decker

REVIEW

Early Surgical Excision of Giant Congenital Hemangiomas of the Scalp in Newborns: Clinical Indications and Reconstructive Aspects Luigino Santecchia, Maria Francesca Bianciardi Valassina, Federica Maggiulli, Giorgio Spuntarelli, Rita De Vito, and Mario Zama

Background: Infantile hemangioma is the most common vascular tumor in newborns, with an incidence from 12 to 23% among preterm infants with low weight at birth and a female to male ratio of 3:1. The head and neck is the most frequently affected area (60%), and the scalp is a typical site for such large lesions. Objective: We describe some clinical and medical aspects in comparison with the surgical approach to giant infantile hemangioma of the scalp. Methods: The indications to treatment are discussed. An outcome basis evaluation, by reviewing some clinical cases, is provided to help readers better understand when and how to undergo surgery safely. Conclusion: Early excision of huge infantile hemangioma of the scalp is the treatment of choice if feasible within 5 months of age. Contexte: L'hémangiome infantile est la tumeur vasculaire la plus fréquente chez les nouveau-nés; son incidence varie de 12 à 23% chez les prématurés de faible poids à la naissance, et le ratio filles/garçons est de 3/1. La tête et le cou sont les régions le plus souvent touchées (60%), et le cuir chevelu est le siège de prédilection de ces grosses lésions. Objectif: L'article porte sur certains aspects cliniques et médicaux liés au traitement chirurgical de l'hémangiome infantile géant du cuir chevelu. Méthodes: II sera question des indications du traitement. Nous présenterons, après l'examen de certains cas cliniques, une évaluation de base des résultats afin d'aider les lecteurs à mieux comprendre quand et comment la chirurgie peut être effectuée en toute sécurité. Conclusion: Le traitement à privilégier est l'exérèse précoce de l'hémangiome infantile géant du cuir chevelu à pratiquer, si l'intervention est possible, au cours des 5 premiers mois de vie.

rpHE CLASSIFICATION drawn up in 1996 by the -1. International Society for the Study of Vascular Anomalies (ISSVA) separates tumors from malformations, with obvious consequences for clinical and surgical treatment.'"* Infantile hemangioma (IH) is the most frequent vascular tumor due to the rapid proliferative phase of vascular endothelium, starting in the first months of life. This condition is followed by a slow and regressive phase From the Plastic and Maxillofacial Surgery Unit and Clinical Laboratories Department, Bambino Gesit Children's Hospital, Rome, Italy. Address reprint requests to: Luigino Santecehia, MD, Plastic and Maxillofacial Surgery Unit, Children's Hospital Bambino Gesii, Piazza S. Onofrio, 4, 00165 Rome, Italy; e-mail: [email protected].

DOI 10.2310/7750.2012.11113 i^ 2013 Canadian Dermatology Association

(cellular apoptosis), starting between 12 and 15 months of age and continuing up to 5 or 7 years of age.^"'° Most of the time, the proliferative phase turns up without any sign (except in congenital hemangiomas when lesions are present at birth), whereas at the end of regression, a fatty fibrous residue of different size is often visible.^'''^ IH is the most frequent benign tumor in newborns (1012%), particularly in premature infants with a body weight less than 1,000 g at birth, for whom the incidence is as much as 23%.^'^'^ The female to male ratio is 3:1, and localization is to the head and neck in 60%, the trunk in 25%, and the limbs in 15%.^'^''^ Recently, new forms of IH have been identified through the use of specific markers: noninvoluting congenital hemangioma, rapidly involuting congenital hemangioma, and abortive-type hemangioma.^*"'* Herein we discuss the indications to treatment. An outcome basis evaluation, by reviewing some clinical cases.

DECKER^ '106

Canadian Dermatology Association I Journal of Cutaneous Mediane and Surgery, Vol 17, No 2 (March/April), 2013: pp 106-113

Early Excision of Hemangiomas of the Scalp in Newborns

is provided to help readers better understand when and how to undergo surgery safely.

