No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Surgical Treatment of Head and Neck Port-Wine Stains by Means of a Staged Zonal Approach
Abstract
Background:
The majority of patients with capillary malformations (port-wine stains) develop soft-tissue and bony hypertrophy leading to gross facial asymmetry and functional deficits in vision, breathing, speech, and feeding. The authors describe and illustrate a surgical approach for the treatment of these malformations with restoration of facial symmetry and contour based on facial subunits.
Methods:
The authors conducted a retrospective case series of patients from 2004 to 2011 presenting for primary evaluation and treatment to a tertiary referral center specializing in vascular anomalies. The medical records and photographs of patients with facial capillary malformations and soft-tissue hypertrophy were reviewed.
Results:
Of the 160 patients who presented with the diagnosis of facial capillary malformation/port-wine stain, 96 (60 percent) had soft-tissue hypertrophy in one or more dermatomes resulting in facial asymmetry. Only 4.4 percent of patients had solely V1 involvement, 38.8 percent had V2 involvement, and 15.6 percent had V3 involvement. The technique and incisions used for each facial zone are described in detail. In all cases, incisions were placed along existing boundaries of facial subunits. Serial pulsed-dye laser treatments were also performed.
Conclusions:
Sixty percent of patients with facial capillary malformation experience soft-tissue hypertrophy with or without bony remodeling, and surgical correction is required. The authors describe a staged surgical treatment for these patients based on a subunit and zonal approach to the face.
Clinical question/level of evidence:
Therapeutic, IV.
... According to the literature, PDL laser has low efficacy on longstanding CMs with soft tissue hypertrophy and nodular lesions, with an increased risk of scarring [11][12][13]. ...
... Cerrati et al. presented a retrospective study of 160 patients with port-wine stains [11]. They surgically treated 87 hypertrophic head and neck PWS resistant to laser therapy. ...
... All authors agreed on the need to conceal scars and preserve aesthetic facial units. Cerrati et al. retrospectively defined the surgical management for each area of the face using a staged zonal approach, designed on the basis of aesthetic facial units and Langer's lines [11]. ...
Background:
Port-wine stains (PWS) are congenital low-flow vascular malformations of the skin. PWS tend to become thicker and darker with time. Laser therapy is the gold standard and the first-line therapy for treating PWS. However, some resistant PWS, or PWS that have tissue hypertrophy, do not respond to this therapy. Our aim is to evaluate the role of surgery in the treatment of PWS birthmarks.
Methods:
A literature search was performed in PubMed, Scopus, Web of Science (WOS) and Google Scholar for all papers dealing with surgery for port-wine stains, from January 2010 to December 2020 using the search strings: (capillary vascular malformation OR port-wine stains OR Sturge Weber Syndrome OR sws OR pws) AND (surgical OR surgery).
Results:
Ten articles were identified and used for analysis. They were almost all case series with a short follow up period and lacked an objective-systematic score of evaluation.
Conclusions:
Delay in treatment of port wine stains may result in soft tissue and bone hypertrophy or nodules with disfiguring or destructive characteristics. The correction of PWS-related facial asymmetry often requires bone surgery followed by soft tissue corrections to achieve a more harmonious, predictable result.
... The leptomeningeal involvement can result in severe seizure disorder and intellectual disability, while the facial port-wine stain extends across the trigeminal nerve distribution, affecting both bones and soft tissue and potentially causing severe facial disfigurement [9]. The management of the resulting facial disharmony is undertaken by reconstructive plastic surgeons and includes laser treatments and challenging surgical reconstruction of the soft tissue and bony malformation to restore symmetry [9][10][11][12]. ...
... A major component of Sturge Weber Syndrome is the significant facial disfigurement caused by soft tissue and bony overgrowth secondary to the associated vascular malformation. The surgical treatment of this deformity, however, has received little coverage in the literature [12][13][14][15]. Even with full patient cooperation, appropriate surgical intervention by reconstructive surgeons to restore normal anatomy and improve quality of life is extremely challenging and requires multi-staged procedures [16,17]. ...
