Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 257 - файл
.pdf
Incidence: 0.3% of newborns. Most common
location is on the face.
3:1 female:male ratio.
Treatment
Observation is appropriate although important
to note
Lesions do not regress.
Can progress to “cobblestone”
appearance.
Pulsed dye laser
Typically requires multiple treatments.
70%-80% of patients respond with
decrease in pigmentation of the lesion.
More favorable results on the lateral face
as compared to midface, trunk, and
extremities.
Surgical excision: must be used for
management of soft tissue/skeletal
hypertrophy to address contour deformity
Venous malformation → low-flow lesion
Appearance: bluish, soft, compressible lesion,
which swells on dependent positioning; cluster of
thin-walled veins with smooth muscle surrounding,
many veins lack valves.
Changes in hormone levels can cause
enlargement.
Must monitor for coagulopathy: Always perform
coagulation profile studies as patients can develop
Disseminated intravascular coagulation.
Treatment
Observation
Compression therapy
Useful for pain and edema
Minimizes phlebothrombosis
Sclerotherapy: most effective if performed on
small cutaneous lesions using ethanol
https://t.me/medicina_free
Side effects: blistering, full-thickness
necrosis, neural deficits.
Make sure no important neural structures
are nearby if using ethanol sclerotherapy.
Surgical excision: performed most
commonly after sclerotherapy to improve
cosmetic appearance or remove mass tissue
to optimize function
Lymphatic malformation → low-flow lesion
Appearance: Anomalous lymphatic channels filled
with lymphatic tissue, which may be clustered into
vesicles.
Further classified as microcystic vs
macrocystic
Most common cause of macroglossia,
macrocheilia in children. Can also cause facial
asymmetry, distortion of surrounding tissue, soft
tissue/skeletal hypertrophy.
Treatment
Observation
Intralesional bleeding can be treated with
NSAIDs for pain control and rest.
Antibiotics indicated for cellulitis/other
infections.
Sclerotherapy (mainstay treatment)
Lesion is instilled with ethanol,
doxycycline, sodium tetradecyl sulfate.
Can be used effectively when macrocysts
are present (large volumes of lymphatic
fluid without small loculations as seen on
US or MRI). Microcystic disease, in which
many small loculations are present, is not
readily amenable to sclerotherapy.
Surgical resection
Direct excision can be effective but
carries a high likelihood of significant
complications.
https://t.me/medicina_free
Suction-assisted lipectomy has been
used to debulk lesions.
Complications often include the following
Cellulitis
Hematoma
Persistent drainage
Recurrence of vesicular lesions
Need for skin graft
depending on extent of excision
Arteriovenous malformation → high-flow lesion
Appearance: abnormal connections between
arteries and veins
Arteries have thick, fibromuscular veins with
prominent elastic lamina and stroma.
Veins are “arterialized” and hyperplastic.
Clinical features
Intracranial AVMs are more common than
extracranial AVMs.
Always present at birth, but NOT always
apparent. Puberty and trauma can stimulate
enlargement.
Schobinger stages of development
Stage 1 Quiescence—bluish discoloration
and warmth of skin with AV shunting
noted on Doppler examinations
Stage 2 Expansion—AVM begins to
enlarge and demonstrates bruit, thrill, and
pulsations
Stage 3 Destruction—begins to bleed,
cause pain, and destroy surrounding
tissue
Stage 4 Decompensation—persistent
destruction to surrounding tissue with
cardiac failure
Associated syndromes
Bannayan-Zonana syndrome: AVM +
microcephaly + lipomas
https://t.me/medicina_free
Riley-Smith syndrome: AVM + microcephaly +
pseudopapilledema
Osler-Weber-Rendu disease
Multiple cutaneous telangiectasias with
visceral AVMs (most commonly in lungs,
liver, brain)
Often presents as frequent nosebleeds
Treatment
Observation: used for small, clinically stable,
asymptomatic lesions
Embolization with surgical excision
Used for stage 3-4 lesions.
Ligation/embolization of proximal feeding
vessels must never be performed. Can
cause recruitment of nearby vessels to
exacerbate AVM.
Wide local excision is necessary to
minimize recurrence rates.
Reconstruction with flaps is often
necessary after excision.
Malformations associated with other anomalies
Klippel-Trenaunay syndrome: capillary and/or lymphatic
venous malformation (patchy port-wine stain on an
extremity); skeletal and soft tissue hypertrophy
(axial/transverse) of an extremity
Parkes Weber syndrome: capillary malformation + AVM
with associated soft tissue/skeletal hypertrophy
Servelle-Martorell syndrome: similar to Klippel-Trenaunay
syndrome with limb hypertrophy secondary to venous
malformation, occasionally arterial, with skeletal hypoplasia
Sturge-Weber syndrome
Port-wine stain (capillary malformation) in V1/V2
distribution of the face
Leptomeningeal malformations
Seizures
Contralateral hemiplegia
Warrants MRI of the head
https://t.me/medicina_free
Developmental delay
Glaucoma and retinal detachment: screen using
biannual fundoscopic and tonometry examinations for
1-3 years, then yearly examinations
Maffucci syndrome: enchondromatosis with multiple
cutaneous hemangiomas
Cobb syndrome: capillary malformation localized to the
trunk; associated with spinal AVM
Combined: involves more than two types of vascular
malformation in one lesion
PEARLS
1. The lymphatic system is collects and transports fluid back to the
venous system, transports antigens and immune cells and
transports fat, lipids and chylomicrons from the GI tract.
2. Imaging with lymphoscintigraphy, MR lymphangiography and
ICG lymphography are important to staging, monitoring and
surgical planning.
