1) The study introduces the "corset suturing" technique for treating large diffuse venous malformations in the head and neck region. Corset suturing involves continuous suturing that incorporates the lesion and strangulates the vessels to induce occlusion. 2) The technique was performed on 90 patients with non-cutaneous venous malformations. Most lesions resolved within 4-8 weeks with minimal complications and good cosmetic outcomes. 3) While corset suturing provides an effective and low-cost alternative treatment, the study had limitations as a retrospective study without controls to fully evaluate the technique.

1. Presented by- Dr Dibya Falgoon Sarkar

2. Corseting: A new technique for the
management of diffuse venous
malformations in the head and neck region
S.C. Nair, J.P. Chawla, S.S. Shroff, B. Kumar, A. Shah
International Journal of Oral & Maxillofacial Surgery (December 2018)

3. Introduction
• Venous malformations are characterised by an
abnormal collection of veins, which do not have
any demonstrable mitotic activity in endothelial or
pericyte cells and often lack a uniform smooth
muscle layer.
•The degree of ectasia increases with age and the
clinical features depend on the depth and size of
the lesion. Pheloboliths are often present in the
lesion.
(Colletti G, Colombo V, Mattassi R, Frigerio A. Strangling technique
to treat large cervicofacial venous malformations: a preliminary
report. Head & neck. 2014 Oct;36(10):E94-8.)
•Incidence: Most common vascular malformation,
estimated to occur in between 1 of 5000 and 1 of
10,000 childbirths

4. Classification of venous malformations
(Puig S, Aref H, Chigot V, Bonin B, Brunelle F. Classification of venous malformations in
children and implications for sclerotherapy. Pediatric radiology. 2003 Feb 1;33(2):99-103.)
Type Description
Type I Isolated malformation without peripheral
drainage
Type II Malformation that drains into normal veins
Type III Malformation that drains into dysplastic
veins
Type IV Venous ectasia
•Extra-truncular venous malformations are infiltrative
in nature and are inseparable from surrounding
tissues and vital structures
(Belov ST. Classification of congenital vascular defects. International angiology: a
journal of the International Union of Angiology. 1990;9(3):141-6.)

5. Sclerotherapy is the
first line of treatment
PYM: Pingyang-
mycin injection
(Zheng JW, Mai HM, Zhang L, Wang YA. Guidelines for the treatment of head and neck venous malformations.
International journal of clinical and experimental medicine. 2013;6(5):377.)

6. Aim of the study
To describe and introduce the corset suturing technique,
which is a simple, aesthetic, and cost-effective method for
the treatment of large venous malformations of the head
and neck.
Disadvantages of existing treatment modalities for venous malformations:
• Venous malformations in which surgery is hampered by localization
and extent of the lesion.
• Recurrent cases which are resistant/ not suitable for embolization,
sclerosants and surgery.

7. Subjects & Methods
• Study design- Retrospective study.
•Place of study- Department of Oral and Maxillofacial Surgery at
Bhagwan Mahaveer Jain Hospital, Bangalore.
•Duration of study: January 1999 to October 2017 (18 years)
•Study population: 235 patients with vascular lesions

8. Subjects & Methods
Inclusion criteria Exclusion criteria
Low-flow vascular malformations High-flow vascular malformations
Difficulty in speech Lesions having self-healing tendency
Difficulty in swallowing Lesions involving critical structures
such as eyes and carotid artery
Lesions causing primary facial
deformity Lesions in inaccessible spaces of head
and neck

9. Surgical technique
 Incision: Placed within the junction lines of
cosmetic subunits and skin tension lines closest
to the area involving the lesion.
Raising the flap: Subcutanoeus or sub-SMAS
plane depending on the type of lesion
Corset suturing:
1. Bioresorbable sutures that runs in a
continuous vertical looping fashion from
subcutaneous to deep layers incorporating
the lesion within the suture
2. Suturing done in a parallel fashion covering
the whole lesion in superior, inferior, medial
and lateral direction.
3. Sutures were tightened cautiously and
slowly

10. Aimof corset suturing is to obliterate the
centrally placed low resistance vessels
while preserving the vital structures so
that involution of the lesion occurs.
Post opCorset suturing
Excess skin was marked on the flap

11. Results
Out of 235 patients
with vascular lesions
90 patients met the
inclusion criteria
Contrast CT
68%
MRA
15%
MRI
2%
No investigation
15%
Imaging

