Not In Vein

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Luis Navarro, M.D., FACS, FACPh, is the Founder and Medical Director of The Vein Treatment Center in New York City. Established in 1982, The Vein Treatment Center is the first facility devoted exclusively to the treatment of varicose veins and spider veins and has been at the forefront of several breakthrough treatments. “Basically, I’ve dedicated my life to veins,” says Dr. Navarro.

The quest for youth and beauty leaves no stone, or rather, vein unturned. Bulging varicose veins have been effectively dispatched for years with various treatments including phlebectomy, sclerotherapy and more recently, Endovenous Laser Ablation (EVLA, aka Endovenous Laser Treatment or EVLT).  But, it’s not just unsightly leg veins which are being banished from view.  Spider veins, blue veins, cherry angiomas — all manner of unsightly venous displays — are being eradicated from head to toe in an effort to achieve the smooth, unblemished skin of bygone years.  Today, there’s no body part that can’t be treated — not the hands, not the chest, not even the eyelids.

“Eliminating visible veins on the face, breast and hands is becoming fashionable,” states pioneering vein specialist, Dr. Luis Navarro. “Veins in those areas usually are not varicose veins.  They are normal veins which, because of the aging process, have lost subcutaneous fat, elasticity and water content.”  The effects of gravity take their toll too.  Fortunately, these areas respond well to treatment, generally requiring only one to three sessions.  Results are good because the veins there don’t carry as much pressure as the veins in the legs.

Bulging hand veins are not diseased like varicose veins. Nor do they necessarily become larger with age. Their prominence is due to the fact that as we age, the fatty tissue surrounding them disappears and the skin becomes thinner. Their elimination via sclerotherapy treatment is permanent.

Bulging, age-betraying hand veins are usually treated with sclerotherapy, also known as injection therapy.  Sclerotherapy involves the injection of a chemical liquid or foam directly into the vein to shut it down permanently. The closed vein is eventually absorbed by the body, explains Dr. David Fox, a board-certified vascular surgeon. The results are permanent.  Because hand veins are not diseased, like varicose veins, the likelihood of new veins developing in the hand is very low. Would the removal of veins compromise the circulation of the hand, however? No, reassures Dr. Fox. “There are many more blood vessels in the deeper layers of the hand that provide adequate blood flow. The bulging hand veins are superficial and not required for normal circulation.”

When it comes to veins on the face, including the cheeks, nose and eye area, there are essentially two treatments — sclerotherapy and laser.  Injections have better results according to Dr. Navarro, unless the veins are especially tiny and widespread.  Then, laser becomes the more effective treatment. It is important to keep in mind, however, that a laser’s efficiency decreases with a vein’s depth. The deeper the vein, the less effective the laser therapy.

Founder of Manhattan’s Fox Vein Care center, David Fox, MD, FACS is a board-certified vascular surgeon specializing in the treatment of venous disease. On the removal of veins, Dr. Fox says: “It’s important to realize that the venous system is really a network with a lot of redundancy in it. So, if we close off or remove certain parts of the venous system, the blood is going to immediately and automatically re-direct to other parts of the venous system. Treatment of the faulty veins almost always results in improved blood flow in the overall vein system.”

The aging process plays a part in causing veins to become visible on the face, and so do genetics. Surgical procedures like facelifts can be a culprit too. “You quite often see neovascularization or the formation of new blood vessels with facelifts,” explains noted laser specialist Dr. Roy Geronemus. “That’s generally caused by the pulling and manipulating of tissue. We do a lot of post-facelift treatments for that very reason and the same thing is true of the eyelids.”

Renowned dermatologist and laser specialist, Roy G. Geronemus, M.D. is the Director of the Laser & Skin Surgery Center of New York. On vein treatment: “I think lasers are still the best option pretty much anywhere on the body except for the legs and the hands. Telangiectasias (aka spider veins) do really well with laser treatment.”
Before and after laser treatment on the cheeks.

