venous malformation is defined as malformations comprised of slow - flowing , abnormal dilated veins , and venous network . clinically venous malformations ( vm ) are present at birth and tend to grow steadily in proportion to the somatic growth of the child . venous malformations are congenital lesions that affect boys and girls equally with a reported risk of developing other conditions within a specified period of time . the occurrence rate is 1 - 2 per 10,000 births and 0.1 - 1% of a population are found to have this condition . histologic and histochemical studies show that abnormalities are formed by small and large dysplastic post - capillary , thin - walled vascular channels with patchy deficiency of mural smooth muscle . a 28-year - old male was referred to the oral and maxillofacial clinic for evaluation of multiple swellings on the left side of the face and inside his mouth . the patient first noticed the swelling over the temple when he was 11-years - old . as the boy grew , the swelling also proportionately increased . multiple poorly defined swellings were noted on the left side of the head and neck region around the temple , cheek , and submandibular region [ figure 1a and b ] . similar lesion was noted in the supraclavicular and scapular region [ figure 2a and b ] . the swelling was pulsatile and increased in size the when patient was standing ( dependent position ) . intraorally lobulated swelling was noted on the floor of the mouth in the left sublingual region . the lesion measured 3  4 cm , filling the entire floor of mouth , and purplish discoloration was also noted over the swelling [ figure 3a and b ] . ( a ) photograph ( front view ) shows swelling over the temple region and ( b ) photograph ( side view ) reveals well defined swelling over temple ( large arrow ) diffused swelling in the cheek , and submandibular region ( small arrow ) . ( a ) photograph shows a well - defined swelling measuring 1  1 cm in the left supraclavicular region and ( b ) photograph of the scapular region shows a diffused swelling . ( a ) intraoral photograph shows swelling in the floor of mouth filling the entire floor of mouth ( arrow ) and a small swelling in the buccal mucosa that has a purplish hue ( small arrow ) . ( b ) intraoral photograph of the labial sulcus reveals a purplish swelling ( arrow ) . ultrasonography of the submandibular region showed a well - defined hypoechoic lesion having anechoic areas with septations , showing flow inside the lesion . ultrasonography of the submandibular region with 7 mhz small parts transducer shows heterogeneous hypoechoic lesion with slow flow and hyperechoic foci suggestive of calcifications ( arrow ) . magnetic resonance imaging ( mri)-t2-weighted fat suppression , post - contrast axial images showed hyperintense lesions , which are well - defined with no flow voids . all the lesions in the submandibular , cheek , and temple region had similar findings [ figure 5 ] . direct puncture phlebogram of the left frontal scalp region revealed pooling of contrast into cavernous spaces draining into external jugular vein [ figure 6 ] . ( a ) axial section at the submandibular region shows well - defined hyperintense lesion ( arrow ) in the floor of mouth . ( b ) axial section at the level of cheek shows well - defined hyperintense lesion in the cheek region ( arrow ) . phlebography of the lesion in the temple region shows filling of the entire lesion and draining to the regional area ( arrow ) . histopathological examination revealed several thin - walled venous channels lined by flattened endothelium , supported by a dense uninflamed fibrous connective tissue stroma . hematoxylin and eosin stained specimen ( 40 ) shows irregular venous channels ( large arrow ) lined by thin endothelium . venous malformation ( vm ) is the second most common vascular anomaly of the head and neck after hemangioma . venous malformations can occur anywhere in the body but are most frequently seen in the head and neck ( 40% ) , extremities ( 40% ) , and trunk ( 20% ) . vms are slow - flow vascular anomalies composed of ectatic venous channels that will continue to grow throughout the patient 's lifetime . they grow slowly in size with age , but their growth may be exacerbated following trauma , sepsis , or hormonal changes and they do not regress spontaneously . both men and women are equally affected . vascular malformations are believed to be the result of a congenital error of vascular morphogenesis that occurs between the 4 and 10 weeks of intrauterine life . vascular malformations have a quiescent endothelium and are considered to be localized defects of vascular morphogenesis , likely to be caused by dysfunction in pathways regulating embryogenesis and vasculogenesis . these lesions vary in color depending on depth of involvement and range from mild detectable color change to deep purple color . these lesions fill when the patient is standing and are compressible , which helps to distinguish them from lymphatic malformations on physical examination . areas frequently involved in the head and neck region are masseter , temporalis , tongue musculature , as well as oral and airway mucosa . soft tissue lesions are most frequently facial in location , with the buccal region being the most common site followed by the mandibular space , sublingual space , tongue , and orbit . intraosseous calvarial involvement is most frequent in the