Pilot targeted treatment of enlarged supratrochlear vein of the forehead with 1320 nm endovenous laser ablation

Enlarged forehead veins are a frequent patient complaint, becoming particularly prominent during Valsalva or increased blood pressure. The supratrochlear vein (STV) at the medial canthal line (also referred to as the central ¹ or ascending ² –more appropriately, descending– vein) is most often clinically apparent, although the supraorbital vein at the medial corneal limbus line and the oblique vein of the lateral forehead may also be implicated.^1,2 They are characteristically larger on one side of the forehead, producing unilateral aesthetic complaints. ¹

Unfortunately, sclerotherapy of these veins can be dangerous due to arterio-/veno-venous anastomoses and risk of product migration into the ophthalmic circulation, ² while phlebectomy is both technically challenging and associated with prolonged downtime. Cutaneous lasers are likewise problematic, being unable to reliably achieve transmural ablation of these large vessels due to insufficient pulse durations that carry a high risk for excessive dermal heating. Endovenous laser ablation (EVLA), however, is the gold standard treatment of large, superficial lower extremity veins, producing irreversible transmural thermal damage that eventuates in fibrotic vascular occlusion and often permanent vessel eradication with low risk of recanalization. ³ Unlike the vast majority of arteriovenous pairings, the STV accompanies the artery only in the medial canthus, ² with a mean intervessel distance of 6.5 mm at the supraorbital rim; the risk of accidental arterial cannulation or collateral arterial damage from EVLA is thereby highly unlikely, affording excellent procedural safety.^1,2

A 37-year-old female with a longstanding cosmetically bothersome right STV that periodically dilated to 6 mm in diameter underwent 1320 nm EVLA (Figure 1(A)). The patient was placed supine in 15-degree Trendelenburg, and gentle pressure on the medial aspect of the right medial cheek at the level of the infraorbital foramen was used to exert pressure on the facial/angular vein, further dilating the STV. Vein width and length were marked, and the vein was confirmed under duplex ultrasound (DUS, Terason 3200T, Terason, Burlington, MA).OPEN IN VIEWER

After sterilely prepping the area, the STV was cannulated at the junction of the frontal scalp and upper forehead with a 24 G retractable peripheral intravenous catheter (Insyte Autoguard, BD, Franklin Lakes, NJ). When catheter flashback was confirmed, the needle was retracted, and intraluminal position was confirmed by aspiration of nonpulsatile venous blood. A 550 μm bare-tip laser fiber (RTB-550, LP Surgical Fibers, Plymouth, MN) was introduced directly through the catheter and advanced until the fiber tip light-emitting diode (LED) was approximately 3 mm above eyebrow level. Fiber tip position was confirmed with DUS, the intravenous catheter was retracted, and the patient was returned to 180°.

Thirty mL of perivenous tumescent anesthesia solution (0.05% lidocaine, 1:1,000,000 epinephrine, and 8.4% sodium bicarbonate in normal saline) was then infiltrated with a 21 G spinal needle and variable-rate peristaltic pump (HK Surgical, San Clemente, CA). Attention was given to meticulous infiltration between the vein and skin surface. A fully compressed vein with proper fiber tip position and at least 2–3 mm of separation between the vein and skin surface was confirmed on DUS. The fiber was connected to the 1320 nm Nd:YAG laser (CoolTouch CTEV, Roseville, CA), and treatment was performed at 3W continuously at 50 Hz while being withdrawn at 1 mm/s. Total energy delivered was 54 J with 900 pulses. Treatment was stopped when the fiber LED was 3 mm from the entry-point. A small adhesive bandage was placed at the entry site. The patient reported mild localized edema and delayed ecchymosis (yellow discoloration) of the nasal root and tear troughs lasting 5 days. No burns or other serious adverse events occurred. Clinical eradication of the right STV was evident at 3-month follow-up (Figure 1(B)) and persisted at 5 months.

Although a sheathed radial fiber may produce less bruising and potentially faster recovery than a bare-tip fiber, ³ the use of a 550 μm bare-tip allowed us to advance the laser fiber through a 24 G catheter without the need for an introducer/dilator or guidewire, minimizing the size of the entry wound and patient discomfort. The far greater optical extinction coefficient (absorption to scattering ratio) of blood at longer wavelengths (≥1320 nm) leads to superior efficacy and fewer adverse events, given that lower power is needed to produce equivalent laser-tissue interactions.^3,4

A prior retrospective study of 1470 nm EVLA (3W, 0.7–1.0 mm/s) for STVs in 15 patients demonstrated treatment success after a mean of 1.2 ± 0.4 sessions. ⁵ None demonstrated lack of clinical benefit, although 2 patients had patent, albeit narrowed, veins. They described 1 small superficial burn after inappropriately early repeat treatment at 4 W on postoperative day 3 and one report of skin tethering high on the forehead. Insufficient tumescent infiltration between the anterior vein wall and the skin surface may have played a role in both. Our result is in line with their results, given the high efficacy and low downtime of this procedure.

While a prospective clinical trial is needed, preliminary evidence demonstrates that EVLA of the STV has a high benefit-to-risk ratio that may be superior to that of other options. Given that this is a pilot single patient report with follow-up limited to 5 months, a prospective study with long-term follow-up would serve to optimize treatment parameters and technique and determine posttreatment recanalization rates.