LETTERS AND COMMUNICATIONS
Treatment of a Deep Infantile Hemangioma Using a Penetrating Insulated Electrosurgical Electrode (Sublation) Persistent infantile hemangiomas of the skin may be treated surgically, although scarring is the major complication with most surgical modalities. Vascular lasers may be used to treat superficial vascular lesions; however, their penetration depth is less than a few millimeters.1 Electrocoagulation of a variety of internal tumors has proven successful using penetrating electrodes.2 In this report, we present a case of a significantly reduced infantile hemangioma of the lip after treatment with deep submucosal electrocoagulation with an insulated electrode. We use a newly coined term “sublation” to describe this method.
Patient and Technique A 16-year-old girl presented with a 2-cm tumoral infantile hemangioma of the right upper vermilion lip. The lesion first appeared at the age of 1 month, grew up to the age of 6 months, and had some regression at the age of 1 to 3 years. The lesion was selected for treatment. To ensure electrocoagulation of the deeper angiomatous tissue, an electrosurgical generator with an output frequency of 0.4 MHz in monopolar biterminal cutting mode was connected to a 20-gauge intravenous catheter, which served as the penetrating electrode (Figure 1). The nonconductive plastic sheath over the intravenous catheter insulated the proximal part of the metallic needle and prevented the superficial tissue from electrocoagulation. The unsheathed tip of the needle served as the active electrode.
and around the lesion. Ten minutes were allowed to permit maximal vasoconstriction after which the treatment catheter was inserted 1 cm lateral to the lesion and advanced through the submucosal tissue into the lesion (Figure 2). To maximize control over the movement of the activated electrode through the tissue, the electrosurgical unit was activated only during retrograde withdrawal of the electrode. The electrosurgical power was increased gradually up to a level that spark formation in the tissue was felt or heard while slowly moving the electrode backward through the tissue at a rate of approximately 1 cm per second. Multiple passes of the catheter in the deep angiomatous tissue, parallel to the surface, resulted in fractional ablation of the deep abnormal tissue without destruction of more superficial layers. The extent of deep tissue coagulation, as well as the possibility of ischemic necrosis of the overlying superficial layers, was limited by trying to maintain a 4-mm distance between the passes of the electrode and a depth of 3 to 4 mm from the surface. After the procedure, the area was compressed for 10 minutes to prevent possible hematoma formation.
Local anesthesia was administered using a solution of 1% lidocaine with 0.001% epinephrine infiltrated into
Figure 1. An intravenous catheter was used as the electrode. The needle is insulated except for the most distal tip. An insulated metallic wire connected the needle to the electrosurgical unit.
702
Figure 2. Method of movement of the catheter in the tissue. The catheter was placed in the mucosa 1 cm lateral to the lesion and was advanced toward the lesion through the submucosal tissue. The area was fractionally coagulated during retrograde movements of the electrode through the target tissue.
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Hemangiomas, however, change the normal architecture of the skin, and, as a result, there is potential for scarring both after spontaneous resolution and laser or surgical interventions.3
Figure 3. (Top) The infantile hemangioma before the treatment. (Bottom) Seven months after 2 sublation sessions, there is a significant reduction in both visual intensity and volume of the lesion.
For a period of 2 to 3 weeks after the treatment, the target appeared inflamed and larger than at baseline. Subsequent shrinkage occurred gradually over the next several months. A second procedure using the same parameters was performed 6 months later. The 6-month interval was chosen between the first and second treatment sessions to allow for maximal healing and tissue contraction. There were no significant adverse effects after either procedure. Seven months after the second session, the volume and intensity of the lesion were reduced significantly (Figure 3). The upper lip was nearly symmetrical. By this time, only minor surface irregularities remained, and residual erythema was minimal in the background of the vermilion lip. The patient was gratified with the final cosmetic results. Discussion Vascular lasers are first-line treatment of superficial vascular malformations and noninvoluting superficial flat hemangiomas.1 Capillary vascular malformations can be treated without resulting in scarring.
Pedunculated or tumoral hemangiomas with excess skin are usually treated with surgery. Deep tumoral hemangiomas without excess skin can be treated using vascular lasers for destruction of superficial component and elimination of erythema if present.1 Sublation can then be used adjunctively to reduce the volume and flatten the deeper component. Such an approach may be preferred to surgical excision because it does not result in linear surface scars and may be easier to perform than larger excisions that may require complicated reconstruction of the resultant defect. However, in cases where the architecture of the skin has already been severely altered by the hemangioma, surgical excision of the underlying hemangioma and the affected skin may be preferable. High-frequency alternating currents can leak through insulations as capacitive currents. This leakage can occur even with the use of nonconductive plastic sheaths overlying intravenous catheters. Because higher frequency currents theoretically leak more easily than lower frequency currents, an electrosurgical generator with relatively low frequency (0.4 MHz) was used to limit potential leakage and consequent thermal injury to the superficial tissue around the proximal part of the catheter.4 When set in cutting mode, electrosurgery results in a 0.1- to 2-mm depth of coagulation on either side of an electrosurgical incision.5 In our patient, by performing the electrocoagulation at a power level just enough to engender sparking in the tissue, we estimated the depth of coagulation around the electrode to be
Treatment of a Deep Infantile Hemangioma Using a Penetrating Insulated Electrosurgical Electrode (Sublation) Persistent infantile hemangiomas of the skin may be treated surgically, although scarring is the major complication with most surgical modalities. Vascular lasers may be used to treat superficial vascular lesions; however, their penetration depth is less than a few millimeters.1 Electrocoagulation of a variety of internal tumors has proven successful using penetrating electrodes.2 In this report, we present a case of a significantly reduced infantile hemangioma of the lip after treatment with deep submucosal electrocoagulation with an insulated electrode. We use a newly coined term “sublation” to describe this method.
