Q: When should a hemangioma be treated?

A: This is the most fundamental question. We believe that all hemangiomas should be seen by a specialist in this field. In many instances, early laser treatment can prevent a hemangioma from developing. All too often, the child is seen too late for this. It is therefore important that the child be seen early. In all but the small hemangiomas, some form of treatment will help.

Q: Are there different types of birthmarks?

A: Yes, there are 3 different types of vascular birthmarks:

1) VASCULAR TUMORS: The most common type we call HEMANGIOMAS. Hemangiomas are an example of a vascular tumor. The distinguishing feature of these types of birthmark is that they always proliferate (grow rapidly) during the first few months of life. This is especially so during the first, second, and third months of life. By about the sixth month, their growth rate slows down and they usually stop growing by the ninth month. From then on, the hemangioma will involute (shrink). This growth cycle is common to almost all hemangiomas.

2) VASCULAR MALFORMATIONS are different in that they never proliferate, and never involute. Instead, they will increase in size throughout the life of the patient. They will never shrink (with exception of Lymphatic Malformations which may fluctuate in size).

3) VASCULAR TUMORS other than hemangiomas are by far the most uncommon. This group has a variable behavior and usually diagnosed by exclusion. They also keep growing throughout the patient's life. The most common of these is called Kaposiform Hemangioendothelioma which causes bruising of the overlying skin and may eventually cause generalized bleeding.

Q: My child has a hemangioma. We have been told that all hemangiomas will disappear by the time my child is two. Is this true?

A: From about the age of nine months, most hemangiomas will begin the process called "involution". This means that they will shrink. The rapidity with which they shrink will determine the end result. Generally speaking, the faster the process of involution, the better the result. The cutoff age is about 6. Those hemangiomas that complete the involution phase before the age of 6, will leave very little residuum. On the other hand, those that involute later than 6 years of age will leave a considerable residuum and will very likely need corrective surgery. About half of all hemangiomas will leave some sort of residuum that is likely to require corrective surgery.

Q: My child has a hemangioma on his face and my pediatrician has advised me to leave it alone. Should I seek another opinion?

A: We believe that all hemangiomas of the face or neck should be seen by a specialty vascular anomalies team. Visible facial hemangiomas should be carefully followed and in many cases treated. Early aggressive treatment of segmental hemangiomas can prevent complications and avert years of reconstructive surgery if done early.

Q: My doctor has told me that I should not have my child's hemangioma treated until he/she is 6 or 7 years old. Can something be done sooner?

A: Although there are differing opinions, there are many reasons to intervene early. Firstly, a child develops an image of him/herself by about 2 1/2 to 2 1/2 years of age. Although there is no data, we believe that a disfigured child will become aware of his/her disfigurement by this age. In some children this happens sooner. Early intervention will prevent or minimize this. Secondly, the younger the child, the better they heal. A surgical wound on a 1 to 2 year old will leave less of a scar than a surgical wound on a younger child. Thirdly, blood loss can be avoided with meticulous surgical technique. Obviously, the more experienced the surgeon, the less likely this is to be a factor. All of these factors mitigate for early rather than late intervention. There is nothing to be gained by waiting and a lot to be lost.

Q: I have an arterio-venous malformation of my face and neck. My doctor has told me it cannot be cured. He has told me to leave it alone. Is this the right thing to do? Can anything be done?

A: Although it is not possible to "cure" an arterio-venous malformation (AVM) we can very often remove almost all of it and significantly improve the quality of life of our patient. Using a combination of embolization and surgery, we are able to minimize blood loss and remove enough of the AVM to relieve the symptoms and very often, the patient's appearance will be greatly improved. In some instances, we have been able to remove the entire lesion and have seen no recurrence for many years.

Q: Will my hemangioma come back after treatment?

A: The growth period of a hemangioma will vary depending on the type of lesion. Focal hemangiomas grow for between 6 and 9 months. Growth beyond this time is rare. Rebound growth of focal hemangiomas has been seen after cessation (stopping) of steroids as well as after cessation (stopping) of propranolol before the end of the growth period. Rebound growth after surgical resection is extremely unlikely by the right surgeon. If surgery is done after 9 months, rebound is virtually impossible. Segmental hemangiomas can grow for up to 24 months. Any treatment, whether it is steroids, propranolol or surgery, done before the end of this period can result in regrowth but is least likely with surgery.

Q: My 3 month old child has a hemangioma. Should she undergo surgery, laser treatment or treatment with propranolol?

A: This is an important question that can confuse many parents. This decision is best made by the physician treating your child but as a parent, it is however your prerogative to be informed.
During their growth period, segmental hemangiomas are best treated with propranolol or steroids. If there is a skin component (red skin overlying the hemangioma, this should be treated with laser. Early aggressive management can, in many cases, return the skin color and contour to normal by the time the child is one year of age.

Regarding focal hemangiomas, a disfiguring facial hemangioma should be treated. If it is superficial, laser treatment is best. If there is a deeper component, laser treatment together with propranolol treatment is best. Surgery should be contemplated if there is involvement of the eyelid, airway or there is ulceration. If it seems likely that surgery will ultimately be necessary then on occasion, this may be contemplated.

