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British Journal of Oral and Maxillofacial Surgery 52 (2014) 43–47

Sclerotherapy of face and oral cavity low flow vascular

malformations: our experience
E. Górriz-Gómez, M. Vicente-Barrero ∗ , M.L. Loras-Caballero, S. Bocanegra-Pérez,
J.M. Castellano-Navarro, D. Pérez-Plasencia, A. Ramos-Macías
University Hospital Doctor Negrín, Insular University Hospital of Las Palmas de Gran Canaria, University of Las Palmas de Gran Canaria, Spain

Accepted 10 April 2013

Available online 6 May 2013

Abstract

We have reviewed our experience (15 patients during the period 2008–2012) in the treatment of low flow vascular malformations (LFVMs)
of the face and oral cavity with polidocanol foam sclerotherapy. They were diagnosed clinically and with the help of Doppler ultrasound and
magnetic resonance imaging. The maximum dose recommended for each session was 20 mg/day and the minimum interval between sessions
was 4 weeks. Embolisation was repeated as many times as needed until the size of the lesions and the symptoms had been reduced sufficiently.
Patients were followed up 1, 6, and 12 months after treatment had finished, and the size of the lesions was assessed objectively.
The 8 men and 7 women were aged between 18 and 71 (mean 44) years. The lesions had reduced and symptoms had improved in all
cases. During the follow-up period, one patient relapsed and developed further symptoms. The pain and postoperative inflammation were
successfully controlled with an analgesic and an anti-inflammatory drug. There was only one complication (superficial necrosis), which healed
completely by second intention.
Direct puncture and sclerosis with polidocanol foam are an effective treatment for LFVM of the face and oral cavity.
© 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Vascular malformations; Sclerotherapy; Foam; Ethanol

Introduction approach to treatment,1 and many foam and liquid sclerosing

agents have been developed. Though there are many publi-
Low flow vascular malformations (LFVMs) are the result cations about sclerotherapy for LFVM of the lower limb, we
of errors in vascular morphogenesis during the embryonic know of few on the subject of lesions of the head and neck.
period. The scarcity of cases means that a systematic study In this study we have reviewed retrospectively our expe-
would be difficult, their unpredictable behaviour yields uncer- rience of the treatment of LFVM of the face and oral cavity
tain prognoses, and often results of treatment are poor. with polidocanol foam sclerotherapy.
Even though there is broad agreement about the difficulty
of removing the lesion completely, there is still disagree-
ment about the most appropriate treatment and other possible
Patients and methods
options.
Traditional resection may result in haemorrhage, muscu-
Fifteen patients with LFVM of the face and oral cavity were
lar and nervous complications, and relapse. Sclerotherapy
treated between 2008 and 2012.
has therefore become the widespread and most appropriate
The treatment was indicated for aesthetic disorders (n = 7),
pain (n = 1), and discomfort when chewing, or occasional
∗ Corresponding author at: c/ Alcalde Henríquez Pitti 13, 1◦ izq, 35400- bleeding, or both (n = 7). Physical examination, Doppler
ARUCAS, Las Palmas, Spain. Tel.: +34 928602951; fax: +34 928634736. ultrasound, and magnetic resonance imaging (MRI) led to the
E-mail address: [email protected] (M. Vicente-Barrero). diagnosis. The Doppler ultrasound showed typically contin-

0266-4356/$ – see front matter © 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjoms.2013.04.006
44 E. Górriz-Gómez et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 43–47

Fig. 1. Case 1 before sclerotherapy.