While eliminating veins on the eyelids is not a frequent request, it is not unpopular under certain circumstances.  The most common instance is following a blepharoplasty or eyelid surgery where the skin is either pulled tightly or manipulated during the course of the surgery. “Or,” explains Dr. Geronemus, “it could be a serendipitous type of thing where it just occurs based upon suturing or any kind of irritation to the area.”

L. to r.: Before and after laser treatment
on the cheeks.; Before and after laser treatment around the eyes.

And is there a potential danger of the laser penetrating through to the eye? According to Dr. Geronemus, careful use of the eye shields would eliminate any significant risk in this regard.  The main hazard rather, is that of pigmentary change with someone who has darker skin.  The skin may darken or lighten, but there are ways of minimizing this outcome. And, like with any procedure, there is a risk of scarring, but it’s very rare.

Co-founder of CompleteSkinMD, Julie Karen, M.D. is a board certified dermatologist who specializes in Mohs micrographic surgery, laser surgery, skin cancer, and the treatment of leg veins.

That’s because, as Dr. Geronemus explains, eyelid skin is thin so it responds to a relatively low level of energy. An aggressive energy setting, therefore, is not necessary in order to obtain a response.

When it comes to the veins around the eyes and the temples (the periorbital and temporal veins), doctors have differing opinions about how or even if to treat them. “There aren’t a lot of great options, here.  Those veins are connected to the scalp.  They’re draining the scalp,” explains Dr. Julie Karen who offers laser therapy to treat the area. “So, people will laser them but all I will promise is a temporary shrinkage of the vein.”

Like Dr. Karen, Dr. Geronemus also prefers laser treatment for periorbital veins, but sees no downside to removing those veins:  “I think laser is very quick and very easy and they’ve gotten better over the years. We’re so much better at that now than we were a few years ago based upon newer technology and I just think it’s much easier for the patient to do a laser procedure.”

As with the veins on the eyelids, great care must be taken for the long wavelength lasers which are typically used to treat the area can cause damage to the eye if certain precautions aren’t taken. “You must be careful to laser outside the bony orbit,” cautions Dr. Karen.  And of course, just like with the periorbital veins, the use of protective metal eyeshields is a must.

Ocular laser eye shields.

While laser is a popular treatment option for the periorbital veins, sclerotherapy offers an alternative therapy.  “There is no communication between the veins below the eye (infraorbital), those on the side of the eye (temporal) and the central retinal vein, so this is a safe thing to do,” assures Dr. Fox, who favors injection therapy in this area because “these veins are generally too large to be considered for laser treatment.”  Laser treatment for facial veins, according to Dr. Fox, is best applied to the fine spider veins — small pink, red or purple vessels — that develop on the nose and cheek.

Plastic surgery can also be a factor in the formation of unsightly blue veins on the breasts and décolletage.  That’s because, during a breast augmentation, the skin is forced to stretch and thin out, causing veins to become more visible.  In fact, there are numerous reasons for the appearance of breast veins.  Natural breast growth along with significant weight gain or loss are factors as is pregnancy with its hormonal changes and the inflammation caused by breast feeding.  Aging and sun exposure play a role too.  In addition, the appearance of these veins can also be worsened by radiation treatments for cancer.  Lastly, as with blue veins on the décolletage, genetics play a part too.  They can appear when a woman is quite young, especially if she has a genetic predisposition to veiny skin.  The preferred treatment here is sclerotherapy.  “There is no recovery time,” says Dr. Navarro.  “It is a quick, safe procedure.”

Before and after treatment of chest veins. “Veins on the breasts, chest wall and back are generally treated with foam sclerotherapy, informs Dr. Fox. “These veins generally respond very well. Again as we go higher in the body there is lower hydrostatic pressure and we can expect a better response to treatment. Large veins are often most efficiently treated with microphlebectomy.” (Phlebectomy, which is also known as microphlebectomy or ambulatory phlebectomy, is an outpatient procedure which entails the removal of large or medium-sized veins through a tiny – less than ¼ inch – incisions.)

