FEATURE

Facial – diagnosis and treatment options

BY VICTORIA SMITH AND MARK WHITELEY

Facial veins can be treated with a wide range of aesthetic and surgical procedures. Victoria Smith and Professor Mark Whiteley, both experts in the area, provide a comprehensive overview of diagnosis and the different treatment options available.

atients with unwanted facial veins each location. Therefore, when we describe can be rigidly defined. Problem veins that commonly present to aesthetic veins by the anatomical area on the , it need treatment might cross between two or medicine practitioners. Problem usually indicates what sort of is likely more types of facial veins. Pveins on the face range from very to be found. superficial ‘capillaries’ to large bulging Telangiectasia (‘spider’ or ‘thread’ veins) subdermal veins. In our practice we have Basic classifications of facial veins Telangiectasia are classically very fine veins found that, to provide a full service to – size and depth of vein that are very superficial (Figures 1 and 2). these patients, we need a combination of Before going into the different classification If bright red, the blood is usually in small traditional aesthetic approaches with a of each sort of vein, it is important to that lie before the capillaries, more invasive surgical approach. In addition, remember that the venous system is a whereas if the blood is blue or purple, it is also important to be able to recognise network of little veins, draining into larger it usually lies in veins after the capillary facial veins that might be a sign of a more veins. It is often called ‘branching’ although network [1]. The veins themselves are complex problem that should be referred in reality, it is the reverse of branching. colourless, appearing white when empty. away from an aesthetic practice. Thousands of little veins (called venules) The colour of veins only comes from the Because of the combination of aesthetic drain venous blood from capillaries, and blood within the vein. The thicker the vein or surgical treatments that might be these veins drain into larger veins that are wall and the deeper the vein, the more the needed, some patients are offered a joint varied and un-named. From these, the colour changes from blue through to green consultation between aesthetic practitioner venous blood drains into the larger named until eventually, when the vein is deep and venous surgeon. However, we have veins such as the temporal or facial vein, enough, there is no colour seen in the veins found that a few simple screening questions and from there to the , superior which are sub-dermal. asked at the time of first enquiry, often vena cava and right heart. Therefore, when backed up with a picture sent by the assessing a vein that looks like a branching Reticular veins potential patient by email, can usually tree, remember that the blood flow is from Reticular veins are veins that are seen as determine which one might be optimal to peripheral to central and it is actually a a green line through the skin, but without give the first opinion. collection of tributaries draining to a central any bulging (Figure 3). This is the same We classify facial veins in terms of how vein. name as given to reticular veins in the big and how deep they are, and where As the most superficial veins will join legs or elsewhere in the body. The fact they are found – i.e. the size of the vein, together and drain into slightly deeper that they appear to have a green colour is the depth of vein – either within or under veins, and these deeper veins might do the very important when it comes to possible the dermis, and the anatomical area of same again, one sort of problem vein might treatments. the face affected. Fortunately, there is a be associated with another sort of problem good correlation between the anatomical vein of different size and depth. Hence no Subdermal veins location and what sort of vein is found in classification of problem vein to be treated When veins are both big enough and deep

Figure 1: Telangiectasia (thread veins) on the chin as distinct veins in a group. Figure 2: Diffuse redness of cheek Figure 3: Periorbital reticular vein. Green Suitable for treatment with advanced electrolysis/radiofrequency (electrocautery) suitable for treatment with IPL. in colour and not raised, so suitable for or transdermal laser. treatment with transdermal laser – usually ND:YAG (1064nm) for this sort of vein.

The PMFA Journal | DECEMBER/JANUARY 2019 | VOL 6 NO 2 | www.thepmfajournal.com FEATURE

