Malformations venous

Venous Malformations

These lesions are made up of a plexus of dilated veins. Venous malformations can be localized or diffuse, superficial or deep.

Certain anatomical sites are frequently involved; these include mouth, lips, tongue cheek, side of the face and neck.
If the venous malformation is superficial, the skin and/or mucosa has a bluish hue.
Since venous malformations are essentially on the venous side of the circulation, they will enlarge when the area involved is in the dependant position.
As the patient gets older, the malformation will expand and if the overlying skin or mucosa is very thin, this can result in bleeding.
Venous malformations may be multifocal and they have a spongy consistency to palpation.

The underlying cause of venous malformations is probably the same as port wine stains except that the level of involvement is at a deeper level.

Laser treatment

Treatment with a Neodinium YAG (Nd:YAG) laser can be extremely effective for treating superficial venous malformations or it can be used to treat the superficial component of a deep lesion. It is essential that this treatment be done by a physician who has extensive experience in this because there is a very narrow therapeutic range. This means that the power settings necessary to obtain the desired effect fall within a very narrow range and will vary from patient to patient. If the physician wanders out of this very narrow range, scarring will result. It is important to note that a power setting effective for one patient, can cause scarring on another. It is thus critical that the treating physician be experienced in this form of treatment.

The Nd:YAG laser is capable of effectively reducing the bluish discoloration of skin (Fig. 2) and mucosa (the lining of the lip and mouth)( Fig 1.). By using a cooling device together with the laser, the skin is spared and it is possible to treat through intact skin. Using an Nd: YAG laser with cooling, we have been able to successfully treat the superficial discoloration associated with these lesions. This is recent innervations. Laser treatment is thus often combined with surgery and sclerotherapy to successfully treat compound venous malformations.

Surgical excision

Surgical removal of the venous malformation can be staged (done in stages over a few months) or if it is possible, in one operation. The venous malformation is usually sclerosed before the operation. This will usually greatly facilitate the ease of surgery and greatly reduce blood loss during surgery.

Regarding the extent of the surgical resection there are some points of discussion.
A venous malformantion usually presents as a diffuse lesion. This means that the lesion infiltrates tissues indiscriminately and can be around important facial structure such as nerves muscles, bones, glands, etc.
It is important to realize that the chief complain of the patient with a venous malformation in the majority of cases is aesthetic .Other cases do also have a profound functional impairment, for example an enlarged tongue because of a venous malformation results in speech, masticatory and swallowing difficulties. Both of these categories are treated, by removing as much of the malformation as necessary, in order to avoid damage to important anatomical structures, but on the other hand, to achieve the best possible esthetic and functional outcome.
Vascular malformation is not a malignant lesion and should not be surgically managed with an amputation of facial structures. If a part of the malformation must be left behind, this part can be treated with the additional more conservative treatment modalities such as lasers and sclerotherapy.
On the other hand, when dealing with a localized lesion with well defined margins, a complete removal must be attempted, having in mind the anatomical restrictions of the area.
When there is a recurrence or regrowth of the lesion, the surgeon can utilize the three major treatment modalities in order to intervene; surgery, sclerotherapy and laser treatment or a combination of the above.
In terms of managing the expected hemorrhage, the lesion must be treated with sclerotherapy before resection. This will minimize the bleeding during the procedure and will allow the surgeon to safely recognize and dissect the important anatomical elements and the margins of the lesion. Lesions that haven't been sclerosed preoperatively may be very difficult to manage intra operatively. The surgeon is also able to utilize all the available surgical aids in order to achieve haemostasis such as haemostatic clips, ligation of vessels, thermoscalpels, topical haemostatic agents, etc
Remember that the attempt to provide a normal appearance of the face and correct the functional abnormalities without risking permanent damage to facial organs.

Slerotherapy and Surgery

As previously mentioned all our venous malformation cases have to undergo a sclerotherapy procedure before the surgical excision. This combination serves multiple purposes

The first is to achieve a dry surgical field (hemostasis) during the excision.
The second is to reduce the lesion's size preoperatively, thus performing a less extended resection.
The third is to further evaluate the lesion as during sclerotherapy we monitor under fluoroscopy the spaces filled with a dye before injecting the sclerosing agent into the lesion.
In our treatment protocol we perform the sclerotherapy procedure 6-8 weeks before the planned surgical excision.
Our affiliated colleagues in the US have recently perfected a treatment whereby the lesion is first sclerosed and then within 24 - 48 hours, it is excised.

Sclerotharapy as a sole treatment.

When dealing with a diffuse or defined lesion and the patient does not want a surgical correction, we utilize sclerotherapy as the only treatment.

Sometimes this may be combined with laser treatment of the mucosal or skin surfaces.
Sclerotherapy is done under general anesthesia in the angiography suite.
It is performed by the interventional radiologist with the presence of the surgeon.
We always monitor the administration of the drug with fluoroscopy.
We use mainly alcohol injections or other sclerosing agents, accordingly.
The patient has to be admitted for overnight stay in the hospital.
A swelling of the treated region is expected and desired. This will last for 7-10 days.
We check and compare the results with a pre and post sclerotherapy magnetic resonance imaging (MRI)

Our aim is to control the lesion and thereby improve the quality of life of the patient.