Can a hemangioma be removed in patients, including pediatric and adult cases?

Can Hemangioma Be Removed?

Yes, hemangiomas can be removed surgically, but removal is typically reserved for specific indications and timing—most infantile hemangiomas do not require surgical intervention and should be managed medically first, with surgery delayed until 3-5 years of age when indicated. 1

When Surgical Removal Is Appropriate

High-Risk Situations Requiring Intervention

Surgery may be considered in infancy only under specific circumstances: 1

• Failure of medical therapy (propranolol or corticosteroids) to control life-threatening or functionally impairing lesions 1
• Focal lesions in anatomically favorable locations where the resulting scar would be identical whether removed during proliferation or after involution 1
• Life-threatening complications including airway obstruction, high-output cardiac failure, or severe hepatomegaly 1, 2
• Ulcerated lesions that fail to respond to wound care and pharmacotherapy 1

Optimal Timing for Elective Surgery

Surgery should generally be delayed until 3-5 years of age because: 1

• The lesion becomes smaller and primarily adipose tissue rather than vascular, making surgery safer with less blood loss 1
• Most hemangiomas do not improve significantly after 3-4 years of age, so waiting longer provides no additional benefit 1
• Performing surgery before age 4-5 years allows correction before self-esteem and long-term memory are well established 1
• Maximal involution has occurred, facilitating reconstruction and potentially reducing the number of required interventions 1

Why Surgery Is NOT First-Line Treatment

Risks of Early Surgical Intervention

Resection during the proliferative phase (infancy) is generally not recommended due to: 1

• Higher anesthetic morbidity in young infants 1
• Increased risk of blood loss from highly vascular tumors 1
• Greater risk of iatrogenic injury 1
• Inferior cosmetic outcomes compared to delayed surgery 1

Medical Therapy Takes Precedence

Propranolol (oral beta-blocker) is the FDA-approved first-line treatment for problematic infantile hemangiomas at 2-3 mg/kg/day in divided doses 1, 2, 3. Corticosteroids serve as alternative therapy when propranolol is contraindicated or ineffective 1.

Location-Specific Considerations

Facial and Cosmetically Sensitive Areas

• Nasal tip and lip lesions: Final cosmetic results are superior when surgery is delayed until growth has ceased and interventions can be minimized 1
• Facial hemangiomas ≥2 cm (or >1 cm if ≤3 months of age) are high-risk for disfigurement but should still be treated medically first 1

Hepatic Hemangiomas

• Small to medium lesions (<5 cm): Managed conservatively with observation 3
• Giant hemangiomas (>5 cm): Require increased monitoring; rupture risk is 3.2% overall, increasing to 5% for lesions >10 cm 3
• Diffuse hepatic hemangiomatosis: Life-threatening condition requiring immediate propranolol therapy, not surgery 2

Vertebral Hemangiomas

• Asymptomatic vertebral hemangiomas require no treatment or routine surveillance 4
• These do NOT undergo spontaneous involution like infantile hemangiomas and propranolol has no role 4
• Surgery only indicated for symptomatic lesions causing spinal cord compression 4

Surgical Techniques and Outcomes

Recurrence Rates

The overall recurrence rate after surgical excision is approximately 22%, with marginal resection being the most common approach for superficial lesions 5. Intramuscular hemangiomas pose greater therapeutic challenges and may require wide local excision when limited in size 5.

Alternative to Surgery: Laser Therapy

Pulsed dye laser (PDL) may be useful for: 1

• Early superficial hemangiomas 1
• Focal lesions in favorable locations 1
• Telangiectasias and residual skin changes 6

However, laser therapy has limited efficacy for thick, bulky lesions and carries risks of scarring, hypopigmentation, and rarely ulceration 1.

Critical Pitfalls to Avoid

• Do not perform surgery during infancy unless specific high-risk criteria are met and medical therapy has failed 1
• Do not wait beyond 3-5 years for elective correction of residual deformities, as further involution is unlikely and early intervention minimizes psychosocial impact 1
• Do not assume all hemangiomas behave identically—vertebral hemangiomas are distinct from infantile cutaneous hemangiomas in natural history and management 4
• Do not bypass medical therapy—propranolol should be initiated before considering surgical options for most problematic hemangiomas 1, 2

Algorithm for Decision-Making

1. Identify if hemangioma is high-risk (life-threatening, functional impairment, ulceration, disfigurement risk) 1
2. If high-risk: Refer to hemangioma specialist immediately 1
3. Initiate propranolol as first-line therapy for problematic lesions 1, 2
4. Reserve surgery for:
   • Failure of medical therapy 1
   • Residual fibrofatty tissue or scarring after involution 1
   • Age 3-5 years for elective correction 1
5. Monitor low-risk lesions without active intervention 1