Case Reports Case 1 A 4-month-old female, weighing 5.5 kg at the time of surgery, presented with a vascular tumor of the occipitoparietal area of the scalp (Figure 1). The tumor had a small ulcération in the middle (diameter 0.5 cm) that had been treated with antibiotic ointments. At the time of surgery, the lesion measured 14 X 10 cm, with a round base of 10 cm in diameter. The lesion was already present at birth but smaller in size, and a sonogram revealed its vascular nature. The child grew regularly, and all preoperative blood examinations were in the normal range, except for hemoglobin (9 g/dL with a hematocrit value of 20%). The results of both electrocardiography and echocardiography were normal. Surgery was performed under general anesthesia, with the patient in the prone position with the head higher than

the trunk. No local anesthetic injection or epinephrine was administered. The surgical incision was performed all around the lesion in normal tissue, and the lesion was removed as a single piece on the supraperiosteal plane (Figure 2). Once hemostasis was achieved, the residual defect, measuring 10 X 12 cm, was closed with two opposing scalp flaps, one pedicled in the front and the other in the back. Two Jackson-Pratt drains were positioned, and the wounds were sutured in layers (Figure 3). The specimen was sent to the pathologist, and the result was positive for glucose transporter 1 protein (GLUTl) and CD3 antigen but negative for D240 antibody and podoplanin, giving the spectrum of an IH. The postoperative period was uneventful, and drains were removed 3 days after surgery and stitches 7 days later. Blood loss during surgery was minimal due to the fast excision of the lesion (Raney clips were used), but due to the low preoperative hemoglobin value, a single unit of packed red blood cells was transfused. The total blood collected in the drains was 30 cc. One year after surgery, the scars were normal and a slight cicatricial alopecia was detected (Figure 4).

Case 2 A 3-month-old female had two IHs of the temporoparietal area of the scalp. The tumors had no ulcération on the

Figure 1. Patient 1 (4-month-old female): preoperative condition of a giant hemangioma of the scalp.

Figure 2. The hemangioma after surgical excision.

' Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 17, No 2 (March/April), 2013: pp 106-113

107

Santecchia et al

Figure 3. The patient 10 days after reconstructive surgery using two rotational opposite scalp flaps.

surface (Figure 5). The lesions measured 4 X 3 and 3 X 2 cm, respectively, at the time of first observation. In 10 months, they reached 6 cm in size, and then a slow and progressive phase of regression began (Figure 6). When she was 4 years old, two areas of residual alopecia were detected in the areas of previous vascular anomalies. Skin expander positioning was performed under general anesthesia. The right amount of skin coverage was reached within 2 months (Figure 7). The second operation was performed, removing the hairless scalp and sliding coverage with advancement flaps (Figure 8). The postoperative period was uneventful. Drains were removed 3 days after surgery and stitches 10 days later. Particular attention was paid to the flaps to avoid disruption of the overall orientation of the hair.

Figure 4. Postoperative condition 1 year after surgery. There is slight residual scar tissue on the scalp.

Skin closure was performed under general anesthesia by direct approximation (Figure 10). Obviously, we needed to orient the incisions to be tensionless so that damage to the hair follicles was minimized. Blood loss during surgery was minimal, and no transfusion was required. Stitches were removed after 14 days. Case 4 A 3-month-old female presented with a giant IH of the frontoparietal scalp (Figure 11). The lesion measured 7 X 5 cm, with a round base of 6 cm in diameter. The patient's parents did not allow us to perform skin expander positioning, so scalp closure was achieved using multiple hatchet flaps under general anesthesia (Figure 12). No postoperative complications were detected.

Case 3 A 4-month-old female, weighing 5 kg at the time of surgery, presented with an IH of the temporoparietal area of the scalp. At the time of surgery, the lesion measured 4 X 3 cm (Figure 9). '108

Discussion In life- or function-threatening IH, systemic therapies are needed to minimize massive bleeding, hypovolemic shock, wide ulcération, or serious infections.^^"^^ The mainstay of

Canadian Dermatology Association I journal of Cutaneous Medicine and Surgery, Vol 17, No 2 (March/April), 2013: pp ¡06-113


r

Figure 5. Patient 2 (3-month-old female): two infantile hemangiomas of the temporoparietal area of the scalp.

treatment is oral propranolol, which was recently shown to have good results as an effective systemic therapy. Vincristine and interferon-a can also be used in certain cases or in conjunction with other drugs."^'""^ Systemic corticosteroids (prednisone, prednisolone) have been the preferred therapy for hemangiomas for the last 50 years.^^"^* The dose of prednisone (2-3 mg/kg/d) depends on the patient's clinical situation. The average length of treatment is 3 to 6 months.^^'^* Potential side effects are well known and include gastrointestinal upset

Figure 6. Appearance at 10 months: a slow and progressive phase of regression has begun.

