Facial veins that cause embarrassment or distress in patients are one of the most common presentations to aesthetic practitioners. Such veins range from small red or purple telangiectasias through to green veins that may be flat or bulging, to large colourless blood vessels that bulge conspicuously.
Traditionally, aesthetic practitioners have been happy to treat individual telangiectasia, multiple telangiectasias, rosacea or small blue/green veins with a number of different electrical or light-based modalities. However, as the field of aesthetic phlebology increases, more patients are presenting with larger bulging veins of the temple, forehead or face that cannot be treated with these traditional approaches.
In this article, the authors will briefly detail current practice but will primarily concentrate on some of the new and exciting techniques for treating larger and more complex facial veins and blood vessels.
Clinical classification of facial veins
Any classification is only useful if it helps practitioners to understand appropriate treatment strategies for each category. For facial veins, the most useful four pieces of information are position, colour, size and flat or bulging appearance.
Position
Most facial vein problems occur within specific areas. Telangiectasia (also known as spider veins, thread veins or broken capillaries) tend to occur on the cheeks, around the nose, above the upper lip or on the chin (Figure 1). Prominent blue or green veins tend to occur in the temporal region, periorbital region and on the sides of the face down to the jawline (Figure 2). Bulging, relatively straight forehead veins that are colourless, start at the hairline or top of the skull and run down to the top of the nose between the eyebrows are dilated supratrochlear veins (Figure 3).
Figure 1. The usual distribution of facial telangiectasia 
Figure 2. The usual distribution of distinct blue/green or green veins of the face 
Figure 3. The usual distribution of prominent vertical forehead veins (supratrochlear veins)
These are often said to be incurable. However, a treatment has been developed for these, as well as a method patent, which is being considered for the procedure (Pereira et al, 2021).
Tortuous, colourless and very prominent blood vessels that emerge in front and above the ear, run forwards onto the forehead and then turn upwards towards the top of the scalp are often thought to be facial veins. Hence, they are included here (Figure 4). However, such vessels are usually arteries called the frontal branch of the superficial temporal artery. Traditionally, this has also been thought to be incurable. A treatment for this has been developed and published (Whiteley, 2021).
Figure 4. Usual distribution of the bulging frontal branch of the superficial temporal artery
Colour
Many aesthetic practitioners are unaware that veins are colourless. When they first perform any venous surgery, it can be a surprise to surgeons to see a vein and realise that the vein wall is bright white. The reason that veins appear to have a colour is that they are full of blood.
Venous blood is always roughly the same colour: a dark red. Therefore, the vein's colour depends on how much tissue lies between the blood and the surface. Telangiectasias with incredibly thin walls that sit high in the dermis have very little tissue above them and appear red. Often, those that are very bright red also have an arterial component. Those telangiectasias that are slightly bigger and sit slightly deeper in the dermis appear purple or blue. Discreet veins that lie under the dermis in the subcutaneous tissue and, again have thicker walls, appear to be blue/green or, if bigger and deeper, green.
When the veins have very thick walls and are very deep, there is no colour seen. These veins bulge and are colourless. In facial veins, only the supratrochlear veins that appear as vertical veins on the forehead appear as colourless and bulging. The frontal branch of the superficial temporal artery is also colourless due to the thickness of the artery wall and the depth of the artery under the skin and fascia. However, as this is an artery and not a vein, it is a special case in understanding and treating facial veins.
Size
As can be seen from the previous discussion, size and colour are intimately linked. However, size alone becomes more important when considering treatments.
The areas where treatments vary depending on size are generally in treating telangiectasia and in treating discreet veins in the temporal area, periorbital area and lateral face. This will be discussed in the treatment section.
Flat or bulging
The only facial veins where a flat or bulging appearance is particularly relevant to are those of the temple, periorbital area and lateral face. The difference between a flat or bulging vein helps practitioners to decide whether they are going to use an extracorporeal laser or refer or resort to surgical techniques.
Treatments
Before discussing treatments, it is worth considering the aims of treatment and how a specific procedure might achieve these.
It is known from other areas of venous surgery that the optimal way to treat veins is to ablate them. This means that the vein wall is destroyed, which is a process called transmural death (Whiteley and Holdstock, 2004). In transmural death, all of the cells are killed across the whole of the vein wall. In the past, it has often been thought that damaging the vein's inner lining (the endothelium) allows the vein walls to be stuck together.
