Capillary malformation (CM), or port wine birthmark, is a congenital low-flow vascular malformation of dilated capillaries and postcapillary venules. It often affects the face and may darken, thicken, or develop nodules over time. Most CMs are isolated but can be associated with syndromes such as Sturge-Weber, characterized by a facial CM, leptomeningeal vascular malformation, and ocular findings such as glaucoma. CMs also occur in other syndromes, emphasizing the need for thorough clinical evaluation. Management is multidisciplinary, with pulsed-dye laser as the gold standard treatment; excision may be required for tissue overgrowth.
Infantile hemangioma (IH) is the most common benign soft tissue tumor of infancy with its pathogenesis yet to be elucidated. IHs are defined as vascular tumors of infancy and the diagnosis of IH is largely based on clinical findings, most commonly the characteristic strawberry appearance. IHs follow a stereotyped life cycle of rapid growth, a plateau, and eventual involution, and most do not require treatment. If complicated, first-line medical treatment of IH is oral propranolol, currently the most commonly used and efficacious drug. Surgery remains an option but is reserved for IHs primarily not responsive to medical treatment.
This article reviews the evolving role of laser therapy in the management of vascular anomalies, emphasizing advances in selective photothermolysis, wavelength optimization, pulse modulation, and epidermal cooling that have improved treatment precision and safety. It outlines the principles of laser-tissue interaction and discusses how different laser systems, including pulsed dye laser, Nd:YAG, alexandrite laser, and IPL, are tailored to lesion depth and vascular characteristics. The article further examines lesion-specific management strategies for infantile hemangiomas and port-wine capillary malformations, highlighting indications, outcomes, limitations, and multimodal approaches. Emerging therapies such as photodynamic therapy are also discussed as promising options for resistant vascular lesions.
Vascular anomalies are classified as malformations or tumors. Depending on the vascular anomaly's location, extent, genetics, and effect on the patient, symptoms may be managed surgically, medically, using interventional means, or with all modalities. Surgical resection requires extreme care and diligence to ensure maximal resection and patient safety. Recent advancements in genetics and treatment agents have helped physicians provide targeted medical therapies.
Vascular anomalies span a wide biological spectrum, from self-involuting infantile hemangiomas to life-threatening arteriovenous malformations. This review focuses on the conditions most commonly managed by interventional radiology, organized within the 2025 International Society for the Study of Vascular Anomalies classification framework. It covers the principles and agents of sclerotherapy for venous and lymphatic malformations, including comparative evidence for sclerosing agents, and embolization strategies for arteriovenous malformations and hereditary hemorrhagic telangiectasia -related pulmonary arteriovenous malformations. Also reviewed is the role of cryoablation in fibroadipose vascular anomaly, complex lymphatic anomaly management and the emerging techniques of bleomycin electrosclerotherapy and bleomycin electroembolotherapy.
Lymphatic malformations (LMs) are rare congenital vascular anomalies commonly affecting the cervicofacial region and frequently associated with somatic PIK3CA mutations. According to the 2025 International Society for the Study of Vascular Anomalies guidelines, LMs are classified into isolated lesions, complex anomalies, and lymphedemas. Diagnosis relies on ultrasound, MRI, and magnetic resonance lymphangiography for anatomic and functional evaluation. Management has evolved from primarily surgical excision to a multidisciplinary, multimodal strategy. Sclerotherapy and sirolimus now play central therapeutic roles, while surgery remains important for reconstruction and deformity correction. Emerging techniques such as bleomycin electrosclerotherapy and laser therapy further enhance individualized treatment outcomes.
Lower-extremity reconstruction in pediatric patients is a challenging yet highly rewarding field. Reconstructive principles should mirror that of the adult patient population, however, with special considerations. An emphasis on the psychosocial adjuncts, the use of appropriate anticoagulation and postoperative activity restriction, and pain control should be tailored to each individual patient. When these factors are carefully considered, one can achieve a high rate of limb salvage with stable long-term outcomes compared to the adult population. There is a strong role for the inclusion of a microvascular surgeon in pediatric surgery, as innovations in reconstructive microsurgery have made limb salvage a viable option in patients who otherwise would face amputation. In children, lower extremity reconstruction is often warranted after an acute trauma or in the setting of oncologic reconstruction. It was once thought that attempting microvascular reconstruction in this patient population would be fraught with complications secondary to smaller vessel size and increased risk of thrombosis; however, multiple studies have found that microvascular reconstruction is safe and effective and should be attempted in this patient population.20,21 When able, microsurgeons should be involved in these cases so as to provide the patient with the best achievable outcomes given the unique nature of pediatric lower extremity reconstruction.
