Treatment of facial reticular veins with dynamically cooled, variable spot-sized 1064 nm Nd:YAG laser

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Treatment of facial reticular veins with dynamically cooled, variable spot-sized 1064 nm Nd:YAG laser
March 2007
Stephanie W Lai MD, Mitchel P Goldman MD
Journal of Cosmetic Dermatology/Blackwell Synergy

Summary

Background Facial reticular veins are often seen on the temple and periorbital areas in patients with genetic predisposition or after facial cosmetic surgery.

Aim The purpose of this study was to evaluate the efficacy and safety of dynamically cooled, variable spot sized 1064 nm Nd:YAG laser in the treatment of facial reticular veins.

Patients/methods This is a retrospective study. Twenty patients with facial reticular veins who underwent treatment with dynamically cooled, variable spot sized 1064 nm Nd:YAG laser were evaluated. Patients were followed up 1 month to 2 years after the procedure.

Results Objective and subjective improvement scores after one or two treatments of dynamically cooled, variable spot sized 1064 nm Nd:YAG laser were nearly 100% when appropriate parameters were used.

Conclusion Dynamically cooled, variable spot sized 1064 nm Nd:YAG laser is a safe and effective treatment for facial reticular veins. Most patients responded to one treatment and experienced no significant side effects other than tolerable pain associated with the procedure.

Introduction

Facial reticular veins are often seen on the temple and periorbital areas in patients with genetic predisposition or after cosmetic surgery. Treatment of these veins is a commonly requested cosmetic procedure.

Various treatments for telangiectases and reticular veins on the legs have been reported. These treatments include sclerotherapy, laser therapy, and vein surgery. The literature on the treatment for facial veins remains scant. For the treatment of facial telangiectasias, various lasers (diode, pulse dye and KTP and Nd:YAG lasers) and intense pulse light have been reported to be effective. However, purpura can be a problem in treating larger facial veins, especially reticular veins. Eremia and Li 1 first reported 1064 nm Nd:YAG laser effective in the treatment of facial telangiectasias and reticular veins in 2002. With the 1064 nm near-infrared laser, the wavelength is able to penetrate deeper to the vessels with minimal risk of epidermal damage. The 1064 nm wavelength allows darker skin types to be treated as well. We now report a retrospective study that examines the efficacy and safety of dynamically cooled, variable spot size 1064 nm Nd:YAG laser (CoolTouch VARIA, Roseville, CA) in the treatment of facial reticular veins.

Patients and methods

Twenty patients, skin types IÒIV, who sought treatment for facial reticular veins were enrolled after informed consent. Treatment sites were in the periorbital and temporal areas. Treatment parameters varied according to the size of the veins treated. Reticular veins ranging from 1 to 3 mm were treated with 180Ò210 J/cm2, 3.25Ò3.5 mm spot size and a 25Ò50 ms pulse width depending on the vessel size; 1 mm vessels were treated with a 25 ms pulse width and 2Ò3 mm vessels were treated with a 50 ms pulse width. A 30 ms cryogen spray was used in pre- and post-laser cooling. The treatment goal was to achieve immediate blanching of the vessels which normally requires one to two passes. The vessels were treated from distal to proximal without overlap. All patients were required to wear protective goggles during the procedure. Patients were followed up from 1 month to 2 years after the initial treatment. Fourteen patients were evaluated in person and photographs were taken before and at follow-up visits (Fig.1) and six patients were evaluated by telephone-interviews. Patients who did not respond completely after the first treatment had the option of a second treatment.

Results of 14 patients were judged by two physicians both with direct patient examination and by comparison of before and after photographs. Results were ranked in five categories based on the percent improvement: 5, complete resolution; 4, 75Ò99% improvement; 3, 50Ò74% improvement; 2, 25Ò49% improvement; 1, < 25% improvement. PatientsÌ overall satisfaction was ranked on a scale of 1Ò3 with 1 being minimal improvement and 3 being completely satisfied.

Results

Twenty patients were evaluated. Among 14 patients who were able to return for follow up, the physiciansÌ objective improvement scores were 5 in 11 patients and patientsÌ satisfaction scores were 3 in 12 patients (Table 1). Among the 6 patients who received telephone interviews, the subjective satisfaction scores were 3 among 5 patients (Table 2). The subjective and objective improvement scores for patients who underwent one or two treatments were nearly 100% when appropriate parameters were used.

All patients tolerated the procedure well, with five complaining of mild to moderate pain. Four patients experienced transient erythema or bruising which completely resolved within 10 days of the procedure. No other side effects were reported, such as blistering, crusting, or pigmentation changes.

Discussion

Although sclerotherapy is the gold standard in the treatment of varicose veins on the legs, it never gained much popularity on the face due to reports of ulceration. 2 The periocular area is technically difficult and posts a potential for loss of vision. 3-5 Theoretically, it is also possible that the sclerosing agent may travel downstream and damage normal, nonvisible vessels. Therefore, the development of a laser device to treat facial veins is highly desirable. In the past, various lasers such as CO2, argon, argon pumped tunable-dye, copper vapor, flashlamp pulsed dye, 532 nm Nd:YAG, and intense pulse light have been reported useful in the treatment of facial telangiectasias. However, many patients suffer from permanent scarring, prolonged purpura, and pigmentary changes as a result of the treatment. 2,6 The literature on the treatment of facial reticular veins remains scant. The main light absorbing chromophore in vessels is hemoglobin. It has a broad band of absorption from 500 nm to 1100 nm. The wavelength of 1064 nm penetrates deeper into the dermal blood vessels and decreases the risk of epidermal damage. It also allows individuals of darker skin types to be treated due to minimal interaction with epidermal melanin. 7,8 Dynamically cooled, variable spot size 1064 nm Nd:YAG has the advantage of reproducible epidermal cooling which protects the epidermis from laser-induced thermal damage. As a testament to this advantage, no patient in our study experienced blistering, crusting, or pigmentation changes. There have been multiple reports of dermal scarring with depression from use of other 1064 nm lasers without dynamic cooling. 9

Patients who have 2Ò3 mm reticular veins responded better to a higher fluence, 200Ò210 J/cm2. Interestingly, of those with larger caliber of 2Ò3 mm veins, five patients required a second treatment. Those who were treated with a lower fluence of 180 J/cm2 often required a second treatment. It is possible that a higher energy is essential for full thickness vessel penetration.

Two patients, who noted reappearance of veins 6Ò12 months after the initial treatment, were treated again and responded well. The phenomenon may be due to rechanneling of the existing veins or the appearance of new veins.

Dynamically cooled, variable spot size 1064 nm Nd:YAG laser (Cool-Touch Varia) is a safe and effective treatment for facial telangiectasias and reticular veins. For patients with skin types IÒIV, no significant side effects were reported other than discomfort associated with the procedure. The vessels usually resolved immediately after the treatment when appropriate parameters were used. The overall patientsÌ satisfaction and objective improvement scores were nearly 100%.
References

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