Hemangiomas

The Vascular Anomalies Center in the Division of Plastic and Maxillofacial Surgery at Childrens Hospital Los Angeles specializes in the treatment of a complex group of conditions caused by abnormally developed blood vessels. These can include arteries, veins, lymphatic channels, and/or capillaries. Vascular anomalies can be difficult to accurately diagnose and treat. For a small percentage of patients, there is no available treatment. To ensure the best possible outcome, children with vascular anomalies require the combined expertise of an interdisciplinary team of specialists whose primary focus is the management of these multifaceted disorders.

The Vascular Anomalies Center is composed of a core interdisciplinary team of seven physicians and one nurse practitioner who collaborate in the evaluation, management, and emotional support of children with vascular lesions.

We currently hold one interdisciplinary clinic each month. This gives patients the convenience of being seen by more than one specialist during the same visit and enable physicians to share their assessments and concerns with one another, as well as with patients and family members.

Team members (linked to their bios on the Childrens Hospital Los Angeles website):
Andre Panossian, MD (co-director), Plastic Surgery
Dean M. Anselmo, MD (co-director), Pediatric Surgery
Alex Arkader, MD Orthopedic Surgery
Philip Stanley, MD Interventional Radiology
Jeffrey Hammoudeh, MD Plastic Surgery
William Magee, III, MD, DDS Plastic Surgery
Sheryl Lewin, MD Plastic Surgery
 Mark M. Urata, MD, DDS Plastic Surgery
Justine Park, MD Pediatric Dermatology
Leo Mascarenhas, MD Hematology-Oncology
Donna Nowicki, PNP, Nurse Practitioner
Alyson Harrison, Manager
Karla Viquez, Coordinator

For general information and to make an appointment, please contact the Vascular Anomalies Center at 323-361-5682.

Physicians and their offices may refer patients directly to our Physicians Line at 323-361-8212. Your call will be answered immediately by one of our staff.

COMMON QUESTIONS

What are the different types of vascular anomalies?
Vascular anomalies may be categorized in two major groups: Hemangiomas and Vascular Malformations. Although lesions in these two groups may be similar in appearance, they are biologically distinct. This has implications on proper treatment.

Identification of the lesion is generally based on the history reported by the patient or family, physical examination of the lesion(s), and radiologic testing. Frequently, this includes magnetic resonance imaging (MRI), angiography, and/or a specialized ultrasound exam.

Hemangiomas
What are hemangiomas and what do they look like?

Hemangiomas are the most common vascular anomaly and the most common tumor of childhood and infancy. They are classified as non-cancerous blood vessel tumors that may occur anywhere in the body, whether in the skin or within organs. Abnormally dense collections of dilated small blood vessels (or capillaries) comprise hemangiomas. Although not necessarily present at birth, they do typically appear in the first 2 weeks of life.

Deeper hemangiomas may not be apparent until two to three months of age. There may be a faint discoloration or barely visible spot at birth in approximately 30 percent to 40 percent of patients. Most hemangiomas (80 percent) appear as a single lesion on the body. Less commonly (20 percent), they may appear in multiple locations. There are more female patients with hemangiomas than there are males (approximately 3:1).

Hemangiomas often appear on the infant’s head and neck area or other areas that are easily noticed. This can be quite disconcerting to parents as they are frequently asked if their baby was injured or has some tumor. In rare instances, these lesions may occur in locations that interfere with normal function. Depending on the size, hemangiomas may interfere with breathing, feeding, or even urination. For example, hemangiomas involving the eyelid can interfere with development of normal vision and must be treated urgently.

How are hemangiomas diagnosed?
Hemangiomas are most frequently diagnosed by patient history and physical examination. When there is a deep lesion, magnetic resonance imaging (MRI) may be performed to delineate the extent of the problem and any involvement of internal organs. Rarely, hemangiomas are associated with unusual syndromic conditions. A thorough examination and additional studies may be required to detect the presence of these syndromes.

