to stop the blood flow to the malformation to surgically removing it. In larger lesions, both options may be utilized to more effectively reduce the size before removing the mass. Additionally, there are times when the lesion itself can be injected with a chemical that will cause the vessels to clot off, similar to the procedure used for varicose veins. This treatment option is usually only for smaller lesions and those with a connection between the veins.
Treatment options vary depending on the size and location of the hemangioma. In general, hemangiomas will grow until a child reaches about 18 months or 2 years of age. After this time, hemangiomas typically begin to shrink. In about 50 percent of cases, hemangiomas will shrink by the time the child is 5 years of age, and 90 percent will shrink by 9 years of age. Some practitioners advocate waiting this long before attempting removal. Unfortunately, when these hemangiomas shrink, the soft tissue is still left behind.
Our philosophy is to treat hemangiomas early, to prevent growth and to shrink them enough so when the time comes to remove whatever remains, the mass will be significantly smaller. Also, as the child gets closer to kindergarten and faces more peer interaction, having a smaller lesion is much easier on the child than waiting for the hemangioma to run its natural course. Treatment methods include either laser therapy, propranolol (an oral medication) or removal, depending on the size, location and specificities of the lesion itself.
Laser therapy involves the use of a laser that targets the blood vessels in the hemangioma and helps obliterate them. This is done as an outpatient surgery because patients require sedation for the actual treatment. Usually, several treatments are needed. As a rule of thumb, six treatments are typically enough, depending on the hemangioma. The area treated also needs routine wound care with an ointment in addition to sun precautions; patients and families often equate it to a bad sunburn. We typically wait about three months between treatments.
Propranolol therapy is a relatively new treatment method and can generate excellent results. Although it is a heart drug, it is also effective against hemangiomas. To start the therapy, we often plan for a 23-hour admission to the hospital, to enable us to monitor the child as he or she begins the propranolol. After three doses, patients are discharged with a prescription for the medicine and are instructed to take it three times daily. Most parents notice effects within the first 24 hours, however the full result of the medication might take up to several months. After the medicine has decreased the hemangioma as much as possible, patients are then gradually weaned off the medication, and rarely does the hemangioma come back. At this time, because the hemangioma is much smaller and less red, we can then laser or surgically remove the lesion. No two lesions are the same, and most require a consultation to best determine which treatment plans are the best.
The previous descriptions and notes are intended to give an overview and are not at all comprehensive. Should you have any questions or concerns, please do not hesitate to contact UK Pediatric Plastic Surgery for a clinic consultation.
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