Sturge Weber Syndrome is characterized by the classic triad of a facial port-wine stain, leptomeningeal angiomatosis, and glaucoma. The resultant facial vascular anomaly can lead to soft tissue and bone irregularities, causing psychosocial distress and mental health morbidity. When severe, patients can opt for multi-staged surgical intervention by reconstructive surgeons to restore normal symmetry and improve the aesthetic appearance of the face. This study reports a case of surgical correction for severe facial vascular malformation resulting in poor outcomes due to the associated mental comorbidities seen in Sturge Weber Syndrome. A 37-year-old male with previously diagnosed Sturge Weber Syndrome presented to the outpatient craniofacial clinic for surgical evaluation of a large facial tuberous hemangioma. The patient underwent multiple operations for facial reconstruction including a staged full-thickness skin graft, facial recontouring, and extracranial correction of vertical orbital dystopia. The case was complicated by the patient's poorly controlled seizure disorder and psychosocial illness, resulting in self-mutilation of the repair and poor follow-up. Over the span of 10 years, the patient's mental illness caused him to fail numerous attempts at facial restoration and ultimately led to a poor final result. The psychosocial distress seen in patients with Sturge Weber Syndrome can adversely affect surgical outcomes. Physicians should be mindful of the possible complications that can arise in these patients and have the clinical means to address them.
... Cerrati i suradnici u svojem radu iz 2014. smatraju da je terapija sigurna i učinkovita, uz minimalno povećani rizik od krvarenja, jer se malformacija uglavnom nalazi u površinskim tkivima (3). No naš je pacijent imao velike lezije (> 20 cm), pa bi tehnike liječenja opisane u literaturi svakako bile izazov s povećanim rizikom od smrti. ...
... The prognosis and treatment of vascular malformations arising from PWS is controversial. In 2014, the treatment was considered safe and effective by Cerrati et al, with only a minimally increased risk of bleeding, since the malformation is mainly located in superficial tissues (3). However, our patient had extensive lesions (> 20 cm), therefore, the treatment techniques described in the literature would certainly be a great challenge for our healthcare team, with an increased risk of death. ...
Objective
Vascular malformations are structural anomalies in the blood vessels. They are present at birth and persist throughout life. These malformations can be classified according to the type of vessel involved. A port-wine stain is a vascular malformation characterized by an increased number of ectatic vessels in the dermal vascular plexus, which can be found in any part of the body, including the head and neck region. Over time, most of these stains result in soft tissue hypertrophy and this growth can cause severe facial deformity.
Materials and Methods
This study describes a rare case of a giant proliferative vascular anomaly arising from a port-wine stain on the face.
Results
The report highlights the continuous and proliferative growth of the malformation observed after follow-up of 18 years, as well as the difficulty in establishing the diagnosis due to the complexity and dimension of the lesion and the conditions related to the patient’s low socioeconomic status.
Conclusions
We have described a rare and unusual case report of a giant proliferative vascular malformation arising from a Port-wine stain on the face.
... 3-6 Surgical treatment is typically reserved for lesions that interfere with eating, involve the lips, are larger than 2 cm 3 , or have associated soft-tissue hypertrophy. 3,4,7 Management of large, deforming arteriovenous malformations (AVM) can be a clinical challenge for surgeons and a major burden for patients. Depending on the location and size of these malformations, patients can experience significant functional, aesthetic, social, and psychological consequences. ...
