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Varicose Veins:
What are They?
The vascular system is made up of arteries and veins. Arteries deliver
oxygenated blood to all organs of the body. Veins return deoxygenated blood
back to the heart and lungs. Unlike arteries, veins contain one-way valves that
when functioning properly permit the flow of blood toward the heart at a very
low pressure. When valves become damaged and fail to either open or close
completely, blood flow is altered and pressure in the veins increases.
Failure of valve closure is most commonly called venous insufficiency, or venous
reflux. This leads to gradual dilatation or enlargement of the veins which is called
varicose veins. Because of the high pressure in the vein, it not only
increases in diameter, but it increases in length as well, leading to the
commonly seen tortuosity or spiraling, if the veins under the skin. Gravity
also plays a significant role in the development of varicose veins and this
problem is often seen in people whose occupation requires prolonged standing.
This increased venous pressure plays a significant role in the development of
spider veins and Telangietasias.
What are the symptoms of Varicose
veins?
Varicose veins in their very early stages may cause no symptoms at all. With
the passage of time however, burning, itching, and aching may occur. Dry scaly
skin with ankle swelling are commonly seen in late stages. Many patients simply
complain of a "heavy" feeling or "tiredness" in the legs. Many early symptoms
can be relieved by compression stockings and the progression or worsening of
the problem can be slowed.
Ultimately if left untreated varicose veins may progress to the severe stages
where the skin around the ankles develops a brownish discoloration with marked
thinning and scarring of the skin and underlying fat that becomes very fragile
and is prone to breakdown and ulcer formation.
Inflammation of the skin is common and when
this occurs the skin takes on a Leather-like quality. At this stage, treatment
becomes quite complex and time consuming and healing of ulcers is painfully
slow.
What causes Varicose veins, Spiders and
Telangiectasias?
Heredity is an important factor in the development of varicose veins, spider
veins and telangiectasias. A family history of the problem is commonly reported
by patients. Women are approximately twice as likely to suffer from this
problem than men. It is estimated that approximately 20% of the population
suffer from venous disorders, while 40% of women have them. Birth control pills
and Hormone Replacement Therapy may aggravate the condition.
There are numerous other factors that play a role in the development of venous
disease. Pregnancy and hormonal changes with puberty and menopause are believed
to play a very significant role in women. As many as 70-80% of pregnant women
develop some degree of varicose veins during their pregnancy. Pregnancy causes
elevated hormone levels, increased circulating blood volumes and varying
degrees of venous compression in the pelvis as the uterus enlarges. Many of the
enlarged veins during the pregnancy will spontaneously disappear following
delivery.
Other significant environmental factors also play a significant role in the
development of varicose veins. Occupations that require prolonged standing such
as nurses, surgeons, sales assistants, flight attendants, waitresses and
teachers are all at risk.
How are Varicose Veins diagnosed?
Large varicose veins are easy to diagnose by simple physical examination. The
full extent of the problem and underlying cause may however require further
investigation. This is especially true in patients who have had previous vein
surgery or a history of phlebitis (blood clots in the veins). Proper treatment
requires knowledge of the origins and underlying communications of the veins.
Although some of this information can be obtained by physical examination by an
experienced surgeon, frequently further study with ultrasound imaging is
necessary. This is a painless test that gives accurate pictures of the venous
system. Occasionally other noninvasive tests may be required if your doctor
needs further information to plan your appropriate treatment. Almost all of
these tests are done non-invasively and do not require needle
punctures.
Treatment options for the treatment of Varicose
veins?
Conservative Therapy:
For many patients who have only mild symptoms from varicose veins or who wish
to prevent worsening of their problem, special support stockings will be
prescribed by your surgeon to meet your specific needs. Depending on your size
and body shape and distribution of your veins, custom fitting by experienced
people may be required. Unfortunately, custom fitted support stockings can be
rather expensive and not all insurance companies will pay for them. If you have
the problem however, the investment in good support hose is worth every penny
you spend. If worn regularly they should be replaced once or twice a year as
they gradually lose their elasticity. If they become easy to put on, they need
to be replaced. Support stockings should be worn daily from morning to night.
Exercise is extremely important if you have varicose veins. Blood flow
is enhanced by exercise and if done while wearing support hose, blood flow is
improved even more! You must avoid prolonged standing as well as prolonged
sitting, if possible. Keep moving at least once an hour.
Elevate your legs whenever possible. Ideally, if you could keep your feet above
the level of your heart the pressure in the veins would be negligible. This is
rarely practical, so any degree of elevation is better than none. Discuss this
with your doctor.