Figure 5: A combination vein complex with a bulging sub- Figure 4: The Whiteley-Smith provocation test for forehead veins. Patients often say that forehead veins are only visible when they dermal periorbital vein (marked with surgical marker) which smile, laugh, exercise or are hot. This simple sign, pressing on the cheeks beside the nose, occludes the facial vein and shows the is suitable for phlebectomy and temporal veins suitable for forehead veins in the dilated state even when sitting upright. transdermal laser (ND:YAG). enough, they can make the skin bulge sorts of veins that patients want to have Periorbital areas above them, giving the appearance of removed. Many patients complain of reticular or a ‘varicose vein’. Of course a ‘varicose bulging veins in the periorbital areas. vein’ of the face is not really a varicose Cheeks, chin and nose These are usually directly under the eye vein as we would understand it in the Most patients presenting with ‘facial or under and lateral to the eye (Figure 3). legs. In the legs, such varicose veins veins’ present with veins in these areas They can be blue / green and not raised or occur because the valves fail and blood and so aesthetic practitioners will be most can be bulging. Often they are both. When accumulates in the vein due to gravity. In comfortable with these patients. The veins present, they can appear in isolation, or veins in the face, blood falls with gravity in these areas tend to be telangiectasia. can be bilateral. Commonly, they are also back towards the heart. However, these They are usually bright red (often being associated with veins in the temple area and veins can still dilate, causing cosmetically arterial even though they are still referred to can often be seen to be continuations of the unsightly bulges, particularly when certain as veins), but can be darker, tending towards same veins (Figure 5). provoking manoeuvres are performed purple or blue. When darker, they tend to be such as smiling, talking, straining or larger and slightly deeper. They can occur Temples leaning forwards. A new sign, never individually, in small groups (Figure 1), or Increasing numbers of patients are coming described to our knowledge before this can occur in large patches (Figure 2). On the to see us with veins in the temple area. article, is the ‘Whiteley-Smith provocation cheekbones, such red patches showing a These appear to be a branching tree arising sign’ for forehead veins. In this new sign, large number of thread veins can indicate from a single vein at the lateral side of the subdermal veins of the forehead appeared sun-damage. This is different from a ‘diffuse eye, and a fan of several veins branching up after manual compression of the cheeks redness’ commonly known with the public towards the hairline. Of course in reality, (Figure 4). This mimics the dilation of the as having a ‘high colour’ or ‘skin flushing’. they are tributaries coming from the hairline same veins seen with the other provoking This is a generalised redness of the skin and coalescing into a single vein at the manoeuvres identified above. These veins rather than individual telangiectasia. Such lateral corner of the eye, as the blood is tend to show no colour as they are deep ‘high colour’ can be clinically referred to as draining from the scalp into this vein. It is to the dermis and the colour of the blood rosacea. useful when thinking about treatment, to cannot be seen through such a thick layer Many patients present with complaints think of the vein as a ‘tree’ branching up from of vein wall and skin. about telangiectasia around the nose. These the lateral eye, but when thinking of the As any practitioner will know, and can be individual or in small groups. They problems with sclerotherapy, it is well worth as pointed out at the beginning of this often occur around the nasal alar (the skin remembering that the blood is flowing down section, there is quite a crossover between crease between side of lower nose and these veins towards the orbit. reticular veins and subdermal veins. cheek) or at the entrance to the nostril, or These veins drain into the main facial Quite often green reticular veins will start can be on the nose itself. When there are a vein, but also can drain into veins inside the bulging as they get larger and deeper. large number of telangiectasia on the bulb orbit and around the eyeball, and from there Similarly, telangiectasia can often be seen of the nose, the nose can look particularly into the sagittal sinus. This is one of the to be draining into a green reticular vein. red. This is often thought to be associated major venous sinuses between the cerebral Therefore, when it comes to assessment with heavy alcohol consumption and many hemispheres of the brain. A sagittal sinus and treatments, careful notes should be people get very embarrassed by it. Of thrombosis, although rare, is a disaster and taken as to the target vein that the patient course, alcohol may be the cause in some should always be at the back of your mind wants treated and sometimes more than patients, but in a great number of patients it when treating veins in this area. one treatment strategy is required to get is not. Also, be careful of conditions such as The veins that are near the hairline are rid of the whole complex of problem veins. rhinophyma when the soft tissue of the nose usually green / blue and rarely bulge too is enlarged and the skin red. If the contours much. However, the vein at the lateral part of Basic classification of facial veins of the nose are abnormal, do not think the the eye that they drain into is often bulging – anatomical position target veins problem is merely telangiectasia and be and is sometimes too deep to show colour. As noted before, there are certain areas of sure to get an expert ENT opinion before This vein can often be linked to a periorbital the face that are associated with certain thinking of treatment options. vein running from beneath the eye.

The PMFA Journal | DECEMBER/JANUARY 2019 | VOL 6 NO 2 | www.thepmfajournal.com FEATURE

Figure 6: Forehead veins, bulging and too deep to see any colour. Suitable for phlebectomy under local anaesthetic, a far more complicated procedure than phlebectomy elsewhere on the body due to the muscles of facial expression inserting into the skin.