Pediatric lower extremity reconstruction, especially following trauma or oncologic resection, presents unique challenges requiring a multidisciplinary approach. Management emphasizes early, thorough debridement, appropriate fixation-often with flexible intramedullary nails-and timely, well-vascularized soft tissue coverage. Nerve injuries are addressed with autografts or allografts, with children demonstrating better regenerative capacity than adults. Postoperative protocols focus on immobilization, pain management, psychosocial support, and structured rehabilitation, with family involvement crucial for adherence. Microsurgeons are essential for complex reconstructions and addressing complications like critical limb ischemia. The field continues to evolve, prioritizing functional limb salvage and long-term quality of life for pediatric patients.
Gustilo IIIC fractures represent the most severe spectrum of lower extremity trauma, characterized by high-energy skeletal injury, vascular disruption, and soft-tissue loss. Contemporary management demands early orthoplastic collaboration, rapid revascularization, and thoughtful soft-tissue reconstruction to optimize limb salvage. This review synthesizes current evidence and evolving strategies, including timing of coverage, flap selection, and adjunctive microsurgical techniques including flow through flaps, to guide decision-making in these complex injuries. Emphasis is placed on functional restoration, prevention of complications, and integration of modern limb-salvage paradigms to achieve high-quality outcomes in this challenging patient population.
Chronic lower extremity (LE) wounds represent a growing source of morbidity, limb loss, and health care expenditure, driven by rising rates of diabetes, vascular disease, and advanced age. Effective management requires a comprehensive understanding of underlying wound pathophysiology, etiology, and patient risk factors. This article reviews the assessment and multidisciplinary management of chronic LE wounds, emphasizing infection control, vascular optimization, and biomechanical correction. Institutional outcomes using a coordinated "vasculoplastic" approach demonstrate that complex limb salvage for chronic LE wounds with free tissue transfer can achieve high flap success, durable wound healing, and meaningful functional recovery in high-risk patients.
This review focuses on the complex pathophysiology of the burn injury and its effects on lower extremity reconstruction in acute burns. Multiple aspects of burn care are discussed in conjunction with lower extremity reconstruction principles. Key discussion points include considerations for acute management such as full thickness burn injuries with exposure of critical structures, circumferential injuries, high voltage electrical injuries, the risk for compartment syndrome, strategies for meticulous wound care and infection prevention, adequate excision, early definitive or temporary coverage. The role of reconstructive options including skin substitute, skin grafting, local flaps, free flaps, amputations and late consequences is reviewed.
The orthoplastic approach to lower extremity reconstruction describes a multidisciplinary management strategy for lower extremity wounds of all causes, which optimizes patient outcomes through its focus on expedient bony and soft tissue reconstruction and early focus on rehabilitation. In this review, the authors discuss the general orthoplastic algorithm for lower extremity wound assessment, management, and reconstruction of lower extremity composite defects, while highlighting technical innovations and ongoing research advancing the field of orthoplastic surgery.
Lower extremity reconstruction has evolved from a focus on limb salvage to prioritizing functional restoration. This shift has been driven by advances in microsurgery, fixation techniques, imaging, and the integration of orthopedic and plastic surgery expertise through the orthoplastic approach. This collaborative model emphasizes simultaneous bone stabilization and soft tissue reconstruction, recognizing their interdependence in healing. Evidence shows reduced infection rates, faster definitive treatment, and improved functional outcomes with orthoplastic care. Modern strategies favor the "reconstructive elevator" concept, enabling tailored, often single-stage, solutions using perforator-based and microsurgical flaps to address complex bone and soft tissue defects effectively.
Fixation of vascularized bone grafts (VBGs) relies upon established osteosynthesis principles. VBGs offer the opportunity to transfer living bone with remodeling and hypertrophy potential for reconstruction of bone defects throughout the lower extremity. In defects of the pelvic ring, femoral head and neck, ankle, and foot, as well as for juxta-articular and intercalary long-bone defects, pedicled and free fibula and medial femoral condyle flaps are used to this end. These options provide an autologous structural donor that allows patients to achieve osseous union and functional success.
Lower extremity (LE) reconstruction presents unique challenges due to complex wound environments, compromised vascularity, and high functional demands. Compared with other anatomic regions, free flap reconstruction in the LE demonstrates higher complication and failure rates. Early microsurgical intervention improves outcomes, though negative pressure wound therapy can bridge to delayed coverage. In oncologic patients, radiation and chemotherapy impair tissue quality and recipient vessels, necessitating meticulous planning and vessel selection outside the zone of injury. Anatomic location influences reconstructive options, ranging from local flaps to free tissue transfer. Risk stratification models, such as the A-Sarc score, support evidence-based reconstructive decision-making.
