Hemangiomas are the most common benign vascular tumors of infancy, typically characterized by a rapid proliferative phase during the first year of life, followed by a slow involution phase over the next several years. Many infantile hemangiomas resolve spontaneously without the need for intervention. However, a subset of cases requires active treatment due to complications, risk of permanent disfigurement, or functional impairment.

While medical therapy—especially with propranolol—has revolutionized the management of hemangiomas, surgery remains a valuable option in select scenarios. 

Indications for Surgical Treatment

Surgical management of hemangiomas is generally reserved for cases where medical therapy is ineffective, not tolerated, or where complications necessitate urgent intervention. Key indications include:

1. Residual Deformity After Involution

Many hemangiomas leave behind fibrofatty tissue, redundant skin, or telangiectasias even after complete involution. Surgical excision of these remnants is often performed for cosmetic reasons and can significantly improve psychosocial outcomes, especially in school-aged children.

2. Ulceration and Bleeding

Ulcerated hemangiomas, particularly those in the diaper area or on mucosal surfaces, can be painful, prone to infection, and slow to heal. If conservative management fails, surgical debridement or excision may be necessary.

3. Functional Impairment

Hemangiomas located near critical anatomical structures—such as the eyes, nose, lips, airway, or ears—can interfere with vision, breathing, feeding, or hearing. Surgery is considered when rapid control is needed or if non-surgical therapies do not yield sufficient improvement.

4. Rapid or Atypical Growth

While many proliferative-phase hemangiomas are monitored conservatively, unusually rapid growth or atypical presentation may warrant early surgical consultation, particularly if there is concern for an alternate diagnosis or risk of tissue destruction.

5. Parental Preference and Psychosocial Concerns

In some cases, families may seek surgical intervention due to cosmetic concerns, particularly when a lesion is prominently located (e.g., facial) or causes social distress. During infancy and toddlerhood, children are typically less aware of their appearance. However, parental concern is often high. It is generally accepted that children with an obvious lesion will reach the point of being aware of the lesion's existence by the age of 2-2.5 years. As children become more socially aware, they begin to notice physical differences. They may experience staring, questions from peers, curiosity, or teasing in school or public settings as they grow older. These facts can lead to emotional consequences such as shame or embarrassment, social withdrawal, and reduced self-esteem. Children may also develop avoidant behaviors, such as refusing to participate in group activities or being reluctant to appear in photos. Visible facial hemangiomas can have lasting psychological effects on children, especially if left untreated in the presence of social challenges.

Surgical intervention for hemangiomas is generally safe and effective when appropriately timed and executed by experienced surgeons—often pediatric Plastic, ENT, or Maxillofacial specialists.

The optimal timing of surgery depends on the indication:

Urgent cases (e.g., ulceration, functional compromise): Early intervention—sometimes in infancy—is warranted when hemangiomas threaten vision, airway patency, or feeding. In these cases, surgery is often coordinated with other specialists and performed under general anesthesia.

Failed medical therapy: In patients who do not respond to propranolol or experience intolerable side effects, surgery may be considered earlier, depending on lesion characteristics.

Near or Post-involution correction: In cases that haven't received treatment, presented late for medical advice, or were previously instructed to "wait and see," elective surgeries for residual deformities are performed after the hemangioma has completed its natural involution, typically around 4–6 years of age.

Surgical excision remains the mainstay of operative treatment. Key principles include:

• Complete removal of the lesion when feasible, with preservation of surrounding structures.

• Meticulous planning of incision lines, often along natural skin creases, to optimize cosmetic outcomes.

• Maintain minimal skin tension during closure to minimize the risk of scarring.

Smaller, well-circumscribed hemangiomas—especially nodular or pedunculated types—are typically easier to excise with excellent outcomes.

In cases where excision results in a tissue defect, reconstructive techniques may be necessary

For suitable candidates, surgical treatment of hemangiomas typically yields high rates of patient and parent satisfaction when performed by experienced surgeons. Cosmetic results are often excellent, particularly for localized, well-defined lesions. Scarring is generally minimal when incisions are well-planned, especially in cosmetically favorable areas. Functional improvements—such as restored visual fields or relief from airway obstruction—can be dramatic in cases involving critical structures. Multiple studies and anecdotal reports emphasize the positive psychosocial impact of surgical correction—especially for facial lesions that draw social attention or stigma. Parents often report high satisfaction even when minor scaring is present, as long as the lesion is significantly improved or removed.

The timing of interventions is critical. Early multidisciplinary involvement—including Dermatology, Pediatric surgery, ENT, or Plastic/Maxillofacial surgery—can help prevent complications and optimize outcomes. Children with facial hemangiomas, ulceration, or signs of obstruction should be evaluated early. 

Surgical excision, although generally reserved for select cases, can offer a rapid, definitive solution and excellent cosmetic results when performed appropriately and by experienced hands. Clear communication with families about the nature of the lesion, the likely course of involution, and the expected outcome of surgery is essential to guide decision-making.

Laser therapy, particularly pulsed dye laser, provides a non-invasive or minimally invasive option for managing hemangiomas. It has an established role as being particularly effective for superficial and residual hemangiomas and is best used as part of a multimodal treatment plan.

The mechanism of action is based on selective photothermolysis—targeting blood vessels in the lesion without significant damage to surrounding tissue.

Laser therapy is not a first-line treatment for most hemangiomas but plays a valuable role in specific situations:

• Superficial hemangiomas in cosmetically sensitive areas (e.g., face, eyelids)

• Ulcerated lesions to promote healing and reduce pain

• Residual telangiectasias or redness after natural involution or medical/surgical treatment

• Adjuvant to propranolol for faster pigment clearance or reduction in superficial components

Best results occur during the early proliferative phase, ideally before 6–9 months of age. Multiple sessions are usually required (often 3–6 treatments spaced 4–6 weeks apart). Outcomes are variable and depend on the lesion’s depth, location, and skin type. Superficial lesions may respond very well, with lightening and flattening after a few sessions. Deep or mixed lesions typically show limited improvement with lasers alone. Adjunctive laser therapy may reduce residual redness after involution or following propranolol treatment.

Early referral to experienced pediatric vascular laser treatment centers and clear communication about expected outcomes are essential for maximizing the benefits of Laser treatment when indicated. 

Infantile hemangioma
Hemangiomas may need treatment if they are in certain areas in the body or if they cause bleeding and pain.  A common treatment is beta-blockers. 

Propranolol is the first medication studied and approved for use and is taken orally. Topical ointment is also useful in cases where the hemangioma is small, superficial and thin.  Side effects are minimal and will be discussed directly with the patient.

Congenital hemangioma
Medication is not helpful in the case of Congenital hemangiomas.