Forehead Unlike the skin of the leg, the skin of the Increasing the alternating current from Problem veins of the forehead are face is constantly exposed to ultraviolet kilohertz to megahertz and calling the almost always large, fairly vertical, cause radiation from the sun and is therefore procedure radiofrequency ablation is very considerable bulging and rarely have colour. very resistant to thermal damage. As such, good marketing, but there is little scientific They run beneath the dermis and so usually, transdermal laser can be used directly evidence that the results are different no colour is visible through the skin. They to treat appropriate facial veins with low using the different frequencies found in are large, and hence cause the bulging of chances of causing skin burns. This is the electrolysis machines or radiofrequency the skin above them. Sometimes they can reverse of what is found in treating leg veins. machines. be single, running from hairline to a place The skin on the legs is rarely exposed to Electrocautery devices are relatively between the eyebrows. Sometimes they ultraviolet radiation and as many aesthetic cheap and as the techniques are effective [2] can be multiple. Patients often say that practitioners have learnt to their cost, trying and suitable for individual or small clusters these veins make them look like a ‘Klingon’ to perform laser on leg thread veins often of veins, they should be part of any practice (a reference to the TV series Star Trek), and leads to skin burns. These burns do not treating facial veins. that they tend to ruin holiday photographs, become apparent until three months after being prominent in the heat and when the treatment due to the healing process of Sclerotherapy patients are smiling, causing shadows on the skin after a burn. The use of sclerotherapy in facial veins is the forehead in photographs. controversial. Sclerotherapy is used to treat Advanced electrolysis / radiofrequency small veins on the legs and body and when Treatment options ablation (electrocautery) made into a foam, has been used to treat The most important principle to remember One of simplest ways to treat individual larger veins. A quick search on the internet is that facial veins lie above the heart. veins is to use heat generated at or near the will show that many practitioners offer As such, we do not have to consider point of a needle. Electrolysis machines sclerotherapy for facial veins. However, gravity, failure of valves or venous reflux and radiofrequency machines, although experts in the field have pointed out that when assessing and treating facial veins. often marketed as different technologies, sclerotherapy “can be used on larger blue Conversely, telangiectasia or varicose veins have the same basic characteristics telangiectasia but may be complicated from of the legs are situated below the heart and and indeed use the same needles. An inadvertent injection into arterioles” [1]. are therefore almost always associated with alternating current is passed into the needle This can lead to skin necrosis or, very rarely, gravity problems. These veins usually are (‘monopolar’), making the tip positive, blindness in one eye [3]. associated with the failure of valves in the followed by negative, followed by positive Furthermore, sodium tetradecyl underlying veins of the legs or pelvis, and and so on, rapidly changing the current and sulphate (STS), the most commonly used venous reflux with gravity. hence polarity. The rate at which the current detergent sclerosant in the UK, is not Therefore, the whole approach and alternates (and hence the polarity of the licensed for use in facial veins, and the understanding of facial veins is completely needle) ranges from thousands of times nursing and midwifery council (NMC) has different from that of veins of the legs, as are per second (kilohertz or KHz) to millions of already ruled in one case where STS was the treatments. If you are using the same times per second (megahertz or MHz). This used and a complication ensued [4]. In approach and treatments as you would for alternating polarity attracts electrons in the the UK, practitioners can use products for leg veins, then you are mistreating one or tissue then repels them at these very high unlicensed indications, but should be able other of these groups of patients. frequencies, generating heat in the tissue. to explain that no licensed medication or Fortunately, for aesthetic practitioners Alternatively, a two electrode approach technique would be able to be used instead. dealing with facial veins, these are easier to (‘bipolar’) can be used with two needles As there are other techniques to treat all assess and treat than leg veins. Unlike leg or other conductors with an alternating sorts of facial veins, which do not involve the veins, we do not need to get venous duplex current between them at the same high risks of sclerotherapy, it is hard to see how ultrasonography to look for underlying valve frequencies. practitioners can justify using sclerotherapy failure in these veins. Treatment options for When the tip of the monopolar needle for facial veins. Although complications are facial veins can almost always be selected is placed on a very , heat is rare, when they do occur they can be severe from visual assessment alone. generated in the tissue destroying epidermis [5]. As such, we do not recommend the use When thinking about possible treatment and vein, and if deep enough sometimes of sclerosants for any facial veins despite options, the selection of the appropriate superficial dermis. Although electrolysis some authors having published good results treatment comes down to colour, size is often dismissed as a treatment to in their own hands [6]. and depth of the target vein with a small remove hair only, advanced electrolysis consideration as to the location once the techniques such as red vein removal can Intense pulsed light (IPL) other factors have been taken into account. be highly effective in experienced hands. IPL machines produce very concentrated