The management of large, deforming facial arteriovenous malformations (AVMs) can be a daunting clinical challenge for patients and surgeons. Many patients delay treatment due to fear of surgical intervention and concern for unfavorable cosmetic outcomes. Delaying treatment can lead to soft-tissue hypertrophy. Occasionally, facial AVMs can also present with lip involvement, necessitating surgical intervention. A major potential issue regarding AVMs managed with surgical excision is excessive bleeding due to the enlarged dermal vascular plexus. Here, we present a simple surgical technique used to manage deforming AVMs involving the lips. A 32-year-old man with Sturge-Weber syndrome and a 72-year-old man with AVMs of the left face presented to clinic for management. The malformations involved the lips in both patients. Both patients had constant drooling and difficulty eating and talking, in addition to aesthetic concerns. They both underwent surgical excision of the redundant tissue with minimal undermining, advancement flaps, and layered closure. Minimal undermining allowed successful removal of the AVMs and redundant tissue without excessive blood loss and allowed healing without complications. Both patients had significant improvement in eating and talking without drooling. Aesthetically, satisfactory outcomes were maintained at 1-year follow-up appointments. Removal of AVMs while minimizing blood loss can be a challenging endeavor. Here, we have presented a successful, effective technique for restoring both form and function in patients with AVMs involving the lips, with good long-term results.
... This partial benefit of laser therapy is particularly evident when applied to those progressive and thicker PWSs with nodularity and hypertrophy, which are usually both persistent and resistant [38]. In order to obtain better outcomes and avoid the need for the possible disfiguring surgery [39], many authors recommend early PDL treatment, possibly within the first year of age [40][41][42]. ...
Capillary malformations (MCs), also referred to as port-wine stains (PWSs), or port-wine birthmarks (PWBs) represent one of the most common congenital vascular birthmarks. They consist of ectatic postcapillary venules within the papillary and superficial reticular dermis. The pathogenesis is due to a somatic activating mutation in guanine nucleotide–binding protein G(q) subunit alpha which mosaically occurs in endothelial cells (ECs) during embryogenesis. As a true congenital vascular malformation, PWSs are always present at birth, appearing as a flat pink to red macula mostly arising in the head and neck unilaterally. Although lightening during the first few months of life is possible, these lesions generally stay stable or thicken and darken over time. Consequent functional impairment, tissue thickening, development of blebs, and psychological burden may be relevant, so early laser therapy should often be considered to deter progression. What we present here is a unique cohort of 10 children presented to the Vascular Birthmarks Foundation (VBF) in Latham, NY, between 2016 and 2021, who were followed over time for cutaneous vascular anomalies present at birth. The clinical features were strongly suggestive of PWSs. However, all 10 of these children showed a significant spontaneous regression of the lesions during the observational period. In four cases, there was complete resolution. According to the international literature, capillary malformations persist throughout life and typically grow and darken if early laser treatment is not initiated. Such spontaneous improvement is extremely rare after the first 6 months of life. In the present case series, we photographically documented this previously unreported circumstance.
Level of evidence: Level V, risk/prognostic study.
Background: Port-wine stain (PWS) patients may simultaneously have accompanied soft tissue hypertrophy. The outcome of laser therapy can be poor. Objective: To study the imaging and histopathological characteristics of PWS patients with facial overgrowth. Materials and methods: We retrospectively assessed the effect of therapy on a subset of PWS patients with facial overgrowth. The degree of hypertrophy and the density of enhanced signals on T1-weighted magnetic resonance imaging (MRI) were independently graded by two radiologists using a quartile scale. Biopsies/resection of tissue deep to the facial muscle was reviewed and compared with flat PWS. Results: Thirty-two PWS patients with facial hypertrophy and 15 patients with flat PWS were included. MRI revealed a statistically significant correlation between the degree of hypertrophy and the density of enhanced signals (3.02 ± 0.92 vs. 2.47 ± 0.69; p < 0.01). Histological features of a subset of patients showed that vascular malformations existed in the dermis and also in the subcutaneous fat and muscle with much larger vessel diameters (fat, 0.048 vs. 0.020; muscle, 0.035 vs. 0.017) and thicker vessel walls (fat, 0.014 vs. 0.006; muscle, 0.010 vs. 0.006) (both p < 0.05). Conclusions: The imaging and pathological findings indicate that capillary malformation in subcutaneous tissue might be a major cause of poor therapeutic effect of laser therapy for PWS. Clinical trial registration no.: ChiCTR1800014278.
Importance
Vascular anomalies of the head and neck are relatively rare lesions. Management is challenging because of the high likelihood of involvement of functionally critical structures. Multiple modalities of treatment exist for vascular anomalies of the head and neck, including medical therapies, sclerotherapy and embolization procedures, and surgery. This review focuses on the accurate diagnosis and the relative roles of the various therapeutic options.
