Periorbital Rejuvenation




The safety profile of certain techniques, such as sclerotherapy, is questionable in a region as precarious as the periorbital region, where complications related to vision would be catastrophic. Other safe techniques such as phlebectomy can be performed with successful outcomes but are operator dependent, require a reasonable degree of technical ability, and can result in scarring and other complications. The aim of this article is to explore newer, laser-based treatment of these periorbital veins, discuss the physiology and the therapeutic efficacy, and better delineate the safety profile and evolution of the technique that has led to the present treatment paradigm.


Key points








  • The periorbital region is anatomically complex, and age-related changes often prompt patients and practitioners to find solutions to combat the visible signs of aging.



  • Unsightly periorbital reticular veins, and those extending to the temples, represent a relatively frequent complaint of patients.



  • Various treatments such as sclerotherapy and phlebectomy have been promoted with varying degrees of success, but also may have potential for undesirable complications.



  • The authors’ experience with laser-based treatment of these veins has been excellent; this article presents the treatment paradigm and explores patient outcomes.






Background


The periorbital region plays an essential role in communication, emotional expression, health, and aging. Clearly defined goals of facial, specifically periorbital, aesthetics are the basis of successful results in therapeutic rejuvenation of the upper face. A common complaint of patients relates to the prominence or appearance of unsightly periorbital reticular veins, which may become increasingly prominent throughout life. A reticular vein is a dilated bluish intradermal vein, typically between 1 to 3 mm in diameter, and often tortuous in its course.


Age-related changes, including decreased skin thickness, subcutaneous fat depletion, soft-tissue and muscle atrophy, and venous dilatation all contribute to the increased prominence of veins in the periorbital region, leading many patients to seek intervention for this unsightly feature. Increasing use of neurotoxin injectables for periocular rejuvenation has led to heightened clinical awareness of these vessels, from a technical perspective to minimize bruising as well as from an aesthetic viewpoint when they are particularly prominent. In addition, clinicians have noted increasing prominence of veins in the lateral orbital or temporal region subsequent to therapeutic maneuvers that occlude vessels, such as ligation of the sentinel vein during endoscopic brow lifting.


There exist numerous therapeutic options for the treatment of unwanted veins. In general terms, lasers for the treatment of facial telangiectasias and prominent veins have had good success. The authors have had excellent results using a 1064-nm Nd:YAG laser (Cutera, Brisbane, CA), with good clinical outcomes and an excellent level of patient comfort. In the past the treatment of smaller facial vessels (≤1 mm) was generally effective using laser technology. Effective treatment of larger facial reticular veins has remained somewhat elusive.


Sclerotherapy is a commonly suggested and performed treatment modality, with reasonable results in expert hands. However, this procedure does confer some associated risk. Many facial plastic, oculoplastic, and dermatologic surgeons tend to avoid the use of this agent in the periorbital region, secondary to concern regarding diffusion of solution to unintended areas of venous circulation, with possible ophthalmologic and other complications.


Ambulatory phlebectomy is another alternative; however, some view this option as less desirable on the face, for a variety of aesthetic and technical reasons.


Very little literature exists documenting the use of the 1064-nm Nd:YAG laser in the periorbital region, an area with no standardized treatment and an often fragmented therapeutic algorithm on the part of clinicians. The authors’ treatment algorithm has yielded great success with the use of the Cutera long-pulsed, contact-cooled, variable spot-sized Nd:YAG laser.




Background


The periorbital region plays an essential role in communication, emotional expression, health, and aging. Clearly defined goals of facial, specifically periorbital, aesthetics are the basis of successful results in therapeutic rejuvenation of the upper face. A common complaint of patients relates to the prominence or appearance of unsightly periorbital reticular veins, which may become increasingly prominent throughout life. A reticular vein is a dilated bluish intradermal vein, typically between 1 to 3 mm in diameter, and often tortuous in its course.


