British Journal of Plastic Surgery (2005) 58, 1073–1078

Direct percutaneous ethanol instillation for

treatment of venous malformation in the face and
neck
Chih-Hsien Lee, Shyi-Gen Chen*

Division of Plastic and Reconstructive Surgery, Department of Surgery, National Defense Medical Center,
Tri-Service General Hospital, No. 325, Section 2, Cheng-Gung Road, Taipei 100, Taiwan, ROC

Received 29 April 2004; accepted 18 April 2005

KEYWORDS Summary Venous malformations of the face and neck involve multiple
Ethanol; anatomical spaces and encase critical neuromuscular structures, making surgical
Sclerotherapy; treatment difficult; high recurrence rates and high morbidity are well documented.
Venous malformation Various methods of treatment of uncertain value and risk of complications have been
advocated. We present our experience in treating five patients with venous
malformation in the face and neck by using direct percutaneous ethanol
sclerotherapy. Four patients had large lesions (R3 cm; one patient had two large
lesions in the low eyelid), and the other had a mid-sized lesion (1.5–3 cm). Under
general or local anaesthesia, one-third to one-quarter cavity volume of ethanol was
injected percutaneously, directly into the malformation with under fluoroscopy [de
Lorimier AA. Sclerotherapy for venous malformations. J Pediatr Surg 1995;30:188–
93; Johnson PL, Eckard DA, Brecheisen MA, Girod DA, Tsue TT. Percutaneous ethanol
sclerotherapy of venous malformations of the tongue. Am J Neuroradiol
2002;23:779–82; Pappas DC Jr, Persky MS, Berenstein A. Evaluation and treatment
of head and neck venous vascular malformations. Ear Nose Throat J 1998;77:914–22;
Lee CH, Chen SG. Direct percutaneous ethanol sclerotherapy for treatment of a
recurrent venous malformation in the periorbital region. ANZ J Surg.
2004;74(12):1126–7. 1–4]. Four patients required two injections. All patients had
remission and alleviation of their symptoms, with no major complications. Direct
percutaneous injection of absolute ethanol provides a simple and reliable alternative
treatment for venous malformation in the face and neck.
q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All
rights reserved.

Congenital vascular malformations exhibit an endo-

* Corresponding author. Tel.: C886 28 792 7195; fax: C886 28
thelial cell growth cycle that affects the veins,
792 7194. capillaries, or lymphatics.1 These malformations
E-mail address: shyigen@ms26.hinet.net (S.-G. Chen). grow proportionately with age.1,2,5,6 Complete
S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2005.04.014
1074 C.-H. Lee, S.-G. Chen

surgical excision is seldom achieved in the past,

because this usually leads to nerve damage,
massive bleeding, and deformity if the lesion is
extensive or located in the face and neck. Scler-
otherapy is an alternative method of treatment,
and direct percutaneous treatment with 95% etha-
nol has proven effective and safe.2,5 In this report,
we describe and discuss our experience in treat-
ment of venous malformations using direct ethanol
instillation under fluoroscopic guidance.