Observations
Vascular anomalies are classified by the International Society for the Study of Vascular Anomalies into 2 major groups: vascular tumors and vascular malformations. Vascular tumors encompass proliferative lesions ranging from infantile and congenital hemangiomas to kaposiform hemangioendothelioma. Alternatively, vascular malformations are embryologic errors in vasculogenesis. This article focuses on the management of vascular malformations. The 3 primary vascular malformation subclassifications are lymphatic, venous, and arteriovenous. The burden of disease, diagnosis, and current management options are discussed in detail for each subtype.
Conclusions and Relevance
Most vascular malformations of the head and neck require a multidisciplinary approach. Available medical, interventional radiologic, and surgical interventions are constantly evolving. Optimization of function and cosmesis must be balanced with minimization of treatment-associated morbidity. Otolaryngologists–head and neck surgeons must remain up to date regarding options for diagnosis and management of these lesions.
Background
The refractory port‐wine stains are often associated with soft and hard tissue hypertrophy leading to facial asymmetry and psychological problems.
Aims
The authors describe and illustrate a surgical strategy for the treatment of both hard and soft tissue malformations in patients with port‐wine stains to restore facial symmetry.
Methods
The medical records, photographs of two patients with soft and hard tissue hypertrophy were reviewed. After physical examinations, 3‐dimensional computed tomography was conducted to evaluate bony asymmetry. The surgical strategy was designed according to individual malformation and requests.
Results
Both patients had congenital port‐wine stains that were resistant to laser therapy. As they grew up, they developed both soft and hard tissue hypertrophy. Zygoma, maxilla, nose, and lips are involved, causing facial asymmetry, deviated nose, increased dental show and malocclusion. To correct bony malformation, orthognathic surgery, and facial bone contouring including zygomatic reduction, mandibular angles osteotomy and genioplasty were performed. After the correction of the bony factor, soft tissue symmetry was improved via resection, autologous fat grafting, liposuction, and rhinoplasty. Both patients were satisfied with the surgical result.
Conclusions
To acquire facial symmetry, surgical correction is inevitable for patients with port‐wine stains associated with soft and hard tissue hypertrophy. The authors describe the successive correction of bony and soft tissue asymmetry to achieve harmonious surgical outcomes.
Le malformazioni vascolari sono delle anomalie la cui gestione richiede una diagnosi precisa, spesso multidisciplinare. La classificazione biologica adottata dall’International Society for the Study of Anomalies divide le sue lesioni in base al tipo di vasi colpiti e alle loro caratteristiche reologiche. Possono essere isolate, combinate o fare parte di una sindrome. I loro trattamenti, spesso complessi e multidisciplinari, devono tenere conto non solo del tipo di vaso colpito ma anche della dimensione, della localizzazione e della sintomatologia. Qualunque sia la malformazione, la chirurgia è un’arma terapeutica in combinazione o meno con la radiologia interventistica o con un trattamento farmacologico. Questo articolo riunisce le peculiarità di tutte le malformazioni vascolari, la loro gestione e le indicazioni e i principi chirurgici specifici di ciascuna di esse.
Capillary malformations (CMs) and Lymphatic malformations (LMs) are vascular malformations that share a common tendency to cause soft and hard tissue hypertrophy, expressed in the three dimensions of the space. The middle third of the face is the most commonly involved area, with a predominance of the upper lip. To our knowledge, no paper has previously focused on the surgical technique to correct such deformities. We propose and illustrate a surgical protocol, consisting in merging an asymmetric bikini upper lip reduction and a unilateral bull horn resection technique, that allowed to reduce the overall volume of the hypertrophied lip thus restoring lip symmetry. We adopted this technique in 2 patients affected by CMs and 4 patients with LMs, with satisfactory results.