Q: My child has a birthmark. What does that really mean?

A: Many babies are born with birthmarks, which are also called vascular anomalies. In 90% of these cases marks disappear by age one, about 10% of children have a significant vascular birthmark that requires the opinion of a specialist. Vascular birthmarks are made up of clustered blood vessels and can be raised or flat, pink, red, or bluish in appearance.

Vascular Birthmarks generally fall into two categories:
• Hemangiomas- a benign, blood-filled tumor or mass (link to photo)
• Vascular Malformations- an abnormality of the larger deep veins and arteries

Q: What are the differences between hemangiomas and vascular malformations?

A: Typically, hemangiomas are not present at birth. They usually become noticeable between one and four weeks of age and may continue to grow for another 9 to 12 months. Hemangiomas, which are made up of capillaries, then begin a slow shrinking process called involution. In most cases, this natural process of shrinking is insufficient and some intervention will be necessary to restore the patient's appearance. Vascular malformations, on the other hand, are always present at birth, although they may not become apparent immediately. They consist of arteries, veins, or lymphatic channels, depending on the type of malformation. Unlike hemangiomas, vascular malformations do not shrink over time; they tend to grow and expand slowly. Males and females are affected equally by vascular malformations. There are five major types: midline capillary malformations ("stork bites"), capillary malformations (port wine stains), venous, arteriovenous, and lymphatic.

Q. Do hemangiomas cause complications?

A: In some severe cases, hemangiomas interfere with eating, breathing, seeing and hearing and require aggressive treatment. Internal hemangiomas, referred to as visceral, occur in the liver, intestines, airway, and brain. These are difficult to detect and generally require immediate intervention.

Q. How do you treat hemangiomas

A: Among the possible treatment options are laser treatment, surgical removal, steroid therapy (oral, topical, or injection into the birthmark itself), propranolol and the tumor shrinking drug Vincristine. Treatment should be planned according to the stage of the hemangioma's development, as well as its location and size. A laser uses intense and powerful light waves to treat the hemangioma. Different types of lasers are used to treat different types and stages of hemangiomas. In general, several laser treatments, generally done under anesthesia, will be necessary. The goal of this treatment is to restore the normal color and texture of the skin by destroying the dilated blood vessels. Laser can be used on ulcerated Hemangiomas. Surgical excision is often recommended for deep hemangiomas that have ulcerated, stopped growing or that are growing and causing problems to a body organ; such as an eye or nose. Steroids have been used successfully to treat fast-growing, large, or deeper hemangiomas. However, they are ineffective if the hemangioma is no longer growing and, for that reason, steroid are rarely given to a child after age one. Once the correct dose is determined, steroids will be administered for several weeks and the dosage will be reduced slowly over the next few months. To prevent the stomach irritation and acid reflux that is common with steroid therapy, a medication such as Zantac is also given. Steroid injections directly into the hemangioma are an option, particularly if the hemangioma is large or deep. The hemangioma's location often determines if there type of treatment is possible. A maximum of three injections I generally involved and side effects are rare. Depending on the location of the hemangioma the injection will be done under general anesthesia.
Propranolol has been recently found to have a very positive effect when used in the treatment of hemangiomas.

Vincristine is a tumor shrinking drug often used in chemotherapy that has been found effective in the treatment of large, rapidly growing hemangiomas that interfere with body function or in the case of multiple or large internal hemangiomas. Vincristine is administered intravenously in the hospital. Common side effects include nausea, vomiting and hair loss.

Q: How are the different types of vascular malformations treated?

A: There are several types of vascular malformations. Midline capillary malformations are common. You may know them as "Stork Bites" or "Angel Kisses". In general, they fade within a few years. If they do not, laser treatment can be done in later childhood The appearance of capillary malformations, commonly known as Port wine stains, can be much improved through laser treatment. Such treatments may need to be administered intermittently until the child is an adult. If the patient is an adult we can also do laser therapy to lighten malformation. Some adult patients with port wine stains may have thick, hypertrophic tissue over their birthmark. This can be treated with surgical excision to debulk or thin the tissue to have a more normal contour of the affected area. Lymphatic Malformations, frequently located in the head and neck area, consist of abnormal dilated lymph channels. When something disturbs this system, which collects and transfers tissue liquids, the lymphatic malformation is created. Excess fluid accumulates and the lymphatic vessels enlarge, creating a mass. Treatments vary and generally focus on helping the patient maintain normal appearance* and functioning, such as speaking and swallowing. Steroids, lasers, sclerotherapy or surgery may be recommended. A MRI (magnetic resonance imaging) is usually obtained, depending on the location, for proper diagnosis and a treatment plan such as eating or speaking.
Arteriovenous Malformations are associated with defective blood flow, and while present at birth, are not generally noticed until later. They are most often found on the head and neck and have varying growth patterns. Surgical removal is generally necessary. Laser treatment can be used after surgery to treat the skin portion.