Vein Therapy

Vein surgery is one of the most common cosmetic procedures performed in the U.S. Nearly half a million individuals had vein surgery every year in the mid 1990s. As technology advances and the surgery becomes simpler and more risk-free, the numbers continue to increase.

The vast majority of people with vein problems are women, particularly those who've been pregnant. Veins get worse with second pregnancies, though we're really not sure why. Heredity, weight gain, and hormones all seem to play a role.

Until the last few years, the only option besides tight compression stockings for the treatment of unsightly and uncomfortable varicose veins was major surgery requiring general anesthesia, occasionally involving a hospital stay of several days. It was a big procedure, which involved making as many as ten incisions of one-half to one inch in length and vigorously removing the veins with large instruments. It was a brutal process compared to modern methods, and the recovery period was longer and more difficult. Patients were often advised to have extended bed rest, as severe bruising occurred and infections were more frequent.

In the last few years, however, new therapies have been developed. “Sclerotherapy,” or injection therapy, is a minor procedure that is easily done in a physician's office and has become commonplace. Vein removal using new “hooking techniques” with tumescent anesthetic (please read about tumescent anesthetic in chapter 13) is a relatively minor procedure usually done in an outpatient surgical center. In either case, the patient is up and on her feet soon after the procedure. Sclerotherapy is most effective for smaller veins (less than one eighth of an inch in diameter), while hooking is used for larger veins. Scarring is minimal compared to the old procedure, although any incision can be unsightly. There are also new lasers which can be used on the tiniest of spider veins.

People seek help for vein problems when visual clues, such as bulging veins, brown pigment, “spider veins,” and possibly even a firmer surface of the surrounding skin, indicate that the system isn't functioning properly. Veins carry the blood through the body and back to the heart. They have valves every inch or so, which keep the blood flowing in the proper direction. When these valves become defective, the blood is not conveyed back to the heart efficiently. Instead, the blood will “pool,” usually in the legs because they're lowest and subjected to a long column of pressure. This can cause cosmetic problems — varicose and spider veins are not pretty. But in some cases, circulatory problems can occur, as well as aching legs. In the worst cases, circulation can be seriously affected and skin ulcers develop.

The beauty of vein treatments is that they can simply eliminate bad veins, which will then free the entire system to start running smoothly again. There are many, many extra veins, and the normal healthy ones simply take over when the bad ones are removed.

Though some young women have spider veins which can be treated by injection, most candidates for vein procedures are childbearing age and older. After pregnancy, especially a second pregnancy, veins may get worse. Vein treatments are relatively simple procedures, and there are not many situations in which a patient would be advised against it. Women who are taking birth control pills are one exception because, in rare cases, this can contribute to clotting problems. In cases where a patient already has a clotting disorder, it may not be advisable to treat the veins. Also, women should not be treated during pregnancy.

If you are being treated for large veins using vein hooking, you may need to take one to two days off from work. Plan to wear compression socks for about a week, usually with a wrap over this for the first 12 to 24 hours. You may walk normally after your procedure, but long backpacking trips are out for a while. It's a good idea to plan on having someone drive you home from the surgical center if you've had relaxation medicines. In many cases, however, no medication besides the local anesthetics is needed. Make sure you have loose comfortable clothes that will fit over any bandages.

If you're having sclerotherapy, you can return to work the same day. There are no drugs or anesthetic given, and you'll have no problem driving yourself home. You may be wearing some kind of support stocking.

Vein Hooking

Removing large varicose veins, back in the days when it was done in a hospital under general anesthesia, used to involve making incisions about one inch long, threading a long wire through the incision and through the vein from the groin to the knee, hooking the vein onto the wire, and pulling the whole thing out. This caused a lot of bleeding and bruising, and physicians sometimes advised one or two weeks of bed rest, which had the potential to cause circulatory problems because the patient was immobile for so long. Despite the new alternatives, this method is still commonly used.

The new methods are an entirely different story. For anesthesia, we use the same tumescent anesthetic that we use for liposuction, which numbs the area and decreases bleeding. The technique for hooking the vein is similar, but the instrument is smaller, and instead of pulling the entire vein out, we remove it in small segments of up to six inches long. Since the vein was already dysfunctional, the circulation system simply compensates for its removal by channeling the blood through the thousands of other working veins.