3. Surgical success in management of lymphedema is dependent
on patient selection; determining if the patient has edema,
adipose deposition and/or functional lymphatics will aid in
selection of a physiologic or excisional procedure.
4. Determining if the vascular anomaly was present at birth (eg
vascular malformation) vs present after birth (eg hemangioma)
is key to diagnosis.
QUESTIONS YOU WILL BE ASKED
1. What is the most common cause of secondary lymphedema in
developing and developed countries?
In the developing world, it is filariasis caused by W bancrofti
(120 million cases). In the developed world, it is the result of
cancer treatment, specially lymph node dissection.
https://t.me/medicina_free
1.
2.
3.
4.
5.
2. What is the difference between the timing of presentation of
hemangiomas vs vascular malformations?
Vascular malformations are present at birth and continue to
grow as the child ages. They do not involute. Infantile
hemangiomas present after birth and continue to grow until
approximately 1 year of age after which time they often begin to
involute. The exception is congenital hemangiomas, which are
present at birth.
3. What are the indications to perform operative intervention on a
hemangioma?
(1) Obstruction or deformation of critical structures such as the
eye or airway. (2) Bleeding or ulceration that is unresponsive to
pharmacologic management. (3) Easily excisable area with
potential for an acceptable scar.
4. What nerve distribution do port-wine stains usually affect?
V1 and V2 branches of cranial nerve V
5. Name the different syndromes associated with hemangiomas
and vascular malformations along with associated signs.
See sections on pages 7, 10 and 11.
Recommended Readings
Couto RA, Maclellan RA, Zurakowski D, Greene AK. Infantile hemangioma.
Plast Reconstr Surg. 2012;130(3):619‐624.
doi:10.1097/PRS.0b013e31825dc129
Cox JA, Bartlett E, Lee EI. Vascular malformations: a review. Semin Plast Surg.
2014;28(2):58‐63. doi:10.1055/s-0034-1376263
Kung T, Champaneria M, Maki J, Neligan P. Current concepts in the surgical
management of lymphedema. Plast Reconstr Surg. 2017;139(4):1003e‐1013e.
doi:10.1097/PRS.0000000000003218
Rockson SG, Keeley V, Kilbreath S, Szuba A, Towers A. Cancer-associated
secondary lymphoedema. Nat Rev Dis Primers. 2019;5(1):22.
doi:10.1038/s41572-019-0072-5
Schaverien M, Coroneos C. Surgical treatment of lymphedema. Plast Reconstr
Surg. 2019;144(3):738‐758. doi:10.1097/PRS.0000000000005993
https://t.me/medicina_free
*
Denotes common in-service examination topics.
https://t.me/medicina_free
9
Lasers in Plastic Surgery
Naomi Briones
OVERVIEW
DEFINITIONS
Laser is an acronym for light amplification by stimulated
emission of radiation
Light Characteristics
Monochromaticity: light emitted is of a well-defined
wavelength.
Coherence: light waves are in phase temporally and
spatially.
Collimation: light waves travel in parallel without spreading.
There are four outcomes when laser light hits the skin
Reflection: character of target material’s surface. No
biological effect.
Absorption: light hits appropriate target (chromophore) and
transforms to heat through tissue interaction.
Transmission: light passes through tissue unaltered.
Scattering: incoming beam is spread in all directions; limits
depth of penetration.
Lasers are selected based on indication and the target
chromophore
Chromophores (eg, pigment, water, melanin,
hemoglobin) absorb the light, and heat is produced to
create the clinical effect.
https://t.me/medicina_free
If no heat is produced, no clinical effect. If excess heat
is produced, scarring can result from thermal injury.
For example, darker skin has a greater amount of
melanin and greater chromophore concentration.
Therefore, it is more likely to generate heat and
thermal damage with laser therapy compared with
lighter skin tones.
PROPERTIES
Key Parameters
Wavelength: laser dependent and determined by target
chromophore.
Fluence (J/cm2): amount of energy delivered per unit area.
Spot size: diameter of surface beam. Increase for deeper
penetration.
Pulse width (duration): how long the tissue is exposed to
the laser.
Cooling: extracts heat at skin surface and minimizes
epidermal damage.
Lasers can be delivered in several modes
Continuous mode: a constant, uninterrupted beam (eg,
argon lasers).
Quasicontinuous: rapid succession of low-energy pulses;
behaves like continuous mode (eg, 1064 nm ND:YAG)
Pulsed mode (Hz): single or train of pulses (eg, pulsed dye
laser [PDL])
Q-switched mode: high-power, short-pulse duration (eg, Qswitched ruby)
LASER PHYSICS
All lasers have four essential parts
A medium (gas, liquid, solid, semiconductor), through which
energy excites atoms.
Power supply or a source of energy to excite the medium.
https://t.me/medicina_free
Mirrors for amplification.
Delivery system to deliver light to the target.
Selective photothermolysis is the primary principle behind
laser surgery
Wavelength must penetrate to depth of skin target and
correspond to absorption by chromophores within that
target.
The time of laser exposure (pulse duration) is shorter or
equal to thermal relaxation time (cooling time) of the
chromophore.
Thermal relaxation time (proportional to the square of
the target diameter): time required for the heated tissue
to lose half of its heat.
If a pulse duration is longer than the thermal relaxation
time, heat is not confined to target structure and can
damage surrounding tissue.
LASER APPLICATIONS (TABLE 9-1)
Table 9-1 Common Applications of Lasers in Plastic Surgery
https://t.me/medicina_free
Соседние файлы в папке @xirurgi_2025