frontoparietal region and the mandible is the most frequent location within the facial skeleton . there may , however , be no visible manifestations with deeper lesions . in our case , the first anatomopathologic classification of vascular lesions based on the microscopic appearance was developed by virchow and wegner . mulliken and glowacki ( 1982 ) developed a biological classification of vascular anomalies that included physical findings , clinical behavior , and cellular kinetics and classified them as hemangiomas and vms . a more recently updated classification of vascular anomalies by international society for the study of vascular anomalies is now widely used [ table 1 ] . classification of vascular anomalies ( issva 2007 ) plain radiographs have limited role in the investigations as they can identify only phleboliths . ultrasound ( us ) is often the initial investigation to evaluate vascular malformations and it may characterize and define the extent of more superficial lesions . on gray - scale imaging , venous malformations can appear as hypoechoic or heterogenous lesions with anechoic structures visible in 50% of cases . in addition , the doppler flow is generally monophasic low velocity flow , and in some cases flow is only discernible with compression and release of the lesion . they typically appear as isointense or hypointense lesions on t1-weighted images , but could be hyperintense depending on the presence of intralesional fat . lesions are typically lobulated , which gives them the characteristic  bunch of grapes  configuration . septations and rounded signal voids corresponding to phleboliths are additional distinguishing features . in t2-weighted or inversion recovery sequences , vms demonstrate high - signal intensity.this imaging modality is used to determine the full extent of the lesion and its relationship to adjacent vital structures . gradient echo sequences reveal areas of low signal corresponding to calcification or hemosiderin or thrombosis . t1-weighted post contrast imaging demonstrates homogenous or heterogeneous enhancement , and dynamic contrast - enhanced mri has increased the specificity of venous malformation diagnosis . vms are best demonstrated by direct phlebography , which fills the sinusoidal spaces and any anomalous veins , allowing assessment of the size and extent of the lesion . in the present study , phleboliths were seen on plain radiography and us features were suggestive of vascular anomaly with slow flow rate . whereas , the mri features were suggestive of venous malformation , which was confirmed by direct phlebography where the lesion was seen draining the regional vein . venous malformations usually are associated with syndromes like proteus syndrome and blue rubber bleb nevus ( bean ) syndrome . multiple treatment options exist for venous malformations , including conservative measures such as head of bed elevation and compression , laser therapy , sclerotherapy , and surgery . conservative management of venous malformations is usually reserved for smaller isolated asymptomatic lesions and is also important in controlling the growth and symptoms . elevation of the head of the bed is important as it decrease hydrostatic pressure in the malformation , which can lead to expansion and can also decrease symptoms of airway obstruction , swelling , and pain that are experienced . sclerotherapy remains a good option for the treatment of venous malformations in the head and neck . sclerotherapy involves percutaneous injection of a substance to induce inflammation and thrombosis of the lesion , which then will lead to more long - term fibrosis and hopefully decrease or eliminate the expansion of the lesion . sotradecol foam or ethibloc ( glue ) , or the sclerosant is mixed with fibrin glue or ethyl cellulose , bleomycin ( pingyangmycin ) and picibanil ( ok-432 ) have recently been used as sclerosants in asia with promising results . large cervicofacial venous malformations present a much greater challenge , and one must be prepared to use multimodal therapy to keep the lesion under control . these lesions generally can not be cured as doing so would leave devastating functional and cosmetic results . therefore , therapy is used to control growth , maintain cosmesis , and decrease symptoms . venous malformations are either superficial or deep veins that are abnormally formed and dilated . a thorough examination and investigation of the condition is needed to establish the exact extension of the condition and plan proper treatment .
vascular malformations are congenital lesions that are present at birth and do not regress 
 . however , they often present later in life . 
 they are subdivided into two categories : ( 1 ) slow- or low - flow and ( 2 ) fast- or high - flow malformations . 
 low - flow malformations contain combinations of capillary , venous , and lymphatic components . 
 venous malformations can occur anywhere in the body , but are most frequently seen in the head and neck ( 40% ) . 
 these lesions present in a variety of ways , from a vague blue patch to a soft blue mass , which may be single isolated or may occur in multiple areas . 
 treatment depends on the type of lesion , the location , degree of involvement , and the clinical symptoms . 
 here we are report the imaging and histopathologic findings in a patient with multiple venous malformations affecting the left side of the face and trunk .