Capillary malformations (CMs), also known as port-wine stains, are the most common type of congenital vascular malformations. Facial CM often occurs with a quasidermatomal distribution according to the sensory trigeminal nerve distribution. With time, these lesions darken progressively, and soft tissue hypertrophy, bony hypertrophy, and/or nodule formation can develop. Multiple treatments for CM have been reported. However, the mainstay and gold standard therapy for facial or aesthetically sensitive CM is still the pulsed dye laser treatment. In patients with associated soft tissue/bony hypertrophy, surgical management is helpful in restoring the normal anatomy and in re-establishing a symmetric contour.
BACKGROUNDA percentage of patients with capillary malformation (CM) develop soft tissue hypertrophy, bony hypertrophy, and/or nodule formation.OBJECTIVE
To determine the incidence, age of onset, anatomic distribution of soft tissue/bony hypertrophy, and nodule formation in patients with untreated CM.METHODSA retrospective medical records review of head and neck CM patients presenting to a tertiary referral center over a 7-year period (2004-2011) was performed.RESULTSOf the 160 patients with CM, 96 demonstrated progression of disease to include either soft tissue/bony hypertrophy or nodule formation. Of these, 87 patients had not received previous treatment and met the inclusion criteria for analysis. On average, soft tissue hypertrophy began at 9 years of age. The V2/maxillary segment was most commonly involved with upper lip hypertrophy being the most prominent. Fourteen percent of the patients also presented with bony hypertrophy, which began at an average age of 15 years. Nodules were present in 38/87 (44%) of patients with an average age of onset of 22 years.CONCLUSION
This study demonstrates the nature progression of CM and quantifies the clinical characteristics of hypertrophy and nodule formation with untreated head and neck CM. Early and continuous treatment is recommended in hopes of preventing CM progression. © 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
Vascular ectasia observed in port wine stain (PWS) birthmarks might be secondary to localized reduction of neural innervation and associated loss of autonomic stimulation. Our objective was to investigate this theory and evaluate nerve density, blood vessel density, and average blood vessel size in untreated and pulsed dye laser with cryogen spray cooling (PDL-CSC) treated PWS skin.
Biopsy skin specimens were taken from 14 adults with a PWS, categorized by: uninvolved skin; untreated PWS skin; PWS skin with a history of good blanching, and PWS skin with a history of poor blanching both in response to PDL treatment. Seven specimens of normal, unaffected skin were used as the experimental control group. Indirect immunohistochemistry was performed on all specimens followed by confocal microscopy imaging with computer analysis to determine nerve density, blood vessel density, and average blood vessel size.
Nerve density was significantly decreased in all PWS sites as compared to uninvolved skin (p < 0.01). Average blood vessel diameter was larger in untreated as compared to treated PWS sites and varied between different sites within a single PWS.
Nerve density was decreased in all evaluated PWS sites, and this may be a factor in lesion pathogenesis. PWS blood vessel size correlated with the PDL blanching response and may prove to be a useful prognostic indicator of therapeutic outcome.
• Background and Design.—
Anecdotal reports and clinical observations have suggested that the response of port-wine stains to treatment with the pulsed dye laser is variable and dependent on the anatomical location of the lesion. To investigate anatomical variation in response to treatment, a retrospective study of 259 adults and children with port-wine stains of the head and neck treated with the pulsed dye laser was undertaken. Evaluation was performed by comparing simultaneously projected pretreatment and completiontreatment photographs. Anatomical differences in response were evaluated in three ways: (1) by anatomical subdivision of the head and neck into regions, (2) by dermatomal distribution, and (3) by response for midline lesions. The head and neck was subdivided into eight anatomical regions, which were independently evaluated for response. In addition, response for individual dermatomes and for midline lesions was evaluated. Response in all cases was assessed by determining the percentage of lightening from 0% to 100% (where 100% represents complete response) at the completion of treatment. Response grades were also assigned, using grades poor (0% to 25% lightening), fair (26% to 50% lightening), good (51% to 75% lightening), or excellent (76% to 100% lightening).
