Sociedade Brasileira de Dermatolodia Surgical & Cosmetic Dermatology

IR PARA

ISSN-e 1984-8773

Volume 2 Number 3


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Surgical pearls

Cerclage and radiofrequency in hemangiomas

Lesões vasculares tratadas com cerclagem e radiofreqüência


Maria Isabel Cárdenas1, Luciana de Abreu1, Nathalia Anaya1, Ana Beatriz Solano Novellino1, Joaquim Mesquita Filho1

Second year Dermatology Postgraduate,
Prof.Rubem David Azulay Dermatology
Institute,Santa Casa de Misericórdia do
Rio de Janeiro – Rio de Janeiro (RJ),Brazil.1, Second year Dermatology Postgraduate,
Prof.Rubem David Azulay Dermatology
Institute,Santa Casa de Misericórdia do
Rio de Janeiro – Rio de Janeiro (RJ),Brazil.1, Second year Dermatology Postgraduate,
Prof.Rubem David Azulay Dermatology
Institute,Santa Casa de Misericórdia do
Rio de Janeiro – Rio de Janeiro (RJ),Brazil.1, Dermatology Preceptor,Prof.Rubem
David Azulay Dermatology Institute,Santa
Casa de Misericórdia do Rio de Janeiro4, Instructor and Head of Dermatologic
Surgery,Prof.Rubem David Azulay
Dermatology Institute,Santa Casa de
Misericórdia do Rio de Janeiro.5

 

Abstract

Capillary hemangioma is a benign tumor comprised of endothelial cells, common in childhood, which frequently disappears on its own. Port-wine stains are vascular malformations caused by capillary dilatation, initially characterized by macules with colors ranging from rose to violaceous red. Present at birth, they are usually permanent, and can thicken and cause deformities. Many treatments have been proposed: cryotherapy, surgery, corticotherapy, radiotherapy, and laser therapy. However, such treatments involve technical difficulties, high costs, complications, or unaesthetic results.This study proposes a new, easy to perform and cost effective association of techniques: percutaneous cerclage and radiofrequency electrosurgery for the treatment of hypertrophic lesions of vascular origin.

Keywords: HEMANGIOMA, SURGERY, THERAPEUTICS

INTRODUCTION

In 1982, Mulliken and Glowacki classified vascular lesions into two categories;hemangiomas and vascular malformations, based on their cellular,clinical,and history characteristics. 1,2

Hemangiomas are tumors secondary to vascular anomalies that involve the proliferation of endothelial cells. 3 Its prevalence in children is 10-12% during the first year of life.The lesions are solitary in 80% of the cases,and occur more frequently in the head (60%),trunk (25%) and extremities (15%). 3,4 The hemangiomas''''''''growth phase starts in the first weeks of life,and around 30% of the lesions involute before the child is three years old, 50% before the age of five,and 85-90% before the age of nine. In most cases,an expectant approach is adopted;however in 10- 15% of cases the lesions behave in a manner that requires intervention.3,5-7

Unlike hemangiomas,vascular malformations present a regular reproductive cycle of endothelial cells.Most lesions (90%) are recognized at birth,presenting growth proportional to that of the child;most do not disappear spontaneously.This group includes the port-wine stain (PWS),which affects 0.3% of the population;approximately 80% of these lesions are locat- ed on the face or neck.They are usually unilateral and segmen- tary,respecting the median plane and increasing proportionally with the child''''''''s growth.There is no tendency towards sponta- neous regression,and they darken and enlarge with age,mainly after the individual reaches his/her forties.In that period,the stains do not respond to laser treatment,and surgical correction may be necessary. 1,2

The cerclage technique was initially described by gynecol- ogists in the 1950s for treating istmo-cervical incompetence, late-term miscarriages and/or premature births caused by early dilation of the cervix.Cerclage ("encircling suture") was used to keep the cervix closed to prevent its dilatation before the end of pregnancy,to prevent premature birth.Adapting the concept of cerclage,we describe two cases in which percutaneous sutures were performed to treat hemangiomas and PWS surgically. 9

METHODS

We present two patients (52-year-old female and 72-year- old male) with hemangioma in the right inferior eyelid (Figure 1) and PWS on the left side of the face,respectively.Both described the lesions as present at birth and previous treatments as unsuccessful.

We describe the steps of the surgical procedures of the cer- clage of the vascular lesions and subsequent radiofrequency,in addition to the post-operative aspects of the two cases.

