The Management of Leg Veins

By Bryce Renwick and Dr Simon Ravichandran / 01 Jun 2014

Mr Simon Ravichandran and Mr Bryce Renwick discuss the treatment of leg veins with various modalities

Leg veins are increasingly becoming part of the workload of the UK-based aesthetics clinic. This is due, in part, to a reduction in the NHS management of uncomplicated veins in various regions, but also due to a greater patient awareness of veins. This awareness has dual components. The first component is associated with an increasing interest in our own body image that is multifactorial in nature, and evidenced by increased presentation for aesthetic treatments in general. The second component is an increased awareness of the ease with which leg veins can be treated, as the public gains knowledge of non- surgical developments. The reasons given for presentation are many, with aesthetic concerns being the main driver, particularly at the time of year when people are planning for good weather. Other concerns related to veins include an aching sensation in the legs, particularly when the patient has been standing for prolonged periods of time, and alsoanassociateditchingorswellingwith general decreased quality of life.

DEMOGRAPHIC

It is difficult to put a reliable figure on the proportion of the population who suffer from leg veins. Prevalence studies are rare and reported incidences vary between 2.6% in women and 2% in men1, with other studies suggesting greater than 50% prevalence in both men and women2. The definitions of varicose veins also vary, and this may play a part in the differing results from prevalence studies. One definition describes a varicose vein as “a dilated subcutaneous vessel greater than or equal to 3mm in diameter in the standing position”3. This considerably underestimates the prevalence of presentation to an aesthetics clinic with leg veins, as the bulk of ‘varicose vein’ consultations actually involve mainly superficial spider or thread veins. However difficult it is to get an idea from study of the literature, the presentation to the author’s clinic is currently >95% female, with an age range of between 35 and 69. Increasing age typically correlates with a more extensive problem on presentation, as does increasing number of pregnancies.

TREATMENTS

The treatment protocol in our clinic involves a consultation with a doctor, either myself (Mr Simon Ravichandran) or our vascular surgeon (Mr Bryce Renwick). Before a treatment plan is decided upon, a thorough history is taken, and a discussion takes place regarding the expectations of the patient and the expected outcomes. As with all aesthetic interventions, a clear setting of expectations is paramount to patient satisfaction. Assessment of the veins involves direct inspection, with the patient standing. Photographs are taken and documentation is made indicating the location and nature of the veins. We categorise veins in terms of their depth and size: spider veins are thin, typically 1mm or thinner, and superficial, and the deeper the veins are, the bluer they become. Larger subcutaneous blue veins are often soft to palpate and compression will show reduction in surrounding superficial veins. An ultrasound scan of the lower limb venous system is undertaken on all patients to identify any issues which will impact on treatment. Specific detail is noted at the sapheno-femoral junction, in order to identify incompetence of the valve, which indicates a lower likelihood of success.

Classification of varicose veins; CEAP grading.4
CEAP C0No visible or palpable signs of venous disease
CEAP C1Telangiectatic or reticular veins
CEAP C2Varicose veins
CEAP C3Oedema
CEAP C4aPigmentation or eczema
CEAP C4bLipodermatosclerosis or atrophie blanche
CEAP C5Healed venous ulcer
CEAP C6Active venous ulcer
CEAP SSymptoms (Including ache, pain, tightness, heaviness and muscle cramps)
CEAP AAsymptomatic
CEAP E/A/PClassifies venous problems on the basis of Aetiology, Anatomy, Pathophysiology


