Special Considerations in Vascular Anomalies: Operative Management of Craniofacial Osseous Lesions  Renee M. Burke, MD, Robert J. Morin, MD, Chad A. Perlyn, MD, PhD, Boris Laure, MD, S. Anthony Wolfe, MD  Clinics in Plastic Surgery  Volume 38, Issue 1, Pages 133-142 (January 2011) DOI: 10.1016/j.cps.2010.08.013 Copyright © 2011 Elsevier Inc. Terms and Conditions

Fig. 1 (A) A 4-year-old boy with a left zygomatic intraosseous VM, overlying soft tissue thickening, and capillary malformation of the left cheek. (B) Three-dimensional reconstruction demonstrating a large calcified sclerotic and spiculated lesion involving the left zygoma extending into the lateral wall of the orbit and the zygomatic arch. (C) Surgical specimen at the time of resection, later determined to be an intraosseous VM on pathologic evaluation. (D) Lead template and split calvarial bone graft used to reconstruct the left lateral wall and zygoma. (E) Calvarial bone grafts in place. (F) Postoperative 3D CT scan demonstrating a reconstructed zygoma, lateral orbital wall, and zygomatic arch. (G) A 2-year postoperative picture sent by his family in South America. Clinics in Plastic Surgery 2011 38, 133-142DOI: (10.1016/j.cps.2010.08.013) Copyright © 2011 Elsevier Inc. Terms and Conditions

Fig. 2 (A) Left forehead mass near temporal hairline. (B) Full-thickness calvarial defect after resection. (C) Resected specimen determined by pathology to be a VM of the bone. (D) Split-thickness cranioplasty reconstruction. (E) Normal forehead contour 6 months postoperation. Clinics in Plastic Surgery 2011 38, 133-142DOI: (10.1016/j.cps.2010.08.013) Copyright © 2011 Elsevier Inc. Terms and Conditions

Fig. 3 (A, B) Large AVM in the left cheek and buccal space. (C) CT angiogram (CTA) of AVM originating from the left facial, lingual, and internal maxillary artery. (D) CTA of the AVM originating from the left facial, lingual, and internal maxillary artery. (E, F) Expansion and sclerosis of the left aspect of the body of the mandible, with destruction of the anterior and inferior cortex. (G, H) Postoperative result after excision of the AVM and left mandibular third molar, genioplasty, and correction of macrostomia. Clinics in Plastic Surgery 2011 38, 133-142DOI: (10.1016/j.cps.2010.08.013) Copyright © 2011 Elsevier Inc. Terms and Conditions

Fig. 4 (A) A 5-year-old boy with massive cervicofacial LM with secondary mandibular hypertrophy, oral incompetence, and lower facial palsy. (B, C) Patient at 15 years of age, after multiple debulking procedures, bilateral commissuroplasties, and fascia lata sling to lower lip. The patient has an anterior open bite and mandibular hypertrophy that require further treatment. Clinics in Plastic Surgery 2011 38, 133-142DOI: (10.1016/j.cps.2010.08.013) Copyright © 2011 Elsevier Inc. Terms and Conditions

Fig. 5 (A) A 5-month-old girl with massive cervicofacial LM requiring a tracheostomy at 1 month of age. This patient displays significant mandibular overgrowth and anterior open bite that are frequently seen in these patients. (B) The patient at 3 years of age, after reduction of the tongue, debulking of the tumor in the soft tissues, and closure of the oral commissures. She continues to show significant mandibular hypertrophy and a significant anterior open bite. (C) CT scan of the patient at age 10 years. She had previously undergone osteotomies from just anterior to the gonial angle superiorly to the sigmoid notch. Also, bilateral coronoidectomies were performed to obtain proper occlusion. (D) CT scan of the patient at age 12 years after repeat mandibular osteotomy and reduction of chin. Clinics in Plastic Surgery 2011 38, 133-142DOI: (10.1016/j.cps.2010.08.013) Copyright © 2011 Elsevier Inc. Terms and Conditions

Fig. 6 (A) Patient at 3 days of age, with massive LM requiring debulking from both an external approach for the cervicofacial portion of the lesion as well as a median sternotomy for the mediastinal involvement. (B) Patient at 1 year of age, after completion of the OK-432 injections, with continued progressive enlargement of the LM. (C) Patient at 2 years of age, with increased size of the lesion. However, the patient died of progressive bronchopulmonary compression. Clinics in Plastic Surgery 2011 38, 133-142DOI: (10.1016/j.cps.2010.08.013) Copyright © 2011 Elsevier Inc. Terms and Conditions

Fig. 7 (A) A 13-year-old boy who presented with recurrent nose bleeds, loss of all but light perception in the left eye, and decreasing vision in the right eye. (B) CT scan showing a mass extending and occupying the entire cranial base. (C) Mass involving the entire left maxillary sinus during preoperative angiographic embolization of the left internal maxillary artery. (D) Proposed approach to facial bipartition for resection of tumor. (E) Intracranial exposure of the JA. (F) Resected tumor specimen, later confirmed by pathology to be JA. (G) Closure of facial bipartition and coronal incision with resuspension of temporalis muscle. (H) Postoperative CT scan demonstrating bone grafts to the cranial base. (I) Patient 1 week after surgery, with good facial proportions and well-healed coronal and nasal incisions. (J) Mirror displaying a well-healed palate at 3 weeks after surgery and normal occlusion. Clinics in Plastic Surgery 2011 38, 133-142DOI: (10.1016/j.cps.2010.08.013) Copyright © 2011 Elsevier Inc. Terms and Conditions