Figure 7. Appearance after 2 months of skin expansion.

and irritability, weight gain, moon facies/cushingoid appearance, and hypertension.'^ Oral propranolol is the most recent systemic therapy for treating IH, with more predictable shrinkage of the hemangioma tissue even after the growth phase is pleted.^*'^^'^'' Since the initial report by Léautè-Labrèze and colleagues,^^ many studies''''^^'^' have confirmed the

Figure 8. Final appearance after removing the hairless scalp and sliding coverage with advancement flaps.

'\ff Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 17, No 2 (March/April), 2013: pp 106-113

109

Santecchia et al

Figure 9. Patient 3 (4-month-old female): infantile hemangioma of the temporoparietal area of the scalp.

Figure 11. Patient 4 (4-month-old female): giant infantile hemangioma of the frontoparietal scalp.

beneficial effects of propranolol in IH involving not only the skin but also the liver and airways.^'''^* Doses have typically been in the range of 1 to 3 mg/kg administered two to three times daily. The potential side effects of propranolol are hypoglycemia, hypotension, and bradycardia. An additional concern has been raised in infants affected by PHACE syndrome (posterior fossa malformations, hemangiomas, arterial anomalies, coarctation of the aorta and other cardiac defects, and eye abnormalities) with structural anomalies of the cerebrovasculature who could, at least theoretically, be at increased risk for stroke if treated with propranolol.^"'^' In all cases, it is advisable to consult a pédiatrie cardiologist to determine the safest regimen. Another possible indication might be as preparatory therapy for surgery that would

require a scar that is too long or in a difficult place to deal with surgically, such as the ear. Recombinant interferon-a (2a and 2b) has been used, particularly in complicated hemangiomas that have failed to respond to oral corticosteroids.^° However, due to the possible serious neurologic sequelae, we consider this a second- or even third-line treatment.^^ Vincristine can be used for the treatment of life- or function-threatening IH. It is administered intravenously at a dose of 1.0 to 1.5 mg/m^/wk.^^'^^ Recently, timolol maléate gel, a topical nonselective ß-blocker, has been reported as a potentially effective treatment for superficial IH, especially in the early proliferative phase.^^^^ Parents are often afraid of increased risk of anesthesia during the neonatal period, so this is the foremost reason for delaying operation. As evidenced by Harris and

Figure 10. Skin closure by direct approximation.

Figure 12. Scalp closure by multiple hatchet flaps.

lio

Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 17, No 2 (March/April), 2013: pp 106-113

Early Excision of Hemangiomas

colleagues, pédiatrie anesthetic and intensive care support are necessary within a specialized center, and close postoperative monitoring is required, paying attention to the nasal airways.^^ The authors, however, did not find a higher neonatal anesthesia risk. From a surgical perspective, early excision of a giant IH of the scalp is a safe procedure if particular attention is paid to normal hemoglobin values, positioning the patient with the head higher than the trunk, incision in normal tissue, and excision in the avascular supraperiosteal plane.^^'^^'^' In this way, blood loss will be minimal, and patient will not face severe intra- or postoperative Preoperative screening should not include routine computed tomography unless there is a suspicion of intracranial vascular connections, as for lesions of the Ulcération or hemodynamic instability due to a giant IH can lead the pediatrician to request a surgical opinion. In most cases, large scalp hemangiomas, although not immediately life-threatening, potentially can be as they tear with huge blood loss. Other lesions can completely distort the anterior hairline or, due to the involution process, can result in a large zone of alopecia. Giant IHs extending into the parietal region can determine bone alterations instead, consisting of aural anatomy because of growing forces here.'*" However, we trust in early excision of large hemangiomas of the scalp because the involution itself always develops a fibrofatty tissue with thin/atrophic dermis, often without normal skin appendages. Obviously, the larger the exophytic growth of the hemangioma, the larger the chance of scarring. By planning and customizing the surgical approach early, we can achieve much more satisfactory aesthetic results. The second reason for an early surgical approach is the great elasticity and pliability of the newborn scalp as a consequence of the thin galeal layer. Closing a scalp defect by primary closure or with rotation/transposition flaps is easier in newborns, without the need for tissue expansion. Many IHs can be closed by direct approximation within 5 months of age, and only a few cases need flaps. These are easily mobilized, without traction and the risk of necrosis'*^"'*'* (see Figure 8 and Figure 9). Secondary intention healing or skin grafts are potential options to close large scalp defects.''^ However, the resultant alopecia and poor tissue match are undesirable. Granulation tissue itself takes several months to be reabsorbed and allow normal reepithelialization.