Results.—
One hundred thirty-seven adults and 122 children were included in the study. Evaluation by subdivision of the head and neck into regions revealed that in adults and children the centrofacial regions (medial aspect of the cheek, upper cutaneous lip, and nose) responded less favorably than the other grouped regions (periorbital, forehead/temple, lateral aspect of the cheek, neck, and chin); the centrofacial regions showed a good response (mean lightening, 70.7%), while the other grouped regions of the head and neck showed an excellent response (mean lightening, 82.3%). Evaluation by dermatomal distribution revealed that dermatome V2 showed a good response (mean lightening of 73.8%), while combined dermatomes V1, V3, and C2/C3 showed an excellent response (mean lightening of 82.4%). Evaluation of midline lesions revealed excellent responses in adults and children (mean lightening, 92.4%).
Conclusions.—
Port-wine stains of the head and neck in adults and children demonstrate differences in response to treatment with the pulsed dye laser according to their anatomical location. Centrofacial lesions and lesions involving dermatome V2 in adults and children respond less favorably than lesions located elsewhere on the head and neck. Midline lesions respond very favorably in adults and children.(Arch Dermatol. 1993;129:182-188)
Background Pulsed-dye laser (PDL)-mediated photothermolysis is the current standard treatment for port-wine stain (PWS) birthmarks. Vascular-targeted photodynamic therapy (PDT) might be an alternative for the treatment of PWS.
Objectives To compare clinical outcomes of PDT and PDL treatment of PWS.
Methods Two adjacent flat areas of PWS lesions were selected from each of 15 patients (two male and 13 female; age 11–36 years) and randomly assigned to either single-session PDL or PDT. PDL was delivered using a 585-nm pulsed laser. PDT was carried out with a combination of haematoporphyrin monomethyl ether (HMME) and a low-power copper vapour laser (510·6 and 578·2 nm). Clinical outcomes were evaluated colorimetrically and visually during follow-up.
Results A total of nine red PWS lesions and six purple PWS lesions were treated. For red PWS, colorimetric assessment showed that the blanching rates of PDL and PDT at 2 months ranged from −11% to 24% and 22% to 55%, respectively. For purple PWS, blanching rates of PDL and PDT ranged from 8% to 33% and 30% to 45%, respectively. Overall, there was a significant difference between the blanching effect of single-session PDL treatment and a single-session PDT treatment.
Conclusions This side-by-side comparison demonstrates that PDT is at least as effective as PDL and, in some cases, superior. The true value of PDT for the treatment of PWS deserves further investigation.
The 755-nm ms pulsed Alexandrite laser (MSPAL) has been reported to be successfully in the treatment of port wine stains (PWS) that are refractory to pulsed dye laser (PDL).
This was a prospective pilot study to assess the degree of improvement after a series of treatments with a MSPAL for hypertrophic, nodular, and macular PWS refractory to PDL. Treatment was administered to the PWS using the 755-nm MSPAL at settings of 3-ms pulse duration, 8- to 12-mm spot, 40 to 60 J/cm(2), and dynamic cooling of 60/40. Patients received a series of two to four treatment session, given at 6- to 8-week intervals.
The eight patients in this study had undergone a mean of 25.9 treatment sessions with PDL over 8.8 years. The number of MSPAL sessions required for significant improvement of PWS ranged from two to four (mean 2.6). From before treatment to 2 months after treatment, the mean score decreased from 3.2 to 1.4 for skin color (56.3% mean improvement, 95% confidence interval (CI)=53.2-59.4%), from 2.5 to 1.0 at (60.0% mean improvement, 95% CI=55.9-64.1%) for skin texture, and from 3.2 to 1.3 (59.4% mean improvement, 95% CI=56.2-62.6%) for overall cosmetic outcome (all p<.05).
In this pilot study, PDL-resistant PWS responded significantly to a series of MSPAL treatments. Given the potential for adverse effects and narrow therapeutic index, treatment with conservative parameters and close observation of tissue response are essential.