STEPS OF THE SURGICAL PROCEDURES

The proposed surgical stages (Table 1) were:surgical mark- ing (Figure 2) and anesthetic infiltration with 2% lidocaine with vasoconstrictor;the percutaneous cerclage begins with the encircling suture in the base of the hypertrophic portion of the vascular lesion with 4.0 nylon sutures (Ethicon ©) (Figure 2B and 2C).This kind of suture was chosen for its resistance,ten- sion force and flexibility,and the fact that a sliding stitch might be more easily tightened.It is a non-absorbable suture that,by definition,would produce little tissular reaction.

Subsequently,the electrocauterization of the tissue just above the cerclage was performed,using forceps that must be touched by the electrocautery,aiming at completely electrocau- terizing the hypertrophic portion of the vascular lesion through radiofrequency (Figure 3).A scalpel incision was not carried out in the first case;the aesthetic treatment of the periorbital region was completed later with superior and inferior bilateral ble- pharoplasty (Figure 4).In the second case (Figure 5),due to the great size of the PWS''''''''hypertrophic portion,following the anesthesia and the cerclage (Figures 6 and 7)),the excision of the prominent region was accomplished with a scalpel (Figure 8). Afterwards,electrocoagulation through radiofrequency was per- formed in the base of the lesion.It is important to note that there is almost no bleeding (only minor in the second case) dur- ing the procedure,with tissular retraction occurring immediate- ly (Figure 9).After 15 days,the cerclage''''''''s suture is removed, revealing a satisfactory aesthetic result (Figure 10).

DISCUSSION

In the descriptions of the combined techniques – cerclage of the hypertrophic vascular lesion and subsequent electrocoag- ulation through radiofrequency – it is possible to verify a reduc- tion in the transoperative bleeding and,more importantly,of the surgical complications in the immediate and late post-operative periods.We have demonstrated how to accomplish a technical- ly straightforward surgery,in two surgical visits,for treating large hemangiomas and PWS located on the face – where the aes- thetic factor can cause psychological and social problems.We draw attention to the fact that the final aesthetic result was quite satisfactory for the patients,thus confirming that this combina- tion of techniques is an alternative to surgical treatment for hemangiomas and PWS.

This combination of surgical techniques for the treat- ment of hemangioma hypertrophic lesions and PWS of con- siderable size comprises simple and practical outpatient pro- cedures and avoids intercurrences inherent to the disorder, such as intense bleeding.It is confirmed,therefore,that it is frequently possible to conduct simple and effective procedures by employing creativity and the correct combination of sur- gical techniques.

CONCLUSIONS

The technique described:
1) Is straightforward,quick,and cost effective.
2) Presents low morbidity (low rate of complications) due to the low invasiveness character,and does not require hospitalization.
3) Has a precise indication as an alternative treatment for vascu- lar hemangiomas and PWS types of hypertrophic lesions loca- ted on the face.
4) Presents encouraging short- and long-term results.

References

1 . Gontijo B, Pereira L, Silva C. Malformações vasculares. An bras Dermatol. 2004; 79(1):7-25.

2 . Wolff K et. Al. Fitzpatrick – Dermatología en Medicina General. 7ª Ed. – Buenos Aires:Médica Panamericana.Malformaciones vasculares.2009. v. 3. p. 1651-1656.

3 . Nina BID, Oliveira ZNP, Machado MCMR, Macéa JM. Presentation, progression and treatment of cutaneous hemangiomas – Experience of the Outpatients Clinic of Pediatric Dermatology - Hospital das Clínicas da Universidade de São Paulo. An Bras Dermatol. 2006;81(4):323-7.

4 . Bruckner AL, Frieden IJ.Hemangiomas of infancy. J Am Acad Dermatol. 2003;48(4):477-93.

5 . Serra MAS, Soares FMG, Cunha Jr AG, Costa IMC. Abordagem terapêutica dos hemangiomas cutâneos na infância. An Bras Dermatol. 2010;85(3):307-17.

6 . Haggstrom AN, Drolet BA, Baselga E, Chamlin SL, Garzon MC, Horii KA, et al. Prospective Study o f Infantile Hemangiomas: Clinical Characteristics Predicting Complications and Treatment. Pediatrics. 2006;118(3):882-7.

7 . Hemangioma Investigator Group,Haggstrom AN,Drolet BA, Baselga E, Chamlin SL, Garzon MC, et al. Prospective study of infantile hemangiomas: demographic, prenatal, and perinatal characteristics. J Pediatr. 2007;150(3):291-4.

8 . Kalil CLPV, Curcio BL, Cignachi S. Laser Nd:Yag e luz intensa pulsada no tratamento de mancha vinho do porto. Surg Cosmet Dermatol. 2009;1(2):95-98.

9 . Mattar R. A cerclagem para prevenção da prematuridade: para quem indicar?. Rev Bras Ginecol Obstet. 2006; 28(3):139-42.


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