Introduction Vascular malformations of the head and neck encompass a wide range of lesions, including lymphatic malformations, hemangiomas, venous malformations and true arteriovenous malformations. Treatment of these lesions is challenging because of the vital structures in the region as well as the need to preserve function and aesthetics. The mainstay of treatment has been reconstructive surgery and glue embolization. Onyx is an ideal embolization material; however, its use has been limited due to concerns of tattooing the skin. We present three cases of high flow facial arteriovenous malformations effectively embolized transarterially and/or percutaneously with Onyx without complication.

Case presentation Patient No 1 is a 22-year-old man with arteriovenous malformation of the right lower lip with a high flow fistulous component. The patient presented because of prominence of the lower lip and daily episodes of pulsatile bleeding from the lip. Patient No 2 is 16-year-old woman with a left malar arteriovenous malformation (AVM) who presented because of asymmetric prominence of her left cheek that was intermittently painful and occasional episode of epistaxis. Patient No 3 is an 11-year-old girl with a large left maxillary AVM who presented with multiple episodes of epistaxis, bleeding from her mouth after brushing her teeth and emesis consisting of swallowed blood.

Results The three patients were successfully embolized utilizing either a transarterial or percutaneous approach with Onyx. Specifically, patient No 1 had embolization of the facial artery and lower lip AVM in two stages. There was some tattooing of the lower lip which was acceptable as it was within the planned resection field. There were no other areas of tattooing along the remainder of the lip, lateral commisure or chin. Patient No 2 had transarterial embolization of the descending palatine artery and sphenopalatine arteries with cure. No tattooing of the left check or nasolabial fold was seen. She has persistent hypertrophy of the left cheek soft tissues and is planned for reconstructive molding of the cheek. Patient No 3 had embolization of the sphenopalatine artery, descending palatine artery and facial artery as well as direct percutaneous embolization of her maxillary AVM. No tattooing of her cheek, lips, oral mucosa or gums were noted.

Conclusion Transarterial and percutaneous embolization of facial AVMs can be safely performed with little risk of tattooing the skin or mucosal surfaces.