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Fractional Photothermolysis for Involuted Infantile Hemangioma

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Fractional Photothermolysis for Involuted Infantile Hemangioma THE CUTTING EDGE SECTION EDITOR: GEORGE J. HRUZA, MD; ASSISTANT SECTION EDITORS: MICHAEL P. HEFFERNAN, MD; CHRISTIE AMMIRATI, MD Fractional Photothermolysis for Involuted Infantile Hemangioma Hans-Joachim Laubach, MD; Richard Rox Anderson, MD; Thomas Luger, MD; Dieter Manstein, MD; Klinik und Poliklinik fu¨r Haut- und Geschlechtskrankheiten, Universität Münster, Münster, Germany (Drs Laubach and Luger); Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston (Drs Laubach, Anderson, and Manstein) The Cutting Edge: Challenges in Medical and Surgical Therapeutics REPORT OF A CASE ried out. The skin lesion spontaneously resolved over the following years leaving the residual skin changes. The An otherwise healthy 14-year-old white girl presented to skin lesion had remained unchanged for the last 4 years our dermatologic laser clinic with a protruding tumor without further improvement in appearance. above the right nasolabial fold. The patient’s parents re- Physical examination revealed a protruding subcuta- ported that the patient had a fast-growing red tumor dur- neous tumor, abnormally lax overlying skin with several ing the first months after birth in the same area. The le- linear indentations, and a soft atrophic scarlike surface tex- sion at that time was diagnosed as infantile hemangioma ture (Figure 1A and Figure 2A). Several telangiecta- by the pediatrician, and no further intervention was car- sias were discernable within the skin lesion and in its im- mediate surrounding skin. The oral mucosa of the patient appeared to be free of any alterations. Findings of the gen- A B eral skin examination were unremarkable: no other simi- larly protruding skin lesions were found. THERAPEUTIC CHALLENGE The patient was referred for consideration of treatment alternatives to the proposed surgical intervention for the removal of the involuted facial infantile hemangioma. Of special concern for the patient was the irregular surface structure of the skin lesion rendering the application of make-up in an attempt to mask the lesion impossible. In- Figure 1. Close-up photographs taken at a 45° angled view to emphasize the vasive ablative procedures including traditional laser re- rough surface structure before (A) and 4 weeks after (B) 5 fractional surfacing were also deemed to be too aggressive and risky photothermolysis treatment sessions. The same photographic and flash setup by the patient’s parents. Less invasive procedures to im- was used for the before and after pictures, assuring constant light and prove the cosmetic appearance of the skin lesion were photography angles. sought. A B SOLUTION The patient consulted our department for treatment alter- natives to surgical excision of the involuted facial infantile hemangioma. The patient and her parents agreed to a trial of nonablative fractional photothermolysis (nFP) as a first treatment because of its favorable adverse effect profile, its demonstrated efficacy in treating atrophic scar tissue,1-4 and its reported improvement of telangiectasias.5-7 We advised the parents that several nFP treatment sessions would likely Figure 2. Close-up photographs taken at 90° angled view (profile) to emphasize be needed and that additional liposuction might be nec- the herniation of the skin lesion before (A) and 4 weeks after (B) 5 fractional essary to reduce the residual fibro-fatty mass.8-10 photothermolysis treatment sessions. The same photographic and flash setup was used for the before and after pictures, assuring constant light and For the nFP treatments, 2 different 1550-nm glass- photography angles. fiber lasers were used (Fraxel 750 and Fraxel re:store; Re- (REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 7), JULY 2009 WWW.ARCHDERMATOL.COM 748 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 liant Technologies Inc, Clear View, California). The first It has been clearly established that corticosteroids 3 treatments were done with the Fraxel 750 device at a and/or pulsed-dye laser treatments can cause early invo- microbeam energy of 16 mJ per microthermal treatment lution of infantile hemangiomas. These early treatments zone (MTZ) and a final MTZ density of 1250 MTZ/cm2 might reduce the need for corrective procedures after natu- delivered in 10 passes at 125 MTZ/cm2 per pass. Two sub- ral involution has occurred. sequent treatments were executed with a Fraxel restore To avoid psychosocial functional impairment, addi- device, an upgraded instrument model from the same tional treatment of these residual lesions is often carried manufacturer, at a fluence of 35 and 40 mJ/MTZ, treat- out. More than 80% of these common tumors are located ment