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Popescu Technique Revisited: Review of the Literature and Case Series

Popescu Technique Revisited: Review of the Literature and Case Series



Popescu Technique Revisited: Review of the Literature and Case Series




Journal of Oral and Maxillofacial Surgery, 2020-11-01, Volume 78, Issue 11, Pages 2000-2007, Copyright © 2020 American Association of Oral and Maxillofacial Surgeons


Management of vascular malformations depends on the size, type, age of the patient, location, dissemination, and depth of penetration. Treatment options include propranolol, which reduces endothelial vessel proliferation, minimally invasive sclerotherapy to induce fibrosis, or surgery. In 1985, Valerian Popescu described a new approach to treatment consisting of intratumoral ligation by compartmentalization. This technique allows for high doses of the sclerosant agent to be delivered as systemic dissemination is restricted by a series of strangulating suture loops that divide the mass into segments. We describe the management and outcome of 2 patients who presented with vascular malformations in the orofacial region and were managed using a Popescu suturing technique. Vascular obliteration was achieved by a series of strangulating suture loops placed percutaneously throughout each lesion using a curved needle with a resorbable material (Vicryl; Ethicon, Somerville, NJ). The aim was to segment the vascular malformation into manageable sections for subsequent injection of a sclerosant. The compartmentalization also ensured that the sclerosant stayed within these compartments and was not washed out into the general circulation. Good esthetic outcomes were achieved in very visible areas such as the commissure and the vermillion border. In these areas, a surgical resection would have certainly caused a disruption of the esthetics of the lips and, in the second case, probably an alteration of function. Intratumoral ligation can be used safely to achieve control of vascular malformations with good esthetic outcomes.

Vascular anomalies are a heterogeneous group of lesions that may occur anywhere in the body. Broadly, there are 2 categories of vascular anomalies according to the endothelial morphology: vascular tumors, exhibiting endothelial hyperplasia, and vascular malformations, in which endothelial turnover is normal. Although the exact incidence of vascular anomalies is unknown, a malformation requiring treatment is diagnosed in approximately 5 per 1,000 individuals.

Although difficult to quantify, the impact of vascular malformations is undoubtedly substantial, particularly given their predilection for visible parts of the body. Appearance is an important determinant of self-concept, social integration, and the establishment of relationships. Deformity, particularly of the orofacial region, does have a substantial impact on long-term psychological functioning for the affected individual. Moreover, behavioral studies assessing the responses of parents to childhood vascular anomalies support that the psychosocial impact of childhood deformity extends into the wider family unit. , As medical professionals who strive for holistic management of our patients from a biopsychosocial perspective, the optimal management of vascular malformations is one that both ensures resolution of the underlying disorder and minimizes the impact to esthetics and function.

Treatment options include sclerotherapy, embolization, and surgical excision. The vascular nature of vascular malformations predisposes them to substantial bleeding that, if not effectively managed, may be catastrophic. Moreover, blood flow may limit the efficacy of an injected sclerosing agent through leaching to the systemic circulation. In 1985, Valerian Popescu described a new approach to surgery for vascular malformations in the orofacial region and described his method of treatment by intratumoral ligation. His method consisted of an interception to the blood supply to the vascular malformation by vascular obliteration, which was achieved by a series of strangulating suture loops that divided the mass into segments ( Fig 1 ). His technique was reported to be safe and provided good long-term control with satisfactory cosmetic outcomes when used for the treatment of cavernous hemangiomas of the orofacial region. Over the years, this technique has fallen out of favor and is not part of the surgeon's routine armamentarium in the management of vascular malformations.

