Charles Esteves Pereira, MD,* Carlos Alberto Rover, MD,* and
Mark Steven Whiteley, MBBS, MS, FRCS(Gen)† AQ : 1

AIMS To describe a new method of treating prominent vertical forehead veins and to report the early results. AQ : 4
OBJECTIVE Many patients complain of prominent vertical veins in the center of their forehead, worse when
smiling, wrinkling the forehead in bright light, leaning forward, and when vasodilated in heat, when exercising,
or with alcohol. Previous attempts to treat these with external laser, sclerotherapy, and phlebectomy have not
been successful.
MATERIALS AND METHODS We used endovenous laser ablation with a 1470 nm diode laser in 15 patients
(F:M 12:3; mean age 38.4 years range 24–69). A bare fiber was used once and a 400-mm single ring radial fiber
(Biolitec, Vienna, Austria) in all other cases. Tumescence was placed around the vein and a power of 2 to 3 W
with a pullback of 7 to 10 seconds per centimeter.
RESULTS Twelve of the 15 patients (80%) ended up with a good cosmetic result and were satisfied, although
2 needed redo treatment. One patient had minor skin tethering, and 2 (13%) suffered burns—one was the only
bare fiber case and the other, the only one where 4 W was used.
CONCLUSION We present a novel technique to treat prominent vertical forehead veins, with apparently good
early results.
The authors have indicated no significant interest with commercial supporters. M.S. Whiteley applied for a AQ : 3
patent for this technique on April 21, 2020.

The treatment of unsightly facial veins is
commonplace in the aesthetic and cosmetic
world. However, such treatments usually involve
treatment of telangiectasia or small reticular veins of
the cheeks, periorbital region, or temples. These are
usually treated with laser,1 intense pulsed light,2 or
different electrocautery treatments.3
Larger veins may be too large for such methods and
may require surgical removal, such as phlebectomy4
with some opting for sclerotherapy.5

However, prominent vertical veins, either single or mul-
tiple, in the center of the forehead are particularly difficult

to treat with any of the previously mentioned treatments.

These veins are called the right and left supratrochlear
veins.6 However, they have various other names, with
some calling them “frontal veins,”7 and Shimizu and

colleagues8 calling them “ascending veins of the fore-
head” in their description in Clinical Anatomy.

Such veins, although not associated with any medi-
cal condition, are cosmetically damaging. They

become prominent when smiling, wrinkling the
forehead in the sunlight, bending forward, lying
down, or when vasodilated, such as in the heat,
exercising, or after alcohol ingestion. As such, they
are often prominent at times when photographs are
taken, frequently causing upset and hence patients
seeking help to remove them.

*Charles Esteves Vascular Medicine, Goiânia, Brazil; †

The Whiteley Clinic, Guildford, United Kingdom AQ : 2

© 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 1076-0512 · Dermatol Surg 2020;00:1–6 · DOI: 10.1097/DSS.0000000000002778

ENDOVENOUS ABLATION OF CENTRAL FOREHEAD VEINS
Figure 1. A simplified anatomical diagram of the relevant
venous drainage of the supratrochlear (vertical forehead)
veins.

Anatomically, these veins drain blood from the front
of the scalp. They descend in the center of the forehead,
typically as 2 veins although they can vary, presenting
as one main vein or even be separated into several
veins. On reaching the top of the nose between the
eyebrows, they are joined by the supraorbital vein on
each side and are connected by the nasal arch. They
then continue to form the facial vein at the medial
1⁄2F1 corner of the eye (Figure 1).6–8

This anatomy allowed for the description of the
“Whiteley–Smith” provocation test in 2018.9 To
assess how prominent these veins can become in the
erect patient, the patient is asked to place their hands
on their cheeks either side of the nose and just under
the eyes. The patient is asked to press gently backward,
compressing their cheeks to the underlying bone. This
causes the supratrochlear vein to dilate becoming
1⁄2F2 visible in these patients (Figure 2).

The authors have tried various techniques in patients
with dilated central forehead veins and a positive
Whiteley–Smith sign, including transdermal Nd:YAG
laser, foam sclerotherapy, and phlebectomy with limited
success. Over the last year, the authors have developed a

technique of endovenous thermal ablation using a radial
laser performed under local anesthetic.
The aim of this article is to report the methodology of
the technique developed in 2 co-operating centers (one
in Brazil and one in England), and present the early
results in our combined series of patients.