Patient and Technique A 16-year-old girl presented with a 2-cm tumoral infantile hemangioma of the right upper vermilion lip. The lesion first appeared at the age of 1 month, grew up to the age of 6 months, and had some regression at the age of 1 to 3 years. The lesion was selected for treatment. To ensure electrocoagulation of the deeper angiomatous tissue, an electrosurgical generator with an output frequency of 0.4 MHz in monopolar biterminal cutting mode was connected to a 20-gauge intravenous catheter, which served as the penetrating electrode (Figure 1). The nonconductive plastic sheath over the intravenous catheter insulated the proximal part of the metallic needle and prevented the superficial tissue from electrocoagulation. The unsheathed tip of the needle served as the active electrode.
and around the lesion. Ten minutes were allowed to permit maximal vasoconstriction after which the treatment catheter was inserted 1 cm lateral to the lesion and advanced through the submucosal tissue into the lesion (Figure 2). To maximize control over the movement of the activated electrode through the tissue, the electrosurgical unit was activated only during retrograde withdrawal of the electrode. The electrosurgical power was increased gradually up to a level that spark formation in the tissue was felt or heard while slowly moving the electrode backward through the tissue at a rate of approximately 1 cm per second. Multiple passes of the catheter in the deep angiomatous tissue, parallel to the surface, resulted in fractional ablation of the deep abnormal tissue without destruction of more superficial layers. The extent of deep tissue coagulation, as well as the possibility of ischemic necrosis of the overlying superficial layers, was limited by trying to maintain a 4-mm distance between the passes of the electrode and a depth of 3 to 4 mm from the surface. After the procedure, the area was compressed for 10 minutes to prevent possible hematoma formation.
Local anesthesia was administered using a solution of 1% lidocaine with 0.001% epinephrine infiltrated into
Figure 1. An intravenous catheter was used as the electrode. The needle is insulated except for the most distal tip. An insulated metallic wire connected the needle to the electrosurgical unit.
702
Figure 2. Method of movement of the catheter in the tissue. The catheter was placed in the mucosa 1 cm lateral to the lesion and was advanced toward the lesion through the submucosal tissue. The area was fractionally coagulated during retrograde movements of the electrode through the target tissue.
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Hemangiomas, however, change the normal architecture of the skin, and, as a result, there is potential for scarring both after spontaneous resolution and laser or surgical interventions.3
Figure 3. (Top) The infantile hemangioma before the treatment. (Bottom) Seven months after 2 sublation sessions, there is a significant reduction in both visual intensity and volume of the lesion.
For a period of 2 to 3 weeks after the treatment, the target appeared inflamed and larger than at baseline. Subsequent shrinkage occurred gradually over the next several months. A second procedure using the same parameters was performed 6 months later. The 6-month interval was chosen between the first and second treatment sessions to allow for maximal healing and tissue contraction. There were no significant adverse effects after either procedure. Seven months after the second session, the volume and intensity of the lesion were reduced significantly (Figure 3). The upper lip was nearly symmetrical. By this time, only minor surface irregularities remained, and residual erythema was minimal in the background of the vermilion lip. The patient was gratified with the final cosmetic results. Discussion Vascular lasers are first-line treatment of superficial vascular malformations and noninvoluting superficial flat hemangiomas.1 Capillary vascular malformations can be treated without resulting in scarring.
Pedunculated or tumoral hemangiomas with excess skin are usually treated with surgery. Deep tumoral hemangiomas without excess skin can be treated using vascular lasers for destruction of superficial component and elimination of erythema if present.1 Sublation can then be used adjunctively to reduce the volume and flatten the deeper component. Such an approach may be preferred to surgical excision because it does not result in linear surface scars and may be easier to perform than larger excisions that may require complicated reconstruction of the resultant defect. However, in cases where the architecture of the skin has already been severely altered by the hemangioma, surgical excision of the underlying hemangioma and the affected skin may be preferable. High-frequency alternating currents can leak through insulations as capacitive currents. This leakage can occur even with the use of nonconductive plastic sheaths overlying intravenous catheters. Because higher frequency currents theoretically leak more easily than lower frequency currents, an electrosurgical generator with relatively low frequency (0.4 MHz) was used to limit potential leakage and consequent thermal injury to the superficial tissue around the proximal part of the catheter.4 When set in cutting mode, electrosurgery results in a 0.1- to 2-mm depth of coagulation on either side of an electrosurgical incision.5 In our patient, by performing the electrocoagulation at a power level just enough to engender sparking in the tissue, we estimated the depth of coagulation around the electrode to be
