A long path

The path to real improvement in the disease sometimes requires interventions or operations, which carry high expectations. Before an operation, the attending physician will go through an information process with the patient, which is tedious and sometimes painful. The patient has to learn that the nature of his or her illness means it often cannot be completely cured and that in most cases the goal aspired to must be defined more modestly than the patient might have imagined. It is A LONG PATH.

Since a step-by-step approach may be necessary in multiple smaller steps, and even if each step is clearly defined with individual goals in several interventions that often last several years, this may be difficult to accept. Therefore early and entirely open information is essential for a relationship of trust. All parties involved need the time to build this relationship.

It is only when realistic expectations are successfully established among those affected and their relatives that the relationship between doctor and patient/relatives, which is usually very long-term, can be built on trust that is stable enough to survive disappointments and setbacks.

The approach is different to tumor surgery, where the most radical possible resection of the lesion within safe oncological margins is the primary goal, to which cosmetic and possibly functional aspects must be subordinated. Other primary goals are defined in the surgical therapy of malformations. Even minimally invasive interventions often require a whole series of procedures in individual stages to guarantee long-term success because of their limited effectiveness. The risks involved are by no means always minimal.

Maintaining or restoring the best possible quality of life in the shortest possible time and for the longest possible period is the primary goal of these interventions. Such a goal is more vaguely defined than in tumor therapy and should therefore always be explained, consented to and jointly developed with the patient. Especially in the head and neck area, the cosmetic aspect plays an important role and must be considered as a matter of urgency. It is even more important to weigh functional aspects wisely against radicality. Sometimes it is wise to offer a young patient an incomplete resection of the lesion, knowing that follow-up procedures may have to be performed under less favorable conditions. The advantage of this strategy may be an external appearance that allows the patient to socialize better than the alternative of early, more radical surgery with significant visual consequences.

Another difference from interventional tumor therapy is found in the chronological sequence of the treatment steps. Whereas in oncology the first intervention usually determines the success of the therapy, in the case of malformations surgery in partial steps is not only permissible  but is necessary for a good result in a large number of cases. This requires not only a great deal of understanding of the disease on the part of patients and their relatives, but also great patience.

The special feature of minimally invasive procedures that may be necessary several times lies in a certain protecting of access routes, e.g., through the skin or vessels avoiding scars, and the fact that the a postoperative recovery time is often faster. The effects of the individual procedure are meant to be cumulative, and truly satisfactory results are often only achieved after several invasive procedures. This has to be made clear and openly communicated from the beginning to all involved parties.

General principles of surgery and oncological intervention cannot be transferred to malformations. Communication with patients and relatives must be adapted to the very specific situation, especially if cosmetically relevant areas are affected by the disease. Successful surgery of vascular malformations requires the attending physicians to rethink and adapt the procedures learned in oncological intervention or surgery. However, at the end of a treatment series, with all its ups and downs, there is usually a satisfactory result.