Meticulous hygiene is also very important. Moisturizing lotions are very
beneficial if the skin is dry. Avoid even minor trauma of the lower legs for
even minor wounds may rapidly worsen and become infected and difficult to
treat.
Sclerotherapy:
Sclerotherapy is an injection technique that uses various solutions that upon
injection into a vein cause damage to the inner lining of the vessel. This then
permits scar tissue to develop and leads to eventual disappearance of the vein.
The injection is done with a tiny needle that causes minimal discomfort. As the
solutions are injected, a mild to moderate burning sensation may be noted.
Occasionally patients will experience some muscle cramping near the injection,
that usually subsides within a few minutes.
Occasionally a small blood clot will develop in the injected vein. Most of the
time this causes no problem, other than some minor tenderness. If the vein is
large and filled with clot, your doctor may recommend removal of the clot with
a needle using a small amount of local anesthesia. This will relieve the
discomfort and reduce the chance of significant skin staining. Minor
bruising and skin staining are quite common and this usually gradually
disappears over a period of weeks to months.
Your doctor may recommend the use of ACE elastic bandages over the treated area
for a period ranging from one day to a week or more if indicated. Following
removal of the ACE wrap, it is advised that you wear support stockings to
assist in healing and prevention of reappearance of the veins. Your doctor will
discuss the use of appropriate support stockings during your initial
consultation. It is advisable that you purchase support stockings before the
initiation of treatment.
Sclerotherapy is ideal in the treatment of small to medium sized varicose veins
and spider veins over one millimeter in diameter. For smaller spider veins,
phototherapy with the PhotoDerm VL/PL may be more
appropriate. When varicose veins are symptomatic, insurance companies will
usually but not always cover the cost of treatment. When treatment is
recommended for cosmetic reasons alone, insurance will not cover the
costs and you will be fully responsible for payment. You must discuss
costs with your doctor before beginning treatment.
Surgery for Varicose Veins:
When varicose veins are numerous and huge, surgical removal may be recommended
by your surgeon. Although the vast majority of varicose veins can now be
treated with injection sclerotherapy, surgical therapy can provide a more
complete elimination of diseased veins at one treatment session. Unlike in the
past when many unsightly scars were required to eliminate veins over the entire
leg, new techniques permit removal through tiny (2-3 mm or 1/8th in.) stab
wounds that when healed leave minimal visible scarring. This technique is
called the "stab avulsion" method of vein removal. Ligation and stripping are still required from time to
time but it too can be done through tiny incisions that look better and result
in much less postoperative discomfort.
At the completion of the operation, the leg is wrapped with ACE bandages that
gently but firmly compress the leg to limit swelling and reduce the amount of
bruising that is inevitable. The leg should be elevated as high as is
comfortable for the first 72hours. Walking around, even if the patient is
comfortable, should be limited to meals and bathroom necessities. After
72hours, walking is encouraged and should be steadily increased as tolerated.
Pain medication is provided for use as needed, after returning home.
Bandages are to remain in place at all times for one week. They will be
removed at the one week follow-up visit with your surgeon. Stitches or staples
if used will most likely be removed at this time as well, although occasionally
they are left in place for two weeks, particularly in large patients. When ACE
wraps are removed, support stockings should be worn for at least one month
after surgery. Your surgeon may recommend that you wear support stockings
indefinitely, if you have had a particularly severe problem and additionally,
if an ultrasound has demonstrated deep venous insufficiency. In theory, any
patient with venous disease should wear support stockings throughout the day
for the rest of their lives; but many patients find this
intolerable.
The Vasculight machine is an even newer version of the Photoderm machine which
combines features of the original Photoderm treatment as well as a laser component,
which permits treatment of larger vessels. Also because of the long wavelenght of
light emitted, darker skinned people may be treated with less risk of burning
the skin.
Spider veins are extremely small vessels that become larger as small
venules in or under the skin become dilated or larger. This occurs when the
pressure inside the veins increases enough to exceed or overcome the normal
resistance to blood flow. The ability of veins to resist increased pressure is
decreased in women, when the blood level of the hormone estrogen is reduced, or
as tissues become more fragile with age.
Telangiectasias are similar to spider veins but occur primarily on the
face, neck and upper chest. They are most common around the nose and on the
cheeks. They may appear as red, blue or purple vessels matted together. These
blood vessels are abnormal and serve no essential function and therefore can be
very safely removed. The cause of these abnormal blood vessels is unknown but
they seem to be most prevalent in people with facial flush or blush, or those
with excessive sun exposure. Other associated aggravating factors include
rosacea (an adult form of acne), ingestion of hot or spicy foods, exercise,
hormone level fluctuations, steroid medications, and more rare skin
diseases.
