PURPOSE: In recent years several different protocols for the management of nasal tip hemangiomas have been proposed. Controversies in the treatment of these lesions include: (1) timing of intervention relative to the natural history of the lesion; (2) medical vs. surgical intervention; (3) surgical access using an open rhinoplasty approach vs. direct external incisons; (4) redraping/resection of the involved skin. The present report addresses a multidisciplinary approach to the treatment of hemangiomas of the nasal tip.

METHODS: A retrospective review was performed of all cases of nasal tip hemangiomas presenting to the Multidisciplinary Vascular Anomalies Clinic at the Children's Hospital of Wisconsin from 1999 to 2004. Parameters for review included onset age, symptoms, medical therapies utilized, age and status of lesion at time of surgery, outcome, and complications. Medical therapy consisted of oral steroids (prednisone) during the proliferative stages of the hemangioma followed by laser therapy (flashlamp pumped pulsed dye) through the proliferative and plateau phases. Surgical technique consisted of an open tip rhinoplasty approach with a mid-columellar and extended rim incisions. Excision of the hemangioma with associated fibrofatty tissue was performed followed by approximation of the splayed domes using transdomal sutures. Redundant skin from the nasal dome was then advanced caudally, at which point the skin was tailored and excess skin resected at the alar rims and distal columella. Our preference was to perform surgery during the post-involutional phase, but at parental request, surgery was done sooner in selected cases.

RESULTS: Seventeen patients were included in the study with a mean onset age of 1.7 months. To date, 8 patients have been treated medically (range 1.5-2 months), and 9 patients have been treated both medically and surgically. The medical cohort will undergo surgery on involution of their hemangioma. Oral prednisone was administered during the first year of life and an average of 2.3 laser treatments were performed using a pulsed dye laser after the first year until involution. Surgical resection has been performed on nine patients. At parental request, four of the nine patients had early surgical correction during the proliferative-plateau phases having a mean age of 1.6 years (range 1.5-2 years). Five of the nine patients had surgical correction in the post-involutional phase, having a mean age of 5.4 years (range 2.5-9 years). In the early surgical correction group, one child developed a hematoma, which resolved non-operatively, and two patients required minor revisions of their alar rims. The remaining 7 patients achieved excellent aesthetic results after one surgical procedure, and no other complications were noted.

CONCLUSION: We recommend a combined treatment approach to nasal tip hemangiomas, beginning with early medical management concentrated in the first year of life to halt the proliferative phase and enhance involution. Timing for surgical resection is based on the needs of the patient and family, and in most cases can be performed prior to school age. Early surgery performed prior to age two years has demonstrated satisfactory results; however, these children are more likely to require secondary correction. Although technically more challenging than a direct external excision, we prefer an open tip rhinoplasty with advancement and resection of redundant skin at the columella and alar rim. This technique provides direct visualization of the involved tissues, accurate soft tissue redraping, and a less visible scar than an external approach. We conclude that a combined medical and surgical approach offers the best method to treat the challenging and controversial problem of the “Cyrano Nose”.
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