Podcast Episode 37: Bulging blood vessels on the temples

Hello there, this is Mark Whitesley discussing bulging blood vessels on the temples in this special podcast So in this podcast, I'm going to discuss the two main sorts of blood vessels that we can find bulging on the temple area of the face How we can tell the difference between them and also the treatments of each as they are both very different First of all, where is the temple area? most people know that the temples are the bits that of the forehead really that around the side so to speak it's above and in front of the ear and above and behind the eye so it's the area of the head just really in front of the hairline in most people obviously if you are bald is where the hairline would be now this area the temple area comes originally from the temporal bone and And that's temporal, meaning the passing of time. And the reason it's called the temporal area is because it's the passing of time. It's the first area that we go grey traditionally. And so therefore it shows that we're getting older. And hence that's the temporal area, the temporal bone. And it's now been shortened really to be called the temple. So what are the two sorts of blood vessels we can see bulging there? Firstly we can have veins and secondly we can have an artery. Unfortunately both of these blood vessels can coexist as well and so it's important to know which are which and if you've got both. All of these bulging vessels get worse on leaning forward, on getting excited, in heat, drinking alcohol, on exercise. And so whether you've got veins or arteries they can bulge really for on any of these reasons and people can get quite embarrassed especially if they've been to the gym or if they're on a night out and they've had some alcohol been dancing had a bit of exercise and then get really worried about these bulging vessels. Some people have them just on one side some people have them on both sides. So what are they? Most people call them veins but there is a difference between the veins and the arteries in this area. Let's talk first of all about veins. If you have bulging veins in the temporal area, you can see them as blue or green. If they're big, they're almost always green. The blood inside them is what gives them the colour because veins are actually white in themselves. And that's why when you don't have any blood in them, they seem to disappear. When the vein wall dilates and they're full of blood, they look really quite greeny as I say if they look a bit bluey they tend to be smaller. So what we're most interested in this podcast is the ones that are big and the reason is that most aesthetic clinics or most beauty clinics can use external laser usually one called an ND YAG laser which is a special laser that hits blood in the inside the veins and causes it to boil destroying the veins And if the veins are small enough, so if they're blue or if they're green and quite flat, then you can use an ND YAG laser and quite simply take these veins away without any worry. And there are a great many beauty clinics that will do that. However, we're talking in this podcast about veins that are too big for the ND YAG laser. And these tend to be the ones that bulge. They come down from the temporal area. they may have several tributaries or branches actually over the temples they come down the side on the of the eye on the outside of the eye and often come onto the face and onto the cheek. And in one or two cases they actually come right over the cheek and down over the jaw. Although those are quite extreme. Most of my patients see the prominent area from the lateral side the outside of the eyebrow down past the eye and onto the cheek and sometimes a bit higher up from that and the temple area. So as I said before if it's a vein these are green and they fill up whenever the vein dilates and when you feel them there's no pulse they squash quite easily. When we took at the arteries on the other hand the arteries are completely different. The artery seems to appear from just above and in front of the ear it wiggles forwards it's never straight It goes in a sort of wiggly area towards the upper eyebrow, really above the eyebrow, and then suddenly takes a turn back up onto the scalp. More importantly, it's never got any colour. The artery, you can't see a colour in it at all. So this is just a dilated wiggly vessel that goes from the area just above the ear and in front of the ear, over the temple, and then diverts up into the hairline. Sometimes it can branch into two. Sometimes it's just the one. Most importantly, when we're discussing whether this is an arterial vein, firstly, as I said before, there is no colour in it. So this is colourless. Secondly, it's very wiggly. It does not go down past the eye and onto the cheek. It goes onto the forehead and then goes up into the hairline or if you're bald, goes up onto the scalp. And most importantly, if you feel it very, very gently with the tips of your fingers and don't push too hard you'll also feel a pulse in it. Now this is an artery this is completely different this is taking blood to the scalp whereas veins are taking blood from the scalp. Also it's at high pressure so you cannot use a laser to destroy the artery. It's very important to know that the treatment is different. So having sorted out what are veins and what arteries, what are the treatments? Well going back to the veins first of all. If this vein is too large for an ND YAG laser we have found the best way to do this treatment to take away these veins is local anaesthetic mini