Surgical Excision of an Infantile Hemangioma

Primary treatment of infantile hemangiomas now centers around the use of beta-blockers.  If there is a suboptimal response to propranolol, or if a steroid injection does not result in improvement, surgical excision can be considered.  Focal lesions on the eyelid without significant orbital extension are the best candidates for surgical excision.  As this is a vascular tumor, significant bleeding can occur.

This is Richard Allen at oculosurg.com.  This video demonstrates surgical excision of an infantile hemangioma that did not respond to propranolol.  The lesion is focal and on the upper eyelid, causing ptosis and astigmatism.  The skin had expanded from the hemangioma and a small blepharoplasty is marked to match the contralateral side.  The 15 blade is used to make an incision along the blepharoplasty marking.  A flap of skin and orbicularis muscle is removed to expose the underlying orbital septum.   The orbital septum is opened.  Westcott scissors are then used to dissect in a subcutaneous plane inferiorly towards the lash follicles.  Bleeding is controlled with the bipolar cautery.  The goal of this dissection is to expose the anterior portion of the hemangioma.  Dissection is then redirected to superior boarder of the tarsus.  In doing this, the levator aponeurosis will be disinserted from the anterior surface of the tarsus.  Bleeding is controlled and the lateral extent of the lesion is identified.  The lesion is then dissected from the anterior surface of the tarsus.  This dissection proceeds along the anterior surface of the tarsus from lateral to medial.  Bleeding is controlled, and the dissection proceeds.  I think that bipolar cautery is preferred in this situation over monopolar cautery.  The lesion is dissected free and sent to the pathologist for evaluation.  Additional dissection is performed with the Westcott scissors to excise any residual hemangioma from the posterior surface of the skin and the anterior surface of the tarsus.  Inspection shows good debulking of the lesion.  It is useful to use your finger to help excise any residual tumor.  Pretarsal orbicularis has been removed, but there is adequate preseptal and orbital orbicularis to provide adequate closure of the eye.  This debulking of the residual tumor is performed along the posterior surface of the dermis and the anterior surface of the tarsus.  Almost complete excision of the visible tumor has been excised.  The levator aponeurosis is reattached to the anterior surface of the tarsus with interrupted 7-0 Vicryl sutures.  The eyelid crease incision is then closed with interrupted 5-0 fast absorbing sutures with soft engagement of the end of the levator aponeurosis to help in lid crease formation.  Postoperative photos at one month show adequate lid height and contour with debulking of the eyelid mass.  On downgaze there is residual discoloration in the area of the hemangioma which I think will fade with time.