level 8, and 8 passes. Local anesthesia was achieved in the head and neck region.19 Of 100 cases of parotidal by 60-minute incubation without occlusion of a custom- hemangioma retrospectively studied by Greene et al,17 66% made topical anesthetic cream containing lidocaine, 23%, were deemed to need reconstructive surgery after natural tetracaine hydrochloride, 3.5%, and tetracaine base, 3.5%. regression had occurred. Ninety-two percent of these pa- Furthermore, a forced-air cooling device (Zimmer Cool- tients underwent preauricular excision of redundant skin ing Device; Medizin Systems, Irvine, California) was used and/or fibrofatty tissue, and 37% of patients needed au- on a setting of 3 during the laser exposure to reduce dis- ricular revision. Surgical excision of excess tissue and/or comfort and the potential risk of bulk heating. local tissue flaps and grafts often result in an extra wide The patient tolerated each procedure with mild to mod- scar. The classic surgical approach of elliptical excision has eratediscomfort.Treatmentintervalsvariedbetween4weeks been improved by Mulliken et al20 and Vlahovic et al,21 who and 4 months. Immediately after each treatment there was proposed a circular excision and purse-string closure confluent erythema and edema typical for nFP treatments. technique. With this technique, the residual scar size is A cold compress was applied to the area immediately after approximately 70% the size of the scar resulting from stan- each laser treatment to reduce edema and patient discom- dard lenticular excisions. Another advantage of the purse- fort, and the patient was instructed to continue to cool the string closure technique is minimal distortion of surround- treatmentareatoreduceposttreatmentedemaanderythema. ing structures.20,21 One month after the fifth treatment, the involuted he- However, even this improved technique results in a sig- mangioma showed a clear improvement in the cutaneous nificant residual surgical scarring and might not be appli- texture and laxity and surprisingly an apparent reduc- cable in cases with a larger affected area. Surgical proce- tion in volume of the lesion (Figure 1B and Figure 2B). dures are also associated with all the risks of general The patient and her parents were very satisfied with the anesthesia and common surgical adverse effects of infec- result. The patient herself was especially pleased with the tion, tissue necrosis, and nerve damage. Another less in- ability to camouflage the lesion with make-up, which had vasive technique to change the appearance of the invo- been impossible before the nFP treatments. luted lesion is the volumetric reduction of the fibro-fatty tissue mass by different liposuction techniques.8-10 Al- though beneficial in volumetric reduction, this method does COMMENT not resolve the overlying dermal and epidermal changes. Traditional ablative laser resurfacing or dermabrasion Infantile hemangioma is a benign vascular proliferation can be used,22,23 but these techniques cause wounds with showing some similarities to placental vasculature.11 With the risk of permanent hypopigmentation, infection, and scar- an incidence of approximately 10%, this is the most com- ring. The potential for these adverse effects was strictly re- mon neoplasia in childhood.12,13 Common infantile hem- jected by our patient and her parents. We therefore de- angiomas have a distinct evolution consisting of a pro- cided to use nFP. liferative phase during the first year of life, followed by The principle behind the nFP technique is to create an gradual and often very slow regression with softening of array of small thermal lesions within the skin called MTZs the tumoral mass taking up to a decade or more. using focused laser microbeams.3 The tissue within those During the time of rapid proliferation and growth, in- MTZs is completely denatured, but the skin can recruit fantile hemangiomas can displace the surrounding tissue the surrounding unharmed tissue to regenerate very quickly, in a manner similar to that of a tissue expander. The nor- thus reducing adverse effects significantly.5 In addition, mal dermal architecture is commonly destroyed result- nFP has been shown to improve the appearance of atro- ing in an abnormal cutaneous laxity. The vascular tumor phic acne scars as well as surgical scars.1,4,6,24,25 Facial tel- mass is frequently not entirely absorbed during involu- angiectasias and postinflammatory erythema have also been tion, but is replaced partly by a loose fibro-fatty stroma reported to respond to treatment with nFP.6,7,26 Figure 1B with lobular architecture.14,15 This leads to a residual tu- and Figure 2B demonstrate improvement of the invo- mor in the affected area even after the vascular tumor has luted infantile hemangioma after nFP. completely regressed (Figure 1A
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