12. Results Male
60%
Female
40%
Out of 90 patients
Male
Female
No Type I lesions
were included in
the selection

13. Results
3-5days post op: Regression of the
local phenomena with reduction in
size of swelling. No suppuration
noted
4 week post op: Reduction in size
of tumour mass due to necrosis
and return to normal function
8 weeks post op: Lesion almost
disappeared. Patients attained
near normal appearance., color
and consistency.
Most malformations took 4-8 weeks to resolve.
Recurrence: 10 cases out of 90 required further treatment later like surgery and
intralesional injections.
Transient facial nerve palsy: 7 cases ( Type III: 5 & Type II: 2)
 63 patients came for follow up for 18 years. Two patients were lost to follow up
after 1 year. Rest reported for a minimum 5 years follow up.
Postoperatively

14. Discussion
• Mechanism of action: This intra-tumoural ligation technique eliminates the
whole blood flow within the venous malformation by 2 effects:
1. Strangulated vessels produce buried scars that obstruct the vascular
channels.
2. Blood stasis within the sutures produces blood clots, which undergo
normal organization and occludes the vessels.
•Entrapment of vital structures like salivary glands and duct, lingual nerve,
facial nerve and its branches were avoided.
• Main complications encountered:
i. Transient facial nerve palsy (due to strangulation of nerves by the sutures
prior to their absorption)
ii. Soft tissue swelling and necrosis
iii. Haemorrhage

15. Discussion
Indications of corset suturing:
 Diffuse vascular malformations of face
Intraoperatively unresectable vascular malformations
Recurrent vascular malformations
Large lesions involving vital structures
Advantages: Simple, cost-effective, aesthetically acceptable, no foreign
body reaction seen
Limitations:
1. Cutaneous/ mucosal lesions
2. High flow lesions
3. Airway compromised patients

16. Popescu technique
Popescu V. Intratumoural ligation in the management
of orofacial cavernous haemangiomas. J. Maxillofacial
Surg 1985; 13: 99-107

17. Disadvantages of Popescu techinque
Transcutaneous
track formation
Multiple scarring
Use of non-
resorbable sutures
which needs to be
removed after 10-
12 days.

18. Strangling technique to treat large cervicofacial venous
malformations: A preliminary report
G, Colombo V, Mattassi R, Frigerio A. Strangling technique to treat large cervicofacial venous
malformations: a preliminary report. Head & neck. 2014 Oct;36(10):E94-8.
•This study aimed to describe
an ancillary approach to
address large VMs not
responsive to sclerotherapy,
when a radical removal is not
possible
Purpose
• Unresectable venous
malformations were
decompressed in 2 patients by
means of a number of
nonresorbable stitches from the
surface of the lesion to the
periosteum, tailoring a permanent
pressure dressing.
• The stitches were placed parallel
to the course of the facial nerve
fibers, in order to avoid any injury.
Methods • Outcomes at 12-month
follow-up were stable, with
good cosmetic results and
satisfaction reported by both
patients. No long-term side
effects related to the
procedure were observed.
Conclusion

19. Limitations of this study
Retrospective nature of the study.
No randomisation/ blinding has been done to reduce the bias.
There are nopreoperative CTorMRI for the reader to perceive the
extent of the malformations and, hence, the indications for surgical
treatment, given that the accepted first approach to venous
malformations was, and still is, sclerotherapy.
 Extensive use of CT over MRI, which is considered as a gold standard
for diagnosis and staging of venous malformations, not to mention the
exposure to radiation.
(Colletti G, Ierardi AM. Understanding venous malformations of the head and neck: a
comprehensive insight. Medical Oncology. 2017 Mar 1;34(3):42.)

20. Limitations of this study
This paper reportedly deals with venous malformations, but in the
table “indications, advantages and limitations of corset suturing” the
authors invoke the term ‘haemangioma’, which is another disease.
Dessy et al in their letter to the editor of IJOMS claimed that Nair’s
corseting technique is far too similar to the ‘strangling technique’ by
Colletti et al and thus, cannot be surmised as a new one.
(Dessy M, Giovanditto F, Cucurullo M, Dionisio A, Liberale C, Colletti G. Considerations on
the'corseting'or'strangling'technique to treat large venous malformations. International
journal of oral and maxillofacial surgery. 2018 Oct.)

21. Conclusion
Corset suturing has an important role in the management of large
venous malformations of head and neck, with careful case selection as
described.
It is a simple, cost-effective and less scarring method of treatment of
non-cutaneous venous malformations of head and neck that may
provide an effective alternative to other expensive methods like
embolization.
Corset suturing can be done parallel to the facial nerve branches in
order to prevent transient facial nerve palsy.