You are in: eMedicine Specialties > Plastic Surgery > ANCILLARY PROCEDURES SclerotherapyArticle Last Updated: Sep 28, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Laurence Z Rosenberg, MD, Southeastern Plastic Surgery Laurence Z Rosenberg is a member of the following medical societies: Alpha Omega Alpha and Phi Beta Kappa Coauthor(s): Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics; Gary D Monheit, MD, Associate Professor, Department of Dermatology, University of Alabama at Birmingham; John D Kayal, MD, Consulting Dermatologist, NW Georgia Dermatology and Skin Cancer Specialists, LLC Editors: Shahin Javaheri, MD, Chief, Department of Plastic Surgery, Martinez Veterans Affairs Outpatient Clinic; Consulting Staff, Advanced Aesthetic Plastic & Reconstructive Surgery; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Mark E Krugman, MD, Assistant Professor of Plastic Surgery and Clinical Professor of Otolaryngology-Head and Neck Surgery, University of California at Irvine School of Medicine; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics Author and Editor Disclosure Synonyms and related keywords: telangiectasia, reticular veins, sclerosants, unwanted vasculation, thromboembolic disease, telangiectatic vessels, varicose veins, varicosities, varicosity, incompetent perforators, aspiration technique, puncture fed technique, puncture-fed technique, air bolus technique, empty vein technique, spider telangiectasia, spider veins INTRODUCTIONSection 2 of 10
  Sclerotherapy remains the primary treatment for small-vessel varicose disease of the lower extremity. These small vessels include telangiectasias, venules, and reticular veins. Telangiectasias are flat, red vessels smaller than 1 mm in diameter. Venules and reticular veins are blue and smaller than 2 mm, whereas reticular veins are 2-4 mm. Large varicosities do not respond as well as small varicosities to sclerotherapy. Treatment of telangiectasias and reticular veins may greatly improve their appearance. Treatment may also improve the associated painful symptoms. These vascular abnormalities are common. Telangiectasias are present in up to 28.9% of men and 40.9% of women (Engel, 1988). EtiologyGenetics and individual behavior patterns are important factors in the development venous disorders. Familial inheritance is reported in 15-40% of cases. Caucasians are most commonly affected. Pregnancy, prolonged standing, or prolonged walking also predisposes people to venous disease (Parsons, 2004). INDICATIONSSection 3 of 10
The major indications for sclerotherapy are to improve the cosmetic appearance and to reduce the associated pain and burning. RELEVANT ANATOMYSection 4 of 10
A thorough review the lower extremity venous system is essential before treatment is administered. The lower extremity has both a superficial and a deep venous system. The deep venous system includes the femoral and popliteal veins. The superficial system includes the saphenous system. Several communicating vessels are present between the systems called perforating veins. Also, telangiectasias may communicate with the deep system. CONTRAINDICATIONSSection 5 of 10
Contraindications to sclerotherapy include pregnancy, thrombophlebitis, pulmonary emboli, hypercoagulable states, and allergy to the sclerosing agents. WORKUPSection 6 of 10
Imaging Studies
TREATMENTSection 7 of 10
Surgical TherapySclerosants include the following (Parsons, 2004):
The most commonly used agents are hypertonic saline, sodium tetradecyl sulfate, and polidocanol. Hypertonic saline 23.4% concentration is approved by the US Food and Drug Administration (FDA), but its use in sclerotherapy is off label. It does cause pain and may cause burning. Dilutions are 23.4% for midsized vessels (2-4 mm), 11.7% (half strength) for small vessels (1-2 mm), and 6% (quarter strength) for fine vessels ( <1 mm). Regarding adverse effects, extravasation may cause skin ulceration, and the injection may cause burning. Sodium tetradecyl sulfate is FDA approved; however, no major manufacturers in the United States produce this agent. The standard concentration is 3%. Dilutions are 3% for large vessels (4 mm), 1% for midsized vessels (2-4 mm), and 0.1-0.5% for small vessels (<2 mm). Regarding adverse effects, extravasation may cause skin ulceration, the injection may cause burning, patients may develop an allergy, and anaphylaxis has been reported. Polidocanol