The leg has two major veins, either of which can be varicose and need removal. One begins at the groin and is seen on the entire inside of the leg. Another is located at the back of the knee, appearing on the upper calf. Several other leg vein systems may be dysfunctional and need to be removed as well. Tiny incisions are made wherever the veins bulge, and they are hooked out with our new tiny specialized tools. If the valves for the large groin vein are not working properly, they will frequently be tied at the groin, cutting off their connection to the rest of the system. This is called “flush ligation.” The incision is sometimes made in the groin crease, where the scar is less visible. The entire procedure usually takes between one and three hours, and the patient feels little or no discomfort.

Some new procedures have been developed to destroy these veins from the inside as well. These involve threading the large veins with an instrument that can be turned on to destroy the vein internally.

Sclerotherapy

Sclerotherapy can be used on the larger veins I've described above, but the results may be only temporary, with a good chance of recurrence within two years. Sclerotherapy is best used for small spider veins. While sclerotherapy is usually successful, it occasionally produces new spider veins. These do well when treated with the vein lasers.

When you arrive at the office for sclerotherapy, you'll be put into an examining room and asked to put on a gown. There is no anesthetic necessary, since the procedure uses tiny injections instead of hooking. You may have photographs taken and be given a consent form that describes the possible complications.

The doctor will then inject your spider veins with a tiny needle, almost the smallest ever used in clinical practice, so small and sharp that most people barely feel it. Using magnifying glasses and a good light, the doctor injects solution into the “feeder system” of veins that runs underneath the obvious spider veins. The spiders can also be injected directly, but the feeder method gives the best results. Depending on the number of areas injected, the procedure can take anywhere from 10 to 30 minutes. There is little bleeding or pain, and you'll probably walk out of the doctor's office with nothing more than an ace bandage or a compression stocking. Several injection sessions may be needed to get the best result, depending on your particular veins and the doctor's skill. Allergic reaction to the medication is extremely rare, but can be serious. Your doctor should have the drugs to treat such a reaction. If this injection hurts much, your doctor may be using concentrated salt water (hypertonic saline), which is obsolete for this use.

After you leave the office, you may be wearing a compression stocking, possibly covered with an ace bandage. There may be leakage of tumescent fluid if you've had a vein hooking procedure, and this will have a pink tinge or red color. This is the fluid mixed with a tiny amount of blood.

After vein hooking, you can resume limited normal activity as soon as you leave the office. What you don't want to do is to completely immobilize yourself. It's important to keep active in order to keep the blood flowing. Normal activity, like walking, light bike riding, and housework is not only fine, but recommended. Don't overdo it — mountain climbing is out for a while. You'll be wearing a bandage or compression socks for a week, even in the shower (you can cover them with plastic to keep them dry). When you take the bandage off, the big veins are usually gone. You may have a few fragments left, which can be treated with sclerotherapy (or, rarely, another surgery) during your follow-up visits. Brown discoloration for several months (rarely longer) is common.

After sclerotherapy you can do whatever you want. You may be given compression stockings to wear during your waking hours for several days. When you remove these, you may see hard and ropy-looking veins, but don't worry — they're generally on their way to improvement. Sometimes the doctor will remove blood from these during the follow-up. You may also see bruising after sclerotherapy, which most frequently lasts a few weeks. Skin discoloration can occasionally persist for months or even be permanent for a rare patient, but it almost always looks much better than the veins. But while all this is going on, you should see the veins disappearing. You may want to look for that old mini-skirt in the back of the closet.

The risks in vein injection (sclerotherapy) and vein surgery (vein removal) include, but are not limited to, development of more veins, itching, pain, swelling to the lower legs, hyperpigmentation (darkening of the skin), bruising, localized skin death, allergic reaction to the medication, phlebitis, blood clots, infection, nerve damage (causing numbness or funny sensations to the lower legs), or even death due to reaction with medicine or blood clots. In order to make a well-informed decision regarding treatment, you should ask your surgeon for more details about these potential complications.

In simple terms, the usual results are better looking legs than what you had to begin with. A 70 percent improvement is a good result, and the vast majority of our patients are very happy. However, we do tell our patients that injection therapy is like going to the dentist; they may have to come back every several years for a touch-up. The vein hooking procedures are usually more permanent