and trauma. 4 Vascular malformations do not tend to exhibit a proliferative stage followed by stabilization and involution as seen in hemangiomas. 5 In the absence of a life-threatening indication, management is planned through multidisciplinary teams and can be handled with a single operation or a staged fashion. Treatment centers around sclerotherapy, with or without embolization and complete surgical excision. Subtotal resection may be required due to invasive growth into unresectable structures or as a bail-out procedure for patient stabilization in an emergency. It should be noted that subtotal resection carries increased risks of severe hemorrhage and is not a definitive procedure with high risk of recurrence. In rare cases, this may be life-threatening, particularly in the case of airway bleeding or relative blood loss seen in neonates and infants. Airway complications cannot be underestimated. Even with nonoperative sclerotherapy, inflammation and swelling resulting in airway loss can result. 6 Vessel sealing instruments are commonly used in other fields of surgery for ligamentous dissection as well as efficacious division of vascular tissue such as thyroid, omentum, and mesentery. They have also been described in vascular control of head and neck tumors, including thyroid surgery and intra-oral cancer surgery. In a singlecenter case-control study, Kanno et al determined that vessel sealing devices in head and neck tumor resections, ''significantly reduced intraoperative blood loss [with] no differences between the 2 groups with regard to postoperative complications and recurrence. '' 7 There is a paucity of published literature of large VMs being managed with energy devices. Hosny et al performed a single-center study of 14 patients with VMs of the head, neck, trunk, and extremity. Two major complications were seen in their review including stroke/ TIA and 1 death, demonstrating the occasional severity of these lesions. The complications were not felt to be related to the energy devices, in fact, the authors stated that these devices will improve the safety and broaden the role of surgical management of large VMs. 8 We agree with the authors' comments that vascular clamps and suture ligation of vessels can be difficult and tedious, and traditionally, VMs are resected with laborious suture ligation which can put both blood vessels and lymphatic channels at risk of tearing during dissection for proximal and distal vascular control. Vessel sealing devices have the advantage of gaining hemostasis during dissection of vessels 8 mm and larger, 9 and reliably seal surrounding lymphatic channels that may be at risk during traditional dissection/suture ligation techniques. 10 Common vessel sealers on the market are the Impact Ligasure Exact by Medtronic, Enseal, and Harmonic Scalpel by Johnson and Johnson, Bowa Lotus torsional ultrasonic scalpel from Bowa Electronic, and Thunderbeat from Olympus, among others. In the cases discussed above, surgical technique included extensive use of vessel sealing devic...
