April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Waner & O

On ultrasonography imaging, a heterogeneous mix of cysts separated by echogenic septa is evident. Ultrasonography can also be helpful in identifying abnormal venous flow, which is common with mixed venous LMs (See Jared M. Steinklein and Deborah R. Shatzke’s article, “ Imaging of Vascular Lesions of the Head and Neck ” for further details).

TREATMENT

The treatment of LMs encompasses several modalities and is best undertaken by a multidisciplinary team. It is hoped that this will result in the most appropriate treat- ment. Treatment modalities include observation, surgery, sclerotherapy, and medical management. Management of the exacerbations as well as the various components of an LM is also considered. General Considerations The risks and benefits of 3 modalities should be considered. They are sclerotherapy, sur- gery, and medical therapy. Each of these modalities can effectively treat an LM but may not be the treatment of choice for a particular lesion. In addition to this, Perkins and col- leagues 28 advocate that, because a percentage of lesions in their series spontaneously shrunk, conservative management is appropriate in some cases. Given the tendency for lesions to exacerbate and remit, it is reasonable to wonder whether or not those lesions that had spontaneously regressed were in remission and would eventually exac- erbate given enough time. However, because some lesions spontaneously regressed or were in remission for several years, conservative management is a reasonable approach in a select group of cases. These cases include patients inwhomthe lesion seems tohave disappeared and inwhomthere are noother sequelaeor complications. Thework of Has- sanein and colleagues 19 should also considered; they found that, in 85%of children with LMs, the lesions expanded and/or became symptomatic during childhood. Sclerotherapy Sclerotherapy has been popularized as a primary modality for treating LMs. Although several agents have been used, the most commonly used are OK-432 (Picibanil) and bleomycin. 20 Smith and colleagues 13 showed that OK-432 was highly effective when used to treat macrocystic lesions; 94% had a complete or substantial response, whereas none of their patients with microcystic lesions responded. They also showed that, compared with aggregated surgical outcomes, OK-432 was 4 times more likely than surgery to result in a successful outcome and fewer complications. However, Balakrishnan and colleagues 21 showed no significant difference in efficacy between surgery and sclerotherapy. In a systematic review by Acevedo and colleagues 22 of pa- tients treated with predominantly bleomycin and OK-432, 43% of patients had an excellent or complete response, whereas 45% had a good or fair response. Note that these rates of response do not apply to a single treatment but are the result of an aggregate of around 4 treatments. Complication rates with bleomycin and OK-432 seem to be low. 23,24 Neither of these agents is neurotoxic and they are therefore safe when used adjacent to the facial nerve. Smith and colleagues 13 reported major complications in 3 of 30 patients treated with OK-432. These complications included airway obstruction, cellulitis, and prop- tosis. 23 Bleomycin is less likely to cause postoperative swelling and is therefore safe when used in the orbit. Precautions must be taken with skin adhesives and skin irri- tants because these can cause irreversible skin staining when used within 72 hours of bleomycin sclerotherapy. Electrocardiogram adhesives are therefore not removed for 72 hours and patients are told not to scratch themselves during this time.

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