giant haemangiomas, scalp and face
A Rahoma. Giant Haemangiomas Of The Scalp And Face. The Internet Journal of Plastic Surgery. 2008 Volume 6 Number 1.
Haemangiomas often are threatening to life when they are presented in certain deeper tissues. They can cause morbidity in the orbit, bowel, liver, Lung or spleen. Often they casue severe haematuria if located in the kidney. In this report we dealt with one huge scalp and one big face haemangiomas. They needed special care during excising them and good preoperative investigations .
Haemangiomas are common benign vascular tumors. They are presented in any site including deep tissues as bones, muscles, tendons, liver and bowel mainly rectum, or stomach as arterio-venous malformations as Dieulafoy’s lesion and rectal Angiodysplasia. it may be a part of a syndrome or can be found as a sole lesion.
Large haemangiomas of the scalp, though uncommon, present unique challenges to the reconstructive surgeon. If not treated early, these lesions can result in large areas of alopecia, distortion of the hairline, or deformation of the ear.
Material and methods
In the year 2002, a- 45-years old Malay lady was presented to the Plastic Surgery Clinic, University Malaya Medical Center with a huge swelling on the right temporo-paieto-occipital regions of the scalp (Figure 1,2).
Physical examination revealed a compressible swelling with alternating areas of hard and soft consistency (Lamellated blood clots). The tumor measured 30 cm horizontally by 25 cm vertically. No defects in the underling bone could be felt.
Preoperative investigations: like X-ray for the skull did not reveal any bone defects and CT scan also confirmed no bone defects and no intracranial extension. No evidence of bone perforation or communication with the intra-cranial cavity. The patient was prepared by cross matching for 6 blood units and all preoperative investigations as coagulation profile and haemoglobin concentration. Surgery was performed for excision of the vascular tumour by simple controlled excision with three assistants and operation theatre nurse. Staged controlled ligation of feeding blood vessels was done starting with the superficial temporal artery, then other distal branches from contra lateral side. Distal and proximal ends of vessels were securely clamped and ligated. The periosteum was left intact. After excision of the tumor and hemostasis the raw area was grafted by a split thickness skin graft.
The excised mass was sent for histopathology examination, which revealed no malignant changes.
The result was satisfactory and the wound healed well. The patient was prepared for later reconstruction of the scalp by expanding the normal scalp and then covering of the bald area after graft excision. (Figure 3). Fig 4 shows the excised tumor.
Case [II] data
In the year 1997, a 5-year old Saudi boy was presented to the plastic surgery clinic in King Khalid Civilian Hospital in Tabuk region with a hug swelling in the left side of the face figure (5,6). The father was confirmed to have chronic myeloid leukemia and he was under chemotherapy for several months. The swelling was circumscribed of 7 cm in diameter causing distortion of the nose which was deviated slightly to the right. It was cystic and compressible but not pulsating, and not reducible.
It was diagnosed by the vascular surgeon and referred to plastic surgery clinic which prepared by making all necessary investigations, complete blood count, coagulation screening, and cross matching for 4 fresh packed red cells and other four units of fresh frozen plasma.
Surgery was done through a naso-labial incision and careful dissection of the swelling after devascularization. The surgery team was composed of the author and other two assistants with scrub nurse.
After excision of the tumor the space was closed in layers with good hemostasis. The patient did not bleed and there was no need for any transfusion.
Wound healed over few days and the patient was sent home 2 days after surgery. He was followed up in the outpatient clinic for two weeks.
Figure (7) shows complete healing and symmetry of the face few months after surgery where he was brought for another surgery for tonsillectomy.
Haemangiomas are common benign vascular tumors. They can occur in any tissue especially in the skin and scalp, where they are seen at birth or within the first several years of life. The deeper soft tissue haemangiomas may involve any soft tissue, such as muscle, tendon, connective tissue, fatty tissue, synovium, or bone . They are classified histologically into capillary, cavernous, venous and arteriovenous. A capillary haemangioma is composed solely of capillaries. If the capillaries are widely dilated, the tumor is called a cavernous haemangioma. If a vascular tumor has thicker walls and contains smooth muscle cells, it is called a venous haemangioma. The arteriovenous haemangioma is composed of abnormal communications of arteries and veins from persistence of the fetal capillary bed. 
The haemangiomas manifest as soft tissue masses may be described as a poorly circumscribed, localized or diffuse swelling. These tumors vary in size from less than 4 cm to over 20 cm, but most are less than 9 cm in diameter. Plain radiographs may reveal soft tissue mass with calcifications. Phleboliths are rounded calcified masses frequently demonstrating a laminated structure inside the tumor. Occasionally, metaplastic ossification may be found in haemangiomas, and this is the third type of calcification. Non-enhanced CT and ultrasound can be used to dagnose deeper lesions including retroperitoneal. Haemangiomas are commonly seen in the extremities, neck, face and sometimes scalp. Cavernous haemangiomas are reported to be in different deep tissues including CNS. Recorded cerebral, spinal types which can cause sudden symptoms when rupture to give a haematomas. Cavernous hemangiomas are common intra-orbital tumors found in adults can manifest as a painless, progressively proptotic eye. Most of these tumefactions are exceedingly unilateral. Bilateral cases have been reported but are rare. The patient may have such cutanoeuos haemangiomas with other deeper ones.
Scalp haemangiomas often erode deeply the bone of skull and may present withan intracainial extension. 
All patients with cutaneous haemangiomas need to be screened for any deeper ones.
Haemangiomas may manifest early in life if they are superficial, or presented with complications later if they are deep. Surgery requires special skills to control and secure feeding blood vessels when try to resect.
Special care should be given for deep haemangiomas as they may present inside narrow spaces and in critical anatomical regions. All patients with cutaneous haemangiomas need to be screened for deeper ones.