[Oral venous malformation treated with pulsed-dye and neodymium:Yttrium-aluminum-garnet sequential laser].

Venous malformations are slow-flow vascular malformations present at birth, although they occasionally do not become clinically evident until several years later. They manifest clinically as soft, nonpulsatile masses of blue or violaceous color that compress easily on palpation. Their presence within the mouth is not uncommon and can be associated with bleeding, ulceration, pain, difficulty swallowing, airway obstruction, and facial deformity.1,2 The classic approaches to these lesions include sclerotherapy and surgery although this can occasionally result in significant deformity, prolonged pain, skin necrosis, nerve damage, or systemic toxicity. This has led to the use of various lasers—carbon dioxide, argon or diode—sometimes in combination with radiofrequency current3 and, more recently, alexandrite2 or long-pulsed Neodymium:YttriumAluminum-Garnet (Nd:YAG) lasers.4,5 The Nd:YAG laser is considered the treatment of choice for this condition. We present the case of a 16-year-old man with a soft, compressible bluish tumor on the mucosa of the cheek, lower lip, and half of the tongue on the right side (Figure 1). The patient reported the lesion had been present since birth and had increased progressively in size over the years. Doppler ultrasound confirmed the tumor to be a slow-flow vascular malformation. Sequential treatment with pulsed dye laser (PDL) and Nd:YAG laser (Cynergy with Multiplex, Cynosure, Westford, MA, USA) was recommended in view of the diagnosis of venous malformation, the patient’s difficulty swallowing, and the marked deformity. The patient received 7 sessions of treatment over a 10-month period, using PDL (595 nm wavelength) followed by Nd:YAG (1064 nm wavelength) with a 1-second delay. The following parameters were employed: 7 mm spot size; 10 ms pulses with a fluence of 10 J/cm2 with PDL, and 15 ms pulses with a fluence of 70 J/cm2 with the Nd:YAG laser. Throughout the treatment a pre-cooled airflow skin cooling system (Cryo5, Zimmer Medizinsysteme GmbH, Neu-Ulm, Germany) was used at its highest setting. Treatment was applied in a slow and progressive manner in order to avoid causing lingual edema that could compromise the airway, and 20 mg to 40 mg of intramuscular methylprednisolone was administered in the initial sessions. Anesthetic infiltration of the lesion with mepivacaine 2% was required prior to laser treatment but in the 2 last sessions no anesthesia was needed. Moderate edema was observed in the treated areas but there was no respiratory compromise and no other significant adverse reactions were seen. Follow-up 8 months after treatment showed a marked reduction in the size of the venous malformation, with complete resolution in some areas (Figures 2 and 3).