Vulvar Region
Pregnancy can be responsible for veins to appear on other parts of the body too such as the vulvar region. Vulvar varicosities, or varicose veins in the vulva, tend to occur most often after pregnancy due to the changes that occur in the pelvic veins from a pregnant uterus and an increase in female hormone levels. Occasionally, these pudendal veins are due to obstruction of major veins in the pelvis. Sclerotherapy is a very effective treatment.

Before and after treatment of veins in the vulvar region.

Sometimes, veins from the vulvar area contribute to or are even the sole source of varicose veins in the legs. But the source of varicose veins in the legs is usually found on the same leg however, commonly a faulty main vein.  “Veins are long, muscular tubes which carry blood from the legs and feet against gravity back towards the heart,” explains Dr. Fox.  “Inside the veins are one-way valves which, when working properly, keep the blood moving back towards the heart, preventing the backwards flow of blood.”  People who develop varicose veins and some but not all people who develop spider veins have had damage to the valves.  “So, when they’re standing,” continues Dr. Fox, “there’s nothing to stop the blood from flowing backwards.  The blood flows down the leg.  This raises the pressure and cause the veins to bulge.”  It can also cause symptoms like leg swelling and aching and pain.

Before and after treatment of varicose veins. Photo: Fox Vein Center
Before and after treatment of spider veins. Sclerotherapy, is the most common treatment for spider and varicose veins on the legs. Photo: The Vein Treatment Center

The number one determinant for someone developing varicose veins is genetics.  Pregnancy is also a major risk factor.  “Very often, it’s the second or subsequent pregnancies which really brings it out because your veins have been taxed,” explains Dr. Karen.  The reason why pregnancy is such a risk factor is hormonal influences.  “Progesterone which increases during the first trimester relaxes the vein wall, causing the vein to distend,” explains Dr. Karen who, for this reason always tells patients early on in pregnancy wear compression stockings to minimize damage done by the pregnancy.  “If you wait past the first trimester,” warns Dr. Karen, “the pregnancy has already taken its toll.”

“There’s also increased blood flow during pregnancy and there’s also just increased pressure on the legs from the baby and the expanding uterus.  So, all these hormonal and physiologic conditions combine to make your legs work really, really hard,” continues the dermatologist. “For this reason, “I like to say that varicose veins are inherited meaning you get them from your parents and from your children,” jokes Dr. Fox.

Varicose veins are almost always associated with venous reflux. This occurs when the valves in the leg veins don’t work well, and backward blood flow causes pooling in the lower leg. Without treatment, the pressure this creates may increase over time and cause additional varicose veins and symptoms. People with a family history and who are older, obese or are pregnant may be at increased risk of developing varicose veins. Source: Fox Vein Center
Invented by Dr. Luis Navarro of the Vein Treatment Center, Endovenous Laser Ablation (EVLA), also referred to as Endolaser and EVLT, is a minimally invasive procedure which is now used worldwide in the treatment of large varicose veins. EVLA uses existing laser and ultrasound technology to close the main vein from the inside with laser energy. EVLA, which is administered under local or regional anesthesia, makes costly hospitalizations, the need for anesthesia, incisions, the need for a surgeon, and patient downtime for recovery completely unnecessary. Source: The Vein Treatment Center
Cryotherapy is another advance in technology. Unique to sclerotherapy at the Vein Treatment Center, the cryotherapy machine delivers short bursts of super-cooled air to numb the skin and reduce inflammation during the injections. This results in a more comfortable procedure, faster cosmetic results, and faster healing time. Source: The Vein Treatment Center. “This changes the patients’ comfort level completely,” says Dr. Navarro. “If you have 40, 80, 120 injections, it can feel like Chinese torture. With cryotherapy, patients can have much longer sessions and we have faster and better results.”

Spider veins, in addition to reticular feeding veins, are smaller veins which also appear on the legs.  They are usually located on the outside of the thigh, right beneath the skin.  Treatments include both laser and injections with a very fine needle.  The larger reticular veins require injections.  “It’s important to treat both to get the best possible results and decrease the likelihood of recurrence,” advises Dr. Fox.