The PMFA Journal | DECEMBER/JANUARY 2019 | VOL 6 NO 2 | www.thepmfajournal.com FEATURE

resistant to high laser powers, allowing high energies to be passed into veins to be treated without damaging the skin. This is the reverse of the situation in the “Phlebectomy of facial legs where the skin is sensitive to burning veins is technically difficult and transdermal laser for leg thread veins frequently ends up in permanent burns and requires considerable leaving white scars. practice.” Phlebectomy Phlebectomy of facial veins is technically Figure 7: Ultrasound of forehead vein in transverse section. difficult and requires considerable practice. The scale shows that the vein is 0.177 cm in diameter and is about the same depth. In our experience we find it useful for larger bulging veins particularly in the and well-controlled bursts of white light wavelengths of light. When it absorbs periorbital, temporal and forehead regions. in pulses. This white light also includes sufficient energy, it can be disrupted In particular, veins in the centre of the some infrared and ultraviolet wavelengths, or can heat up. Therefore, for vascular forehead are often very large, subdermal, ranging from about 400nm through to lesions such as thread veins on the face, a and therefore show no colour. These are 1200nm [7]. A variable number of pulses wavelength is used that is readily absorbed too deep and large for electrocautery, IPL can be chosen, each of the defined length, by oxyhaemoglobin or deoxygenated or transdermal laser and with the high flow with a defined length of rest in between haemoglobin. Such lasers include the KTP rates potentially flowing through them each pulse. The white light is at an intensity (532nm – green light) and the ND:YAG into the orbital veins, sclerotherapy is not a that it will heat tissue. Different hand pieces (1064nm – microwave) lasers although sensible option [3]. then put different filters in the way of the other lasers can also be used. The KTP does We prefer phlebectomy using local white light before it hits the skin. For red not penetrate very deeply and so is used anaesthetic (lignocaine) with adrenaline vein treatments, a yellow filter is used. for very superficial veins that are bright red (epinephrine) to reduce bruising. Incisions This filter allows a relatively narrow band or bright blue. It heats the haemoglobin, are made using the smallest possible blade of wavelengths of light through it, around causing the heat to be passed into the vein and in line with where skin creases will 500nm wavelength (yellow light). As the wall and destroying the vein. The ND:YAG, develop if there are none present. Of course absorption peaks for oxyhaemoglobin which has a wavelength exactly twice that if there are skin creases already, incisions (predominantly found in red veins) and of the KTP, also interacts with haemoglobin should be made within these. Phlebectomy deoxygenated haemoglobin (predominantly causing it to heat. However, this longer hooks can be used but it should be noted found in blue veins) are 418nm and wavelength penetrates deeper into the skin, that these veins are very small and difficult 542nm respectively, this is ideal for facial allowing larger green veins to be treated to remove. They are often adhered to the telangiectasia. IPL handpieces often have that lie deeper under the skin. It is effective skin and access with the hook is difficult due a wide ‘footprint’ meaning that quite large to at least 1.5mm deep to the skin. to the muscles of facial expression (frontalis areas can be treated with each shot fired. Lasers allow many different factors to be muscle on forehead) inserting into the skin Thus, IPL is ideal for large areas such as for changed. The area to be treated for the ‘spot around the vein. With experience, good diffuse telangiectasia or rosacea. size’ can be varied, allowing for individual results can be obtained (Figure 6) but we veins to be targeted with a very small spot have found it is a long learning curve to get Transdermal laser size or areas with a larger spot size. Different good at this and so we restrict the practice LASER is an acronym for light amplification powers can be used and when a power is to one surgeon in our clinic. In addition, we by the stimulated emission of radiation. selected, this is divided by the area of the have ready access to vascular ultrasound Although some lasers do produce light, spot, giving the ‘fluence’ (power per square which is helpful in identifying the position others produce microwaves which are centimetre of skin). In addition, the pulse of veins, checking there is no arterial flow invisible to the naked eye. Originally these length can be varied. Pulses are usually in and ensuring that there is no abnormality used to be called MASERs but now tend the range of milliseconds. This variability associated with the target vein (Figure 7). to be called LASER as well for simplicity. makes laser a very flexible tool to use, Wounds are easily closed with Steri-Strips Unlike IPL, which uses white light and then although it needs considerable experience and patients are warned that bruising can selects bands of wavelengths using filters, to master. Many aesthetic companies take up to four weeks to disappear, and laser produces light of one wavelength pre-programme settings for different the wounds similarly up to four weeks to only. This is called ‘monochromatic’ light. In lesions, allowing those who are not very disappear. Patients are advised not to go out addition, all of the photons (individual rays experienced to have a relatively safe, if not in the sunlight during the healing process. of light) in a laser are precisely aligned or individualised, treatment setting. Apart from scars and bruising, patients ‘in step’. This is called coherent light. When Therefore, with access to lasers of must be warned about the risks of infection, light photons are all lined up ‘in step’ with different wavelengths and different failure to remove the vein completely, poor each other, they can carry a tremendous spot sizes and powers, telangiectasia cosmetic result and damage to surrounding amount of energy. and reticular veins can be treated in the tissues including sensory nerves. We have As a laser produces a precise wavelength, majority of cases. As a general rule, if recently had a case where a patient had the appropriate laser can be chosen to the vein has colour and is not large and previously undergone surgery to his brow, target any particular pigment such as bulging, then laser can usually be used if with an incision across the top of his head oxyhaemoglobin or haemoglobin. When the correct wavelength and settings are above the hairline and the skin and muscle such a pigment or chemical is targeted selected. Furthermore, as the skin of the reflected down off of the frontal bone. by laser, it is called a ‘chromophore’. face is always exposed to sunlight, it is quite At subsequent surgery the veins were so Chromophores absorb or reflect different resistant to burning. Therefore, it is quite scarred that they could not be removed

