What is the recommended surgical plan for a 17-year-old patient with a symptomatic intramuscular hemangioma measuring 13mm x 8mm x 13mm on the lateral deltoid muscle and a smaller lesion on the posterior deltoid muscle, causing pain?

Surgical Management of Symptomatic Intramuscular Hemangioma in a 17-Year-Old

Complete surgical excision is the definitive treatment for this symptomatic intramuscular hemangioma, and should be performed now given the patient's age, focal anatomically favorable location in the deltoid, and presence of pain. 1, 2

Rationale for Immediate Surgical Intervention

The evidence strongly supports proceeding with surgery in this clinical scenario for several key reasons:

• Age appropriateness: At 17 years old, this patient is well beyond the typical age considerations for infantile hemangiomas (which apply to infants and young children), and intramuscular hemangiomas in adolescents and adults do not spontaneously involute 1, 3

• Symptomatic presentation: Pain is a clear indication for intervention, as it significantly impacts quality of life. In surgical series of intramuscular hemangiomas, pain (both with activity and at rest) was the major presenting symptom requiring treatment 1

• Anatomically favorable location: The deltoid muscle represents an accessible surgical site where complete excision can be achieved with acceptable functional outcomes 4, 2

• Natural history: Unlike infantile hemangiomas, intramuscular hemangiomas in this age group will not regress and require surgical removal to prevent continued symptoms and potential growth 1, 3

Preoperative Planning

Essential preoperative imaging should include MRI to fully characterize the lesion extent, vascular supply, and relationship to surrounding neurovascular structures 1, 2:

• MRI is the gold standard imaging modality for intramuscular hemangiomas, though it may appear suspicious for malignancy 1
• Imaging helps distinguish between capillary type (nonvascular, spongy appearance) and cavernous type (large dilated vessels) 1
• For lesions in the shoulder region, assess for arteriovenous shunts and feeding vessels from major trunks 4

Surgical Approach and Technique

The surgical plan should aim for wide, complete excision of both lesions to minimize recurrence risk 1, 5:

• Primary objective: En bloc resection with clear margins, as incomplete excision leads to local recurrence 1, 5
• Muscle-splitting approach: The deltoid muscle fibers can be split to access and excise the lesions while preserving muscle function 2
• Address both lesions: Both the 13mm lateral deltoid lesion and the smaller posterior deltoid lesion should be excised in the same procedure 1
• Preserve neurovascular structures: Careful identification and preservation of the axillary nerve and posterior circumflex humeral artery is critical 2

Expected Outcomes and Follow-Up

Surgical excision provides excellent pain relief with low recurrence rates when complete resection is achieved 1:

• In a surgical series with mean follow-up of 3 years and 4 months, only 1 of 11 patients developed recurrence, while all others achieved complete pain relief 1
• Postoperative monitoring should assess for nerve damage, muscle dysfunction, and signs of recurrence 2
• Follow-up at 4-6 weeks postoperatively can confirm absence of complications, with longer-term surveillance for late recurrences 2, 5

Critical Pitfalls to Avoid

Do not attempt conservative management or observation in this symptomatic adolescent patient 1, 3:

• Unlike infantile hemangiomas that may involute spontaneously, intramuscular hemangiomas in adolescents require surgical excision 1
• Medical therapies like propranolol have no role in treating intramuscular hemangiomas (these are distinct from infantile hemangiomas) 6
• Incomplete excision significantly increases recurrence risk, so wide margins are essential 1, 5
• The infiltrative borders and deep location can mimic malignancy; histopathologic confirmation is necessary 5