Varicose and spider vein treatment is a vast field that is increasingly finding its way into cosmetic practices. Though many agree on which treatment modalities are effective, each physician has his or her own preference when it comes to selecting treatment tools for specific indications and providing post-care instructions.
“There’s no such thing as a cure at all,” says Torrance, California-based dermatologist David M. Duffy, MD. “It’s a maintenance situation for both small vessels and varicose veins. Repeated treatments may be necessary over the years.”
Visible Veins on the Legs
Varicose veins are, in many cases, a wound healing abnormality with a strong genetic component, says Dr. Duffy. Humans acquired the ability to grow vessels quickly as a wound healing capability, and varicose veins occur in those people who make too much vascular tissue.
While modalities such as ambulatory phlebectomy, foam sclerotherapy and endovenous lasers are all commonly used to treat varicose veins in the legs, opinions vary on which procedures are best for specific indications.
Neil Sadick, MD, of Sadick Dermatology in New York, offers all three modalities and selects treatment based on vein size. “For medium-sized varicose veins we use foam sclerotherapy, and if they’re large veins we use ambulatory phlebectomy,” he says. “If the patient has problems with reflux in the greater lateral saphenous vein, at this time, we’re using the endovenous laser.”
“It all depends on the size and location of the vein,” agrees Mitchel P. Goldman, MD, medical director of Goldman, Butterwick, Fitzpatrick, Groff & Fabi: Cosmetic Laser Dermatology Center in San Diego.
Dr. Goldman co-invented the 1320nm CoolTouch CTEV laser for endovenous ablation of larger varicose veins. “If the great saphenous vein or the small saphenous vein—which are very large truncal veins—are abnormal, I treat those with the endoluminal CTEV laser treatment. If they’re non-truncal veins, those I’ll usually treat with either ambulatory phlebectomy or foam sclerotherapy,” he says.
Conversely, Dr. Duffy prefers to treat larger veins with polidocanol foam sclerotherapy, though he agrees that endovenous lasers, radiofrequency devices and other methods can be effective as well. “My favorite is Asclera; I use it almost exclusively,” he says. “Foam is really good for large vessels: It’s inexpensive and works very well. But there are some problems with it too, having a lot to do with its potency. You have to be a little careful with it.”
He points out that treating these larger veins usually yields fast results, but patients may experience streaks of pigment or small clots that often need to be drained, though they are not dangerous.
At RGV Cosmetic Surgery & Vein Care in Texas, Filiberto Rodriguez, MD, FACS, treats varicose leg veins with a combination of endovenous ablation—specifically the 1470nm laser from Total Vein Systems—and micro-phlebectomy. “The endovenous laser is a very well-tolerated procedure and it’s highly reproducible. The higher wavelengths (such as the 1470nm or the 1320nm CoolTouch) target the water rather than the red blood cells and are associated with less bruising and less discomfort, which is why we like it for saphenous vein ablation,” he says. “Then for the remaining varicose veins, we prefer the micro-phlebectomy procedure where we do tiny little needle sticks and gently tease out the vein with no staining, minimal bruising and no scarring.”
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