A Port Wine Stain (PWS) is a vascular birthmark and is pink, red or purple. The
color of a PWS comes from blood within small blood vessels in the skin. PWS may
occur on any part of the body and may be as small as a dime or cover extensive
areas of the body. PWS occur in all ethnic backgrounds, and are slightly more
common in girls than boys.
What Causes PWS?
It is not known exactly what causes PWS. They occur in approximately 3 out of
every 1000 births. They are not caused by any fault of the parents nor can they
be prevented. Because parents have one child with PWS, does not mean that they
are more likely to have a second child with PWS.
Treatments are performed in the Dr's. office. Eyes are covered with a
protective shield or glasses while a test patch is done on a small area to
determine the ideal treatment settings for your lesion. During the treatment, a
cold gel is placed on the skin and a glass prism placed over the gel which
transmits the pulse of light. Each pulse treats an area about the size of a
stick of "Trident" chewing gum (5/16" x 1 1/16").
Hemangiomas:
What is a hemangioma?
Hemangiomas can be small to very large sacs of unsightly red, purple or blue
blood vessels. They can appear at birth or shortly thereafter, or later in
life. Hemangiomas can enlarge sometimes to very alarming sizes. In certain
locations large hemangiomas can interfere with proper development and function
of organs. For example, an hemangioma close to the eye can prevent proper
vision from developing. In other areas, they are simply large and unsightly.
They may resemble a strawberry, and are often called strawberry hemangiomas.
Usually these kind of hemangiomas will go away by themselves in anywhere from
several to ten or twelve years. In the meantime, they can cause some maturation
damage, and be more than just a cosmetic concern.
Older persons often grow many small hemangiomas, ranging in size from a
matchhead to a pea. While harmless, they may cause cosmetic discomfort. Also,
blood vessel formations may grow between them, and can be of serious cosmetic
concern, as well as interfere with normal functioning.
These blood sacs are abnormal. They are not necessary for any essential body
function. Destroying them results in a more positive self-identity, and may
prevent damage to other structures.
Lips Before
PhotoDerm VL Treatment Lips After
Four PhotoDerm VL Treatments
The cause is unknown. Strawberry hemangiomas and other bulky hemangiomas can be
thought of as a kind of birthmark. The smaller cherry angiomas are associated
with aging.
How are hemangiomas treated?
Previous treatments have included painful liquid nitrogen or surgical removal,
both of which can leave unsightly scars. For extensive hemangiomas, high dose
cortisone by mouth may affect them more quickly, but there are major side
effects associated with cortisone therapy. X-ray has been used, but this is
usually avoided, since X-ray can cause cancer to occur in the treated area
years later.
In recent years, many of the newer laser devices have been tried, but most
hemangiomas are too bulky for these devices to be effective.
This remarkable new treatment zaps the hemangioma with a high energy light
source similar to a laser. This device is a generation beyond laser, and
produces a high energy flash of light that passes harmlessly through normal
light-colored or untanned skin. This light is absorbed by blood and is
converted into heat which destroys the blood containing sacs which are then
absorbed by the body. Lightly colored, untanned skin absorbs very little of the
light and is not damaged by the treatment. The PhotoDerm does not emit harmful
radiation and can be used during pregnancy.
How many treatments would it take to see
results?
Small hemangiomas and cherry angiomas are often completely removed in one
treatment. Several treatment sessions may be required to eliminate more
extensive and bulky hemangiomas. Results become apparent immediately in some
cases. Bulky hemangiomas may take several weeks to results to be seen.
Photographs may be taken so that the progress can be closely monitored.
Sometimes a temporary purple discoloration occurs which fades to show the final
result.
Can all hemangiomas be treated with the PhotoDerm? Are
there any reasons not to have the treatment?
Almost all hemangiomas can be successfully treated. Persons with dark or darkly
tanned skin, or have a history of keloid formation or other healing problems,
should not be treated with PhotoDerm.
Are there any restrictions after the
treatment?
Normal activities may be resumed after treatment. The treated area should be
protected from sunlight and tanning beds until the skin color has returned to
normal.
Will the hemangioma ever come back after being
treated?
Most hemangiomas result from a one time abnormal process, and once destroyed
are unlikely to recur. On the other hand, cherry angiomas are a normal part of
the aging process, and new angiomas will probably occur. New lesions can be
treated as they appear.
Age Spots:
What are Age Spots or Liver Spots?
Age spots are brown spots, that are secondary to prolonged or severe sun
exposure. Don't let your hands give away your age! The full range of benign
pigmented lesions including freckles, age spots(lentigos), sun spots(solar
lentigos), cafe au lait macules(birthmarks), seborrheic keratoses and
hyperpigmentation are treated in our office. It requires no anesthesia. PhotoDerm® PL is the treatment used for age spots.
