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Chapter
Perpendicular
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12
Microthrombectomy
Spider veins (especially those bigger than 0.6 mm in diameter) and reticular veins are likely to form microthrombi after
being injected. This phenomenon is less frequent with glycerin
than with detergent solutions, especially foam. As discussed
in Chapter 8, to prevent pigmentation, microthrom bectomy
is carried out as early as 1 to 2 weeks after injection.
Microthrombectomy is easily executed with any needle, the
important point being to puncture every millimeter of the
‘blue line’ of the microthrombi (Fig. 12.16A–C). In very
small venules, manual pressure is unnecessary; a cotton
ball is applied and kept in place for several hours with an
adhesive tape.
is a complex interwoven network, so treatment of only one
part may not prevent reflux pressure from another part promoting continued blood flow through the treated area (see
Chapter 1). This leads to an increased incidence of complications from blood flow through a damaged endothelial system
(see Chapter 8). Thus, in the treatment of superficial reticular
and telangiectatic leg veins, the only real limiting factor is
patient and physician motivation for treatment and adherence
to using the maximum daily recommended amounts of sclerosing solution that can be injected (see Chapter 7). In addition, if compression is used, it may be best to wait until the
pressure stocking has been removed for a few days before
treatment is continued on the same leg.
Repeat Treatment Sessions
All patients are informed that successful treatment of a given
telangiectasia may require more than one treatment (in
general, and also on each treatment site). Patients easily
understand that, like for wall painting, 2 or 3 thin layers give
Clinical Methods for Sclerotherapy of Telangiectasias
a better result than a thick one. As previously mentioned, the
same vessel or the immediate area is not retreated for 4 to 6
weeks to allow resolution of the endosclerosis or controlled
phlebitis to occur. Waiting also allows appreciation of the
effectiveness of treatment with a given solution and concentration. If little change is apparent 6 weeks after injection, the
second treatment can be performed with a stronger sclerosing
agent or more concentrated solution. Different areas can be
treated as often as every day, but the venous system of the leg
pressure
Cotton ball
Adhesive tape
Venule
Tangential
pressure
Poor Results of Microsclerotherapy:
How to Analyze the Reasons
Objective poor results present in many forms (Fig. 12.17); they
differ from subjective poor results, where patients are not satisfied despite a satisfactory outcome. Most poor results are
related to an inappropriate treatment. Two types of error are
possible:
• strategic, where superficial venous pressure and/or
varicose reservoir have not been taken care of
satisfactorily
• tactic, where application of microsclerotherapy is not
mastered by the sclerotherapist.
The bad strategic approach is usually due to an inadequate
physical examination and/or duplex ultrasound assessment. If
varicose veins are left untreated, although known and identified, microsclerotherapy alone is unlikely to produce a satisfactory result and may even lead to the production of new
lesions.
When the technique is deficient, it can have three consequences. First insufficient delivery of active drug in the spider
network is responsible for a lack of efficacy. Second, excessive
power of the sclerosing agent (too high a concentration and/
or injection pressure and/or volume) results in a transparietal
burn and subsequent inflammation (matting) and blood
deposit with pigmentation. The third possibility is an imprecise injection, outside the vein lumen. This can result in
inflammation or necrosis.
Figure 12.15 Lateral (tangential) and Laplace’s (perpendicular) pressures
exerted by local compression.
A C
Figure 12.16 Microthrombectomy.
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Sclerotherapy Treatment of
Facial Telangiectasia
Sclerotherapy treatment of facial telangiectasia has proved to
be effective and safe (see Case study 12).
B
8
However, there is a
Objective bad results: 2 types
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On the initial lesion Appearance of a new lesion
Insufficient?
Inefficient?
Worsening?
Figure 12.17 Objective bad results: two types.
Matting?
Residual pigmentation?
(hemosiderin, melanin)
Necrosis?
(extravasation,
intraarterial injections)
Scar? (necrosis)
potential for sight-threatening complications from periocular
vascular manipulation. This topic was reviewed and is
abstracted here.
62
Inadvertent intra-arterial injection of corticosteroid suspensions in the periocular region has been reported to lead to
embolic occlusion in the ophthalmic artery distribution,
causing blindness.
63
Inadvertent intra-arterial injection is the
likely factor permitting steroid particulate emboli to reach the
retinal circulation. Severe visual loss has also been reported
following intralesional steroid injection into a chalazion,
again apparently causing retinal and choroidal embolic occlusion, presumably as a consequence of inadvertent intra-arterial
injection.
64
Since it is not a suspension, distal embolic
phenomena would not be expected from an injection of STS.