Methods and Materials

In total, 15 patients have been treated between the 2
centers. There have been 12 women and 3 men, with a
mean age of 38.4 years (range 24–69).

Although early in our experience, our indications for
treatment are patients complaining of prominent and
relatively straight vertical forehead veins that cause them
sufficient distress to cause them to want, and accept the
risks of, treatment. We assess patients clinically with
provocation using the “Whiteley–Smith provocation
test” and ensure that the veins become prominent. We
are starting to use ultrasound with the patient supine and
in the Trendelenburg 15 head down position, to assess
the veins. We hope to produce guidelines for suitability
on ultrasound measurements in the future.

Currently, our contraindications to offering this
treatment are patients with very tortuous veins that
might prevent passage of the laser fiber or with a
diameter that is too small to cannulate. However, such
small veins are rarely prominent enough to need
treatment. A relative contraindication is previous

treatment to the forehead or forehead vein with pos-
sible scar tissue or distortion in the vein lumen.

However, this can be assessed preoperatively with
ultrasound.

Figure 2. (A and B) The “Whiteley–Smith provocation test” described in 2018. Patients sitting in a chair at rest in the
doctor’s office might not show the prominent forehead veins that concern them. Gentle backward pressure over the facial
vein, either side of the nose, blocks the facial veins and makes the supratrochlear veins dilate if they are big enough.
ENDOVENOUS ABLATION OF CENTRAL FOREHEAD VEINS

2 DERMATOLOGIC SURGERY

Figure 3. (A–D) Sequence of 1 patient undergoing treat-
ment with a multiple and complex pattern of prominent

forehead veins. (A) Veins dilated in Trendelenburg (10–15

head down position) precannulation. (B) All veins suc-
cessfully cannulated and laser treatment of first vein

commencing. (C) Appearance immediately after procedure

still on the operating table. (D) Appearance 6 weeks post-
operatively.

the target vein, with particular reference to infiltrating
between the anterior vein wall and skin.
Initially, the patient was placed in the horizontal position
for treatment. In the last 3 cases in the second center, the
patient has been elevated into a 10 to 15 head up
(reverse Trendelenburg) position to reduce any venous
pressure in the vein. The wavelength used for all patients
is 1,470 nm. Initially, the power was set to 2W, although
both centers have nowmoved to a power of 3W for most
cases. In 1 case where patients were treated a second

time, a power of 4 W was used. The laser fiber is with-
drawn at 10 seconds per centimeter in the first center and
7 seconds per centimeter in the second center.

Generally, the authors have used the above settings
and have often felt a “tugging” of the laser fiber as it is
withdrawn. However, in the last 4 procedures in the
second center, a sterile cold ice pack has been placed on
the skin above the vein being treated, in a further
attempt to protect the skin from possible burns.

Postoperatively, the tiny wounds are closed with a
simple sticking plaster. Patients are given a cold pack
to press on the treated area for 30 minutes. They are
discharged home. They are told they can remove the
plasters the following day and to keep out of the sun
until the bruising and any inflammation has settled.

Results

Although this is the first report of a new method of
treating these veins, of the 15 patients treated, 10

ENDOVENOUS ABLATION OF CENTRAL FOREHEAD VEINS

Figure 4. (A and B) Typical case of successful treatment
before (A) and after (B), both while using the
“Whiteley–Smith provocation test.”

patients ended up with a very good cosmetic result and
were very satisfied with their treatment after the initial
1⁄2F4 procedure (Figures 3A, D and 4). Two further patients
were satisfied after their redo procedure.

Two patients had skin burns. The first patient from the
first center, and the only patient in whom a bare fiber
was used, had a small area of skin burn just above the
1⁄2F5 eyebrows (Figure 5). The second patient from the
second center, who had flown into the country for the
treatment and who insisted on early retreatment at
3 days of 2 veins that appeared to still be patent, had
skin burns over the retreated veins. Interestingly, in the
whole series, these were the only veins treated at 4 W.

Four patients required redo ablation. The first in the
second center is already noted above (Case 11) and, in
retrospect, was probably treated far too early (3 days
postoperatively) and might well have settled without
any further treatment.

A second patient from the second center had a failure
of cannulation with hematoma formation and can-
cellation of the procedure without any laser treatment
at all (Case 12). The treatment was repeated 1 week
later with excellent outcomes. A third patient from the
second center also underwent redo ablation 6 weeks
after the original treatment for unsuccessful closure of
the vein (Case 14). The patient was 23-year-old and
seemed to have very superficial veins. As such, a low
power (2 W) had been selected, and this was clearly
inadequate. Six weeks afterward, the procedure was
repeated at 3 W with a very successful outcome.