of the Scalp in Newborns

Tissue expanders^* and galeotomies'*^ (incisions made perpendicular to the direction of advancement through the galea) are well-known techniques, but complications are common. Tissue expansion requires previous surgery for expander positioning, multiple return clinic visits, and an unnatural body appearance for a long period of time. Additional risks of tissue infection or alopecia of the overlying tissue are related to the wrong implant shape and/or reservoir defects.'"' On the other hand, inappropriately performed galeotomies can lead to potential flap necrosis, too much bleeding or postoperative blood loss, and probably flap failure."*** However, skin expansion remains a viable solution for children older than 3 years or in cases of huge lesions in which flap reconstruction is less appropriate and not advisable.'*'^ Purse-string closure is another option for treating excisional defects."'" The benefits include minimizing the final scar size; however, the potential risks of this closure technique include open areas that must heal secondarily, an initially very unpleasant appearance of pleated skin, and a concrete risk of secondary scar revisions.^^

Conclusions Closing large scalp defects with a combination of local flaps is an excellent option, as shown in our case series. With just one early operation, it is possible to be lesion free, minimizing the aesthetic sequelae, reducing the psychological hardships of parents and relatives, and removing the patient's anxiety and apprehension in social relationships once and for all.

Acknowledgment Financial disclosure of authors and reviewers: None reported. References 1. Enjolras O, Wassef M, Chapot R. Color atlas of vascular tumors and vascular malformations. Paris: Cambridge University Press; 2007. 2. Smolinski K, Yan AC. Hemangiomas of infancy: clinical and biological characteristics. Clin Pediatr 2005;44:747-66, doi:10.1177/ 000992280504400902. 3. Haggstrom AN, Lammer EJ, Schneider RA, et al. Patterns of infantile hemangiomas: new clues to hemangioma pathogenesis and embryonic facial development. Pediatrics 2006; 117:698-703, doi: 10.1542/peds.2005-1092. 4. Waner M, North P, Scherer KA, et al. The non-random distribution of facial hemangiomas. Arch Dermatol 2003;139: 869-75, doi: 10.1001 /archderm. 139.7.869.

' Canadian Dermatology Association I Journal of Cutaneous Mediane and Surgery, Vol 17, No 2 (March/April), 2013: pp 106-113

