Hemangioma Debulking & Rhinoplasty 
Medical specialty:  Cosmetic / Plastic Surgery
 Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty.

PREOPERATIVE DIAGNOSIS: , Hemangioma, nasal tip.,POSTOPERATIVE DIAGNOSIS:,  Hemangioma, nasal tip.,PROCEDURE PERFORMED:  ,1.  Debulking of hemangioma of the nasal tip through an open rhinoplasty approach.,2.  Rhinoplasty.,ESTIMATED BLOOD LOSS:  ,Minimal.,FINDINGS: , Large hemangioma involving the midline of the columella separated the lower lateral cartilages at a level of the columella and the nasal domes.,CONDITION:  ,Condition of the patient at end of the procedure stable, transferred to recovery room.,INDICATIONS FOR THE PROCEDURE: , The patient is a 2-year-old female with a history of a nasal tip hemangioma.  The hemangioma has involved at her upper tongue.  There has not been any change in the last 6 months.  We have discussed with the parents the situation and decided to proceed with the debulking of the nasal tip hemangioma.  They understand the nature of the incision, the nature of the surgery, and the possibility of future revision surgeries.  They understand the risk of bleeding, infection, dehiscence, scarring, need for future revision surgery, and minor asymmetry.  They wished to proceed with surgery.,Because of the procedure, informed consent is obtained.  The patient is taken to operating room and placed in the supine position.  General anesthetic is administrated to an oroendotracheal tube.  The face is prepped and draped in the usual manner.  The incision is designed to the lower aspect of the hemangioma, which corresponds to the columella and upper lip junction and then the remaining of the incision is designed as an open rhinoplasty with bilateral rim incisions.  The area is infiltrated with lidocaine with epinephrine.  We waited 7 minutes for the hemostatic effect and proceeded with the incision.  The incision was then done with a 15 C blade starting at the columella and then going laterally to the level of the rim and the double hook is placed at the level of the dome and the intracartilage incision is done through the mucosa, then extended laterally and upward to follow the lower lateral cartilage.  This is done in both sides.  Further incision is done.  A small tenotomy scissors is used and with the help of retraction of the lower lateral cartilage, the hemangioma is separated gently from the lower lateral cartilage on both sides and I proceeded to leave that the central part of the incision lifting up the entire columella to the level of the nasal tip.  The hemangioma is removed and is found to be involving the medial aspects of both medial crura.  This gently separated from the medial crura and from the soft tissue care is taken not to remove the entire hemangioma from the skin as the nose not to devascularize the distal columella portion.  Hemostasis is achieved with electrocautery.  Then, we proceed to place some interdomal stitches with the help of a 6-0 clear nylon and intercrural stitches are placed and then an interdomal stitch, a single one was placed.  The skin is redraped and the nose found to have satisfactory shape.  The columellar piece was tailored on the lateral aspect corresponding to rim incisions to match the newly created width of the columella.  Portions of skin and hemangioma are taken laterally on both sides of the columella distally.  The skin was closed with 6-0 mild chromic stitches, including the portion at the level of the columella and rim incisions medially.  The remaining of the internal incisions are closed with 5-0 chromic interrupted stitches.  The nose is irrigated and suctioned.  The patient tolerated the procedure without complications.  I was present and participated in all aspects of the procedure.  Sponge and instrument count were complete at the end of the procedure.