The PMFA Journal | DECEMBER/JANUARY 2019 | VOL 6 NO 2 | www.thepmfajournal.com FEATURE

surgically. Hence previous surgery in the index of suspicion as to any lesion that area of facial veins is now a contraindication might be presented as a ‘facial vein’ to phlebectomy in our unit. but doesn’t look typical, and should AUTHORS Facial phlebectomy is not something to not feel obliged to treat every patient be performed by anyone who has not got a who attends for consultation. Atypical very good understanding of the anatomy of vascular lesions should be referred to the area, who has had some training by an appropriate specialists for a second experienced trainer and who is performing opinion. the procedure regularly enough to ensure they get through the learning curve and References maintain their experience. 1. Goldman M. Optimal management of facial telangiectasia. Am J Clin Dermatol 2004;5(6):423- Victoria Smith, Conclusion 34. 2. Liapakis IE, Englander M, Sinani R, Paschalis EI. Aesthetic Phlebology Practitioner and Director of The treatment of facial veins is a common Management of facial telangiectasias with hand Aesthetics, The Whiteley Clinic, London, Guildford and aesthetic procedure. As a general rule, cautery. World J Plast Surg 2015;4(2):127-33. Bristol, UK. the smaller and more superficial the 3. Arunakirinathan M, Walker RJ, Hassan N, et al. E: [email protected] Blind-sided by cosmetic vein sclerotherapy: a case vein, the easier they are to treat and the of ophthalmic arterial occlusion. Retin Cases Brief more commonly they are treated. A good Rep 2017; [Epub ahead of print]. understanding of the different veins that 4. Bartlett N. Liverpool nurse warned after falsely can be encountered and the different claiming to have celebrity client and gave botox to patient without proper prescription. Echo 2014. methods of treatment that are available, www.liverpoolecho.co.uk/news/liverpool-news/ will enable an aesthetic practitioner to liverpool-nurse-warned-after-falsely-7309680 Last know which veins they are comfortable accessed October 2018. treating with a high chance of a good 5. Roberts E. Lisa Fairbanks left with lasting ill-effects after treatment to remove a blemish went result, and which veins they should refer badly wrong. Basingstoke Gazette 2014. www. Prof Mark Whiteley to practitioners that specialise in the more basingstokegazette.co.uk/news/11660759. Consultant Venous Surgeon & Consultant Phlebologist difficult and less common facial veins. Blemish_removal_ends_in_agony_for_ and Executive Chairman, The Whiteley Clinic, London, Basingstoke_mum/ Last accessed October 2018. Finally, as with most (if not all) aesthetic Guildford and Bristol, UK. 6. Green D. Removal of periocular veins by conditions, there is no medical need to treat sclerotherapy. Ophthalmology 2001;108(3):442-8. Declaration of competing interests: None declared. every facial vein merely because the patient 7. Goldberg DJ. Current trends in intense pulsed requests it. Practitioners should keep a high light. J Clin Aesthet Dermatol 2012;5(6):45-53.

The PMFA Journal | DECEMBER/JANUARY 2019 | VOL 6 NO 2 | www.thepmfajournal.com