is commonly used because it does not cause burning with injection and is less likely than other agents to cause skin ulceration or pigmentation changes. The maximum dosage is 2 mg/kg/d. Dilutions are 2% for midsized vessels (2-4 mm), 1% for small vessels (1-2 mm), and 0.25-0.75% for telangiectasias. Regarding adverse effects, polidocanol may cause an allergic reaction. Preoperative DetailsDetailed history taking and physical examination should be performed. All of the patient's medications should be reviewed, with attention to hormone replacement, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), vitamin E, steroids, and herbal medications. Symptoms that may be related to arterial or venous insufficiency must be investigated, and lower-extremity duplex ultrasonography may be necessary. Review with the patient the number of treatment sessions that are required and the duration of treatment. Discuss the limitations in activity that may be necessary after each session. Discuss the sclerosants to be used, including potential adverse reactions. Take pretreatment photographs for documentation and for comparison with the postoperative results. The photographs help the patient evaluate his or her progress. Also, many patients forget what their legs looked like before treatment (Weiss, 1999). Intraoperative DetailsBoth the physician and the patient should be comfortable. To perform the procedure, ensure excellent lighting. Use 30-gauge needles, which should be inserted bevel up so the depth of needle penetration can be accurately assessed. The injection should be precise and slow. Severe pain or burning is often a sign of extravasation. If this occurs, inject the site with normal sodium chloride solution or lidocaine to dilute the sclerosant. Hyaluronidase 75 U decreases the rate of ulceration after extravasation (Zimmet, 1993). The pretibial area and ankle skin have the highest propensity for ulceration. Treatment in these locations should not be the first and should be limited in each session. Each injection is usually 0.1-0.5 mL. The 1-mL syringe allows the physician to accurately feel the injection resistance and to control the injection volume. As one gains experience, the 3-mL syringes speeds the injections. After the needle is removed, compression with cotton balls or tape is appropriate. Postoperative DetailsCompression garments may be beneficial after treatment to improve the results and to decrease the risks of complications (Zimmet, 1993). Compression garments with strengths of 20-30 mm Hg should be worn the first night and then daily for 1-3 weeks depending on the vessel size treated. Many practitioners also recommend that patients avoid aggressive exercise or activity. COMPLICATIONSSection 8 of 10
Bruising is transient and clears with time. Hyperpigmentation is usually transient and is less common in small vessels than in large ones. Compression garments decrease the incidence of hyperpigmentation. Allergic reactions include urticaria and possible anaphylaxis. Edema is prevented with compression garments. Telangiectasia matting is due to injections that are administered too rapidly and usually responds to late treatment. Superficial thrombophlebitis usually occurs in large vessels. Treatment is aspirin, compression, and NSAIDs. Necrosis is due to leakage of the sclerosant and may be minimized with hyaluronidase, normal sodium chloride solution, and/or lidocaine. Patients with deep venous thrombosis should be admitted to the hospital for systemic anticoagulation. FUTURE AND CONTROVERSIESSection 9 of 10
The amount of compression therapy necessary after sclerotherapy of telangiectasias and reticular veins is a controversial issue. Use of at least a minimally graduated compression hose is recommended for the first few days and possibly for 7-10 days after sclerotherapy sessions. This compression theoretically helps to improve the results and minimizes adverse effects, such as edema and postinflammatory hyperpigmentation. Class I (20-30 mm Hg) or class II (30-40 mm Hg) compression is best. For patients who cannot tolerate this level, a class I fashion hose support can be used. After treatment, the patient can continue low-impact exercises, such as walking or riding bicycles, but direct isometric exercise to the lower legs should be avoided for at least 1 week. REFERENCESSection 10 of 10
Article Last Updated: Sep 28, 2006 |
