The Northeastern Society of Plastic Surgeons

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Combined Surgery and Intraoperative Sclerotherapy for Vascular Malformations of the Head/Neck: the Hybrid Approach
Rachel Gray1, Rafael Ortiz, MD2, Nicholas Bastidas, MD1.
1Hofstra Northwell School of Medicine, Hempstead, NY, USA, 2Northwell Health System, Hempstead, NY, USA.

Combined Surgery and Intraoperative Sclerotherapy for Vascular Malformations of the Head and Neck: the Hybrid Approach
Vascular Malformations (VMs) of the head and neck can lead to aesthetic problems as well as cranial nerve damage, airway compromise, and vision loss. Large VMs are typically managed surgically, with sclerotherapy or embolization performed in the perioperative period to decrease the risk of excessive blood loss and minimize the size of the VM. However, this initial treatment is frequently insufficient leading to excessive blood loss intraoperatively, poorer margin visualization for the surgeon, and decreased likelihood of complete resection. As a result resections of large VMs are often performed in a multi-stage approach. This paper introduces a new hybrid approach for the management of head and neck VMs.
Three patients with extensive vascular malformations in the facial region were selected for resection with the hybrid approach. The hybrid approach entailed the use of an Endovascular Operating Room where a neuro-endovascular surgeon performs embolization or sclerotherapy intra-operatively as needed in conjunction with surgical excision. Demographics including age and size of VM, as well as operative data including percent resection, estimated blood loss, and blood transfusion requirements were recorded (Table 1).
The hybrid approach improved visualization leading to complete resection in one patient, and nearly complete resections (70% and 90%) in the other patients (Table 1). The technique also helped minimize blood loss as only the youngest patient (23 months old) required a blood transfusion.
Table 1. Patient Demographic and Operative Data

Patient IDAgeSize of VMResection (%)Estimated Blood Loss (mL)Blood Transfusion (mL)
15yr6.0 x 3.4 cm90220--
223 mo.6.1 x 2.7 cm70300200
319 yr.5.5 x 4.0 cm100200--

Implications of these findings include the transition from a multi-staged approach for large VMs to a single stage approach. Additionally, decreases in blood loss may allow for the development and use of minimal access techniques, leading to a decrease in visible scarring for patients. We suggest the consideration of the hybrid approach for large head and neck VMs.

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