Facial Veins – Do’s & Don’ts Ronald Bush, MD, FACS
12/30/12 Facial Veins Most people that seek consultation for periorbital veins have veins that are actually branches of three connecting systems in some form or another. These are branches of the infraorbital, supraorbital, or the superior/medial temporal veins. There is no exact term for the vein that you see. The problem is that this branch connects with both the supraorbital, infraorbital, or transverse facial veins at some point. The real problem is how to keep foam out of the central retinal veins and the ophthalmic veins. Actually, this is quite easy to do. When injecting the vein under the eye, the needle should point to the temporal vein. You should apply pressure at the medial canthus of the eye to occlude the angular vein. (This leads to the supraorbital vein and the transverse facial veins) At the same time, your assistant should occlude the superficial temporal vein before it bifurcates into the frontal and parietal branches. This will concentrate the foam in the desired area. Use a small butterfly needle and use no more than 1cc of 0.2% SotradecolďŁ¨ foam and milk it laterally. I do not use liquid, since this tends to extravasate the vein. Foam is much easier to inject. This is repeated every 2-weeks until the vein disappears. This is very effective. If the vein is more than 2 mm in size, I do a phlebectomy in two incisions, which is very effective and cosmetically acceptable. Regarding the frontal vein that is in the midline of the forehead. This connects to the supraorbital vein, which then becomes the angular vein. If you inject the frontal vein, there is always a chance for foam to go into the eye itself. However, if you apply pressure on the supraorbital notch and the medial canthus to occlude the angular vein and place the needle pointing superiorly, you can do foam sclerotherapy safely with 1cc of SotradecolďŁ¨ foam. However, if the vein is large (2mm), I would do a phlebectomy through two small incisions. I have done many injections on veins around the eyes with no complications. I have also injected veins on the lower face with no problems. I think much of the concern about 2
injecting around the eye is Urban Legend. For veins in the temporal region, foam sclerotherapy, Sotradecol 0.2% or 0.5% Polidocanol is used GENTLE injection is done. Make sure the superficial temporal artery is not cannulated. Start the injection on level with lat canthus, and do 1cc injection one time only.Repeat in 2 weeks if necessary. For veins more than 2mm in diameter, consider phelbectomy using 1mm incisions. You can try a 1064 laser at 150 joules/cm spaced one week apart. See Dr. ppt in ‘Member Library.’ Important points: Under the eye inject so flow of solution goes laterally For midline frontal veins, phlebectomy is advised unless vein is small For temporal veins, inject so flow is superior at lateral canthus Foe veins of the superior eyelid, I have used a 30-gauge needle, ohmic thermolysis and laser depending on vessel size For blue green veins of the face,f oam sclero in same concentrations are used . For red veins on face or nose, use Veingogh or Dornier 940 laser depending on vessel size, and sun exposure.
Image retrieved July 27, 2011, online from http://alturl.com/k52kc
Most patients that seek consultation for periorbital veins for the most part have infraorbital veins. These veins are very amendable to foam sclerotherapy. I use 0.2 % foam sclerotherapy, you must remember that the drainage from the infraorbital vein is through the pytergoide plexus and there is no communication with the central retinal vein. For supraorbital veins, there is a possible connection although slight. However, I have never seen a patient with supraorbital vein pathology. Temporal vein is amendable to foam sclerotherapy. 4
If the infraorbital vein is very large (greater than 2mm), consider doing phlebotomy since this will give you a faster resolution.
Small Red Facial Veins Many patients complain of small red veins on the face (cheeks, chin, & nose) . In some cases these veins may be blue in color. Often times, patients are given the wrong diagnosis of Rosacea Facial spider veins in most cases are the results of sun exposure although environmental, hereditary, and hormonal factors may be present. The treatment for these veins is quite simple and consists of heat therapy. This may be from a laser, intense pulse light, or ohmic thermolysis. One to three treatments are typically necessary. The complications are minimal and usually consist of mild skin redness or very tiny areas of skin crusts that disappear quickly. During treatment, you should avoid sun exposure. Sunscreen should be used even during the winter. These veins can reoccur and yearly re-treatments may be needed.
Dr. Bush treated the patient below with the Dorner 940 laser.
Facial Veins - Copyright ďŁŠ 2011 by www.bushvenouslectures
Facial Veins - Copyright ďŁŠ 2011 by www.bushvenouslectures
Veins on nose - Copyright ďŁŠ 2011 by www.bushvenouslectures
Treating facial veins with Dornier Laser -Copyright ďŁŠ 2011 by www.bushvenouslectures
Go to www.dornier.com for more information!
Prominent Veins of the Forehead & Face This is a 9-year old boy with marked prominent veins of the forehead and face. If veins are located sub-orbital, the injection is towards the ear. Since for the most part in this location, drainage is to the pterygoid plexus. However, as you can see in this case, there are prominent veins up to the level of the hairline. A palpable sagittal suture line is present in the scalp. If you were to inject foam sclerotherapy superiorly blindly, complications could occur. In this patient, I occluded the vein in the forehead with my finger and there was very little filling distally. This finding is indicative of mostly retrograde flow from the sagittal forehead vein. First I divided the vein at the hairline, and then through 2 separate incisions, I removed the vein to the level of the lateral eye. No further treatment was done and you can see the great result that occurred 2-days post op. I injected 0.2 % Sotradecol ďŁ¨ foam into the small residual vein on the face. There was good clearing of this venous complex. The patient will be seen in 8 weeks. When doing veins of the face, know your anatomy and the drainage areas. This is discussed in the blog. Anything above the eyebrow, medially or laterally, I do a phlebectomy. Under the eye, I do foam sclerotherapy with the needle pointed to the pterygoid plexus.
Facial Veins -Copyright 2011 by www.bushvenouslectures.com
Treating of facial veins with phlebectomy - Copyright 2011 by www.bushvenouslectures.com