Port-wine stain (PWS) are congenital vascular malformations characterized by ectatic capillaries in the papillary layer of the dermis. They usually appear at birth and tend to become darker and thicker with age. Many clinicians consider the gold standard to treat PWS is pulsed dye laser (PDL) with wavelengths of 585 nm or 595 nm. But PDL is not suitable for patients with Fitzpatrick skin type V or nodular lesions. Vascular-targeted photodynamic therapy (PDT) might be an alternative approach in the treatment of such patients. The objective of this study was to assess the long-term outcomes and complications of PDT therapy of PWS in Chinese patients retrospectively. Patients with PWS who had received PDT therapy in a 5-year period were reviewed. 642 patients and a total of 3066 treatment sessions had been performed with an average of 2.6-8.2 sessions. Over 5% of patients had complete clearing, while 70% of patients had more than 25% of clearing. More than one-quarter of patients (29.8%) experienced a clearing of more than 50%. Ten percent of patients experienced complications (1.4% blistering, 1.2% hypopigmentation, 4.3% hyperpigmentation, 2.2% scabbing, <0.7% prolonged blistering that persisted for >2 months, 0.4% eczema dermatitis, 0.6% photoallergy). Sex, age, number of treatment sessions, average energy density and type of skin were not related to complication rate using the multiple regression analysis. Chinese patients were well responsive to and satisfied with vascular-targeted PDT (Patient Satisfaction Score 7.8). Dark-skinned patients and patients with vascular papules or nodules can be treated with alternative PDT to significant therapeutic effect in Chinese patients even though they experience few complications.
Defects of up to one third of the lower lip can usually be closed primarily, using one of the excision shapes described above. Defects of 30% to 50% of the lower lip can be closed with a stair-step or lip-switch flap. In most circumstances, stair-step reconstruction attains good function more quickly than the lip switch flap and has a better aesthetic result. Defects of 50% to 75% of the lower lip can be closed with a fan flap or a Karapandzic flap; the Karapandzic flap generally provides a better functional result. Both of these flaps cause rounding of the corner of the mouth that compromise the aesthetic result.
One hundred and three port wine stains, maximum length 5.0 cm or more in adults, and the length of the patient's thumb or more in children, on the unilateral side, were selected to be part of an analysis of port wine stain distribution patterns. Port wine stain lesions were evaluated, and similar lesion patterns were grouped together and outlined on a face map. Six major patterns were found: forehead (F), temporal (T), angular (A), labio-infraorbito-(angular) (L-O and L-O-A), labio-infraorbito-angulo-(forehead)-temporal (L-O-A-[F]-T) and jaw-neck (J-N). A wide-ranging, unilateral, or even bilateral port wine stain may be evaluated as a mixed form, which is composed of several standard patterns of port wine stains. The cause of port wine stains is also briefly discussed.
The nasal surface is made up of several concave and convex surfaces separated from one another by ridges and valleys. Gonzalez-Ulloa has designated the nose an aesthetic unit of the face. These smaller parts (tip, dorsum, sidewalls, alar lobules, and soft triangles) may be called topographic subunits. When a large part of a subunit has been lost, replacing the entire subunit rather than simply patching the defect often gives a superior result. This subunit approach to nasal reconstruction causes unsatisfactory border scars of flaps to mimic the normal shadowed valleys and lighted ridges of the nasal surface. Furthermore, as trapdoor contraction occurs, the entire reconstructed subunit bulges in a way that simulates the normal contour of a nasal tip, dorsal hump, or alar lobule. Photographs show five patients in whom this principle was followed and one in whom it was not.
In an attempt to understand the histogenesis and evolution of port wine stains (PWS), 100 patients with PWS were biopsied; the gross features of each lesion and the patient's associated clinical characteristics were recorded. A detailed analysis of each biopsy including both vessel and nonvessel parameters was made with the assistance of a computer. The central abnormalities characterizing port wine stains are an increase in vessel number (vascular profiles) and ectasia. Vessel number is highest in the immediate subepidermal area and then rapidly diminishes; mean vessel depth is .46 +/- .17 mm. In contrast mean vessel area shows less variation throughout the dermis, ectatic vessels being present when vessel number is very low. The product of both factors determines the percent of dermis occupied by vessels, but the mean vessel area is the major determinant. While age correlates poorly with vessel number, it correlates well with both progressive vessel ectasia and color shifts (pink to purple). Each of multiple vessel parameters analyzed (vessel number, mean vessel area, wall thickness, angulation, and luminal erythrocyte content) exhibited strong layer to layer correlation within the first .8 mm of tissue beneath the epidermis, indicating homogeneity of vessel characteristics within the lesion. The size of the lesion and facial quadrant distribution do not change with age nor are they related to any histological parameters. However the PWS lesion is found most often on the right side and lower quadrants, with a distinctive pattern being present in patients with glaucoma and mental retardation.
