Plastic Surgery for Capillary Malformations Treatment & Management

Updated: Nov 16, 2015
  • Author: Ashok Tholpady, MD, MSc; Chief Editor: Gregory Gary Caputy, MD, PhD, FICS  more...
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Treatment

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. [5, 6, 7, 8, 9] The wavelength and pulse duration corresponding to the optimal thermal damage is 585 nm for 450 μsec. [10] 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. [11] 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. [10] Cooling devices used include convective air cooling, ice cubes, cold gels, cryogen spray cooling, and aluminum rollers. [12, 13, 14, 15, 16, 17]

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. [18]

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. [19] 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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