uous venous recordings, and the MRI focal T2 hyperintense

lesions. Fig. 2. Case 1 during the first of two embolisations.
In all cases, an experienced vascular radiologist directly
punctured the lesion and injected it with 0.5% polidocanol (Case 5). The pain and postoperative inflammation were suc-
foam (a mean (range) of 3 (2–5) procedures/patient were cessfully controlled with an analgesic (metamizole) and an
required). To obtain the foam, we used the technique already anti-inflammatory agent (diclofenac). There was only one
described elsewhere,2–9 and transferred the polidocanol from complication, superficial necrosis, which healed completely
one syringe to another syringe together with carbon dioxide. by second intention.
The foam is obtained by repeatedly and energetically trans-
ferring it back and forth between the syringes (Fig. 2). It takes
a few seconds to obtain the foam, and it is done just before
Discussion
it is injected. CO2 provides stable foam for a few minutes –
enough time to produce an endothelial lesion and subsequent
LFVM are produced by an error in vascular morphogenesis.
thrombosis in the area of the malformation. Because the mix
They may result from hereditary factors or sporadic muta-
is easily obtainable, we may produce the quantity as needed
tions, be it the expression of altered genes or the influence of
for successive operations during the treatment.
environmental factors.10
For small lesions (10–15 mm) a single puncture in the
The clinical presentations are diverse; 40% of cases are
raised area of the lesion sufficed. It was done with a 19-gauge
located in the head and neck.11 The low global incidence
(Terumo Europe N.V. 3001 Leuven, Belgium® ) winged
accounts for the limited experience gained by most profes-
syringe (SURFLO Winged infusion set® ). For bigger lesions,
sionals. The most common symptoms are pain, compression
multiple punctures with the winged syringes were needed.
of surrounding structures, and cosmetic deformities. Ulcers
By spanning the perimeter of the lesion, the largest surface
and bleeding are less common, although they are generally
of malformed tissue possible became exposed to the action
the reaction to trauma.
of the sclerosing agent, and injections were made from each
In the past, the usual treatment for LFVM of the head and
winged syringe introduced into the malformed tissue.
neck was excision. With the arrival of endovascular treatment
The maximum recommended dose of 0.5% lauromacrogol
techniques and new embolising agents, however, embolisa-
400 (EtoxisclerolTM ) is 2 vials (4 ml/20 mg)/session, and the
sessions were repeated as many times as needed until the
size of the lesions had reduced and the symptoms decreased
sufficiently (Figs. 1–3).
Patients were followed up 1, 6, and 12 months after the
treatment, and the reduction in the size of the lesions was
assessed objectively.

Results

We treated 15 patients (9 men and 6 women) between 26 and

71 years of age (mean 48) between 2008 and 2012 (Table 1).
Lesions were reduced in size and symptoms improved in
all cases. During the follow-up period one patient relapsed Fig. 3. Final view of case 1.
 E. Górriz-Gómez et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 43–47 45

Table 1
Details of the15 patients and their treatments.
Case no. Age (years) Sex Site Size (mm) No. of procedures
1 26 M Lip 10 2
2 70 M Tongue 15 2
3 47 F Chin 40 4
4 50 M Lip 10 2
5 28 F Cheek 50 5
6 71 M Lip 10 1
7 63 F Chin 35 4
8 43 M Mucosa of cheek 20 3
9 42 F Mucosa of cheek 15 2
10 50 F Mucosa of cheek 18 2
11 58 M Mucosa of cheek 12 1
12 59 M Lip 10 2
13 33 M Mucosa of cheek 20 2
14a 28 F Lip 30 5
15 50 M Lip 15 2
a Developed superficial necrosis – the only complication in the series.

tion is gradually becoming the treatment of choice, either and discolouration of the skin around the puncture, which
exclusively or as an adjunct to resection.12 resolved after a month).
Many substances are used for embolisation. Polidocanol Alòs et al. published a series of 75 patients and showed that
is a synthetic solution made up of hydroxypolyethoxydode- given the same concentration of polidocanol, the efficacy of
cane, water, and 5% ethyl alcohol. Originally it was used as foam sclerotherapy is higher than that of liquid sclerotherapy,
local anaesthetic, but currently it is almost exclusively used as even though minor side effects (such as pain, inflammation,
a sclerosant. It is a synthetic surfactant that is also used as an and pigmentation of the skin) are also more common.15
antipruritic cream and in some treatments for inflamed haem-
orrhoids. At present it is the most commonly used product
for embolisation because it is well-tolerated, user-friendly,
affordable, and causes few allergies or other complications
(such as pigmentation or skin ulcers). It produces an acute
lesion of the vascular endothelium, which triggers the “cas-
cade” of coagulation. It crosses the placental barrier so is not
advised for pregnant women. Even though it is not as effective
as ethanol, polidocanol has a much lower rate of undesirable
effects,13 so it is safe; the incidence of allergies is low, the
injection is painless, and skin necroses are rare. The greatest
inconvenience is its capacity to pigment treated veins.14
Liquid sclerosants are diluted by blood, so control of
the dose that acts on the endothelium is difficult. If these
Fig. 4. Necrosis of the vermilion after treatment (case 14).
substances are mixed with gases foam is produced, which
prolongs the contact of the sclerosing agent with the vas-
cular wall. Carbon dioxide does not cause allergic reactions
or nephrotoxicity and is quickly eliminated from the blood-
stream, so generous doses may be used without the risk of
side effects.4
During the days after embolisation, patients developed
oedema, pain, and increased functional impotence, which
eased with medical treatment – the symptoms have already
been described.1,11,15,16
Our only complication was in one patient who presented
with superficial necrosis, which healed by second intention
(Figs. 4 and 5). In the series described by Spence et al.11 of 37
cases of craniofacial venous malformations treated with scle-
rosant, 4 developed complications secondary to treatment,
but none were permanent (infection, nausea and vomiting,
Fig. 5. Final view of case 14.
46 E. Górriz-Gómez et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 43–47