Overview of Popescu method for intratumoral ligation. A , Subcutaneous vascular malformation (type undefined here). B , A needle is passed from the periphery of the lesion toward the center, underlying the vascular malformation, to begin the loop. C , The needle is placed back through the initial exit location, passing intradermally above the vascular malformation, to exit at the original entry location. The needle is then drawn tight to promote intratumoral ligation. D , The process is repeated to functionally compartmentalize the vascular malformation. Numbering and arrows are used to demonstrate the path of the needle and the accompanying suture in the formation of strangulating loops: 1) the needle is passed from the periphery of the lesion, through the skin and submucosal tissue, toward the base of the malformation; 2) the needle is extracted at the center of the lesion, creating a suture loop beneath the malformation; 3) the needle is then passed back through the initial exit location and directed into the submucosal tissue or intradermally above the underlying malformation; 4) finally, the needle is directed out of the initial entry location to complete the strangulating loop.
Figure 1
Overview of Popescu method for intratumoral ligation.
A , Subcutaneous vascular malformation (type undefined here).
B , A needle is passed from the periphery of the lesion toward the center, underlying the vascular malformation, to begin the loop.
C , The needle is placed back through the initial exit location, passing intradermally above the vascular malformation, to exit at the original entry location. The needle is then drawn tight to promote intratumoral ligation.
D , The process is repeated to functionally compartmentalize the vascular malformation. Numbering and
arrows are used to demonstrate the path of the needle and the accompanying suture in the formation of strangulating loops: 1) the needle is passed from the periphery of the lesion, through the skin and submucosal tissue, toward the base of the malformation; 2) the needle is extracted at the center of the lesion, creating a suture loop beneath the malformation; 3) the needle is then passed back through the initial exit location and directed into the submucosal tissue or intradermally above the underlying malformation; 4) finally, the needle is directed out of the initial entry location to complete the strangulating loop.

We describe the management and outcome of 2 patients who presented with vascular malformations in the orofacial region and were managed using the Popescu suturing technique.


Patients and Methods


Preoperative Evaluation

Diagnosis of vascular malformations in both cases was principally based on history and clinical examination findings. In case 1, however, the patient noted a progressive increase in the size of a right-sided commissural lesion, so magnetic resonance angiography was considered necessary as a means to identify any further lesions and confirm the diagnosis of vascular malformations. Given the presence of a stable isolated lesion in case 2, further imaging was deemed to add little value in directing management, and a diagnosis of a vascular malformation was made on the grounds of history and clinical examination findings alone.


Surgical Technique

Vascular obliteration was achieved by a series of strangulating suture loops placed percutaneously throughout each lesion using a curved needle with a resorbable material (Vicryl; Ethicon, Somerville, NJ). The aim was to compartmentalize the vascular malformation into manageable sections for subsequent injection of a sclerosant. The compartmentalization also ensured that the sclerosant stayed within these compartments and was not washed out into the general circulation. The suture was initially passed deeply through skin and vascular malformation, including underlying normal tissue, and then brought back out through skin or mucosa. The needle was reinserted under the skin to emerge closer to the former entry point. Each loop was then tightly secured without involving the skin, to occlude the afferent vessels and thus interrupt the blood supply, simultaneously dividing the vascular malformation into sections.


Injection of Sclerosing Agent

In both cases, 3% Fibrovein (sodium tetradecyl sulfate [STS]; STD Pharmaceutical Products, Hereford, United Kingdom) was used as the sclerosing agent. It was injected immediately after placement of strangulating sutures intraoperatively and distributed between the newly created compartments. The volume used was proportionate to the size of the lesion; 1.5 mL of 3% Fibrovein was injected in case 1, whereas 5 mL was injected in case 2 during each procedure.


Follow-up

Case 1 was reviewed at 1 week, 6 weeks, 8 months, 14 months, 26 months, and 36 months postoperatively. The total time free of recurrence was 45 months. Postoperative clinic follow-up was arranged at 1 week, 3 months, and 6 months after the initial procedure in case 2, at which time a decision was made for a further procedure given the finding of partial recurrence (described later). Further clinic follow-up was arranged at 1 week, 2 months, and 10 months after the second procedure. The total time free of recurrence in case 2 since the last follow-up was 22 months. Both cases showed complete resolution of the underlying lesion at the time of the most recent clinic review, and further imaging was not required in monitoring clinical progress.


Case Series


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