However, this is wrong, as damaging the endothelium alone causes thrombosis and temporary closing of the vein, with the vein recanalising in the future. Therefore, the aim of most techniques to permanently remove veins is to cause transmural death of the cells in the vein wall without disrupting the vein. Then, this allows the body's immune system to remove the dead vein, leaving a fibrous scar instead of a vein. Generally, this sort of damage to a vein wall is achieved with heat or chemicals.
Injecting a chemical into a vein to cause transmural death is called sclerotherapy. Although many medical professionals think that sclerotherapy only affects the endothelium, research has shown that successful sclerotherapy causes transmural death of the vein wall (Whiteley et al, 2016).
While some have advocated sclerotherapy to treat facial veins (Green, 2001), it is generally regarded as dangerous and not advised. This is because the veins on the face connect through orbital veins around the eye, to the sagittal sinus in the brain. Hence, there is a risk of thrombosis of any of these veins if sclerosant passes into them during treatment. Additionally, there are now other alternatives available for all facial veins, so sclerotherapy is rarely, if ever, needed. Medicolegal cases have supported this (Roberts, 2014; Arunakirinathan et al, 2019). Therefore, the optimal way to treat facial veins is to heat the vein wall to cause transmural cell death.
As veins are white, practitioners must be careful in their approach to different heating techniques. The authors will briefly detail each.
Advanced electrolysis/electrocautery/radiofrequency
There are different machines that manufacturers claim have varying ways of heating tissue via a standard electrolysis needle. The price difference between some of these machines is staggering. However, they all work on very similar principles.
An alternating electric current is passed into a needle, which is inserted onto or just into the skin. At the point of contact, heat is generated by this alternating current. If the needle is touching the vein wall, heat passes into it, causing transmural death. Obviously, this only happens at one point, so, to treat a section of vein, the process has to be repeated all along the section at regular intervals of 1-2 mm. This sort of treatment is only suitable for telangiectasia. Some people do use it for small discreet veins, although other alternatives are available.
Intense pulsed light
Intense pulsed light (IPL) is normal white light passed through a filter to accentuate the wavelengths that interact with haemoglobin or melanin. By pulsing the light very fast, haemoglobin or melanin can be heated, while the surrounding skin stays cooler. It is important to note that this does not treat the vein wall directly, but only treats the haemoglobin in the blood inside the vein. Therefore, this can only affect veins where the blood can be heated to a sufficient temperature to pass the heat into the vein wall and destroy it. Hence, it cannot be used for big veins where the volume of blood is too large to heat effectively or the blood flows too fast, taking the heat away before it can be passed into the vein wall. So, IPL is most useful for telangiectasia, particularly when there are many of them in one area, such as in rosacea. As these wavelengths also interact with melanin, care must be taken in patients with increased levels of melanin in their skin.
Extracorporeal laser
Laser is another form of light energy using a single wavelength of light (monochromatic), which is also very powerful due to photons in the beam being in step (coherent). Wavelengths that interact with haemoglobin and heat it include 1064 nm (ND:YAG) and 512 nm (potassium titanyl phosphate (KTP)). The longer wavelength (ND:YAG) penetrates deeper into the skin and is, therefore, used for the larger, deeper and greener veins. On the other hand, the shorter wavelength (KTP) does not penetrate the skin well and is much better for the telangiectasia on the surface.
Although laser has a certain mystique about it, the basic principle is still the same as IPL. It heats the blood within the target vein, with the aim to generate enough heat to be conducted to the adjacent vein wall to ablate it. Therefore, just as with IPL, if the vein is too big and has too much blood in it, it will not be able to be to heat it sufficiently.
Additionally, if the blood is flowing too fast, it will be taken away before enough heat can be generated to damage the vein wall. As such, the ND:YAG laser is very good for blue-green and green veins just under the dermis, provided that they are small enough not to bulge or only bulge slightly. The maximum diameter for effective treatment is approximately 2-3 mm.
Phlebectomy
Although the previous ablation techniques cause transmural death, there are still some veins that can only be successfully treated by surgical removal (Figure 5). The removal of a vein by making a very small incision under anaesthetic (usually local) and then using a very fine hook to pull out the vein is called phlebectomy (often marketed as micro-phlebectomy). It is advantageous in temporal, periorbital or facial veins that are too large for successful ND:YAG ablation.