Patients and methods

Between October 1998 and June 2003, five men

with recalcitrant venous malformation in the face
and neck were admitted to and treated at our
university-based teaching hospital. The average age
of the patients was 22 years (range 20–23 years).
Diagnosis was confirmed by either a combination of
history clinical presentations (Fig. 1), gross ana-
tomical findings, or selective external carotid
angiography and magnetic resonance imaging
(MRI) (Fig. 2). All patients had complete medical
records available for retrospective review.
Percutaneous ethanol sclerotherapy was used
under fluoroscopy using intravenous general anaes-
thesia. Rubber bands were used to compress the
patient’s forehead and chin to occlude facial
venous return. Contrast medium was injected
toward the engorged vascular lesion using a No. 18
venipuncture catheter, followed by injection of
one-third to one-quarter cavity volume of 95% ethyl
alcohol into the tumour cavities under fluoroscopic
monitoring (Fig. 3).
Upon withdrawal of the catheter, compression
was maintained for 5 min to fix the solution in the
clot and the vein walls. A venous blood sample was
taken at the end of the procedure to determine the
serum ethanol level. Intravenous dexamethasone
(0.1 mg/kg) was given for 3 days postoperatively to Figure 1 (A) The clinical appearance of soft-tissue
control inflammation. This was then gradually deformity situated around the patient’s right cheek. (B)
tapered off over the following 5 days. The clinical appearance of a soft protruding mass situated
Repeated courses of 95% ethanol injection were around the patient’s left lower eyelid and left cheek.
administered into very large malformations. Over-
all, the five patients underwent eight sessions of Results
ethanol sclerotherapy. The interval between injec-
tions was usually 3–6 weeks, to determine whether Three malformations were located in the cheek,
abnormal venous channels persisted. The patients three in the eyelid—one patient had a combined
were examined with MRI to evaluate the possible lesion in the cheek and eyelid and the other had two
remaining extent of venous malformation. Treat- lesions in the eyelid—and one in the posterior neck.
ment success was determined clinically by All patients had some cosmetic manifestations. The
reduction in lesion size and by patient satisfaction. number of injections ranged from one to two. Three
Ethanol instillation for venous malformation in the face and neck
Figure 2 (A) T2-weighted magnetic resonance image showing an area of high signal intensity, which represents the
low-flow vascular malformation over the left maxillary region and the left infraorbital region (arrow).
patients had undergone previous surgical interven-
tion. One had experienced functional difficulty,
with hearing disturbances after the first surgical
intervention. Direct intralesional contrast injection
was performed under fluoroscopy to demonstrate
and determine the volume of venous cavities. Four
patients had large lesions (R3 cm; one patient had
two large lesions in the lower eyelid), and the other
had a mid-sized lesion (1.5–3 cm). All the patients
had remission and alleviation of their symptoms,
with no major complications. Four patients
required two injections. Two patients had transient
facial paresis, which resolved spontaneously within
3–5 days (Table 1).
Follow-up ranged from 9 to 62 months (mean
43.6 months). The malformation size was reduced,
and all patients expressed satisfaction with the
result.
Figure 3 Operative field. Rubber bands were used to
compress the patient’s forehead and chin to occlude
facial venous return.
1075
Case reports
Case 1
A 21-year-old man had a recurrent venous malfor-
mation of the right cheek. Initial tumour excision
surgery was performed at another hospital 14 years
ago. The symptoms were temporarily relieved, but
gradually recurred. The venous malformation occu-
pied the right cheek and cosmetic problems were
noted (Fig. 1(A)). Percutaneous ethanol sclerother-
apy instillation under fluoroscopy was used in place
of surgery. A total of 50 mL of ultravist contrast
medium (Berlex) was injected into the venous
pouch of the right cheek using a No. 18 venicath-
eter, followed by 13 mL of 95% ethanol. Post-
operatively, hydrocortisone was given
intravenously for 3 days to diminish any inflamma-
tory reactions. Near-complete obliteration of the
venous malformation was achieved after two sets of
injections (Fig. 4(A)). The patient is very satisfied
with the results, and there have been no compli-
cations or recurrences during a 48-month follow up
period.
Case 2
A 21-year-old man had two recurrent venous
malformation of the left lower eyelid. Initial
tumour excision surgery was performed at another
hospital 10 years ago. The symptoms were tempor-
arily relieved, but gradually recurred. This venous
malformation occupied the entire left orbital cavity
and interfered with vision. Physically, his conjunc-
tiva was inflamed and there was a soft tissue mass
with local tenderness around his left lower eyelid
and cheek after Valsalva’s manoeuvre (Fig. 1(B)).
Visual acuity was 1.0 (6/60), bilaterally and no
visual field defect was noted. Complete surgical
1076 C.-H. Lee, S.-G. Chen

