婴幼儿血管瘤的手术治疗

　　 婴幼儿血管瘤一般不主张早期手术治疗。在确定手术治疗时，应考虑以下因素：部位、血管瘤的类型和大小、既往并发症、血管瘤的生长周期、功能损害和相对于其他治疗方法的疗效对比。上海交通大学医学院附属第九人民医院口腔颌面-头颈肿瘤科郑家伟
手术一般限于以各种技术处理纤维脂肪组织残余，即切除多余的纤维脂肪组织和矫正外观畸形。即使巨大的血管瘤，亦应在始终考虑使用药物和（或）激光等侵入性小的治疗方法迅速改善病情后，权衡利弊，由外科医师评价早期手术的指征。

手术指征：
1．预计消退后残留纤维脂肪组织残余且生长迅速的血管瘤；
2．结节状巨大血管瘤累及瘢痕易于隐藏的解剖部位，如颈部、头皮；
3．肿瘤基底部狭窄的蕈样血管瘤，可采用双环法（round block）切除；
4．不消退型先天性血管瘤（NICH）；
5．继发眼睑运动障碍且对药物和（或）激光治疗无效的眼睑血管瘤；
6．造成鼻部软骨畸形的血管瘤；
7．对皮质激素和（或）激光治疗无效的伴溃疡和出血的血管瘤。

手术切除的目的是获得理想的外观效果。在处理巨大增殖期血管瘤时，术中控制出血是外科医师面临的主要挑战，可使用2种方法施行血管瘤部分或全部切除术：一是梭形切口－线性缝合技术，二是环形切除－荷包缝合技术，即双环法（round block technique）。但双环法仅适用于切除直径小于3 cm的较小病变的切除。

Indications and timing for surgical treatment

Indications and timing for surgical treatment are strictly related to each other. There is a general agreement about postponing surgical treatment of Hm in the expectation of a complete spontaneous involution. Therefore indications to surgery are normally restricted to the treatment of fibro-fatty remnants with different techniques: excision of exuberant fibro-fatty tissue and correction of contour deformities.
Indications to early surgical excision of Hm in the proliferative phase are more controversial and can be listed as follows:
1. Rapidly growing Hm with expectance of relevant fibrofatty residuum after involution.
2. Voluminous tuberous Hm affecting anatomical sites where scars would be easily hidden (i.e. neck, scalp).
3. Pedicled tuberous Hm with a narrow implantation base (excisable using the “round block” technique).
4. Non involutive congenital Hm (NICH type).
5. Palpebral Hm with secondary functional impairment of palpebral motility scarcely or not responding to drugs and/or laser treatment.
6. Hm of the nose producing secondary cartilages deformity.
7. Ulcered and bleeding Hm not responding to corticosteroids and/or laser treatment.

The main purpose of surgery for removing Hm, regardless the life-cycle phase (proliferative or involutive) is to optimize the final cosmetic result. When approaching large Hm in the proliferating phase, intraoperative bleeding control is the main challenge for the surgeon: a few surgical tricks can be employed in order to minimize intra-operative bleeding. Two different surgical techniques for partial or total excision of a critical Hm can be used: 1) the lenticular shaped incision and linear closure technique; and 2) the circular excision and purse-string closure technique, which had been previously reported as the “round-block technique”.