However, as an intravascular sclerosant agent it clearly presents
a danger if it gains inadvertent access to normal vessels
supplying the eye in therapeutic concentrations through the
production of an embolus composed of denatured endothelial cells and blood cell elements (see Chapter 8). Presently
accepted standards of injection technique, including careful
placement of the needle, repeated aspiration, and careful stabilization of the syringe, do not guarantee that the physician
can detect if the bevel is against or within the vessel wall if the
vessel is constricted, or if there has been any intra-arterial
placement of the needle.
65
Although Green66 reports that despite the numerous and
variable anastomoses between the superficial facial and deep
orbital venous systems, injection into superficial eyelid veins
is ‘highly unlikely’ to reach the orbit, his technique uses comparatively large volumes (1–3 mL) of STS. Since venous pressure is quite low, it is not inconceivable that intravenous
eyelid injection could reach the orbit (where there are no
venous valves) and hence the ocular adnexae, the central
retinal vein, the choroidal vortex veins, or even the cavernous
sinus through these anastomoses. Monocular blindness has
been reported following STS injection into a venous malformation partially located in the orbit.
67
Green’s technique uses
compression only after delivery of the sclerosing solution. At
that point, compression could conceivably force the solution
into the orbital vessels through the variable anastomotic channels. Since the purpose of his compression is to delay the
return of blood into the treated vein, the sclerosing solution
forced upstream or downstream would not be significantly
diluted necessarily and could be potentially dangerous.
Current treatments for cosmetically objectionable lower
eyelid veins include direct cautery application through small
cutaneous incisions and direct cautery plus surgical vein
transection.
68
These procedures pose no known risks to the
remainder of the vascular system but could be complicated
by cutaneous scars. Surgical removal of the vein through a
2-mm incision with a phlebectomy hook has also been
shown to be effective.
69
The vein can be tied off with an
absorbable 6-0 suture with minimal bruising. However, this
technique requires practice to avoid damage to perivascular
tissue.
Our technique of sclerotherapy of lower eyelid veins has
been reported previously as part of larger series.
8
We recommend using very small quantities of Sclerodex (dextrose,
sodium chloride, phenethyl alcohol) for treating facial telangiectasias and prominent periorbital veins. The technique is the
use of 1 mL or less of sclerosant solution for 24 hours after
proximal vein ligation with a 6-0 Prolene suture. The suture
prevents backflow of the solution into the retro-orbital venous
system. This allows vigorous massage of the area and complements immediate compression. Use of a hypertonic solution
provides for effective sclerosis of the vein within the concentration gradient of the solution. A detergent sclerosing solution like STS may travel for many centimeters from the site of
injection into areas that should not be sclerosed (see Chapters
7 and 8). This technique demonstrates a 90% to 100%
improvement in 70% of patients after one treatment.
70
No
adverse effects have been reported.
Laser technologies, including the long-pulsed, dynamically
cooled 1064-nm Nd:YAG laser (CoolTouch Varia, New Star
Lasers, Rosemont, Calif.) has been reported to treat periorbital
vessels 1 to 2 mm in diameter with a near 100% efficacy.71
Lasers of lower wavelength would not be expected to deliver
sufficient energy at the correct depth to thermocoagulate a
vessel of this size without producing excessive cutaneous
thermal damage.
72
Sclerotherapy Treatment of
Essential Telangiectasia
Vessels of essential telangiectasia are extremely small, usually
measuring less than 0.1 mm in diameter, and are often
associated with a feeding arteriolar component (see Chapter
4). Lasers and intense pulsed light (IPL) are the easiest techniques to cause their involution (see Chapter 13). However,
sclerotherapy may also be used to decrease the extent of the
lesion. Sclerotherapy should be performed with a dilute solution. Lim and Kossard
73
have successfully treated a 56-year-old
patient with STS 0.08% with good efficacy and no adverse
effects.
Conclusion
It is clear that sclerotherapy is the ‘gold standard’ for treating
leg telangiectasia. In certain cases, lasers or IPL therapy is
also effective and recommended (see Chapter 13). The lay
press is filled with products that patients can apply to the legs
to eliminate leg telangiectasia. A scientific evaluation of one
of these products showed conclusively that a vitamin
K-containing cream touted to eliminate vessels has no effect
compared with placebo when used daily over 33 days.
Although we as physicians think of medicine as a science, it
is also an art. Therefore, the sclerotherapy technique just mentioned should not be perceived as dogma. Rather, it should
serve as a logical outline for the physician in planning individualized treatment.