Figure 5. Before and after photos, showing phlebectomy of a temporal, periorbital and facial discrete green vein
Endovenous laser ablation
Endovenous laser ablation (EVLA) has become the standard way of treating leg varicose veins percutaneously. A miniaturised version of EVLA has now been developed for the treatment of the prominent vertical forehead veins (Figure 6). These veins bulge when patients lean forwards, get hot, exercise or drink alcohol. Patients can be distressed by them. The veins are so deep that they do not show any colour and are both too large and too deep to be treated by an ND:YAG laser.
Figure 6. An example of a prominent vertical forehead vein (supratrochlear vein)
Although the authors have previously presented their technique of performing phlebectomy for these veins (Figure 7), they found that some of the veins began to return after a few years. As such, the endovenous thermal ablation technique was developed using small catheters and cannulas under local anaesthetic (Figure 8). The technical details have now been published in peer-reviewed literature (Pereira et al, 2021).
Figure 7. Phlebectomy of a vertical forehead vein. This method of treatment has now been discarded 
Figure 8. Endovenous laser ablation of vertical forehead veins (supratrochlear vein). A method patent for this technique has been applied for
Double ligation technique for the frontal branch of superficial temporal artery
Although the frontal branch of the superficial temporal artery is not a vein, many patients present to aesthetic practitioners with a colourless bulging vessel in the temporal region (Figure 9) and ask for it to be removed. As it is an artery, it cannot be treated with external laser or endovenous laser or removed surgically. A technique has been developed to use microsurgical techniques to perform a double ligation of this vessel. The results appear to be excellent, with the scars disappearing between 4 and 12 weeks. This technique is very new, and it was only published in peer-reviewed literature this year (Whiteley, 2021).
Figure 9. Before and after photographs of the prominent frontal branch of the superficial temporal artery, which has been successfully treated with the double ligation technique
Discussion
The assessment and optimal treatment of facial veins is part of a new branch of phlebology called aesthetic phlebology. This new branch of phlebology includes treatment of hand veins, arm veins, breast veins and veins on the feet.
Unfortunately, currently in the UK, there is no speciality called phlebology. As the NHS does not appoint consultant phlebologists or venous surgeons, venous conditions get treated by various inappropriate specialists. They are inappropriate, as they are chosen because of the location of the veins, despite the fact that they have no background in the pathophysiology or biology of venous disease.
Hence, leg varicose veins usually get treated by vascular (arterial) or general surgeons; thread veins on the legs are treated by aesthetic practitioners (usually without checking for underlying venous reflux); varicoceles are treated by urologists; haemorrhoids are treated by bowel surgeons; pelvic congestion syndrome is ignored by most gynaecologists; and leg ulcers are bandaged and compressed, rather than cured by endovenous surgery.
Conclusion
As with all areas of medicine, the treatment of facial veins depends upon accurate assessment, understanding the anatomy and biology of the vein in question, the science of the techniques that can be used, selection of the correct treatment regime and proper training in the more complex treatments to ensure satisfactory results.
Although this simple article details the very basics of assessment and treatment options, many patients have more than one facial vein problem. By following the proper assessment and treatment schedules, patients can get excellent results, even when more than one technique has to be combined (Figure 10).
Figure 10. A series of figures showing a large bulging green vein in the temporal region overlying a prominent frontal branch of the superficial temporal artery followed by a post-operative photograph showing successful combined treatment
Hopefully, practitioners interested in phlebology and aesthetic phlebology will become interested enough to start specialising in this fascinating speciality that affects the majority of the population in one way or another.
Key points
- Telangiectasia (thread veins) of the face can be treated with electrolysis/radiofrequency, needles, intense pulsed light (IPL) or laser
- Veins are white in colour. IPL and extra-corporeal laser interact with the blood inside the vein, not the vein wall itself
- Veins that are too big (contain too much blood) or too deep cannot be treated with IPL or extracorporeal laser
- Bulging veins of the temples or around the eyes can be removed surgically by phlebectomy
- Bulging branches of the superficial temporal artery can be ligated with the double ligation technique.
CPD reflective questions
- How can you tell the difference between a bulging temporal vein and a dilated superficial temporal artery?
- What does the colour of the facial vein seen by the naked eye depend on?