Table 1 Patient details

Case Age Location Previous Pre- Injected Complication Post- Follow up
No. surgery operative number operative (month)
size (ml) size (ml)
1 21 Cheek Yes 50 2 Mild pain 16 48
2a 23 Low eyelid Yes 25 2 Mild pain 8 62
3 20 Cheek Yes 72 1 Postoperative 8 9
hearing
disturbance,
transient
facial paresis
4 23 Low eyelid, No 3 2 Transient 0.5 49
cheek facial paresis
5 23 Posterior No 20 1 Mild pain 2 50
neck
a
Two malformations were present in the eyelid of this patient.

removal was not possible due to extensive involve-
ment of the left orbital cavity and periorbital soft
tissue. Percutaneous ethanol sclerotherapy instilla-
tion under fluoroscopy was, therefore, used. Two
major venous malformations were treated, and
percutaneous venograms using soluble contrast
media were used to determine the volume of the
growths before treatment. A total of 20 mL of
ultravist (contrast medium was injected into the
larger venous pouch using a No. 18 angiocatheter,
followed by 5 mL of 95% ethanol. In the other
venous pouch, 25 mL of ultravist was injected,

Figure 4 (A) Near-complete obliteration of the venous malformation was achieved after two sets of injections were
given. (B) Near-complete obliteration of the venous malformation was achieved after two sets of injections were given.
Ethanol instillation for venous malformation in the face and neck
followed by 8 mL of 95% ethanol. Postoperatively,
hydrocortisone was given intravenously for 3 days
to diminish any inflammatory reactions. Near-
complete obliteration of the venous malformation
was achieved after these two sets of injections
(Fig. 4(B)). The patient is very satisfied with the
results, and there have been no complications or
recurrences during a 62-month follow up period.
Discussion
Vascular malformations appear at birth as dys-
morphic vessels.7 Depending on the predominant
vasculature involved, they are classified as arterial,
capillary, lymphatic, venous, or combined.1,3,4,7–9
Lesions may be localised, or can involve extensive
areas of the body. Histologically, they comprise
thin-walled channels, deficient in smooth muscle,
and lined by a single layer of endothelium.1,2
With lesions in the face and neck, patient
concern focuses on cosmetic considerations more
than functional difficulties. 3 Symptoms vary
depending on the location of the lesions, which
are soft, compressible, nonpulsatile masses that
may cause sudden pain, and which may exhibit
development of a firm mass that subsides within
days.1,7 Even small venous malformations can cause
severe pain. Phleboliths are occasionally palpable
and are confirmed by radiography.3 Few venous
malformations are radioresistant.1 The lack of
prominent pulsation indicates they are not arter-
iovenous malformations. They can be compressed
to empty the blood contents, but the vascular
channels become slowly distended as the com-
pression is released. Venous malformations of the
face and neck may be become more engorged
during Valsalva’s manoeuvre or dependent
positioning.3
The diagnosis of venous malformations is based
on careful history and clinical examination. MRI can
be used to define the extent of the malformations
of the face and neck, and define the pathway of
venous drainage.1,3,6,8 Venous malformations show
high signal intensity on enhanced MR images,6,8
which can be used to define the muscles or organs
involved. The malformations are classified as large
(R3 cm); medium (1.5–3 cm) and small (less than
1.5 cm).5 The patients were examined with MRI
after sclerotherapy, but the clinical significance of
postimaging is not so clear.9
Venous malformations have been treated by a
variety of techniques over the years, including
irradiation, electrocoagulation, cryotherapy, intra-
vascular magnesium or copper needles, surgical
1077
excision, lasers, compression, and sclerotherapy.8,
10,11
All these techniques have their particular
indications and limitations. Surgical excision is
useful only for localised and limited lesions.
Aggressive excision can lead to significant loss of
motor function, cosmetic problems, nerve damage,
or massive bleeding in patients with extensive
involvement because of the complicated anatomy
of the face and neck.6,12 Previous surgical treat-
ment of one of our patients produced a hearing
