BACKGROUND Soft-tissue loss is expected after resection of large vascular lesions. Autologous fat transfer improves asymmetries; however, systematic outcomes are not previously described for vascular anomaly reconstruction. METHODS Retrospective chart review from 2012 to 2015 included patients receiving autologous fat transfers for soft-tissue defects during or following vascular anomaly surgery at a tertiary care center. Patients received dermal en bloc fat grafts, lipoaspirates, or both. Pre- and postoperative photographs were blindly reviewed by 3 facial plastic surgeons using a 5-point scale. Dermal abdominal en bloc fat grafts were placed immediately after excision of a vascular anomaly. Lipoaspirate fat grafting was performed using liposuction (modified Coleman technique) and centrifugation. The effectiveness of fat transfers was assessed using patients' photographs. Final follow-up was 6 months to 5 years. RESULTS There were 35 autologous fat transfer surgeries in 27 patients. Fourteen patients received en bloc dermal fat grafts (14 total), 13 lipoaspirate transfers (21 total), and 3 both. Ages ranged from 2 to 69 years (mean = 25 years). Majority of patients (81%) had head and neck lesions. Average volume of fat injected was 16.5 mL (range 0.8-100 mL). The average observer rating score was 2.45 [1-5 (5-point scale)] in the en bloc fat graft group versus 3.83 in the lipoaspirate group (P < 0.0001) with acceptable inter-rater reliability between 3 observers (coefficient of concordance = 0.76). Follow-up ranged from 6 months to 5 years. There were 2 complications in the dermal fat graft group and none in the lipoaspirate group. CONCLUSIONS Autologous fat transfer improves symmetry and scarring after surgical treatment of vascular anomalies. Fat grafting is permanent and reliable and creates a more symmetric soft-tissue contour compared with dermal fat grafts.