IPL

We use three different modalities for the treatment of leg veins in our clinic: IPL with a vascular filter, microsclerotherapy and ultrasound guided foam sclerotherapy (USGFS). My experience with IPL has shown good results with very superficial and small veins, but poorer results with deeper and larger veins. IPL is useful for rapidly treating a larger area. Typically, higher fluences are required for a vessel of similar calibre on the face, and superficial blistering of the skin is not uncommon. The likelihood of burns with subsequent scarring and or pigmentation changes increases with darker skin types, and with sun exposure5. Often a good result is initially produced, but early recurrence (within three months) occurs. In these circumstances, closer inspection of the area will often reveal an underlying larger feeding vessel that needs to be treated. Given the availability of other treatments which can result in better outcomes, I tend to advise patients with spider veins greater than 1.5mm, and with spider veins with evidence of deeper feeder veins, to undergo a sclerotherapy treatment first, then use IPL to remove any remaining vessels if required. I use an unravelled paperclip as a vein measuring tool; with a vessel larger than the diameter of the wire, I would recommend sclerotherapy over IPL. Larger spider veins are treated with microsclerotherapy. For this treatment, a solution of sodium tetradecyl sulfate (STS) (Fibro-vein 0.2%) is injected under direct vision into the vessel using a 29G or 30G needle. STS is intensely irritant and causes damage to the endothelium of the blood vessel, leading to its subsequent collapse and destruction6. Immediate obliteration of the vessel is often identified. The damaged vessels typically undergo a browny discolouration before being removed by phagocytosis. Most patients find this treatment relatively painless and an immediate return to normal activities is permitted. Large bulging subcutaneous vessels are best treated by USGFS. In this technique a solution of sodium tetradecyl sulfate (Fibro-vein 1%) is mixed with a gas to create a foam. This foam is then injected into a dilated vessel via a cannula or by hand injection and under ultrasound guidance. Endothelial irritation ensues, followed by vessel sclerosis. In both cases it is necessary to compress the treated area with a graduated compression stocking for a period of days to weeks after the treatment. Compression of the leg and the treated vessel maximises the clinical and cosmetic result, whilst minimising the risk of DVT. 

Treatment Vessel CharacteristicBenefitsRisks/Downsides
IPL/LASERSmall superficial spider vessels, typically smaller than 1.5mmQuick, effective, non-invasive

Purpura / blistering of skin / burns. Not to be used on tanned skin 

Microsclerotherapy

Superficial vessels 1 - 3mm 

Quick, very effective, usually painless 

Extravasation of sclerosant can cause pain, discolouration and scarring 

USGFS 

Deeper vessels and varicosities 

With appropriate level of expertise, it can be used to address the entire truncal system 

Compression stockings required. Risk of extravasation with tissue damage.
Small risk of P.E 

EVLT 

Deeper vessels and varicosities 

With appropriate level of expertise, it can be used to address the entire truncal system 

Expensive and there is a learning curve. Longer to perform treatments 

EVRF 

Deeper vessels and varicosities 

With appropriate level of expertise, it can be used to address the entire truncal system 

Expensive and there is a learning curve. Longer to perform treatments 

Stripping/Avulsion

Usually reserved for complicated / very severe and recurrent disease 

Usually excellent results in the hands of a skilled surgeon 

Operating theatre procedure, scarring and longer recovery time 

Comparison of treatment modalities

Photo 1: This shows a combination of very superficial thin red spider veins, some slightly deeper and larger purple veins with no real significant obvious deep veins. This we would happily treat with micro-sclerotherapy followed by LASER or IPL if required
Photo 2: Shows a collection of veins which is more predominantly deep bluish vessels that are feeding a smaller number of superficial thread veins. We would treat this with USGFS to the larger vessels then microsclerotherapy if sill required at a later visit


DISCUSSION

There is a rapidly increasing demand for a ‘whole body’ holistic approach in the management of the ageing population in the aesthetic clinic setting. As people are active now for longer than in previous generations, there develops a mismatch between the age people feel, and the age they may look. Although this is a relatively new concept in our understanding of ageing psychology, it is clear that there are significant benefits to quality of life in addressing these concerns. The treatment of unsightly leg veins, varicose or otherwise, is a key element in the provision of a whole body aesthetic service. Varicose veins can be safely and effectively treated in the aesthetic clinic if one remains aware of the limitations of office-based techniques, and practises within one’s limitations set by education, training and experience. The best results can be achieved when the practitioner combines knowledge of the venous system and pathogenesis of the presenting veins, with a detailed clinical and ultrasonographic assessment of the venous system and the application of the correct treatment.

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