Surgical treatment of capillary malformations

Capillary malformations (CMs), commonly known as port-wine stains, are congenital vascular anomalies composed of dilated capillaries in the superficial dermis. While many remain flat and blush-colored in early life, lesions often darken, thicken, and develop hypertrophy over time, particularly in adulthood.

Laser therapy, especially pulsed dye laser (PDL), is the first-line treatment, particularly in childhood. However, when CMs become nodular, disfiguring, or refractory to laser, surgical treatment may be considered. 

Indications for Surgical Treatment

Surgery is not the primary treatment for CMs, but it plays a critical role in specific, advanced cases:

 Nodular or Hypertrophic Transformation

• CMs that develop nodules, cobblestone texture, or progressive thickening may no longer respond to laser and may require complete excision with reconstruction.

Soft Tissue and Bone Hypertrophy

• Particularly in the face, lips, or limbs, where the CM is associated with tissue overgrowth.

• May require soft tissue reduction, lip reduction cheiloplasty, or orthognathic/maxillofacial surgery.

Bleeding or Ulceration

• Thickened or traumatized lesions may bleed easily.

• Surgical excision or laser-assisted debulking can relieve symptoms.

Cosmetic Deformity or Patient Preference

• Some patients seek surgical improvement when:

  • Laser fails to lighten the lesion

  • Facial symmetry or contour is visibly affected

  • Nodules are causing social embarrassment

Diagnostic Uncertainty

• Rarely, biopsy or excision may be indicated when a lesion changes rapidly, mimics other pathologies (e.g., hemangioma, melanoma), or becomes suspicious.

Surgical management of capillary malformations (CMs), particularly hypertrophic or nodular port-wine stains, requires a case-by-case approach based on lesion extent, location, patient age, and previous treatments.

• Surgery is most effective when:

  • Lesions are localized, nodular, or refractory to laser

  • There is associated tissue overgrowth (e.g. lip, cheek, jaw)

  • Goals include debulking, restoration of contour, or functional correction

Complete excision of flat lesions is rarely feasible due to their diffuse cutaneous distribution and the potential for scarring.

Common Surgical Techniques

Full-Thickness Surgical Excision

• Used in small, well-localized lesions that are resistant to laser.

• Requires reconstructive closure:

  • Primary closure (small lesions)

  • Local flaps (cheek, lip)

  • Skin grafts (larger areas, especially limbs or scalp)

• Indicated in bleeding, ulcerated, or suspicious lesions.

Lip Reduction Surgery (Cheiloplasty)

• Common in facial capillary malformations with soft tissue hypertrophy, especially of the lower lip.

• Resection techniques include wedge excision, transverse mucosal reduction, and debulking of hypertrophic muscle.

• Aims to improve function (speech, eating) and aesthetic balance.

Maxillofacial or Orthognathic Surgery

• Indicated in severe cases with bone overgrowth of the jaw or facial skeleton.

• Requires 3D imaging, surgical planning, and often multidisciplinary coordination.

• Performed generally in adulthood or post-growth to minimize relapse risk, or sometimes earlier in selected cases.

Secondary Aesthetic Revision

• After initial debulking or excision, patients may benefit from:

  • Laser resurfacing

  • Scar revision

  • Contour sculpting (fat grafting, dermal fillers, etc.)

Surgical treatment of capillary malformations (CMs) — especially nodular or hypertrophic lesions — can provide meaningful improvements in form and function, particularly when laser therapy alone is insufficient. However, outcomes depend on lesion characteristics, the extent of tissue involvement, and the type of surgical intervention used. It often leads to:  

ï  Improved body image and confidence, especially important in adolescents and young adults.

ï  Reduced anxiety and social avoidance, particularly in cases where nodularity or bleeding causes embarrassment.

ï  Enhanced sense of normalcy after years of failed laser treatments or visible progression.

Patients may still require multiple interventions, and a thorough evaluation of their expectations is essential.  

Laser therapy in capillary malformations

Laser therapy, particularly with pulsed dye lasers (PDL), is the first-line treatment for capillary malformations (CMs), especially when initiated early in life. It targets the abnormal dermal capillaries that make up the malformation, aiming to lighten the lesion, prevent hypertrophy, and improve cosmetic appearance with minimal invasiveness. While not universally curative, laser therapy has significantly improved CM management, particularly in children.

The pulsed dye laser (PDL) works via selective photothermolysis — the precise targeting of blood vessels using specific wavelengths of light that are absorbed by oxyhemoglobin, causing thermal damage to the vessel wall while sparing surrounding tissue.

Indications for Laser Use

PDL therapy is indicated in the following CM scenarios:

Early Intervention in Infants and Children

• Laser is most effective when started early in infancy.

• Lesions are flatter, vessels are smaller and more superficial, therefore better lightening can be achieved if the lesion is treated early.

Cosmetic Lightening in Adolescents and Adults

• Reduces red-purple discoloration, improves skin texture, and may prevent psychosocial distress.

• Often used after other therapies or as maintenance.

Preventing or Delaying Hypertrophy

• Early laser may slow the progression of thickening or nodularity, though it cannot reverse existing hypertrophy.

Adjunctive to Surgery

• Laser can be used post-surgically to improve residual redness or smoothen skin tone.

• Also used after debulking to manage remaining superficial vessels.
  

Outcomes and effectiveness

Population: Infants
Expected Outcome: Up to 70–90% lightening with early treatment (within 1st year)

Population: Older children
Expected Outcome: Moderate lightening; fewer treatments needed than adults

Population: Adults
Expected Outcome: Variable response; improvement in color and texture, less impact on thickened lesions.

Early referral = better outcomes.

Laser sessions are typically spaced 4–8 weeks apart, with multiple sessions (6–12+) required.

PDL treatments can be applied to infants with or without anesthesia; adults and older children may require atopical anesthetic. It has low complication rates when performed by experienced providers and can be safely used on the face, neck, limbs, andperiorbital region. As mentioned, the best results are achieved when treatments are initiated early in infancy.In cases presenting later during childhood, adolescence, or adulthood, the results may vary; however, PDL is always offered as a first-line treatment modality.