The second patient in the first center had failure of
closure of 2 of the 6 veins that were treated (Case 2).

Figure 5. Skin burn just above the right eyebrow. This was
the first patient treated and the only patient treated with a
bare-tipped fiber.

These were retreated subsequently with good closure
and a satisfactory result for the patient.
Of the remaining 3 patients, 2 had a much-improved
cosmetic result but had veins that were still visible,
although shrunken and not prominent anymore.

These veins were shown to be still patent on ultra-
sound scanning. One was successfully treated with an
extracorporeal Nd:YAG laser. The final patient had
one area of skin tethering high-up on the forehead,
although all of the other veins had been successfully
ablated.

Discussion

Prominent vertical veins in the center of the forehead
can cause considerable distress in affected patients.
Normal winkles on the forehead run transversely, and
so vertical lines are instantly noticeable. Patients often
say that they have lost their confidence. This is not
surprising, when many of the factors that cause the
veins to become more prominent, such as smiling,
wrinkling the forehead in bright sunlight, heat, exer-
cise, excitement, or alcohol, are often social activities
or times when photographs are taken. Hence, patients
worry about how their friends or partners may per-
ceive them, and worry that photographs and hence
memories are ruined.

The authors have separately tried different methods of
treating these veins before combining to develop the
endovenous technique presented in this article.
The first 2 authors attempted treatment using an
extracorporeal Nd:YAG laser, using different angles
to try and increase the effect within the vein while

skin minimal. However, they had less than 40% suc-
cess with this method.

The third author treated a series of patients with
phlebectomy hooks performed through very small
incisions under local anesthetic. Although achieving
an 80% success rate, the operation was difficult, and
despite a good cosmetic result early after treatment in
most patients, some patients developed regrowth of
veins within 1 to 2 years and some patients complained
of lumps lasting more than a year in the areas of the
phlebectomies.
The third author has also treated 1 patient with
ultrasound guided foam sclerotherapy to these veins,
and other workers have reported treating facial veins

with this technique.6 Although some claim this treat-
ment to be safe, there is considerable concern about

injecting sclerosant into facial veins, particularly those
around the orbit.10
As noted in the introduction, these veins are properly
called the supratrochlear veins.6 It is surprising that
they had been called “ascending” forehead veins9
because blood flows from the scalp down these veins,
and so, if such a nomenclature was to be used, they
should be called “descending forehead veins.” The
continuation of these veins into the facial vein has
previously been noted, along with the
“Whiteley–Smith” provocation test,10which works by
compressing the facial vein and stopping the flow.

However, in addition to the anatomy noted pre-
viously, these veins communicate with the veins in the

orbit through a branch passing through the supraor-
bital notch,6 and the facial vein is connected to the

cavernous sinus through the superior ophthalmic
vein.6 These communications pose a potential risk of

orbital vein or cavernous sinus thrombosis from scle-
rotherapy or foam sclerotherapy treatment. Hence,

the authors advise strongly against this method of
treatment, especially as an alternative now exists.
The effects of endovenous thermal ablation on the vein
wall have been studied extensively by the third author

and his research team, showing that permanent abla-
tion of a target vein seems to be achieved only after

transmural death of the vein wall.11–16 Failure to ach-
ieve this seems to result in thrombosis, which initially

seems to be a successful ablation but ends up with
recanalization of the inadequately treated vein.12,13
Hence, to achieve successful ablation of this vein, it is
necessary to use the correct power and also pullback

timing to ensure transmural death is achieved. Under-
treating the vein is likely to result in endothelial damage

without transmural damage, thrombosis, and recana-
lization in the future and hence failure. Overtreatment

can result in skin burns, particularly if insufficient local
anesthetic is placed between the vein and the skin. Both
complications have been seen in this series.

