Facial veins

“A esthetic phlebology” is a new buzzword in the world of vein surgeons and phlebologists. As the speciality of phlebology separates from vascular (arterial) surgery, doctors specialising in the treatment of varicose veins and leg veins are looking at other veins that can be treated. Professor Mark S Whiteley, leading consultant venous surgeon and founder of The Whiteley Clinic, looks at one of these new treatment areas, facial veins – specifically those that are not well treated by the current methods used in aesthetic clinics.

Most aesthetic medical practitioners are used to facial telangiectasia (aka “thread” or “spider” veins), usually on the cheeks, nose and chin, and small flat blue/ green veins, usually around the orbits or in the temporal area (temples). There are well-recognised approaches to assessing and treating these, usually with light therapies (intense pulsed light or laser), or coagulation with “hot needles” using electrolysis or radiofrequency (monopolar or bipolar) electrical currents.

However, these techniques are limited in the size of veins that they can treat. This limitation is understandable when one considers the physics of the devices used, and the anatomy and physiology of the veins.

Facial veins that cannot be treated with the usual aesthetic devices usually present as bulging green veins in the temples and periorbital regions, or colourless bulging veins running vertically down the centre of the forehead. There are also cases of colourless tortuous bulging blood vessels on the temples, that patients think are veins but are the frontal branch of the superficial temporal artery.

WHY DO FACIAL VEINS APPEAR?

The causes of facial telangiectasia are well documented, as they are so regularly treated, and include skin damage due to sun exposure or other burns, medical conditions such as Scleroderma and Rosacea, as well as those that appear for no obvious reason, particularly around the nose.

Prominent bulging periorbital and temporal veins usually become apparent in adult life, when the subcutaneous fat thins. This is worsened in patients with low body fat, and those with thin skin. In addition, they can also dilate with exercise, meaning those who exercise regularly and subsequently have low body fat, can be more prone to having prominent veins.

However, there is no hard and fast rule for who will develop bulging periorbital and temporal veins. Rather, there is an individual propensity to having dilated veins, which is likely genetic.

With regards to the bulging vertical forehead veins, these can appear in anyone and there are no clear predisposing factors identified at present. As with the bulging periorbital and temporal veins, reduced body fat, thin skin and exercise certainly accentuate any visible bulging vein on the forehead. Many patients who require treatment have a single vertical forehead vein when the anatomy books tell us that that should be two supratrochlear veins. Hence, one predisposing factor could be the anatomical variation of a single supratrochlear vein. However, some patients have two, three or even more of these veins that are large and bulging, so this is certainly not the only reason that this condition occurs.

As with periorbital and temporal veins, a bulging frontal branch of the superficial temporal artery is often seen in men or women who exercise strenuously, with low body fat. Significant levels of exercise can cause this artery to dilate in patients already predisposed to the condition, consequently reducing any surrounding fat and making the vessel stand proud. It is often most obvious in men with shaved heads or who are bald, as the bulging vessel cannot be hidden by hair.

CAN ANYTHING BE DONE TO PREVENT BULGING VEINS AND ARTERIES?

Simply, the answer is no. There does seem to be a predisposition in certain people that is probably genetic. However, the only factors that seem to be changeable are body fat and exercise. Weight reduction and exercise have been proven to have many medical benefits, from heart health to better mental health, so suggesting that either of these should be reversed merely to try to prevent bulging veins on the face or temples would be inappropriate.

It is only when we think of the telangiectasia (thread veins) caused by sun damage that we can truly consider prevention.

ASSESSMENT OF FACIAL VEINS BY COLOUR AND CONTOUR

While all veins on the legs need to be assessed with colour flow duplex ultrasound to check for any underlying hidden causes, facial veins can almost always be assessed clinically. Although position and width are helpful, the two most important features are colour and contour (i.e. whether the vein bulges).

To understand this approach, it is important to remember that the vein wall is white and has no colour. The colour seen by the observer is modified by the passage of reflected light through the vein wall and skin.

• Very thin-walled veins appear red when very superficial in the dermis, just under the epithelium.

• Veins appear blue when the wall is thicker and the veins are deeper, but still in the dermis.

• Veins that appear green have even thicker walls and are usually just below the dermis.

• Veins that have very thick walls, and those that are deep under the dermis, appear as colourless bulges of the skin.

The colour gives us an idea of the depth and wall thickness of the target vein. We can then assess the size of the vein by whether it bulges, or causes the skin to bulge above it, taking into account the thickness of the skin in the individual.

Green bulging temple and periorbital veins.

Bulging temple and periorbital veins are found just under the dermis.

Depending on their size, these veins can be treated with transcutaneous light therapies. A laser penetrates the vein wall and targets the haemoglobin in the blood, intending to generate sufficient heat to damage the vein wall. However, when veins get too large this treatment is not appropriate. It becomes impossible to direct enough energy through the skin and into the blood to damage the vein wall, without damaging the overlying dermis.

The greater mass of the tissue in the vein wall in larger veins also makes ablation difficult or impossible with the “hot needle” type devices.

Although some have used sclerotherapy, liquid or foam, in these veins1, it can be very dangerous to do so anywhere around the eyes, forehead or temples. 2

I would not recommend sclerotherapy on patients suffering from bulging veins in the upper face. There are potential medico-legal consequences if a problem arises from using sclerotherapy on these veins.3

Instead, these veins should be treated by phlebectomy (removal of the veins using incisions and hooks) under local anaesthetic.4It is a difficult procedure as the veins are often within the orbicularis oculi muscles and can be very hard to locate through cosmetic incisions.

However, a recent audit performed of our patients treated to date showed that most patients were happy with the results and scars, and 80% would recommend the treatment to friends or family.5

VERTICAL FOREHEAD VEINS

These bulging veins rarely show any colour, due to being deep, large and thick-walled. They cannot be treated effectively by transcutaneous laser.

In the past, I attempted phlebectomy of these patients, but the results were not as successful as hoped. As such, together with two colleagues of mine in Brazil, I developed a way of treating these using a very small endovenous laser passed into the vein under ultrasound, shrivelling the vein away with heat.6It is a mini version of the endovenous laser ablation (EVLA) that has been proven to be one of the most effective ways of treating leg varicose veins in the last 20 years.

This EVLA treatment of vertical forehead veins leaves the patient without any surgical scars at all, and only one small cannula insertion point per vein treated.

Our published results, which included our learning curve, show very good outcomes and low complication rates.6

BULGING TEMPORAL ARTERIES

Unlike veins, when treating arteries, it is essential to check that the treatment does not cause any necrosis of tissue. As such, these arteries should never be injected with any substance as this can cause ‘embolisation’, stopping blood flow to the capillaries of the scalp.

Using high-powered magnification, it is possible to make very small incisions and to ligate the artery using a non-dissolvable ligature. This takes the pressure out of the artery, allowing it to shrink while still allowing blood to flow into the capillaries via smaller collateral vessels.

In the past, people have used a single point of ligation for each artery, but the results were not very good. For this reason, I developed a double ligation technique and have published the results.7The wounds are so small, the skin is closed with a single blob of tissue glue, meaning no stitches are needed.

SUMMARY

Facial telangiectasia (“spider” or “thread” veins) is well recognised and treated in the aesthetic world. Therefore, aesthetic phlebology is now concentrating on bulging veins on the face that cannot be removed using typical non-invasive aesthetic techniques such as laser and intense pulsed light.

Large periorbital and temporal veins can be removed by facial phlebectomy, vertical forehead veins by endovenous laser ablation using specialised small equipment and a longer wavelength, and bulging arteries on the temples can be successfully treated by the double ligation technique.