“Many patients are distressed by large bulging veins on their feet,” says Dr. Fox who prefers to treat these veins with phlebectomy. “Sclerotherapy is not likely to be effective in this area because of the size of the veins and the high level of hydrostatic pressure that develops in these veins when patients are standing. Smaller spider and reticular veins of the feet can be successfully treated with surface laser and sclerotherapy. Again the hydrostatic pressure in this area makes these veins stubborn as compared to veins higher up in the body.” Photo: Fox Vein Center

And last, but not least there are the feet.  “Those are really, really difficult and it can be unsafe to treat them,” says Dr. Karen. “In expert hands, you can have some of those veins stripped sometimes, but if a patient has varicose veins in the legs and you treat the varicose veins, it will take pressure off the veins in the foot, so they won’t be as bulging and large.”  Treating the leg veins, concurs Dr. Navarro, will minimize bulging foot veins.

What about side effects of all of these treatments? Discoloration is the most common byproduct, according to Dr. Karen. While small veins almost never hyperpigment as a result of sclerotherapy, large veins quite commonly do. This is because blood often re-enters the collapsed vein when the patient stands upright, even with compression stockings, after a procedure. As the vein closes, that blood is trapped, forming a “blood tattoo” on the skin.  Luckily, this is easily remedied with a second visit for a so-called “blood-letting” or draining several weeks after the procedure whereby the vein is manipulated from the outside, providing a means of egress for the trapped blood.

Wearing compression stockings minimizes discoloration after the procedure.

Another way of minimizing this side effect is by wearing compression stockings after the procedure.  “Studies have shown that wearing compression stockings after treatment — by keeping that vein more tightly closed and not letting blood re-enter — you’re less likely to get the pigmentation,” reveals Dr. Karen.

Hyperpigmentation, however, is not a common side effect for the hands:  “We find it’s very unusual to get pigmentation on the hands when you treat veins, but it’s very common on the legs where large veins are being treated,” says Dr. Karen.

Discoloration can occur with laser treatments too.  Instead of it being a blood tattoo, it’s actually a pigment deposition — melanin — on the skin.  “And that really is a function of skin type and sun exposure after the procedure and just the energies that are used and how appropriate they are,” says Dr. Karen. The chances of this occurring, however, are highly unlikely, although more common in patients with darker skin, says Dr. Geronemus. The discoloration can take anywhere from a few weeks to a few months for it to disappear, but it can usually be treated with bleaching creams or pigment-specific lasers

And what does the future hold for vein treatment?  There are two new promising devices coming out later this year, informs Dr. Geronemus, which would reduce the risk of discoloration.  Traser, a non-laser device, has slightly lower energy and has an easier capacity to change wavelengths, making it useful for different purposes.  And preliminary studies have shown that a laser called Prima has “some nice benefits for medium-sized leg veins,” says Dr. Geronemus. Whether through surgery, minimally-invasive and non-invasive procedures, the effective treatment for veins large and small continues to evolve, eliminating unsightly veins with ever greater efficiency.

Expert tip:  “In general, light exercise is good for leg veins because it engages the calf muscles, encouraging normal blood flow,” advises Dr. Karen.  “Pounding exercise on pavement, on the other hand, takes its toll on the veins.  So, if you have a predisposition to varicose veins, it’s important to wear compression garments — there are socks and leggings — when you engage in strenuous exercise.  Our veins have to defy gravity to get blood to the heart and graduated compression stockings ease that flow by taking pressure off, by not letting blood pool in the veins as much as they otherwise would.

The vein wall is not stretched as much which makes it less likely for the valves to fill and lets the body have less of a need to accommodate that increased pressure and increased blood by forming spider veins.” For this reason, compression garments should also be worn during jobs that require prolonged periods of standing:  “I’m a physician, so I’m on my feet every day,” says Dr. Karen. “I wear compression stockings at work every single day.”

For more beauty tips and information, follow Delia on Instagram: @chasingbeautywithdvn

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