Treatment of Periorbital Veins With Long-Pulse Nd:YAG Laser
November 2015 | Volume 14 | Issue 11 | Case Reports | 1360 | Copyright © November 2015
David L. Chen MDa and Joel L. Cohen MDa,b
aUniversity of Colorado Denver, Department of Dermatology, Aurora, CO
bAboutSkin Dermatology and DermSurgery, Englewood, CO
Periorbital veins (POVs) are a common cosmetic concern. Anatomically, POVs are formed by superficial facial veins that start from the bridge of the nose, travel as supraorbital and infraorbital veins, and join venous branches from the lateral forehead and scalp. In patients with fair skin, or in patients whose facial skin is atrophied, POVs can become prominent. This can lead to a fatigued appearance, with perceived “dark circles” around the patients’ eyes. Previously described surgical therapies for prominent POVs are invasive and can leave unsightly scars, and sclerotherapy has been reported to lead to embolization that could lead to blindness. Here, we give examples of the use of 1,064 nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser to non-invasively treat or at least minimize prominent
POVs. We discuss various techniques, and review treatment schedules to achieve the optimal cosmetic outcome. Furthermore, potential pitfalls, such as local site reaction and laser-specific tissue damage, are explored. Overall, Nd:YAG laser does appear to be a safe and effective treatment for POVs that requires minimal post-treatment care. J Drugs Dermatol
Periorbital veins (POVs), while not life threatening or even associated with other medical conditions, are common cosmetic concerns for dermatology and aesthetic patients. Many patients are erroneously told, often by various types of medical providers as well as physicians of different medical specialties, that there are no therapies available. In spite of this, indeed, various treatment modalities including incision with direct cautery of veins, sclerotherapy, and phlebectomy, have been reported.1,2
Anatomically, POVs are superficial facial veins that begin on the bridge of the nose, and travel inferiorly along the nasal sidewall. Supraorbital and infraorbital branches travel laterally, join, and cross over the lateral peri-orbital rim. In this lateral canthal region, these bluish veins meet branches from the lateral forehead and scalp, and eventually drain into the internal jugular vein. Multiple branches points can be seen, and these can present as not only horizontal but also vertical veins in the thin skin of the upper and lower eyelid. In a patient whose peri-orbital skin is fair and/or thin, POVs can be prominent and often contribute to discoloration making these people appear tired with “dark circles” below around their eyes.
The previously described therapies for POVs are invasive and can leave noticeable scars. Sclerotherapy in the periorbital zone is rarely practiced, as it had been reported to cause embolization that could lead to blindness.3 Recently, the 1,064 nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser has been used successfully to non-invasively treat facial veins, including prominent infraorbital veins that can contribute to the appearance of infraorbital dark circles.4,5 With its longer wavelength than most other vascular lasers, the Nd:YAG laser can penetrate deeper into the skin, and theoretically cause less epidermal and melanocyte damage. Here, we report our experiences with using long-pulse Nd:YAG laser for the treatment of visible periorbital veins.
Several different types of long-pulse Nd:YAG lasers, (including the Candela Gentle YAG, Cynosure Cynergy, and Fotona Dynamis) are available in the US. To treat POVs, typically a spot size of 3 mm, pulse duration of 20 ms, fluence of 140 to 180 joules/cm2, at pulse frequency of 1 Hz, is used. Our approach, first reported by Taylor, Cohen, and Berlin in 2013, requires an assistant who uses two cotton tipped applicators to press and block the flow of blood in the treatment vein segment at either end, several centimeters apart.6 In so doing, the blood flow through the vein has been halted or at least slowed – making the chromophore less of a moving target. The vein is then treated with the laser in focused mode, with ice-cube cooling via application over the treatment site every 2 to 4 pulses. The laser setting is adjusted to achieve optimal response, specifically where the blue of the vein should be disappearing immediately. At this point, the blood within the veins is superheated and coagulated, and the veins will denature. If the blue does not disappear, the fluence of the laser should be slowly increased at about 10 joule/cm2 intervals. The optimal setting should also leave the overlying skin unaffected. If the overlying skin turns gray or white with any pulse, the laser fluence is too high and needs to be immediately decreased. Excessive fluence, stacking, or even overlap can lead to blistering and scarring of the overlying