Plastic Surgery for Capillary Malformations Treatment & Management

  • Author: Ashok Tholpady, MD, MSc; Chief Editor: Gregory Caputy, MD, PhD, FICS   more...
 
Updated: Jan 31, 2012
 

Medical Therapy

Reassure patients with asymptomatic lesions that the lesion is benign. Uncommonly, capillary malformations bleed after minor trauma, and the bleeding may be difficult to stop. Compression of the area and immediate medical assistance is necessary. More complex syndromes may require assessment by a team of specialists including pediatricians, radiologists, dermatologists, and plastic surgeons.

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Surgical Therapy

The current treatment of choice for capillary vascular malformations is the pulsed-dye laser (PDL), although only 15-20% of lesions clear completely.[4, 5, 6, 7, 8] The wavelength and pulse duration corresponding to the optimal thermal damage is 585 nm for 450 μsec.[9] However, anatomy of the malformation ultimately guides the physician's choice of laser parameters.

Capillary malformations located on the medial part of the cheek, upper cutaneous lip and nose, and the V2 dermatome respond poorly to PDL. The areas that respond best to treatment include lesions in the periorbital region, neck, and temple. Decreased capillary blood perfusion is thought to contribute to the refractoriness of laser treatment.[10] End results may be due to differences in adnexa, fibrous proteins, density of vessels, and nerves.

The safety of PDL therapy can be enhanced by cooling the skin during treatment. Skin cooling also allows the use of higher wavelengths and fluences.[9] Cooling devices used include convective air cooling, ice cubes, cold gels, cryogen spray cooling, and aluminum rollers.[11, 12, 13, 14, 15, 16]

Excision is useful for small fibrovascular nodules, but patients with extensive fibronodular hypertrophy may require resection and resurfacing with split- or full-thickness skin grafts.

When mandibular prognathism or occlusal canting from hemimaxillary vertical overgrowth occurs, orthognathic procedures are indicated.

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Follow-up

Provide monthly follow-up care to neonates with birthmarks. Hemangiomas begin proliferating within the first month, while capillary malformations enlarge commensurately with the child’s growth. Invasion of important anatomic structures, cosmetic deformity, pain, and swelling may prompt surgical treatment. Monitor patients for recurrence after lesions are resected.

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Future and Controversies

Classification of vascular malformations remains controversial. Findings by Breugem et al suggest that the pathologic abnormalities of capillary malformations appear to be located in postcapillary venules rather than the capillaries themselves.[17] Thus, port-wine stains may need to be redefined from their original classification under capillary malformations.

Future advancements in the treatment of capillary malformations include improved selective laser ablation and gene therapy. However, gene therapy remains experimental, with target cells still being evaluated.

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Contributor Information and Disclosures
Author

Ashok Tholpady, MD, MSc  Resident Physician, Department of Pathology and Laboratory Medicine, University of Texas Medical School at Houston

Ashok Tholpady, MD, MSc is a member of the following medical societies: Academy of Clinical Laboratory Physicians and Scientists, American Society for Clinical Pathology, College of American Pathologists, Harris County Medical Society, and United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas J Gampper, MD  Vice Chair, Department of Surgery, Director of Aesthetic and Laser Surgery, Associate Professor, Departments of Plastic Surgery and Clinical Neurosurgery, University of Virginia

Thomas J Gampper, MD is a member of the following medical societies: American Association of Plastic Surgeons, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society for Laser Medicine and Surgery, American Society of Plastic Surgeons, Association of Academic Chairmen of Plastic Surgery, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Shahin Javaheri, MD  Chief, Department of Plastic Surgery, Martinez Veterans Affairs Outpatient Clinic; Consulting Staff, Advanced Aesthetic Plastic & Reconstructive Surgery

Shahin Javaheri, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Wayne Karl Stadelmann, MD  Stadelmann Plastic Surgery, PC

Wayne Karl Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Plastic Surgeons, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Nicolas (Nick) G Slenkovich, MD  Director, Colorado Plastic Surgery Center

Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Gregory Caputy, MD, PhD, FICS  Chief Surgeon, Aesthetica Plastic and Laser Surgery Center, Inc

Gregory Caputy, MD, PhD, FICS is a member of the following medical societies: American Society for Laser Medicine and Surgery, Canadian Medical Association, International College of Surgeons, International College of Surgeons US Section, Pan-Pacific Surgical Association, and Wound Healing Society

Disclosure: Syneron Corporation Salary Speaking and teaching

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Emmanuella Joseph, MD, and William O Murtagh, MD, to the development and writing of this article.

References

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A 12-year-old boy presenting with bluish discoloration of the right thenar eminence and index finger. The lesion has been present since birth and changes in size when he raises his arms or exercises strenuously. Upon physical examination, the mass is soft and rubbery. No palpable thrill or audible bruit is present.
An image from an MRI study of the right hand of the patient in the image above, detailing the vascularity of the lesion.
Intraoperative view of the lesion in the first and second images shown above. Note the irregular mass of vessels that are adherent to the digital neurovascular bundles, tendons, and lumbrical muscle belly.
The excised specimen from the patient in the previous images.
 
 
 
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