In 2007, a systematic review by Jia et al., 17 analysed 22 procedures, and 2 developed transient facial paralysis and
64 studies included in 104 publications. Most of the 9000 recovered completely. Another patient developed unilateral
patients had been given polidocanol foam to treat varicose paralysis of the vocal cords, which has not been explained.
veins, not specifically in the maxillofacial area but throughout It is worth mentioning that neuropathies developed only in
the whole body. The incidence of severe side effects ranged patients treated with ethanol. Apart from some minor scars
between 0% and 5.5% of cases, depending on the study ana- there were no other long-term complications.18
lysed. The rate of severe side effects was below 1% and In 2011 Blaise et al.7 published a series of 24 patients
included anaphylaxis, pulmonary embolism, and deep vein who were treated with polidocanol foam sclerotherapy. At 5
thrombosis. Other less severe side effects included defective months follow up 23 patients reported that they had less pain;
vision (1.4%), headache (4.2%), thrombophlebitis (4.7%), the volume of lesions had been reduced by more than half in
pigmentation of the skin (17.8%), and pain at the site of 9 patients, and in 14 the volume was reduced by less than
injection (25.6%). Complete occlusion of the treated veins half. Two minor complications were reported.
was achieved in 87% of cases, and there were relapses or According to Kohout et al.,20 intraoperative Doppler study
new veins in 8.1% of cases. Even though the studies were and the bleeding pattern at the margins of the resection are
heterogeneous, they concluded from the meta-analysis that the most effective ways to verify complete removal.
foam sclerotherapy was more effective than liquid sclerother- Histopathological study of frozen samples was not use-
apy but less effective than surgery, at least when the full ful. Lee et al.,19 evaluated the effectiveness of the treatment
obstruction of the vessels’ lumen was measured.17 based on the difference in size – measured objectively by
There have been several retrospective studies specifically nuclear MRI before and after treatment – and on the quantita-
about lesions of the head and neck.18,19 Lee et al.19 reviewed tive measurement of the lower radioisotope count on gamma
the treatment of 87 cases of LFVM that had been treated by radiography before and after treatment. We measured the
305 sclerotherapy procedures with ethanol for craniofacial effectiveness of treatment by the disappearance of lesions and
venous malformations. The technique was judged effective symptoms as described by the European Consensus reached
in 60 of the 87 cases. There were no cases of skin necrosis in 2003 about foam sclerotherapy.21
after any of the treatments. Two patients experienced tran- In conclusion, direct puncture and sclerosis with polido-
sient oxygen desaturation (probably as a result of pulmonary canol foam is an effective treatment for LFVM of the face
hypertension) immediately after the injection of ethanol, but and oral cavity, with low morbidity. Despite the good results
they recovered immediately. A patient with a malformation obtained, conclusions must be cautious because of the small
of the tongue experienced temporary reduced sensitivity, and number of cases in this study. Larger comparative series are
another with a lesion on the cheek developed transient paral- needed.
ysis of the facial nerve. There was no induration or local
inflammation immediately after the injection in any case. The
local postoperative pain was controlled with analgesia given Conflict of interest
either intravenously or intramuscularly. There were no seri-
ous complications related to the procedures such as ethanol None declared.
embolism in the systemic bloodstream, skin lesions around
the lesions, or nervous diseases. No patient reported signs or
symptoms of renal or hepatic toxicity. Ethics statement
To minimise complications, it is recommended that
ethanol should be diluted and injected slowly, followed by Confirmed.
compression with a rubber band, without exceeding 1 ml
of ethanol/kg of body weight, while controlling pulmonary
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