What happens to hemangiomas over time?
During the first six to nine months of infancy, hemangiomas tend to go through a proliferative phase where they grow rapidly. The hemangioma may become more noticeable during this phase. It will appear bright red and take on a slightly raised, or bumpy, configuration. However, if the hemangioma lies deep to the skin, the skin itself may appear bluish and only slightly raised.

The growth of hemangiomas is unpredictable. Similarly, the degree to which these lesions involute (shrink) over time is also difficult to predict. After the initial growth period (proliferative phase), hemangiomas will then enter an involutional phase (regression). This occurs gradually and is sometimes not completed until the child is 10 years of age. During this time, hemangiomas will shrink, and the color will fade to a dull purple or grey. The lesion will feel soft to the touch. Sometimes, the remaining skin overlying hemangiomas may not appear normal and, in fact, may feel and look like crepe paper. If there was an ulceration over the lesion, then there may be an associated scar. If present on the scalp or other hair bearing areas on the body, there may be alopecia (permanent hair loss) in these areas.

There is no reliable way to predict the rate at which a particular hemangioma will shrink. But as a general rule, in approximately 50 percent of patients, regression is complete by five years of age, and by seven years of age in 70 percent of patients. This does not apply, however, to certain types of hemangiomas. Some congenital forms (those present at birth) will shrink more rapidly (rapidly involuting congenital hemagiomas), and others may not shrink at all (non-involuting congenital hemangiomas).

How do you treat hemangiomas?
Most hemangiomas will regress on their own without intervention. For many lesions, patience and time may be the best treatment. However, those lesions interfering with function or for those lesions that may interfere with a normal childhood, we may recommend removal.

In the past, many pediatricians recommended waiting to treat hemangiomas, but we have learned that early treatment provides significant advantages. During the first few months of life, the growing hemangioma acts like a balloon under the skin to expand both the affected and nearby normal skin. In many instances, early intervention allows the surgeon to remove the affected skin and then use the excess normal skin to close with tension; thus, decreasing the size of the scar.

These options may include laser treatment for color changes, surgery to remove redundant skin, or liposuction to remove the fatty tissue under the skin. Makeup is also a good alternative to conceal any minor imperfections.

For serious cases where the hemangioma poses an immediate risk to life or compromises important functions such as eyesight, the use of systemic corticosteroids may be considered. This medication may be given by mouth, through an IV, or injected directly into the hemangioma and surrounding tissues. Corticosteroids can speed the involution phase or prevent further growth of the hemangioma. All interventions have risks and benefits. Using corticosteroids is no different. The benefits of this treatment must be weighed against the potential risks, and a discussion must be initiated with the child’s parents and the treating physicians to determine the best course of action.

In some instances, arterial embolization (blocking the feeding blood vessels) may be possible. This will “choke” the hemangioma and cause it to shrink. However, not all patients are candidates for this therapy, and there is no certainty that the hemangioma will shrink. The procedure is performed by an interventional radiologist.

 What are some of the potential complications of hemangiomas?
The most common complication of hemangiomas is bleeding. This is also the most frightening. Bleeding can be stopped very effectively with direct and continuous hand pressure over the hemangioma for five-15 minutes. If bleeding is uncontrolled with hand pressure, then the child should be seen by a physician in a local emergency department. Bleeding occurs because the skin overlying the hemangioma is much thinner and friable than normal. If this skin dries out and cracks or is scratched, then the area may bleed or become ulcerated (breakdown of skin). Ulcerations can be painful and very uncomfortable. They can also become infected.

Prevention is the preferred treatment. Whether ulcerated or not, we recommend keeping the hemangioma clean with soap and water and moisturized at all times with any fragrance-free, mild moisturizing cream or even simple petroleum jelly. Trimming nails will also lessen the likelihood of inadvertently scratching the lesion. If irritated by clothing or a diaper seam, the hemangioma may be covered with a light gauze dressing to protect it from being rubbed and irritated.

Often, hemangiomas occur on the face or trunk. When present on the face, a hemangioma can cause considerable psychosocial stress for the parents and sometimes the child. Openly discussing these issues with each other and the medical team will alleviate much distress.

Involuted Hemangioma