What are the methods for removing a hemangioma?

Methods for Hemangioma Removal

The optimal approach to hemangioma removal depends on the type, location, size, and symptoms, with medical therapy (particularly propranolol) being the first-line treatment for infantile hemangiomas, while surgical excision is often necessary for symptomatic hepatic hemangiomas or residual lesions after medical therapy. 1, 2

Infantile Hemangiomas (IH)

Medical Management (First-Line)

• Oral propranolol: 2-3 mg/kg/day divided into 2-3 doses
  • Treatment duration: At least 6 months (typically until 9-10 months of age for focal IHs)
  • For segmental IHs, treatment may continue until 18 months of age 1, 2
• Topical β-blockers (timolol 0.5% gel): For superficial or small hemangiomas 2
• Corticosteroids: Alternative when propranolol is contraindicated
  • Oral: Prednisolone/prednisone 2-3 mg/kg/day as morning dose
  • Intralesional: For small, localized hemangiomas 2

Surgical Management

Indications for surgery include:

• Failure to respond to medical therapy
• Significant residual tissue after medical treatment
• Bleeding, ulceration, or functional impairment
• Cosmetic disfigurement 1, 3

Surgical Techniques for Facial/Nasal Hemangiomas:

1. Open rhinoplasty approach: For nasal tip hemangiomas 1
2. Modified subunit approach: Superior results for nasal hemangiomas with better access and aesthetic outcomes 4
3. Laser therapy: Pulsed dye laser (PDL) to salvage skin before surgical resection 1
4. Multimodal approach: Often combining laser therapy to treat skin involvement followed by surgical excision 1

Timing of Surgery:

• Most physicians operate at 1-3 years of age for focal IHs
• Early surgical intervention (before complete involution) may be indicated for nasal tip IHs to prevent permanent cartilage deformation 1, 4

Hepatic Hemangiomas

Management Approach:

1. Observation: For asymptomatic lesions <5 cm 1
2. Surgical options:
   • Enucleation: Removal of the hemangioma while preserving surrounding liver tissue
   • Formal liver resection: For larger or multiple lesions 5, 6
3. Bland embolization: Alternative to surgery for lesions ≥5 cm 1

Indications for Intervention:

• Symptomatic lesions (abdominal pain, early satiety)
• Size ≥5 cm (especially during pregnancy)
• Rapid growth
• Uncertain diagnosis
• Complications (Kasabach-Merritt syndrome, heart failure) 1, 5, 6

Special Anatomic Considerations

Periorbital Hemangiomas:

• Early referral to ophthalmology
• Propranolol as first-line therapy
• Surgical options include endoscopic transethmoidal approach for orbital apex hemangiomas 1, 7

Airway Hemangiomas:

• Higher risk in "beard distribution" lesions
• Propranolol as first-line therapy
• Surgical options: dilation, intralesional corticosteroid injection, or partial resection for non-responsive cases 1

Lip Hemangiomas:

• Vermilion area: Removal via transverse mucosal incision
• Bulkier lesions/crossing vermilion-cutaneous border: Wedge excision
• Eversion correction: Mucosal strip excision
• Inversion correction: May require dermal implant or graft 1

Monitoring and Follow-up

• Regular follow-up every 3-6 months
• Close monitoring during rapid growth phase (5-7 weeks of age)
• Ultrasound with Doppler is preferred initial imaging modality when needed 2

Pitfalls and Caveats

• Intralesional steroid injections near the eye carry risk of retinal artery embolization and blindness 1
• Risk of bleeding is more related to hemangioma size than surgical technique 6
• Segmental hemangiomas have higher risk of complications and may require more aggressive intervention 2
• Hepatic hemangiomas >5 cm require monitoring during pregnancy due to risk of expansion and rupture 1

For optimal outcomes, treatment decisions should be made based on the specific characteristics of the hemangioma, with consideration of referral to a multidisciplinary vascular anomalies center for complex cases 1, 3.