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Facial Veins – Diagnosis and Treatment Options

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Facial Veins – Diagnosis and Treatment Options FEATURE Facial veins – 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 face, it need treatment might cross between two or medicine practitioners. Problem usually indicates what sort of vein 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 arteries 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 jugular vein, 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.
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