Patients who desire cosmetic improvement of the face may request the elimination of visible periocular veins. These occur on the lower eyelids toward the lateral portion of the orbit. Veins around the eyelids are often more visible because there is no subcutaneous fat beneath the very thin periocular eyelid skin. They may also be more apparent in individuals with fair complexions or in older patients with further loss of subcutaneous tissue because of the aging process. The veins are typically asymptomatic, and most patients seek treatment to eliminate the appearance of these dilated, protruding, subcutaneous veins, which are similar to blue reticular veins of the leg 1.
Treatment usually consists of methods to transect or surgically remove the vein or eliminate it using injectable sclerotherapy or laser therapy. Elimination of periocular veins can be achieved using several techniques by either transecting the vein through several small overlying cutaneous incisions or extracting with a phlebectomy hook. This can be done in an ambulatory setting where unipolar or bipolar cautery is available 1.
Sclerotherapy using a 0.75% solution of sodium tetradecyl sulfate has been used for decades to eradicate varicose veins on the lower extremities. It has also been used to eradicate prominent veins at other cutaneous sites, including the face 2,3. However, there has been general reluctance to use sclerotherapy for the removal of periocular veins because of the fear of ophthalmologic and neurological complications 1.
Residual concern with sclerotherapy in the periocular region remains. Although there were no complications in the 50 patients reported by Green 4, sclerotherapy for arterial-venous malformations, extending into the orbit, has resulted in ocular morbidity. Inadvertent vascular infusion of the sclerotherapy agent is also a concern as this may result in cutaneous ulceration. The facial veins have valvous anastomosis that may extend to the orbit and cavernous sinus. Blindness has been reported following a sclerosing injection into a venous malformation partially located in the orbit 5.
Laser treatment of facial telangiectasia has been reported with a variety of laser systems including the 532 nm potassium titanyl phosphate, double-frequency neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers, and pulsed dye lasers (585–600 nm range). All these lasers have been used successfully for the treatment of small facial telangiectasia, but have been disappointing in the treatment of larger facial veins. However, the use of a cryogen spray variable pulse width Nd:YAG 1064 nm laser has been reported to result in excellent improvement in eight patients with periorbital reticular veins 6. Veins in these patients measured from 1 to 2 mm before the laser treatment. Treatment of the reticular veins required 150 J/cm2 using a 6 mm spot size and 50–100 ms pulse width. Cryogen spray was used in postlaser cooling. Treatment goals were to achieve blanching without causing a cutaneous burn. One to two passes were performed in these patients using multiple shots in a nonadjacent order to prevent excessive heat accumulation. Protective eye wear was required. At the 1-month follow-up, 100% of the eight patients with reticular periorbital veins showed resolution of the vessels. Eremia and Li 6 found that pain may require local anesthetic infiltration in some patients. Erythema and mild edema of the overlying skin were found in all treated patients. Fine crusting of the skin was reported in several patients, which subsequently cleared. Small purpuric spots were noted in several patients immediately after the treatment, but resolved within 1 week. The goal of treatment was to damage the vein without causing overlying cutaneous scarring. Skin type IV patients required more of the dynamic cooling device spray before and after treatment. Postinflammatory hyperpigmentation was not noted in any of the patients treated in the study 6.
The number of patients reported in the study remains small for any of aforementioned therapies. Therefore, the aim of this study was to evaluate the long-term efficacy and safety of the Nd:YAG 1064 nm laser in the treatment of periocular veins.
Patients and methods
Twenty-two patients with prominent periocular veins were included in this prospective descriptive study.
Patients were recruited from the Dermatology Clinic at the National Institute of Laser Enhanced Sciences, Cairo University, and from Cosmoderm Clinics, Jeddah, Saudi Arabia, between April 2008 and July 2010. Clinical spot diagnoses were made and all patients provided signed informed consent for treatment. Inclusion criteria included patients with flat prominent periocular veins with a diameter ranging between 1 and 3 mm. Exclusion criteria included: a history of any systemic diseases, hypertension, diabetes mellitus, heart disease, pregnancy, eye diseases such as retinal diseases, intake of systemic medications, and any previous trials of treatment for the condition.
All patients received a single treatment with an Nd:YAG laser with 1064 nm wavelength and without topical anesthesia or analgesia. The target areas were cleaned with a facial cleanser and then wiped before treatment. Treatment parameters were 30 ms pulse duration, 125–130 J/cm2 fluence, and 7 mm spot size. The target areas were cooled with cold air before, during, and after the laser pulses. The treatment end point was vasospasm with the disappearance of the vein. One or two passes of nonoverlapping pulses were sufficient to reach the end point. Eye protection with patient laser-protecting shield was used. The laser handpiece was always pointed away from the globe and directed toward the bone. Ice packs were applied to the treatment area immediately after the treatment and the patients were instructed to keep it on the skin for 10 min to avoid bruises. Any immediate erythema, swelling, bruises, epidermal separation, or blanching of the skin was reported.
Photographs were obtained before and after 1 year from the first treatment session at the end of the follow-up period under standardized conditions of lighting, patient position, and camera equipment.
Patients were requested to come back for a follow-up after 3 weeks, 6 weeks, and 1 year.
During the first follow-up visit (3 weeks after the first treatment), any patient with recurrence was treated again with a slightly higher fluence (5 J/cm2 higher than the fluence used in the previous session). Any adverse effect such as postinflammatory hypopigmentation or hyperpigmentation, textural changes, or scarring was reported.
During the second follow-up visit (6 weeks after treatment), the patients were examined for recurrence or any side effects.