1 1

Santecchia et al

5. Hand JL, Frieden IJ. Vascular birthmarks of infancy: resolving nosologie confusion. Am J Med Genet 2002;108:257-64, doi:10.1002/ajmg.l0161. 6. Wassef M, Enjolras O. Les malformations vasculaires superficielles: classification et histopathologie. Ann Pathol 1999;19:253-64. 7. Gampper TJ, Morgan RF. Vascular anomalies: hemangiomas. Plast Reconstr Surg 2002;l 10:572-85, doi: 10.1097/00006534-20020800000032. 8. Chiller KG, Passaro D, Frieden IJ. Hemangiomas of infancy: clinical characteristic, morphologic subtypes, and their relationship to race, ethnicity, and sex. Arch Dermatol 2002;138:1567-76, doi:10.1001/archderm.l38.12.1567. 9. Garzón MC, Enjolras O, Frieden IJ. Vascular tumors and vascular malformations: evidence for an association. J Am Acad Dermatol 2000;42:275-9. 10. Dethlefsen SM, Mulliken JB, Glowacki J. An ultrastructural study of mast cells interactions in hemangiomas. Ultrastruct Pathol 1986; 10:175, doi:10.3109/01913128609014593. 11. Mulliken JB. Vascular malformations of the head and neck. In: Mulliken JB, Young AE, editors. Vascular birthmarks: hemangiomas and malformations. Philadelphia: WB Saunders; 1988. p. 301-42. 12. Finn MC, Glowacki J, Mulliken JB. Congenital vascular lesions: clinical application of a new classification. J Pediatr Surg 1983;18: 894, doi:10.1016/S0022-3468(83)80043-8. 13. Enjolras O, Mulliken JB. Vascular tumors and vascular malformations (new issues). Adv Dermatol 1997;13:375-423. 14. Marier JJ, Fishman SJ, Kilroy SM, et al. Increased expression of urinary matrix metalloproteinases parallels the extent and activity of vascular anomalies. Pediatrics 2005;l 16:38^5, doi:10.1542/ peds.2004-1518. 15. Chiller KG, Frieden IJ, Arbiser JL. Molecular pathogenesis of vascular anomalies. Classification into three categories based upon clinical and biochemical characteristics. Lymphat Res Biol 2003; 1: 267-82, doi:10.1089/153968503322758076. 16. Cohen MM. Vasculogenesis, angiogenesis, hemangiomas and vascular malformations. Am J Med Genet 2002;108:265-74, doi:10.1002/ajmg.l0260. 17. Beck DO, Gosain AK. The presentation and management of hemangiomas. Plast Reconstr Surg 2008;123:181-91, doi:10.1097/ PRS.0b013e3181a65c59. 18. Rossler J, Wehl G, Niemeyer CM. Evaluating systemic prednisone therapy for proliferating hemangioma in infancy. Eur J Pediatr 2008;167:813-5, doi:10.1007/s00431-007-0561-5. 19. Bennett ML, Fleischer AB, Chamlin SL, et al. Oral corticosteroid use is effective for cutaneous hemangiomas: an evidence-based evaluation. Arch Dermatol 2001;137:1208-13. 20. Bartoshesky LE, Bull M, Feingold M. Corticosteroid treatment of cutaneous hemangiomas: how effective? A report on 24 children. Clin Pediatr 1978; 17:2625-38, doi:10.1177/000992287801700807. 21. Cohen SR, Wang CI. Steroid treatment of hemangioma of the head and neck in children. Ann Otol Rhinol Laryngol 1972;81:584-90. 22. Taban M, Goldberg RA. Propranolol for orbital hemangioma. Ophthalmology 2010;117:195-5:e4, doi:10.1016/j.ophtha.2009.08.04a 23. Marsciani A, PericoH R, Alaggio R, et al. Massive response of severe infantile hepatic hemangioma to propranolol. Pediatr Blood Cancer 2010;54:176, doi:10.1002/pbc.22262. 24. Frieden IJ, Drolet BA. Propranolol for infantile hemangiomas: promise, peril, pathogenesis. Pediatr Dermatol 2009;26:642^, doi: 10.111 l/j. 1525- 1470.2009.00977.x.

