Facial reticular veins are a common cosmetic concern for both men and women. While these veins are often asymptomatic, they can become dilated, tortuous and dark which can be distressing to many patients. Facial reticular veins, commonly located on the temple or periorbital area, are similar in appearance to the reticular veins of the lower extremities. Laser therapy, sclerotherapy, and surgical removal have all been employed in attempts to treat lower extremity reticular veins and telangiectasias.
The first paper detailing the treatment of reticular facial veins with sclerotherapy reported successful treatment of 50 patients with 0.75% sodium tetradecyl sulfate and no adverse squelae. In 2002, Eremia and Li5 first reported the safety and efficacy of 1064 nm Nd:YAG laser for treatment of facial reticular veins and telangiectasias in a prospective study of 17 patients. Since that time, Lai and Goldman6 and Ma and Lin7 have also published data supporting the use of 1064 nm Nd:YAG laser in facial reticular vein treatment. We now report a large retrospective study examining the efficacy, side effects and satisfaction of dynamically cooled, variable spot size, long-pulsed 1064 nm Nd:YAG laser (CoolTouch VARIA, Roseville, CA) for the treatment of facial reticular veins in the periorbital and temporal area.
Patients and Methods
This was a retrospective study of patients who sought treatment of periorbital or temporal reticular veins over seven years. One hundred twenty-six patients, treated by five physicians, were treated with a DCLP Nd:YAG laser. Forty patients were evaluated in person or via telephone interview. Thirty-six were female and four were male. Patients ranged from 27–74 years of age, with the average age being 49.5 years. Skin types I–IV were represented in our group of patients. The length of follow-up from initial treatment ranged from three weeks to 88 months. Reticular veins ranging from 1–3mm were treated with a fluence from 160–230 J/cm2, with the average fluence being 191 J/cm2. The spot size ranged from 3–3.5mm with pulse width of 25–50 msec.
In general, vessels less than 1mm in diameter were treated with a 25 msec pulse and vessels between 1–3 mm were treated with a 50 msec pulse. Epidermal cooling was provided by post-laser cryogen spray of 20–30 msec. Immediate vessel blanching followed by visual elimination of the vessel borders was the end point of treatment and required one to two passes. Veins were treated in a distal to proximal manner with care given not to extend treatment into hair-bearing areas since the long pulse 1064 nm laser has been reported to effectively destroy hair follicles.8 Patients and physicians were required to use protective eyewear during the procedure. Care was taken to aim the laser away from the orbit. After the procedure was finished, an ice pack was applied to the treated areas for two to five minutes.
The results of the treatment were judged by the patient as a percent resolution of veins treated (0–100%), satisfaction with procedure (1- not satisfied, 3- very satisfied), and side effects of the laser treatment.
The average number of treatments required by our patients was 1.63 treatments. One patient required eight treatments in total, however, these treatments were three years apart and a lower fluence of 170-180 J/cm2 was used because the patient was worried about potential ecchymosis. The average patient was very satisfied with their treatment. When asked to rank their satisfaction, 31 of the 40 patients ranked their satisfaction with the treatment at 3, or very satisfied. The average improvement seen by patients was 83.6%, with the majority of patients reporting 75–100% improvement. The most commonly reported event seen after treatment was mild edema with 50% of patients reporting no adverse effects. The average fluence used was 191 J/cm2 independent of vessel size.
The current gold standard for treatment of unwanted lower extremity veins is sclerotherapy. Despite the success of sclerotherapy for the lower extremities, no true gold standard for treatment of facial telangiectasias and veins has been established. The CO2 , Argon, 810 nm Diode, 585- 595 Pulse Dye, 1064 nm Nd:YAG, and 532 nm KTP lasers, along with intense pulsed light (IPL), have all been used to treat facial telangiectasias with variable amounts of success, but these treatments do not specifically target larger reticular veins. Transection and cautery extraction using specialized phlebotomy hook, sclerotherapy and 1064 nm long-pulsed Nd:YAG laser 5,6 are reported as treatment options for facial reticular veins. Many of these treatments are not without risks. Vein transection and cautery and extraction with phlebotomy hook have the potential for hematoma formation, ecchymosis and scarring.
Hesitation regarding injecting the periocular veins with sclerosing agents comes from concern about the potential anastomosis of periocular veins with veins of the orbit and retina. Theoretically, the sclerosing agents may travel to unintended vasculature given that the venous system in the orbital areas is valveless. Monocular blindness after injection of sodium tetradecyl sulphate into venous malformation of the orbit has been reported.
Given the risks associated with many of the treatments listed above, it is easy to see why the use of a laser to specifically target these veins would be appealing. The target chromophore in the vascular system is hemoglobin, which has a wide absorption spectrum. The use of the 1064 nm wavelength provides the benefit of penetrating deep enough into the dermis (1–3mm) to reach the veins and target the hemoglobin chromophore, while having minimal interaction with the epidermal melanin, thus lessening the risk of hypopigmentation. There were reports in the past about scarring with the use of the 1064 nm Nd:YAG for deeper veins due to the high fluence that is required. This is avoided now by using a dynamically cooled 1064 nm Nd:YAG that utilizes epidermal cooling through cryogen spray. This protects the epidermis and superficial dermis from excessive thermal damage.
The most common side effects reported by our patients were edema and mild erythema, all of which resolved within five to seven days. Edema did not seem to be associated with fluence or size of vein being treated. Other side effects reported include ecchymosis, scab, burning sensation, and mild pain after the procedure. No evidence of scarring was seen in any patient.
One patient in our cohort did, however, report initial clearing of veins with subsequent reappearance after six to nine months. A repeat treatment was performed at slightly higher fluence with good results.
Based on our retrospective review and review of the literature, the dynamically cooled, variable spot size 1064 nm Nd:YAG laser is a safe and effective treatment for facial reticular veins with minimal side effects. The results are usually immediate, and based on our long term follow-up, tend to be long lasting.