phlebectomy. Not many places do this there are a few places in England that are specialized in veins but at the Whiteley clinic we've been specializing this now for many years and we are quite regularly seeing patients with bulging veins on the temples of the face. And this quick local anaesthetic procedure usually takes about an hour. That doesn't sound quick to many people, but surgically for such a fine treatment, that is quite quick. We use great magnification and lighting to see exactly where we are. And then using minute incisions and local anaesthetic, we can actually remove the bulging veins. If there are any little green veins left afterwards, then they can be lasered. But in our experience, almost everybody who has the surgery has successful removal and very, very few people need any follow-up treatment. It's very important that you never have these treated with sclerotherapy as any veins around the eyes should never be treated with sclerotherapy. due to the sclerotherapy possibly getting into the veins around the eyes and causing pain or even thrombosis in the veins that go through the orbit and into the cavernous sinus around the brain. So treatment for the veins that are bulging around the eyes is local anaesthetic phlebectomy using mini phlebectomies. Now turning to the arteries, a great many doctors and nurses will tell you that these arteries cannot be treated. However, I invented a technique several years ago now that has been published in 2021 and it's called the double ligation technique and what we do is we use a duplex ultrasound scan to see exactly where this artery goes to and from. We can see it and feel it on the surface but it's important to know that there aren't any branches that we're missing. So we use a duplex ultrasound to image it, we mark it on the skin and then we decide exactly where we're going to treat it and we make two very tiny incisions under magnification. Very cosmetically through the skin we find two places, one very close to the hairline if there's hair, the second one is more on the forehead and we try to get the area where there's a major branch coming from this artery and what we do is we hook the artery up onto the surface using operating things called loops. It's like an operating microscope but they're a very very high magnification. We bring this tiny artery to the surface and what we do is we then loop a little bit of the stitch around it, a stitch that never dissolves and we tie the artery, a surgical technique called ligation. We do this in two different areas because research in the past has shown that if you only do one area then it's quite likely that it will come back again in the future as the body bypasses a single ligation. So we use at least two and very occasionally we use three ligations, three different points and this stops the body from being able to bypass the area and in the vast majority of cases this takes away the artery. You don't need to remove the artery in fact if you do because of the high pressure of blood in arteries unlike veins it will bleed torrentially and so we never remove this artery all we do is we tie it off. Now many patients are worried and they say if you tie off an artery where does the blood go but we're very fortunate in the scalp area. In the scalp area there are so many arteries that as soon as you tie one of these off, blood just goes up the other arteries. So we never have a problem and some people worry about will I lose hair if I have this ligated and the answer is no. There's no evidence at all and we know this because although this is a new technique for getting rid of bulging arteries, there is a similar technique called temporal artery biopsy which has been done now for a great many decades where this artery a section is removed to look for a disease called temporal arteritis and in that case the artery is not only ligated but a small section removed to be sent off for analysis in the laboratory and in those cases no patient has ever been reported as losing hair So, we know this is a safe technique to do. Moreover, at the moment, there is no other way to treat it. There is no external laser. It doesn't have any color for the external laser to work on. Again, you must never use sclerotherapy or injection into this sort of vessel. So, at the moment, the only treatment for this is the ligation technique. And currently, when I described it, I was the only person in the world doing this and it was only available at the Whiteley Clinic in England and we've had several patients flying in from around the world to have this done. I have now written it up and I'm sure that a couple of other doctors will start learning how to do this. I'm sure it will become more widely available in time but at the moment it is something that we have invented at the Whiteley Clinic and we have written up the first paper on it and the first set of results and it's something that our patients are very happy to have. So I hope this podcast has been helpful to tell you the difference between veins and arteries in the temple region. I hope you understand that the treatment for these is never sclerotherapy for veins. If they're small enough it can be lasered and if they're large enough they're mini phlebectomy and for the artery the only treatment that is available is the double ligation technique that appears to be effective. If you've been interested in this podcast and want to know more, please do contact me through the Whiteley Clinic www.thewhiteleyclinic.co.uk and I'm happy to answer any queries at all. Thank you very much for listening to me.