Lipid deposits in human atherosclerotic fibrous plaques exhibit marked differences in chemistry and ultrastructure from lipid deposits in fatty streaks, leading some investigators to question whether fibrous plaques originate from fatty streaks. To examine lesion transition, we employed lipid microanalysis, electron microscopy, and immunohistochemistry on fatty streaks, fibrolipid lesions (small raised lesions), and fibrous plaques from human aorta. Both fatty streaks and caps of fibrolipid lesions were high in esterified cholesterol content (mean, 62% of total cholesterol) and high in cholesteryl oleate content compared with cholesteryl linoleate content. Fatty streaks and fibrolipid lesion caps also showed similar morphology, characterized mostly by macrophage-derived foam cells in the superficial intima. Core lipids in both small and large raised lesions differed markedly from this pattern. Fibrolipid lesion cores showed mostly vesicular extracellular deposits, sometimes accompanied by cholesterol clefts, while fibrous plaque core deposits were also extracellular but had a variable appearance. Compared with fatty streaks, fibrolipid lesion cores showed significantly increased free/total cholesterol fractions (63%) and decreased fractional contents of cholesteryl oleate. Fibrous plaque cores had variable distributions of free and esterified cholesterol but significantly decreased cholesteryl oleate fractions compared with fatty streaks. The results support the concept of lesion transition, which is marked by deep intimal, extracellular deposition of cholesterol-rich, vesicular lipid deposits in small raised lesions. In the core region of larger raised lesions, both cholesterol-rich and cholesteryl ester-rich lipid deposits appear to form in the extracellular space.