We thank the authors for their interest in our study1 and for their valuable comments. Proper diagnosis of vascular anomalies is critical. Clinical, imaging, and laboratory information must be gathered together, and biopsy specimens must be collected if any suspicion remains.
The use of an updated and multidisciplinary diagnostic classification is of paramount importance. The classification currently accepted worldwide was proposed by the International Society for the Study of Vascular Anomalies in 2014 and should be used for this purpose.2 Nevertheless, it is very important to consider the differential diagnosis with other soft-tissue tumors that are not vascular in origin but may mimic their clinical presentation, including malignant tumors.
Proper diagnosis of infantile hemangioma can be made in most cases by clinical findings and imaging.3 The systematic execution of biopsy increases morbidity, and there must be clear diagnostic uncertainty for its indication.
The philosophy of multimodal treatment is currently the best approach. As discussed in our study, the indications for surgery are also part of this proposal. Early surgical treatment during the proliferative phase must always be based on functional purposes.4 Surgical procedures to improve vital functions, termed emergency indications, were more common in segmental and complicated lesions. In these situations, the algorithm of a direct approach and partial or subtotal resection is recommended, because the purpose is mainly to improve function instead of removing the entire lesion. In contrast, for patients with growth-related deformities, our proposal was total resection under a direct or indirect approach to allow adequate positioning of anatomical structures and proper facial development.1,5,6 Elective planning of the procedure offers the surgeon and the patient the greatest opportunity to reach the best outcome.
The authors have no financial interest to declare in relation to the content of this communication. There are no financial disclosures associated with the present study.
Dov C. Goldenberg, M.D., Ph.D.
Patricia Y. Hiraki, M.D.
Tatiana de Moura, M.D., M.Sc.
Division of Plastic Surgery
Andrea Koga, M.D.
Department of General Surgery
Rolf Gemperli, M.D., Ph.D.
Division of Plastic Surgery Hospital das Clinicas
University of São Paulo Medical School
São Paulo, Brazil
1. Goldenberg DC, Hiraki PY, Marques TM, Koga A, Gemperli R. Surgical treatment of facial infantile hemangiomas: An analysis based on tumor characteristics and outcomes. Plast Reconstr Surg. 2016;137:12211231.
2. Wassef M, Blei F, Adams D, et al.; ISSVA Board and Scientific Committee. Vascular anomalies classification: Recommendations from the International Society for the Study of Vascular Anomalies. Pediatrics 2015;136:e203e214.
3. Chiller KG, Passaro D, Frieden IJ. Hemangiomas of infancy: Clinical characteristics, morphologic subtypes, and their relationship to race, ethnicity, and sex. Arch Dermatol. 2002;138:15671576.
4. Watanabe S, Takagi S, Sato Y, Hosaka Y. Early surgical intervention for Japanese children with infantile hemangioma of the craniofacial region. J Craniofac Surg. 2009;20(Suppl 1):707709.
5. Hamou C, Diner PA, Dalmonte P, et al. Nasal tip haemangiomas: Guidelines for an early surgical approach. J Plast Reconstr Aesthet Surg. 2010;63:934939.
6. Dégardin-Capon N, Martinot-Duquennoy V, Patenotre P, Brevière GM, Piette F, Pellerin P. Early surgical treatment of cutaneous hemangiomas (in French). Ann Chir Plast Esthet. 2006;51:321329.
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