Case Study 1
Traumatic telangiectatic patch
A 46-year-old woman was accidentally hit by a tennis ball while
she was ‘playing the net’. A telangiectatic patch on the posterior
medial thigh developed after resolution of the bruise 4 to 6
weeks after the initial injury and did not change in size or color
74
Conclusion
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Chapter
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12
A
Figure 12.18 Case Study 1. A, Telangiectatic patch on posterior medial thigh. B, 10 months after treatment.
Clinical Methods for Sclerotherapy of Telangiectasias
A
B
B
Figure 12.19 Case Study 2. A, Linear telangiectasia
on medial thigh. B, 6 months after treatment.
over the following 4 years (Fig. 12.18A). The patch was treated
on one occasion only, with injections of POL 0.5% in three
locations to blanch the lesion completely. A total of 1 mL was
used. A localized pressure dressing with an STD foam pad was
placed and secured with adhesive tape for 3 days. Figure
12.18B, shows the same area 10 months after initial
treatment.
Case Study 2
Unassociated telangiectasia
Figure 12.19A, shows the appearance of linear telangiectasia
on the medial thigh of a 46-year-old woman, which was noted
during her second pregnancy 22 years previously. The area was
asymptomatic, and treatment was requested for cosmetic
improvement. The appearance 6 months after a single
treatment using approximately 3 mL of POL 0.5% is shown in
Figure 12.19B. A 30- to 40-mmHg graduated compression
stocking was worn for 3 days after the injection. Note some
mild hyperpigmentation in one of the treated vessels.
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Case Study 3
Reticular vein unassociated with the saphenous system
A reticular vein 2 to 3 mm in diameter on the popliteal fossa in
a 32-year-old woman is shown in Figure 12.20A. The same area
18 months after one treatment with 1 mL of POL 0.75% is
shown in Figure 12.20B. The area was compressed for 72 hours
after treatment with an STD foam pad under a 30- to 40-mmHg
graduated compression stocking, after which the compression
stocking alone was worn for 1 more week while the patient was
ambulatory. In the intervening 18 months, the patient wore a
20-mmHg graduated compression stocking on a fairly
consistent basis while she was ambulatory.
Case Study 4
Mixed reticular and telangiectatic veins
Reticular veins approximately 2 mm in diameter associated
with multiple telangiectasias on the lateral distal thigh in a
Conclusion
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A
Figure 12.20 Case Study 3. A, Reticular vein on popliteal fossa. B, 18 months after treatment.
32-year-old woman appeared during her second pregnancy 10
years previously (Fig. 12.21A). The patient requested treatment
because of a dull aching that occurred in the area during
menses and after prolonged standing. The treated veins are
shown immediately after a total injection with 0.5 mL of POL
0.75% in Figure 12.21B, and Figure 12.21C shows the treated
area 1 day after injection after removal of the STD pad and a
30- to 40-mmHg graduated compression stocking. Note the
ecchymosis induced by the pressure dressing. Figure 12.21D,
shows the area 1 week after injection. Intravascular thrombi
were noted and drained at that time. Eight weeks after injection,
the vessels were almost totally resolved. Some mild
pigmentation was present in the distal aspect in which
thrombosis was most extensive (Fig. 12.21E). Finally, Figure
12.21F, shows the area 22 months after initial treatment,
demonstrating sustained resolution of the telangiectasia,
reticular veins, and pigmentation.
Case Study 5
Extensive reticular and telangiectatic veins
A 53-year-old woman had a 30-year history of asymptomatic
reticular and telangiectatic leg veins that had been stable in
appearance since her last of two pregnancies 20 years
previously. She sought treatment for cosmetic reasons (Fig.
12.22A)
feeding reticular veins on the proximal and distal lateral thigh.
Policocanol 0.5%, 2 mL, was injected into the portion of the
telangiectatic mats on the lateral calf and knee, which did not
blanch with the previous injection. STD foam pads were placed
under a 30- to 40-mmHg graduated support stocking that was
worn continually for 7 days after the procedure. When the
stocking was removed, multiple small thrombi were drained.
Figure 12.22B, shows the appearance of the treated area 25
months after the single treatment session.
. A total of 10 mL of POL 0.75% was injected into all
B
Case Study 6
Treatment of cherry hemangiomas
A 48-year-old woman had multiple cherry hemangiomas
on her abdomen and thighs and a 4-mm-diameter
hemangioma located on her anterior thigh (Fig. 12.23A).
Figure 12.23B, shows the appearance 5 months after injection
with 0.1 mL of POL 0.75%. Note the slightly indented and
hypopigmented scar, which was acceptable to the
patient.
Case Study 7
Lateral subdermal plexis
A 59-year-old woman was seen initially with a leg ache from
the lateral thigh veins that had been increasing in severity
over the previous 2 years. Reticular and telangiectatic veins
had been present since age 16. The lateral subdermal plexus,
noted as having 2- to 3-mm diameter reticular veins, was
incompetent to venous Doppler examination (Fig. 12.24A).
