Hemangioma is a benign tumor formed by remnant mesodermal or vascular cells and is most commonly seen in infants and children. They occur mostly in the jaw, head and neck, and oral cavity, and to a lesser extent in the extremities, trunk, and viscera. Most hemangiomas occur superficially in the skin and subcutaneous tissues, but can invade muscle and bone tissue when they develop and expand. A small number of hemangiomas occur in the bone marrow cavity and are called osteo-centric hemangiomas. Although hemangiomas are benign tumors, if they are not treated properly, they often lack effective treatment when they have invaded and destroyed deep important tissues and organs at an advanced stage, so it is of great importance to treat them early and effectively. Classification of hemangioma According to the histological structure and clinical manifestations, hemangioma can be divided into capillary hemangioma, cavernous hemangioma, mixed hemangioma and trabecular hemangioma. In addition, hemangioma can also coexist with lymphangioleioma or lipoma, resulting in lymphangioleioma or lipoangioma. Sometimes hemangioma can coexist with congenital arteriovenous fistula. Capillary hemangioma is a tumor that is slightly elevated on the skin, with clear circumference, irregular shape and size, and color ranging from bright red to dark purple. They are often detected at birth or shortly after birth. Its shape and size can range from small particles to large red spots, sometimes occupying half of the body or half of the face. Clinically, such hemangioma can be divided into two types: (1) Strawberry-like capillary hemangioma (berry nevus): it is a small hemangioma protruding from the surface of the skin, usually found on the face and neck, with an uneven surface, resembling strawberry, with clear boundaries, bright red or purple, and can gradually increase in size and become deeper and invade adjacent tissues and organs. It may gradually increase in size and become deeper and invade adjacent tissues and organs. It has been reported in the literature that this type of hemangioma has a high probability of degenerating on its own, gradually disappearing within a few years, or stopping its development after a certain degree of growth. However, in our clinical experience, the chances of spontaneous regression are not very high. Most strawberry capillary hemangiomas are fast-growing and destructive and should be treated early and properly. (2) Wine spot capillary hemangioma: This is the most common hemangioma after berry nevus, which is a flat and rarely raised plaque composed of numerous dilated capillaries. The area varies in size, and the larger ones can occupy half of the face or torso. The color varies from bright red to dark purple and may recede temporarily with pressure. Sometimes the color does not recede when pressed because of the presence of red pigment in the skin. It occurs most often on the face and neck, but can occur anywhere else in the body. It is usually present at birth and remains stable thereafter. However, in some cases, it can gradually expand and proliferate to the surface with age, with many strawberry-like protrusions and deeper invasion into muscles and other tissues. Wine stains in the lower extremities can also coexist with cavernous hemangioma or congenital arteriovenous fistula. 2.Cavernous hemangioma often appears as a single bulbous protrusion, some superficial, some deep and not affecting the skin, and irregular in shape and size. In some cases, there is a well-defined envelope, which is convenient for surgical removal. However, some of them have no clear boundary with the surrounding tissues. The tumor is soft and compressible, and may fill up due to postural prostration, or shrink with elevation of the affected limb. Granular venous stones can sometimes be found in the tumor, which are produced by blood clotting in the tumor cavity to form a thrombus and then mechanized due to calcium salt deposition. Such stones can also be detected on radiographs. When the tumor is superficial, such dilated or varicose supply veins are faintly visible under the adjacent normal skin. When spongiform hemangioma progresses deeper, it may invade muscle tissue, blood vessels, and nerve spaces, as well as destroy bone tissue and invade the bone marrow cavity. If the bone tissue is invaded, the surface of the bone may be rough and uneven, like a bug bite. When the bone marrow cavity is invaded, the bone trabeculae are destroyed on X-ray, and the bones are sometimes swollen. When the hemangioma is stimulated, it can cause inflammatory reaction in the perivascular tissues, and the patient feels warm, swollen, painful or broken on the surface of the tumor. Local pain also occurs when there is thrombosis. In case of trauma or surface rupture infection, it can cause bleeding risk. Most cavernous hemangiomas are limited, but sometimes extensive invasion of large areas of tissue or the entire limb, including skin, subcutaneous tissue, and muscle, may be seen. Sometimes it is possible to see an extremity without hemangioma lesions in the skin, but with severe subcutaneous and muscular invasion, often making treatment difficult. Spongiform hemangioma of the limb is often complicated by congenital arteriovenous fistula, and the affected limb often shows abnormal development with thickened and elongated bony deformities. Spongiform hemangiomas may also occur in internal organs such as the liver. These hemangiomas may also occur in combination with lymphoma, called lymphatic hemangioma, which is very destructive. This is a kind of cavernous hemangioma with pulsation due to the anastomosis of small arteries and veins, and it can be said to be a mixture of arteriovenous fistula and cavernous hemangioma. The tumor is usually found in the subcutaneous tissues and is initially confined, but as a result of enlarged invasion, the cavity may communicate extensively with deep or marrow vessels. Trapezius aneurysms preferably occur on the scalp and can grow and enlarge rapidly