MASTER CLASS IN PLASTIC SURGERY
Ian T. Jackson
Received: 10 July 2008 / Accepted: 22 July 2008 / Published online: 12 August 2008
Abstract Hemangiomas are vascular lesions of childhood.
They grow rapidly, usually become uniformly red, and they
then involute to a variable degree. In high flow proliferative
lesions, there is pulsation over the lesion and evidence of
high-flow when examined by Doppler. In other less
“active” low flow lesions, this is not the case. Histological
examination shows endothelial hyperplasia in the early
stages. In later stages, the basement membrane is multi-
laminated. The residual scarring may necessitate revisional
surgery. In large lesions on the face, local flap reconstruc-
tion may be necessary. If the areas to be replaced are large,
tissue expansion is frequently utilized in order to have a
flap of sufficient size. In the nasal tip, early excision may
be justified but this requires a case-by-case assessment.
Hemangiomas are low-flow vascular lesions. Approximately
40% are present at or just after birth. They grow rapidly in
the proliferative phase but involute slowly; when this
occurs, they do not recur [1–7]. In the growth phase, new
blood vessels are produced by endothelial cell overactivity.
The volume increase of the hemangioma is variable but is
not predictable. Initially, there is a mass of endothelial cells
which rapidly develops into capillaries. Following this over
a variable period of time, these capillaries slowly regress
and do not reappear. In the area of resolution in some
patients, there may be a small number of residual
capillaries, which are firmer than the initial group. This is
undoubtedly a unique biological phenomenon.
The blood flow through the lesion is low when
compared to arteriovenous malformations, especially those
having an arterial inflow. The low-flow group is lymphatic
and venous malformations and involuted hemangiomas.
The lesion has three phases which are referred to as
proliferating, involuting, and the involuted phase. These
changes can be differentiated using cellular markers.
The proliferating phase
In this phase, the substances, which begin the process and
maintain its progression, are vascular endothelial growth
factor, type IV collagenase, and proliferating cell nuclear
The involutional phase
There are several substances which contribute to the
reduction with eventual disappearance of most of these
lesions; these are: β fibroblast growth factor, von Willebrand
factor, urokinase (CD31) tissue inhibitor of metalloprotei-
nase. In these two phases, the levels of these substances are
In the majority of patients presenting with hemangioma,
the diagnosis is easily made by clinical examination.
Hemangiomas are seen at birth or soon thereafter. The
majority are single lesions, but in approximately 20% of
Eur J Plast Surg (2008) 31:275–280
The author has no financial interest in any of the products, devices or
drugs mentioned in this manuscript.
I. T. Jackson (*)
Craniofacial Institute, Providence Hospital,
16001 West Nine Mile Road, Third Floor Fisher Center,
Southfield, MI 48075, USA