The introduction of the catheter high-up on the fore-
head, and as close to the hairline as possible, gives the

best possible chance of a good cosmetic result with
regards to scarring from catheter introduction. Unlike
phlebectomies, no other incisions are needed on the
forehead.
There is a rich venous anastomosis in the front of the

scalp, and veins that coalesce to form the supra-
trochlear veins anastomose widely with veins forming

the superficial temporal vein.7 Hence, ablation of these
veins does not result in stasis in the scalp because
venous blood diverts into the superficial temporal
system.
This is an early report on a novel treatment of very
superficial veins with an endovenous laser, and hence,
one of the limitations of this study is that we do not
have medium-term or long-term results yet to report.
However, using our understanding of endovenous
thermal ablation of leg veins, early results with low
complication rates are likely to translate to acceptable
long-term results.
In conclusion, we have presented a novel technique to

treat prominent vertical forehead veins (supra-
trochlear veins) using endovenous laser ablation and

have reported a series of cases performed in 2 different
centers sharing results and jointly developing the
procedure, showing good short-term results. Further
studies will be required to ensure good long-term
results and to ascertain precise protocols for veins of
different sizes or different depths under the skin. AQ : 5
PEREIRA ET AL

00:00:MONTH 2020 5
© 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

References
1. Eremia S, Li CY. Treatment of leg and face veins with a cryogen spray
variable pulse width 1064-nm Nd:YAG laser—a prospective study of
47 patients. J Cosmet Laser Ther 2001;3:147–53.
2. Angermeier MC. Treatment of facial vascular lesions with intense
pulsed light. J Cutan Laser Ther 1999;1:95–100.
3. Liapakis IE, Englander M, Sinani R, Paschalis EI. Management of facial
telangiectasias with hand cautery. World J Plast Surg 2015;4:127–33.
4. Ramelet AA. Phlebectomy. Technique, indications and complications.
Int Angiol 2002;21(2 Suppl 1):46–51.
5. Green D. Removal of periocular veins by sclerotherapy.
Ophthalmology 2001;108:442–8.
6. The veins of the head and Neck. In: Williams PJ, Warwick R, editors.
Gray’s Anatomy (36th ed). London, United Kingdom: Churchill
Livingstone; 1980; Chapter 6; pp. 738–9.
7. Frontal vein. Available from: https://en.wikipedia.org/wiki/Frontal_
vein. Accessed May 9, 2020.
8. Shimizu Y, Imanishi N, Nakajima T, Nakajima H, et al. Venous architecture
of the glabellar to the forehead region. Clin Anat 2013;26:183–95.
9. Smith V, Whiteley M. Facial veins—diagnosis and treatment options.
PMFA J 2018;6. Available from: https://www.thepmfajournal.

com/features/features/post/facial-veins-diagnosis-and-treatment-
options. Accessed May 9, 2020.

10. Arunakirinathan M, Walker RJE, Hassan N, Ameen S, et al. Blind-side
by cosmetic vein sclerotherapy: a case of ophthalmic arterial occlusion.
Retin Cases Brief Rep 2019;13:185–8.

11. Whiteley MS, Holdstock J. Percutaneous radiofrequency ablations of
varicose veins (VNUS closure). In: Greenhalgh RM, editor. Vascular
and Endovascular Challenges. London, United Kingdom: BIBA
Publishing; 2004; pp. 361–81.
12. Whiteley M. Varicose veins: endovascular options. In:
Greenhalgh RM, editor. Towards Vascular and Endovascular
Consensus. London, United Kingdom: BIBA Publishing; 2005;
pp. 564–72.
13. Whiteley M. New methods of vein ablation. In: Davies AH, Lees T,
Lane IF, editors. Venous Disease Simplified: Essex, United Kingdom:
Harley; 2006; pp. 113–30.
14. Badham GE, Strong SM, Whiteley MS. An in vitro study to optimise
treatment of varicose veins with radiofrequency-induced thermo
therapy. Phlebology 2015;30:17–23.
15. Badham GE, Dos Santos SJ, Whiteley MS. Radiofrequency-induced
thermotherapy (RFiTT) in a porcine liver model and ex vivo great
saphenous vein. Minim Invasive Ther Allied Technol 2017;26:
200–6.
16. Badham GE, Dos Santos SJ, Lloyd LBA, Holdstock JM, et al. One year
results of the use of endovenous radiofrequency ablation utilising an
optimised RFiTT protocol for the treatment of truncal superficial
venous reflux. Phlebology 2018;33:298–302.
Address correspondence and reprint requests to: Mark
Steven Whiteley, MBBS, MS, FRCS(Gen), The Whiteley
Clinic, Stirling House, Stirling Road, Guildford, Surrey
GU2 7RF, United Kingdom, or e-mail:
mark@thewhiteleyclinic.co.uk