The treatment of vascular malformations (VM) of the extremities is controversial. Six patients with large, localized, symptomatic VMs of the extremities underwent surgical excision. In five cases abnormal vessels were apparent under the skin; in two of these there was also red discoloration of the skin secondary to skin involvement. Magnetic resonance imaging was the most helpful imaging modality in evaluating these patients. Subfascial resection was performed in five cases. Muscle was involved in four patients and was removed in all four cases. At follow-up, there was improvement in symptoms and function with no clinically apparent recurrence an average of 30 months following the operation. There was improvement in pain intensity from an average of 4.3 on a scale of 1 to 10 before surgery to 1.3 after surgery. Surgical excision of localized VMs that are extensive and include fascia and muscle, as appropriate, can successfully improve pain and function without evidence of recurrence at 1 to 5 years of follow-up.