During the last follow-up visit (1 year after treatment), again, the patients were examined for the reappearance of the vein/veins treated or complications and photographs of the treated area were taken.
Three blinded dermatologists were asked to determine the before and after photos of the patients. After the successful selection of the before and after photos, the blinded dermatologists were requested to assign a score for the degree of improvement as follows: 0=no improvement, 1=improved but did not disappear, and 2=disappeared.
Twenty-two patients (16 female and 6 male patients) with prominent periocular veins were included in this study. The veins were located below the eye, over the cheek bone, on the lateral temporal area lateral to the outer canthus of the eye or just above the eye. The vein diameter ranged between 1 and 3 mm.
The age of the patients ranged between 17 and 45 years, with a median of 35.5 years and a SD of 8.3. The skin type of the patients ranged between Fitzpatrick skin type II and IV, with the majority of the patients of skin type III (14/22) (Table 1).
The veins showed immediate vasospasm and disappearance upon the laser impact in all the patients. The patients complained of pain during the treatments that did not necessitate stopping the treatment.
Erythema and mild swelling of the treatment area were observed in all the patients, but these did not remain for more than 2 h. No bruises after the laser treatment were reported.
During the first follow-up visit, 3 weeks after the treatment, four patients out of 22 (18%) had reappearance of the veins treated and required another session. An interesting correlation is the fact that all the four patients showing reappearance of the treated veins had a darker skin type (Fitzpatrick type IV). No adverse effects were noted.
During the second follow-up visit, 6 weeks after the first session, none of the patients showed recurrence of either the treated veins or any kind of side effect.
During the last follow-up visit, 1 year after treatment, only 20 patients returned for the follow-up. None of the 20 patients had recurrence of the treated veins or any adverse effect from the treatment.
All the three blinded dermatologists were able to correctly select the before and after photos of all the 20 patients.
All the post-treatment photos were assigned a score of 2 (disappearance of the vein) by the three blinded dermatologists (Figs 1–3).
The long-pulsed Nd:YAG 1064 nm laser has gained popularity for the treatment of telangiectasia, small-to-medium vessels of leg veins (up to 4 mm in diameter), and reticular veins below the lower eyelids. The advantage of the Nd:YAG 1064 nm laser over other shorter-wavelength lasers is that with the equivalent absorption of blood, the 1064-nm laser has weaker melanin absorption and can penetrate deeper. It also has a high absorption coefficient of methemoglobin and deoxyhemoglobin, which are the main components of blue veins. With the long-pulsed duration setting, this laser is more likely to heat the vessels slowly and uniformly, which allows sufficient vessel damage to cause coagulation, but avoids vessel rupture, subsequent purpura, and possible postlaser hyperpigmentation 7,9.
When using a Nd:YAG 1064 nm laser with the appropriate setting (spot size, fluence, and pulse duration) and adequate cooling (recooling, parallel cooling, postcooling), adverse effects are minimal and include crusting that lasts for 2 to 3 weeks, with or without transient pigmentary alteration 7.
Our results show that an Nd:YAG 1064 nm laser is a safe and effective treatment modality for the treatment of periocular veins. The clearance of the treated veins persisted in almost all our patients for at least 1 year. Patients with skin types II and III did not require more than one session, whereas most patients (four out of five) with skin type IV required a second session. This might be explained by the fact that the partial absorption on the Nd:YAG 1064 nm laser by the epidermal melanocytes might lead to decreased energy delivery to the target vessels.
In 2002, Ermia and Li 6 carried out the first prospective study to evaluate a variable pulse width Nd:YAG 1064 nm laser with cryogen for the treatment of facial telangiectasia and larger periorbital reticular veins on 17 patients. The authors found that pain required local anesthetic infiltration in some patients. This was not the case in our current study and this may have been because of the different modality of cooling we used in the current study. We used cold air cooling, which provides bulk cooling for the area to be treated, allowing prelaser, parallel, and postlaser cooling, compared with only the prelaser cooling of the cryogen. We also strongly believe that infiltration anesthesia before any laser treatment is not advisable as it may alter the tissue optics and hence the laser tissue interaction 8.
During the 6 weeks as well as the 1-year follow-up visits of the patients, no recurrence or side effects were observed in the treated area, which indicates the high safety and efficacy profile of this treatment modality.
The rationale for the use of Nd:YAG 1064 nm lasers for the treatment of periocular veins versus other vascular specific lasers lies in the fact that this particular wavelength is known for the deep penetration that is required when dealing with relatively deep structures such as reticular veins. In contrast, it is important to keep in mind the lack of selectivity of the Nd:YAG laser, which can lead to adverse effects in case wrong parameters are used or if the skin is not properly protected with proper cooling 9.
All patients included in the current study experienced some degree of erythema and swelling for a period of few hours after treatment. None of our patients developed bruises, although it is one of the commonly reported side effects 9. This might be because of the fact that we had instructed our patients to apply ice packs on the treatment area immediately after the session for at least 10 min. It seems that proper cooling may be an additive reason for the absence of bruising.
Crusts, pigmentary changes, and scarring were not observed in any of our patients.
The 7 mm spot size used in the present study was required to achieve a deeper effect and thermal injury of the intima of the treated vessels. The pulse duration of 30 ms was selected to protect the epidermal melanocytes from thermal injury by providing a pulse duration above the thermal relaxation time of the epidermal melanocytes 10.
The fact that all the 20 patients who returned for the follow-up showed no recurrence of the treated veins is very encouraging; however, a longer term follow-up study might be required in the future.
Single or double treatment sessions with the Nd:YAG 1064 nm laser appears to be an effective and safe treatment of periocular veins, with a long-term effect.
Conflicts of interest
There are no conflicts of interest.