Age-related changes, including decreased skin thickness, subcutaneous fat depletion, soft-tissue and muscle atrophy, and venous dilatation all contribute to the increased prominence of veins in the periorbital region, leading many patients to seek intervention for this unsightly feature. Increasing use of neurotoxin injectables for periocular rejuvenation has led to heightened clinical awareness of these vessels, from a technical perspective to minimize bruising as well as from an aesthetic viewpoint when they are particularly prominent. In addition, clinicians have noted increasing prominence of veins in the lateral orbital or temporal region subsequent to therapeutic maneuvers that occlude vessels, such as ligation of the sentinel vein during endoscopic brow lifting.


There exist numerous therapeutic options for the treatment of unwanted veins. In general terms, lasers for the treatment of facial telangiectasias and prominent veins have had good success. The authors have had excellent results using a 1064-nm Nd:YAG laser (Cutera, Brisbane, CA), with good clinical outcomes and an excellent level of patient comfort. In the past the treatment of smaller facial vessels (≤1 mm) was generally effective using laser technology. Effective treatment of larger facial reticular veins has remained somewhat elusive.


Sclerotherapy is a commonly suggested and performed treatment modality, with reasonable results in expert hands. However, this procedure does confer some associated risk. Many facial plastic, oculoplastic, and dermatologic surgeons tend to avoid the use of this agent in the periorbital region, secondary to concern regarding diffusion of solution to unintended areas of venous circulation, with possible ophthalmologic and other complications.


Ambulatory phlebectomy is another alternative; however, some view this option as less desirable on the face, for a variety of aesthetic and technical reasons.


Very little literature exists documenting the use of the 1064-nm Nd:YAG laser in the periorbital region, an area with no standardized treatment and an often fragmented therapeutic algorithm on the part of clinicians. The authors’ treatment algorithm has yielded great success with the use of the Cutera long-pulsed, contact-cooled, variable spot-sized Nd:YAG laser.




Methods


Twelve patients were voluntarily enrolled after informed consent was obtained.


Informed consent involved discussions regarding the unlikely possibility of discomfort during treatment, skin-pigmentation anomalies, possible burns, and the possibility for repeat treatments to achieve adequate elimination of the unsightly veins.


Treatment sites ranged from infraorbital vessels to lateral orbital and temple reticular veins, and in some cases extended to superior temporal forehead regions.


Treatment parameters varied according to the size of the veins being treated. Posttreatment cooling was used. The treatment goal was to achieve blanching of vessels without causing a skin burn. Patients required 1 to 2 passes during the treatment. To prevent excessive heat accumulation, the vessels were treated via multiple shots in nonadjacent order. The entire vessels were treated but without overlap. The periorbital treatments involve carefully aiming the laser beam away from the orbit. All patients were required to wear protective eyewear before treatment.


The laser used was the Cutera 1064-nm Nd:YAG. Precisely controlled variables used to achieve predictable and effective results included spot size, fluence, and pulse duration ( Table 1 ).



Table 1

Treatment parameters for the Cutera 1064-nm Nd:YAG, for treatment of periorbital and temple reticular veins












Spot size 5–7 mm (2–3 mm depth)
Fluence 100–120 J/cm 2
Pulse duration 20–25 ms


Some patients developed an immediate posttreatment urticarial or erythematous response, which resolved in 1 to 2 hours. Each patient received one treatment and was examined 1 month after the treatment. Photographs were taken both pretreatment and posttreatment.


Results were judged by 2 experienced physicians both visually on patients and by comparison of pre- and posttreatment 35-mm color slides and photographs. Determination was made on follow-up visit as to whether another treatment session would be required to further improve the appearance of these veins to the patient’s satisfaction.




Results


The treatments were tolerated well by patients, with occasional pain being well managed using the direct-contact copper-plate cooling mechanism of the laser. The total treatment duration was typically less than 15 minutes per patient, although those patients with very extensive superficial veins requiring a large number of impulses often required slightly longer treatments.


The end point of treatment was determined by appropriate vessel response (gray coloration of the vessel, or visible vessel collapse). In addition, areas of skin that had an erythematous appearance after spot treatment were avoided to prevent thermal injury.


Twelve patients were initially enrolled in the study ( Table 2 ). There were 10 female and 2 male patients. The average age was 42.3 years, with a large age range of 13 to 68 years.


Aug 26, 2017 | Posted by in General Surgery | Comments Off on Periorbital Rejuvenation
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