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Case 3

 

 

“Treatment of a Venus Lake Hemangioma”

David Goteiner DDS, FACD, FICD 

Introduction

Acquired venous lake hemangioma (VLH), also known as “Phlebectases,” is a generally solitary, soft, compressible, superficial or mixed superficial and deep, subcutaneous, dark blue to violet, 0.2cm to 1cm papule commonly found on sun-exposed surfaces of the vermilion border of the lip, face, and ears. Though these lesions may resemble nodular melanoma, the lack of induration, slow growth, and lightening appearance upon diascopy suggest against it, and indicate a vascular lesion. Additionally, lack of pulsation distinguishes this lesion of the lower lip from a tortuous segment of the inferior labial artery. Lesions generally occur between the fourth and fifth decade but can appear among the elderly. Histolopathologically, the vasculature is characterized by various degrees of ectasia. VLH may present with as a localized segmental and diffuse type, with the latter associated with fewer complications. The cause is unknown. It is thought to be associated with sun exposure, leading to a dilated blood-filled vascular channel lined with a single layer of flattened endothelial cells and a wall of fibrous tissue filled with red blood cells in the papillary dermis.1-5

Common locations include the lip, oral mucosa and facial and neck skin.  They have a tendency to enlarge with time and patients can present with a history of bleeding, trauma or cosmetic concerns.

VLH has been treated by a variety of methods over the years.  In the 1960’s lasers of various wavelengths became a modality of therapy. This was based on the principle of selective photothermolysis.6  It soon became clear that dwell time, especially if it was continuous wave was important in avoiding scarring and hypopigmentation.  Today there are various accepted laser modalities such as Pulsed Diode , Er:YAG, and  Nd:YAG.  This case report will deal with  Nd:YAG because it can extend deeper into the tissue.5 

Three aspects of Nd:YAG are intriguing.  First the 1,064 nm wavelength is more penetrating and so it can treat the larger lesions.  Secondly, hemoglobin is not the ideal chromataphore for this wavelength (530-600 nm is better) so the 1064 light can travel further in blood filled spaces before being completely absorbed.   Finally, longer pulse durations tend to be more damaging to larger vessels that shed heat poorly while sparing smaller adjacent tissues that lose heat faster and so are spared injury.7-9

Case Report

At a routine periodontal maintenance visit, our 72 year old patient shared that her dermatologist did not respond to her request about the VLH elimination for cosmetic reasons. After explaining the recent changes in therapy, she asked us to call her dermatologist. After a short conversation, he approved.

On the day of therapy her medical history was reviewed and found within normal limits. Blood pressure was 140/70 RAS. Soft tissue examination was unremarkable. The lesion, papular in nature, measured 0.8 by 1 cm and blanched when compressed (Fig 1). She declined to have the ipsilateral lesion treated. The mucosa opposite #27 was anaesthetized with ½ ampule of Marcaine SeptocaineTM 4% 1/200,000 being sure not to approach the lesion. A Periolase MVP-7 Nd:YAG pulsed laser was set at 100mSec, 3.6 Watts and 20 Hz. The quartz tip was kept approximately 5-10mm above the lesion and until it had turned white after which it was moved (Fig 2). Joule expenditure was 303. Bio-stimulation was not carried out. Postoperative instructions were given and acetaminophen 200-600mg Q3-5H was prescribed. Our patient tolerated the procedure well and when called that evening she claimed to be quite comfortable.

Her first postoperative visit was 7 days later.  A small scab was present and our patient claimed to be quite comfortable.  Three weeks post treatment the area appeared healthy and fully healed.  Comparison to the untreated VLH lesion shows it to be a cosmetic success (Fig4).

Conclusion

The use of a pulsed Nd:YAG laser to treat both superficial and deep VLH lesions is safe, and rewarding for both the patient and the clinician.

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Bibliography

  1. James W, Berger T, Elston D. Andrews’ Diseases of the Skin: Clinical Dermatology 10th ed. 2005. Saunders. Pg. 588. ISBN 0-7216-2921-0.
  2. Habif, TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 2004. Mosby, Inc. 2004. Pg. 825. ISBN 0-323-01319-8.
  3. Sauer G. Manual of Skin Diseases. 1985. Lippincott. Pg. 315. ISBN 0-397-50668-6.
  4. Rapini RP. Bolognia JL, Jorizzo, JL. Dermatology. 2007. Mosby. p. 1620. ISBN 1-4160-2999-0. 
  5. Anderson RR, Astner S. Treating vasular lesions. 2005. Dermatol Surg. 18:267-71. ISSN 1396-0296
  6. Anderson RR, Parrish JA. Microvasculature can be selectively damaged using dye lasers. A basic theory and experimental evidence in human skin. Lasers Surg Med. 1981. 1:263-76. 
  7. Bekhor PS. Long-pulsed Nd:YAG laser treatment of venous lakes: report of a series of 34 cases. 2006. Dermatol Surg. 32:1151–4. doi:10.1111/j.1524-4725.2006.32253.x. PMID 16970696. 
  8. Aihara H, Tanino R, Osada M, OsamuraRY. Attempts to obtain greater dermal depth of vascular injury using dye-enhanced laser technique: a new approach. 1996. Laser Surg Med. 18:260-4.
  9. Groot D, Rao J, Jjohnston P, Nakasui T. Algorithm for using a long-pulsed Nd:YAG laser in the treatment of deep cutaneous vascular lesions. 2003. 29:35-42.

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