disturbance. Sclerotherapy has the advantage of no
external scaring, and few complications in com-
parison with surgical treatment. There are various
choices of agents for sclerotherapy: 5% sodium
morrhuate, sodium tetradecyl sulphate, ethanola-
mine oleate, OK432, bleomycin, ethanol, and
hypertonic saline, alone or in various combinations,
have all been used.1,7,9,13–15 There is no ideal vaso-
occlusive substance applicable to all venous mal-
formations. Bleomycin is an established antineo-
plastic drug, very few studies in the past have made
use of bleomycin as a sclerosing agent and showed
higher incidence of residual disease.14 Ethanol
shows the lowest rate of malformation recurrence
and is the most reliable substance of all of the
sclerosing agents.3,9,12,16 Ethanol is the most of
often used due to its low cost, antiseptic quality,
wide availability and easy of use; however, ethanol
sclerotherapy requires general anaesthesia because
the procedure is very painful.13 Direct percuta-
neous contrast injection into the cavity is also
required to detect the lesion volume and the
possibility of multiple compartments.
The volume of ethanol to be injected is deter-
mined from the percutaneous contrast study. In our
patients, one-third to one-quarter of the cavity
volume of 95% ethyl alcohol was injected into the
tumour cavities.1–4 After injection, ethanol scler-
otherapy requires stagnant flow and prolonged
exposure to the endothelium to cause disruption
of the endothelium, intense inflammatory reac-
tions, and blood coagulation.1–3,13 To achieve the
required result and to minimise the flow of ethanol
into normal venous drainage structures, we used
rubber bands to compress the patients’ foreheads
and chins to occlude facial venous return. Repeated
aggressive treatment is required for very large
malformations because recanalisation can occur,
and to reduce the risk of major morbidity from the
ethanol injection.1,12 Four of the five sclerotherapy
patients in this study had staged treatment, with
multiple injections. The interval between injec-
tions is usually 3–6 weeks, to allow time to
determine whether abnormal venous channels
persist and to allow local reactions to subside.
1078
Themaximum recommended dose of ethanol is
1 mL/kg of body weight.2,7,16,17
Patients were administered 0.1 mg/kg of dexa-
methasone immediately before the procedure, and
then every 8 h while in the hospital. Sclerotherapy
has the potential to fail with inaccessible lesions,
the lack of a proper vein for direct puncture,
premature interruption of therapy, venous outflow
connected to the deep vein system, and the
proximity of nerves surrounded by extensive venous
malformation.12,18 Potential complications of scler-
otherapy include local skin necrosis, transient
nerve palsy, haemoglobinuria, blood loss, and
anaphylaxis.1,3,5,7,8,11–13,18 Two patients in this
study experienced transient facial nerve palsy,
which resolved spontaneously within 3–5 days. The
major disadvantage of this treatment is severe
complication can rarely occur and include acute
pulmonary hypertension with cardio-pulmonary
collapse.13 To avoid such a catastrophic situation,
it is suggested to inject the ethanol slowly
combined with rubber band compression.9,13 Absol-
ute alcohol has not produced any reported allergic
reactions; however, the injection volume must be
limited because cerebral intoxication can occur
with very small amounts.1 The reported compli-
cation rates for percutaneous ethanol sclerother-
apy range from 0 to 15%.8 In this study, all patients
experienced symptomatic or cosmetic improve-
ment without major complications.
Permanent obliteration of lesions using percuta-
neous ethanol sclerotherapy is easier to achieve in
small-diameter vessels, and thus, ethanol scler-
otherapy is an effective alternative treatment for
venous malformations of the head and neck, and it
is wise to begin this treatment as early as possible
once the diagnosis is made. Careful planning is
essential to reduce the potential risks of the
procedure, and long-term follow-up of patients is
needed to detect any recurrence.
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C.-H. Lee, S.-G. Chen
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