15018752330
发表时间:2015-12-07 浏览次数:500次
Introduction
Treatment of large soft tissue vascular lesions remains one of the greatest
challenges in modern plastic surgery. The extent of the disease and the involved
structures, but also the expectations of the patients are important in
determining the way of treatment.
The biologic classification of hemangiomas
and vascular malformations (VMs) by Mulliken and Glowacki in the early 1980s has
not only simplified the terminology, but has also clarified their clinical
behavior and treatment options. In most instances, a hemangioma can be
differentiated from a VM by the history.
Case Report
A 34-year-old Maori man presented with an extensive arteriovenous malformation over his left face. The patient first noted small cherry-sized nodules behind his left ear at 8 years of age. His main symptom was recurrent and spontaneous bleeding, which he controlled with direct pressure. The lesion remained quiescent until 10 years later, when he noticed progressive enlargement of the mass. In addition to the frequent bleeding, he began experiencing increasing pain, skin tightness and troublesome pulsation at night [Figure 1], [Figure 2], [Figure 3].
Magnetic resonance imaging (MRI) demonstrated a large VM, which
predominantly filled the superficial aspect of the left parotid gland
and extended posteriorly into the left external ear [Figure 4]. Its blood supply was derived from the left external carotid artery [Figure 5].
In
preparation for surgical resection, patient underwent embolization 1
week prior to operation. The left occipital artery was embolized with 3
Guglielmi Detachable Coils (Target Therapeutics, Fremont, California,
USA) and the superficial temporal artery with Onyx Liquid Embolic System
(Onyx ® HD-500) [Figure 6]. [4],[5]
This resulted in reduction in lesion size and its vascularity. The
planned excision included the skin directly overlying the parotid as
well as the lower half of the ear [Figure 7]
and extended down into the neck, to allow for closure of the defect as a
cervicofacial rotation advancement flap. Careful dissection allowed for
retrograde identification of the facial nerve branches. The tumor was
circumscribed and simultaneous dissection performed in all directions [Figure 8].
It was possible through this approach to then remove the entire tumor
superficial and deep to the facial nerve, including the lower part of
the ear [Figure 9] and [Figure 10].
It was decided at the end of the procedure not to remove the remaining
components of the pinna as these are quite asymptomatic and removing
them wound mean probably having to use a temporal parietal fascia and
covering it with a skin graft, which is considered unnecessary at
present. However, this would be an easy procedure to do as a second
stage should the pinna component become problematic.
There were no complications related to either the preoperative angiography or embolization procedure. The patient was discharged on day 5 after the procedure. Histology confirmed arteriovenous malformation involving the subcutaneous tissue and parotid gland without any atypia or malignancy present. There has been no recurrence to our knowledge so far.
Discussion
Maxillofacial VMs are formed due to an error of vascular morphogenesis.
They may correspond to a defective remodeling process at the final
stages of vessel formation. Although no hereditary VM exist, the defect
might be genetically based and secondarily expressed in the first few
years of life. VM generally grow in proportion to the growth of the
affected child, but may increase in size secondary to various triggering
factors such as increased blood flow, arterial occlusion and venous
thrombosis, endocrine, trauma, or iatrogenic insults such as incomplete
surgery and proximal embolization, and infection.
High flow in an
existing VM can induce arteriovenous shunting, which, in turn,
increases flow demand, cascading enlargement of the malformation.
Increased
understanding of these additional physiologic variants may help to
define their clinical presentation and evolution and assist in designing
therapeutic strategies. [6]
The diagnosis is usually made based on clinical history and physical
examination. Cross section noninvasive imaging such as computed
tomography (CT) or MRI is helpful for assessment of the extent of the
disease, associated lesions, or multifocal involvement. MRI is the most
useful single imaging modality in the investigation of VMs. The
combination of multiplanar spin echo imaging and flow-sensitive
sequences permits characterization of the nature and extent of most
lesions. Angiography is reserved for patients in whom a decision has
been made to intervene and is generally performed at the same time as
embolization. VM are challenging to treat and require the skills of
multiple disciplines.
Management of these lesions is best
achieved by a specialist who understands the various clinical
expressions of the problem, the natural history of the lesion, and the
patient's needs. The primary goal of treatment is to restore and
preserve function, stop bleeding, and improve or restore cosmesis.
Vascular
malformation in children under 10 years of age may interfere with
natural growth and maturation of the maxillomandibular frame, causing
malocclusion of the mouth or modeling defects owing to external pressure
on the forming bones or sinuses. Early intervention can arrest or even
reverse such changes. [6]
The use of sclerosing and/or embolic agents in the treatment of hemagiomas was first described by Brooks in 1931, [7] documented by Edgerton in 1976. [8]
Since then, preoperative embolization of soft tissue vascular lesions
became almost the standard of care in the surgical management of these
lesions.
The selection of an appropriate agent depends on the
type of lesion, the method of embolization, and the experience of the
interventional radiologist. The embolization procedure not only
decreases the operative bleeding, but also facilitates the
identification of a safe tissue plane for surgical excision.
Total
resection is the gold standard. Three-dimensional (3D) CT scans
facilitate both a better understanding of their complex 3D configuration
and their relations with other anatomic structures such as bones and
vessels. In addition, postoperative visualization demonstrates the
volume of tissue removed. [9]
Conventional imaging modalities, such as MRI and angiography, are good
for understanding both the extent and the flow characteristics of the
disease.
Conclusion
Effective management of hemangiomas and VMs of the head and neck
requires a team approach, in order to understand the biologic behavior
of the lesion, complete the diagnostic studies necessary to define the
area of involvement, and understand the benefits and limitations of
interventional radiologic [10] and surgical procedures. The synthesis of this knowledge can help determine the best treatment. [11]
References
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