Plastic Surgery for Hemangioma Workup

  • Author: Meir Cohen, MD, MPS; Chief Editor: Gregory Caputy, MD, PhD, FICS   more...
 
Updated: Nov 17, 2011
 

Imaging Studies

The most important imaging tool for this condition is contrast-enhanced MRI.[12, 13] This diagnostic test, which requires sedation or general anesthesia for children younger than 6 years, demonstrates the extent of the lesion and helps differentiate between hemangiomas and venous, lymphatic, and arterial lesions. It may also help differentiate between a vascular lesion and nonvascular lesions, such as those found in neurofibromatosis.

  • MRI scans have 3 basic images: T1-weighted spin-echo image, T2-weighted spin-echo image, and contrast-enhanced (gadolinium) T1-weighted spin-echo image. T refers to the time necessary for the protons to discontinue spinning. T1 refers to a value of approximately 600 milliseconds and T2 refers to a value of about 4000 milliseconds. The typical findings in the 3 image modes are presented in the second image below. Hemangiomas. Relaxation time - MRI T1, T2. Hemangiomas. Relaxation time - MRI T1, T2. Hemangiomas. Diagnosis MRI. Hemangiomas. Diagnosis MRI.
  • Hemangiomas have a typical solid appearance with intermediate intensity on a T1-weighted spin-echo image, which is more intense than venous or lymphatic malformations.[12]
  • During the proliferative stage, hemangiomas show a relatively low intensity in a T2-weighted spin-echo image; in the involution phase, they have a very low intensity.
  • Contrast-enhanced T1-weighted MRI shows moderate intensity with prominent flow voids during the proliferative stage because of the high flow at this stage. In contrast, hemangiomas show low intensity during involution as a result of the low flow at that stage.
  • The first image below shows a 5-year-old boy with a left intraorbital hemangioma that had caused vertical dystopia of the left globe. The second image below shows the contrast-enhanced T1-weighted image with visible flow voids and intensity, typical for hemangiomas at the proliferative phase. Left orbital hemangioma. Left orbital hemangioma. MRI of orbital hemangioma. MRI of orbital hemangioma.

Doppler ultrasonography can assess the flow of hemangiomas. Generally, they are characterized by a shunt pattern with decreased arterial resistance and increased venous velocity.

Arteriography is rarely used for diagnosis or treatment of hemangiomas. Superselective embolization may be used in selected bleeding hemangiomas with a detectable regional nourishing vessel.

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Histologic Findings

Proliferating hemangiomas are composed of clusters of rapidly dividing endothelial cells (see the image below). With regression, endothelial activity gradually diminishes and the cells flatten and mature. Mast cells appear in the late proliferating phase and early involuting phase and interact with macrophages, fibroblasts, and other cell types.[3, 14] During involution, light microscopy demonstrates progressive deposition of perivascular and interlobular/intralobular fibrous tissue. Multilaminated basement membranes, an ultrastructural hallmark of a proliferative phase hemangioma, persist in the involuted phase.[3, 14]

Proliferating hemangioma - Light microscopy. Proliferating hemangioma - Light microscopy.

Most endothelial cells and pericytes express proliferating cell nuclear antigen in the proliferative and early involuting phases.[10] Its expression is negligible in the involuted phase.[10] The total number of mast cells is highest in the involuting phase, and the proportion of chymase-positive mast cells decreases with the progression of involution.[10] Type IV collagen and the 2 chains of laminin and perlecan are detected in the basement membranes in all phases.[10]

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Contributor Information and Disclosures
Author

Meir Cohen, MD, MPS  Consulting Staff, Department of Plastic Surgery, Schneider Children's Medical Center of Israel, Tel Aviv University

Meir Cohen, MD, MPS is a member of the following medical societies: American Cleft Palate/Craniofacial Association and Plastic Surgery Research Council

Disclosure: Nothing to disclose.

Coauthor(s)

Eyal Raveh, MD  Consulting Staff, Department of Otolaryngology, Rabin Medical Center, Israel

Disclosure: Nothing to disclose.

Dan Ben-Amitai, MD  Head of Pediatric Dermatology Service, Lecturer, Schneider Children's Medical Center of Israel

Dan Ben-Amitai, MD is a member of the following medical societies: Israel Medical Association

Disclosure: Nothing to disclose.

Shimon Maimon, MD  Head of Invasive Radiology Unit, Beilinson Campus, Rabin Medical Center, Israel

Disclosure: Nothing to disclose.

Benjamin Shalev  MD, Consulting Staff, Ophthalmology Unit, Schneider Children's Medical Center of Israel

Disclosure: Nothing to disclose.

Moshe Lapidoth, MD, MPH  Dermatologist, Head of the Laser Unit, Dermatology Department, Rabin Medical Center, Israel

Moshe Lapidoth, MD, MPH is a member of the following medical societies: European Society for Laser Dermatology

Disclosure: Nothing to disclose.

Eric Bensimon, MD, FRCS(C)  Assistant Professor, Department of Surgery, University of Montreal Faculty of Medicine, Canada

Eric Bensimon, MD, FRCS(C) is a member of the following medical societies: American Society of Plastic Surgeons, Canadian Society of Plastic Surgeons, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada

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

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Hemangiomas. Classification of vascular lesions.
Hemangiomas. Classification of vascular malformations.
Hemangiomas. Diagnosis - Medical history.
Hemangiomas. Diagnosis - Physical examination.
Deep cheek hemangiomas.
Superficial cheek hemangiomas.
Upper lip hemangiomas.
Treatment with steroids of orbital hemangioma.
Panfacial hemangiomas.
Resection of a bleeding forehead hemangioma.
Lower lip hemangioma with intraoral extension.
Hemangiomas. Relaxation time - MRI T1, T2.
Hemangiomas. Diagnosis MRI.
Left orbital hemangioma.
MRI of orbital hemangioma.
Proliferating hemangioma - Light microscopy.
Hemangiomas. Facial nodular fasciitis misdiagnosed as a vascular lesion.
Differential diagnosis of orbital hemangiomas.
The effect of compression on a chest hemangioma.
Use of a bicoronal approach to resect a forehead hemangioma.
Types of nasal hemangiomas.
Resection and primary closure of a nasal bridge hemangioma.
Open rhinoplasty approach to resect a nasal tip hemangioma.
Lower lip hemangioma.
 
 
 
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