Elimination of periocular veins can be achieved with several techniques by either transecting the vein through several small overlying cutaneous incisions or extraction with a phlebectomy hook. Transection of the vein(s) is my preference. This can be done in an ambulatory setting where unipolar or bipolar cautery is available. The skin is cleaned and a skin marking pen is used to outline the course of the vein. Several 3- to 4-mm incisions are marked transversely over the course of the vein spaced at ~1-cm intervals. The skin is prepped with povidone iodine solution, and a small bleb of local anesthetic is then injected over each of the incision sites. The visible periocular veins may be single or multiple, and anywhere from three to six incisions are usually required. A no. 75 eye-knife is generally used to make these fine incisions as a no. 15 Bard-Parker blade is usually larger than desired for these short transverse incisions. The veins lie immediately beneath the dermis on the surface of the underlying orbicularis oculi muscle, and the skin in this area is very thin. Once the incision is made, fine, single-prong skin hooks can be used to retract the skin and reveal the underlying vessel wall. The lumen is then obliterated either with bipolar cautery, using a jeweler's tip, or a unipolar cautery may be used to apply current to the vessel lumen by inserting a 25-gauge needle into the lumen and applying the unipolar tip to the needle. This process is begun at the lateral extent of the visible vein, and after cautery has been applied, one works medially to incise and transect the vein. A cotton-tipped applicator is used to milk the blood from the lumen prior to applying the cautery. Once the entire length of the visible vein has been emptied and cauterized, it is possible to visually confirm that the vein does not reperfuse. The skin incisions are closed usually with a single interrupted 7.0 Vicryl suture at each site.
When making the transverse skin incisions, one must customize the length to allow adequate visualization and application of cautery to the vein. Too short an incision makes this more difficult and increases the risk that electrical current may cause thermal damage to the adjacent dermis. When in doubt, it is best to lengthen the incision to allow adequate exposure of the vein as skin incisions heal imperceptibly in the fine periocular skin. If cautery does contact the margins of the wound, thermal injury to the dermis may result. Although the thermal injury of the dermis may result in greater initial scar erythema and hypertrophy in the immediate postoperative period, the ultimate scar is generally imperceptible.
An alternate surgical approach has been described by Weiss and Ramelet and utilizes a phlebectomy hook specifically designed for reticular veins.2,3
I have no experience with this technique, but it similarly involves marking out the course of the vein and injecting local anesthetic in the midpoint of the length of the vein to be removed. The authors describe introducing an 18-gauge needle in the center of the targeted length of the vein, and a specialized phlebectomy hook of their design is introduced. The stem of the phlebectomy hook is used to undermine the vein on either side of the puncture wound, and a specialized harpoon of the hook is used to grasp the vein once it has been freed up; then it can be distracted and removed with the help of a mosquito clamp. Compression over the puncture site is then maintained for 10 minutes time to minimize hematoma. The 18-gauge puncture site is not sutured closed. The authors reported success in 10 consecutive patients, and in 8 of 10, complete elimination with a single procedure was satisfactory. Two patients required a second procedure because of incomplete removal of the cosmetically visible vein. Reoperation 2 months later in both of these cases was reported to be successful. Two patients developed a minor hematoma, which resorbed.