Two-hundred and fifty-seven patients (136 adults and 121 children) with port-wine stains of the head and neck were treated with the flashlamp-pumped pulsed dye laser. The head and neck was subdivided into 8 anatomical regions (forehead/temple, periorbital, medial cheek, nose, upper cutaneous lip, lateral cheek, chin and neck) which were independently evaluated for response. Response to treatment was found to be associated with the anatomical location of the lesion; in both adults and children the mid-facial region (medial cheek, nose and upper cutaneous lip) responded less favorably to treatment than the other regions of the head and neck (periorbital, forehead/temple, lateral cheek, neck and chin). In adults and children, mean percent lesional lightening of the mid-facial regions was 70.7% compared to 82.3% of the other regions of the head and neck with an estimated difference of 11.6% (95% confidence interval: 8.7% - 14.6%). The mean number of treatments for adults was 3.7, while this number in children was 3.9. All side effects were transient, and included cutaneous depressions, hypopigmentation and hyperpigmentation.
To assess objectively the results of flashlamp-pumped dye laser treatment of port-wine stains (PWS).
Pretreatment and posttreatment photographs were compared with the appearance of the lesion at follow-up examination. Clinical response was determined by assigning a percentage of lesional lightening score by 2 physicians and the patient, and by reflectance spectrophotometric measurements.
University and university-affiliated health center.
One hundred two patients (118 PWS) aged 1 month to 66 years (mean, 20 years; median, 16 years) treated from July 1, 1989, to June 30, 1994.
Eighteen (15.3%) of the 118 PWS had more than 90% lesional lightening (complete or almost complete response), 77 (65.3%) had lightening from 50% to 90% (good response), 21 (17.8%) had lightening from 11% to 49% (poor response), and 2 (1.7%) had lightening less than 10% (no response). Clinical response did not vary among age groups, but showed statistically significant differences between anatomical locations. A return of PWS after initial response was observed in patients who were seen more than 1 year following completion of treatment.
Treatment of PWS by flashlamp-pumped dye laser results in a good to complete response in most patients. Anatomical location of the lesion is a valuable prognostic indicator of response to treatment. The initially impressive results of flashlamp-pumped dye laser treatment of PWS may be tempered by the gradual return of the vascular lesion as time elapses after completion of therapy. Our experience indicates that PWS show a tendency to recur at a rate approaching 50% between 3 and 4 years after completion of treatment.
Port-wine stains are vascular ectasias that can develop thickening or nodules over time. Thickening is a further dilation of the ectatic vessels, and nodules are vascular neoplasms or hyperplasias. The records of 173 subjects with port-wine stains were reviewed for thickening, nodules, and associated characteristics. The incidence of nodules increased with age. Thickening often began in early adulthood, but its intensity and association with nodules continued to increase into older age. Thickening and nodules were most common in the area of the second and third branches of the trigeminal nerve innervating the face and were associated with deepening color. The incidence of thickening alone was greater in male than in female patients.
Soft tissue reconstruction of the forehead and temple challenges facial plastic surgeons to balance esthetic goals with functional concerns. Understanding the muscular and neurovascular anatomy is essential to achieve these ends. Reconstructive considerations include maintaining hairlines and eyebrows, minimizing scarring, using relaxed skin tension lines, and preserving motor and sensory function. Reconstructive options range from healing by secondary intention to primary closure, skin grafts, local flaps, island flaps, or any combination of these techniques.