after birth, destroying the outer plate of the skull and invading the plate vein and connecting with the intracranial venous sinus. The tumor is locally elevated, and the pulsating vessels can be seen beneath the skin in a rosary-like curved and tortuous pattern. In the extremities, it can destroy the muscles and form large spongy masses in the limbs. The skin surface is congested and can sometimes rupture causing hemorrhage. On palpation, the skin surface is warm and catarrhal. The tumor is compressive and there is a persistent blowing murmur on auscultation, and patients can sometimes feel the pulsation themselves. Head and facial trapezius aneurysms may also cause severe headache or tinnitus. Diagnosis and prognosis of hemangioma Superficial hemangioma is generally not difficult to diagnose based on medical history, color, morphology and other characteristics. However, it is often not easy to distinguish capillary and cavernous hemangiomas in clinical practice because of the high possibility of the presence of mixed hemangiomas. Punctate or patchy capillary hemangiomas must sometimes be distinguished from pigmented nevi. Spongiotic hemangiomas are clearly compressive, but deep tissue hemangiomas that do not invade the skin can easily be confused with cysts or lipomas, which can then be diagnosed by puncture aspiration. For trabecular aneurysms or deep cavernous hemangiomas, arteriography or aneurysm angiography can be used to help determine the location, size and extent of the surrounding supply vessels. Cerebral angiography can show the connection between the scalp trabecular aneurysm and the large intracranial vessels, which can facilitate the choice of surgical approach. In addition, traumatic arteriovenous aneurysms should be distinguished from traumatic arteriovenous aneurysms that occur after partial resection of a cavernous hemangioma and that develop gradually as a result of postoperative arteriovenous fistula. This can be clearly diagnosed from the medical history. Most hemangiomas are found at birth or shortly after birth. Except for a few infants who already have extensive hemangiomas at birth, most of them are limited in nature and grow with age, especially under the influence of trauma and infection, and can grow rapidly, invade and destroy the surrounding normal tissues and organs, cause serious deformities, or invade the whole limb. Some skin surface capillary hemangiomas (poplar berry-like) tend to degenerate on their own and can gradually disappear or stop developing within a few years. In the past, this point was particularly emphasized in the foreign literature, where it was believed that such hemangiomas should be followed and observed until they disappeared spontaneously, and that aggressive treatment should not be taken before the age of 5 years, and that premature treatment is not only unnecessary but may often result in adverse consequences. We believe that such observation should be cautious and timely, and that once a hemangioma is found to grow, spread, or deepen, effective measures should be taken actively without age restrictions to prevent serious disability or unmanageable situations. Spongiform hemangiomas are even less likely to degenerate on their own and should be given particular attention. We have seen a case of an infant born with a poplar berry capillary hemangioma at the tip of the nose, which was completely destroyed at the age of 1 year because the family did not agree to surgery at that time. However, in another case of a baby born with a cavernous hemangioma in the left upper eyelid medial canthus, the tumor grew rapidly and was surgically removed when the baby was 40 days old, and the tumor was found to be deep to the periosteum of the medial nasal canthus. No recurrence has been seen in the 12 years since the surgery so far and deformities have been largely avoided. When a hemangioma develops rapidly, the problem of malignancy should be considered. Endothelial hemangioma is a malignant hemangioma, which is rare in clinical practice but must still be noted. Extensive and huge cavernous hemangioma or trapezius aneurysm is difficult to treat because it affects important organs or whole limbs, or important parts of the chest and abdominal wall due to the lack of effective measures at present. Patients may die due to serious conditions such as hemorrhage, airway obstruction, or tumor invasion into internal organs. Treatment of hemangioma There are many treatment methods for hemangioma, including surgical excision, radiotherapy, sclerotherapy injection, freezing, electrocautery, and so on. Sometimes, various combination therapies can also be applied. Each treatment method has its own advantages and disadvantages and certain indications, depending on the different stages of tumor development, the type, size and location of the tumor, the patient’s age, health condition, and the presence of complications. The possibility of self-resolution of hemangioma is limited to a few strawberry-like capillary hemangiomas, while wine spots and cavernous hemangiomas rarely resolve on their own. Only at the time of initial diagnosis and after observation by the family that the hemangioma has begun to degenerate or is in the process of degenerating should a continued observation attitude be adopted. Small hemangiomas on the trunk or extremities of infants can also be temporarily observed because even if they continue to grow and expand over time, there is still a chance that they can be treated completely without causing irreversible deformities. On the contrary, hemangiomas on the head and face and other exposed parts, especially those near the eyes, nose and mouth, can lead to serious consequences if treatment is delayed for a short period of time. Therefore, we believe that the basic principle of hemangioma treatment should be close observation and early treatment, rather than waiting too long. At present, our department adopts the combination of grinding treatment and drug treatment for wine discoloration with good effect.