Tattoo Removal:
The PhotoDerm’s high energy light passes harmlessly
through the skin and is absorbed by the tattoo pigments, breaking up the
particles into microsized particles, allowing the body's natural systems to
absorb and eliminate the pigment. Immediately after a treatment, virtually no
change is seen, yet over the next several weeks the color just seems to fade
away and disappear.
Different colors respond at different rates In many cases, black and blue
respond the fastest and may disappear after the first treatment. In general,
three to five treatments will be required to eliminate most tattoos.
The venous system is made up of deep and superficial systems. These two systems
are connected by small veins containing one way valves and these are called
perforating veins. In the normal venous system, with normally functioning one
way valves, blood flows toward the heart in both the deep and superficial
systems and through the perforating veins, which permit blood to flow from the
superficial to the deep system.
If the one way valves have been damaged by thrombophlebitis or vasculitis, flow
becomes to and fro, resulting in increased back pressure in the veins.
Weakening of the vein walls by hereditary conditions, advanced age, obesity, or
pregnancy results in progressive enlargement of the veins in the presence of
valve leakage. This is known as venous insufficiency or reflux
With longstanding venous insufficiency and the effects of gravity, blood flows
backward and pools or collects in the veins in the lowest portion of the leg.
This often leads to aching and swelling of the feet, ankles and lower leg,
which can be relieved by elevating the leg or wearing support stockings.
Prolonged increase in venous pressure forces fluid to leak through the walls of
the tiny vessels, resulting in swelling or edema. Because of the increased
venous pressure and tissue pressure, the delivery of oxygen and nutrients to
the skin is severely impaired. As a result, the skin and underlying tissues
become very fragile and prone to breakdown and eventual ulcer formation. Even
the slightest trauma to the skin in this situation is potentially serious. A
bump, an insect bite, a scratch or even the simple friction from socks or shoes
may result in an ulcer.
Location and appearance are clues to diagnosis.
Venous ulcers most typically occur on the inner aspect of the lower leg just
above the ankle bone. Occasionally they can occur on the outer aspect of the
ankle. Ulcers almost never occur above the knee or on the sole of the foot, in
the absence of Diabetes. The ulcers can be shallow or deep, sometimes extending
through the underlying fat, near muscle and bone. Most ulcers have very
irregular borders and are very painful. Because of the damage to the tiny
capillaries and surrounding edema, there is usually a continuous weeping or
oozing of fluid from the ulcer and surrounding tissue. The ulcer appears very
raw and the surrounding skin is frequently inflamed, red and swollen. Beyond
the region of inflammation, the skin is frequently dry, itchy and
flaky and hard.
Diagnosis of venous ulceration is usually easily made by physical examination
alone. Documentation of venous insufficiency and particularly incompetent
perforating veins is usually done by Doppler ultrasound studies.
Treatment of venous ulcers:
Conservative:Years ago having a leg ulcer meant hospitalization or strict bed
rest at home. Now, treating leg ulcers generally involves these conservative
approaches:
Dressings-- Wet to Dry dressings promote healing by absorbing weeping fluids
and preventing tissues from drying out. They also reduce the risk of infection
by keeping the ulcer clean and protected from bacteria.
During initial healing, gauze dressings moistened with a saline solution are
changed daily. If an ulcer is free from infection, your doctor may apply an
adhesive film or absorbent gel or foam instead of a gauze dressing.
Elastic and medicated bandages:
Elastic bandages improve venous blood flow and help to speed healing. For very
bad ulcers a medicated wrap called an "UNNA BOOT" is applied. This
dressing is applied wet and is allowed to dry and is kept in place continuously
and is changed weekly. Frequently an elastic bandage applied on top of the boot
for additional support. Obviously bathing is difficult during this treatment
for the bandage must be kept dry. Many patients become quite creative in order
to maintain good hygiene.
Treatment for severe non-healing ulcers:
Rarely, Dr. Szarnicki will recommend surgical treatment for non-healing
venous ulcers. The goal of aggressive surgical therapy is to reduce the venous
pressure in the lower leg. This may involve ligation and
stripping of incompetent varicose veins but frequently requires location of
and interruption of incompetent perforating veins near the ulcer.
Thorough evaluation of patients with non-healing venous ulcers includes not
only analysis of the venous system. Thorough evaluation of the arterial supply
to the leg is necessary to identify those patients with atherosclerosis or "hardening of the arteries" If found
,this must be corrected first, for without adequate arterial blood flow,
healing cannot occur.
