Surgical management of large scalp infantile hemangioma in 30-month-old infant

Abstract

Infantile Hemangiomas (IH) are the most common benign tumor of infancy, occurring in over 10% of newborns. The head and neck is the most frequently affected area (60%), and the scalp is a typical site for such large lesions. Scalp-IHs are usually focal lesions that can be both disfiguring and may lead to complications such as ulceration and bleeding. We describe a case of a 30-months old female who presented a large scalp-IH at birth that rapidly grew in the first year of life. Topical and systemic treatments (with timolol ointment and oral propranolol, respectively) were not effective in reducing dimensions of the hemangioma. After vascular imaging study, the patient underwent surgical resection of the IH and primary closure with excellent cosmetic outcome. When medical therapy is ineffective or cosmetic and functional integrity is threatened, early surgery allows to completely removing large scalp-IHs, with good cosmetic results.

Infantile Scalp Hemangiomas: Surgical Management and Lessons Learned

“…Although excision of IH presents the risk of bleeding due to the vascularity of the tumor, it may be necessary if the lesion is refractory to pharmacological treatment or causing life-threatening sequelae: recurrent bleeding, ulceration, congestive heart failure, or obstruction of a vital structure (airway, ear canal, and visual axis) 7,30 . Indications for surgical intervention of the scalp lesions in our review varied: 32% of patients exhibited critical anatomic disruption (4 ears, 2 eyes), 8,11,13,15 32% had ulceration or erosion, 9,11–14 16% with cardiac involvement, 8,10,15 11% with increased bleeding, 11,18 and 26% due to rapid growth or unresponsiveness to prior therapies 11,12,16,17 . Notably, excision was performed significantly earlier in patients with signs of cardiac involvement (<1 month) 8,10,15 …”

“…Review of the literature revealed 19 previously published case studies (from 1981 to 2022) of pediatric scalp hemangiomas undergoing excision (Supplemental Table 1, Supplemental Digital Content 1, http://links.lww.com/SCS/F594). [8][9][10][11][12][13][14][15][16][17][18] Of the patients whose sex was reported, the majority (78%) were female (F:M ratio of 3.5). Patient age at the time of excision ranged from 2 days old to 14 years old, with a median age of 16 weeks.…”

“…Excluding outliers (14-year-old), the average and SD of surgical age were 24 and 31 weeks, respectively. The anatomic location of the scalp lesions had the following distribution: 32% temporal (including mastoid and postauricular), 9,11,15 21% parietal, 13,14,16,18 21% frontal, 8,11,13,17 11% temporoparietal, 10,12 5% occipitoparietal, 12 5% frontoparietal, 12 and 5% on the vertex of the scalp. 11 The hemangiomas ranged in size from 0.5 × 2 × 1.5 cm 16 to 14 × 10 cm.…”

“…7,30 Indications for surgical intervention of the scalp lesions in our review varied: 32% of patients exhibited critical anatomic disruption (4 ears, 2 eyes), 8,11,13,15 32% had ulceration or erosion, 9,11-14 16% with cardiac involvement, 8,10,15 11% with increased bleeding, 11,18 and 26% due to rapid growth or unresponsiveness to prior therapies. 11,12,16,17 Notably, excision was performed significantly earlier in patients with signs of cardiac involvement (< 1 month). 8,10,15 To mitigate the risk of blood loss from surgery, embolization may be completed preoperatively.…”

“…10,12 Of note, only 2 patients (11%) were prescribed beta-blockers (oral propranolol) before surgical treatment. 16,17 Most patients underwent primary closure or closure with local rotational flaps. The tissue-expanding nature of hemangiomas combined with the laxity of the infant scalp largely eliminates the need for further tissue expansion, but this technique was utilized when necessary.…”