By Dr Ashraf Badawi, Dermatologist and IMCAS Academy Board Member, Canada

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.

The aim of this prospective descriptive study of 22 patients with prominent periocular veins was to evaluate the long-term efficacy and safety of the Nd:YAG 1064 nm laser in the treatment of periocular veins.

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 fluency, 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.

The patients then attended a six weeks and a one-year follow-up visit.

Results and discussion

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 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).

The veins showed immediate vasospasm and disappearance upon the laser impact in all the patients. After one year, three blinded dermatologists were all 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.

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 4mm 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 hyperpigmentation2,3.

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 one 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 a previous study, 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 interaction4.

During the six weeks as well as the one-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 1064nm 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 cooling3.

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 effects3. 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.

The 7mm 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 melanocytes5.

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.

Conclusion

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 provided it has been used with the right parameters and technique.

Sources

1Kersten RC, Kulwin DR. Management of cosmetically objectionable veins in the lower eyelids. Arch Ophthalmol 1989; 107:278–280.

2 Baäumler W, Ulrich H, Hartl A, Landthaler M, Shafirstein G. Optimal para- meters for the treatment of leg veins using Nd:YAG lasers at 1064nm. Br J Dermatol 2006; 155:364–371.

3 Alora MB, Dover JS, Arndt KA. Lasers for vascular lesions. Dermatol Nurs 1999; 11:97–102, 105–107; quiz 108–109.

4 Tanzi EL, Lupton JR, Alster TS. Lasers in dermatology: four decades of progress. J Am Acad Dermatol 2003; 49:1–31.

5 Grossman MC, Dierickx C, Farinelli W, Flotte T, Anderson RR. Damage to hair follicles by normal-mode ruby laser pulses. J Am Acad Dermatol 1996; 35:889–894.

This article is an abridged version of the full study, which was originally published in the Journal of the Egyptian Women's Dermatological Society.