'112

25. Rossler J, Schill T, Bahr A, et al. Propranolol for proliferating infantile haemangioma is superior to corticosteroid therapy—a retrospective, single centre study. J Eur Acad Dermatol Venereol 2011 Oct 31. DOI: 10.1111/j.l468-3083.2011.04314.x. 26. Michel J, Patural H. Response to oral propranolol therapy for ulcerated hemangiomas in infancy. Arch Pediatr 2009; 16:1565—8, doi:10.1016/j.arcped.2009.09.008. 27. Léautè-Labrèze C, Dumas de la Roque E, Hubiche T, et al. Propranolol for severe hemangiomas of infancy. N Engl J Med 2008;358:2649-51, doi: 10.1056/NEJMcO708819. 28. Siegfried EC, Keenan WJ, Al-Jureidini S. More on propranolol for hemangiomas of infancy. N Engl J Med 2008;359:2846-7, doi:10.1056/NEJMc086443. 29. Hoyoux C. Vincristine treatment for management of alarming hemangiomas in infancy. Rev Med Liege 2008;63:14—7. 30. BrandUng-Bennett HA, Metry DW, et al. Infantile hemangiomas with unusually prolonged growth fase: a case series. Arch Dermatol 2008;144:1632-7, doi:10.1001/archderm.l44.12.1632. 31. Glotzbach JP, Levi B, Wong VW, et al. The basic science of vascular biology: implications for the practicing surgeon. Plast Reconstr Surg 2010;126:1528, doi:10.1097/PRS.0b013e3181ef8ccf. 32. Barlow CF, Priebe CJ, Mulliken JB, et al. Spastic diplegia as a complication of interferon alfa-2a treatment of hemangiomas of infancy. J Pediatr 1998; 132:527-30, doi:10.1016/S0022-3476(98) 70034-4. 33. Fawcett SL, Grant I, Hall PN, et al. Vincristine as a treatment for a large hemangioma threathening vital functions. Br J Plast Surg 2004;57:168-71, doi:10.1016/j.bjps.2003.11.003. 34. Chakklttakandiyü A, Phillips R, Frieden IJ, et al. Timolol maléate 0.5% or 0.1% gel-forming solution for infantile hemangiomas: a retrospective, multicenter, cohort study. Pediatr Dermatol 2012;29: 28-31, doi:10.1111/j.l525-1470.2011.01664.x. 35. Khunger N, Pahwa M. Dramatic response to topical timolol lotion of a large hemifacial infantile haemangioma associated with PHACE syndrome. Br J Dermatol 2011;164:886-8, doi:10.1111/ J.1365-2133.2010.10177.X. 36. Pope E, Chakkittakandiyil A. Topical timolol gel for infantile hemangiomas: a puot study. Arch Dermatol 2010;146:564—5, doi: 10.1001 /archdermatol.2010.67. 37. Harris PA, Oliver NK, Slater P, et al. Safety of neonatal cleft Hp repair. J Plast Surg Hand Surg 2010;44:231-6, doi:10.3109/ 02844311.2010.499666. 38. Zheng JW, Wang YA, Zhou GY, et al. Head and neck hemangiomas: how and when to treat. Shangai Kou Qiang Yi Xue 2007;16:337—42. 39. Adouani A, BouguHa J, Abdelali MA, et al. Place du traitement chirurgical précoce dans les hémangiomes périorificiels de la face. Ann Chir Plast Esthet 2008;53:435-40. 40. Spector JA, Blei F, Zide BM. Early surgical intervention for proliferating hemangiomas of the scalp: indications and outcomes. Plast Reconstr Surg 2007;1097:457-62. 41. Enjolras O, Riche MC, Merland JJ, Escande JP. Management of alarming hemangiomas in infancy: a review of 25 cases. Pediatrics 1990;85:491-8. 42. Dubois J, Garel L. Imaging and therapeutic approach of hemangiomas and vascular malformations in the pédiatrie age group. Pediatr Radiol 1999;29:879-93, doi:10.1007/s002470050718. 43. Grisey A, Roth P, Martin A, et al. Diagnostic prénatal et prise en charge d'un cas d'hémangiome congénital du cuir chevelu.

Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 17, No 2 (March/April), 2013: pp W6-U3


44.

45.

46. 47.

J Gynecol Obstet Biol Reprod 2006;35:405-10, doi:10.1016/S03682315(06)76412-2. Picard A, Franchi G, Delbeque M, et al. La chirurgie du cuir chevelu de l'enfant: principes et particularities thérapeutiques. Rev Stom Chir MaxiUo-Faciale 2005;6:334-43, doi:10.1016/S00351768(05)86056-5. Mueller CK, Bader RD, Ewald C, et al. Scalp defect repair: a comparative analysis of different surgical techniques. Ann Plast Surg 2011 Jun 8. DOI:10.1097/SAP.0b013e318218f32a. Frechet P. Scalp extension. J Dermatol Surg Oncol 1993;19:616-22. Kazanjian VH. Repair of partial losses of the scalp. Plast Reconstr Surg 1953;12:325-34, doi: 10.1097/00006534-195311000-00003.

48. Barry RB, Lawrence CM, Langtry JA. The use of galeotomies to aid the closure of surgical defects on the forehead and scalp. Br J Dermatol 2009;160:875-7, doi:10.1111/i.l365-2133.2009.09053.x. 49. Hudson DA, Lazarus D, Süfen R. The use of serial tissue expansion in pédiatrie plastic surgery. Ann Plast Surg 2000;45:589-93, doi: 10.1097/00000637-200045060-00003. 50. Donelan MB, Garcia JA. Purse-string closure of scalp defects following tissue expansion: an eifeaive aesthetic alternative. J Plast Reconstr Aesthet Surg 2008;61:419-22, doi:10.1016/i.b¡ps.2007.02.002. 51. Wu JK, Rohde CH. Purse-string closure of hemangiomas: early results of a follow-up study. Ann Plast Surg 2009;62:581-5, doi:10.1097/SAP.0b013e31819fble2.

"m Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 17, No 2 (March/April), 2013: pp 106-113

113

Copyright of Journal of Cutaneous Medicine & Surgery is the property of Decker Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.