Sclerotherapy began with injection of a total of 4 mL of POL
0.75% to all reticular veins on the left leg while the patient
was supine. All telangiectasias that did not become inflamed
after reticular vein injection were then sclerosed with a total
of 6 mL of POL 0.5%. The leg was compressed for 72 hours
with a 30- to 40-mmHg graduated compression stocking.
A second treatment to the same leg was given 4 months
later with 4 mL of POL 0.75% injected into reticular veins
and 2 mL of POL 0.5% injected into remaining telangiectasias.
The leg was compressed as previously described, and all
veins and bruising resolved within 2 months. Figure 12.24B
shows total resolution of all veins 1 year after the second
treatment.
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Chapter
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12
Clinical Methods for Sclerotherapy of Telangiectasias
A
C D
B
E F
Figure 12.21 Case Study 4. A, Reticular veins associated with multiple telangiectasias on lateral distal thigh. B, Immediately after injection. C, 1 day after
injection and removal of pad and graduated pressure stocking. D, 1 week after injection. E, 8 weeks after injection. F, 22 months after treatment, with
complete resolution.
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Figure 12.22 Case Study 5. A, Reticular veins on
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the proximal and distal lateral thigh. B, 25 months
after treatment.
Conclusion
A
B
Case Study 8
Long-term follow-up of sclerotherapy treatment
of telangiectasia
A 43-year-old woman presented with dilated pretibial reticular
veins 2 to 4 mm in diameter (Fig. 12.25A). She gave a history
of playing tennis and working on a hard floor. No evidence of
truncal vein incompetence was found. She was treated with
one session of sclerotherapy using 2 mL of 0.5% STS and then
wore 30- to 40-mmHg graduated compression stockings 24
hours a day for 7 days. She reported complete resolution of her
veins after 6 to 8 weeks and did not recall any post-treatment
A
pigmentation. She presented 16 years later for treatment of
new veins on her thighs (Fig. 12.25B).
Case Study 9
Long-term follow-up of sclerotherapy treatment
of telangiectasia
A 52-year-old woman presented with scattered telangiectasia in
patches without obvious feeding reticular veins on her anterior
thigh (Fig. 12.26A)
She was treated with one session of sclerotherapy using 1.5 mL
of 0.25% STS and then wore 30- to 40-mmHg graduated
compression stockings 24 hours a day for 7 days. She reported
complete resolution of her veins after 4 to 6 weeks and did not
recall any post-treatment pigmentation. Figure 12.26B, shows
the appearance of the treated area 6 years later when she
presented for treatment of new veins on her calves.
. Veins measured 0.2 to 0.4 mm in diameter.
B
Figure 12.23 Case Study 6. A, Multiple cherry hemangiomas on anterior
thigh. B, 5 months after injection.
Case Study 10
Treatment of telangiectasia and resulting
telangiectatic matting
A 66-year-old woman was seen initially with extensive
telangiectasias and venules 0.2 to 0.6 mm in diameter over the
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Chapter
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12
Figure 12.24 Case Study 7. A, Clinical appearance
before sclerotherapy. B, Clinical appearance 1 year after
treatment (see text for details).
A
Clinical Methods for Sclerotherapy of Telangiectasias
A
Figure 12.25 Case Study 8. A, Dilated pretibial reticular veins. B, Presentation with new veins 16 years after treatment.
left lateral knee (Fig. 12.27A). These veins developed when she
was near 40 years of age after she began estrogen replacement
therapy. There was no previous family history of varicose veins.
In addition to the cosmetic appearance that was disturbing
when she wore shorts while playing golf, her legs ached
continuously, especially over the telangiectasias. These vessels
were treated with POL 0.5%, 2 mL, with the development of TM
4 weeks after treatment (Fig. 12.27B). Examination 3 months
after initial treatment showed a ‘feeding’ reticular vein in the
B
B
region. A 6-0 Prolene suture was placed in the lateral canthal
crease to close the vein circumferentially, and 0.2 mL of
Sclerodex was injected slowly into the bulging vein. Immediate
handheld pressure was applied with an ice pack and
maintained by the patient for 5 minutes. The suture was
removed the next day. Figure 12.28B, shows the appearance 8
weeks after treatment. A tiny coagulum is present in the
resolving vein. Follow-up examination 12 years later showed
continued elimination of the vein (Fig. 12.28C).
telangiectatic area. The feeding reticular vein, 2 mm in diameter,
was treated with POL 0.75%, 1 mL, and the TM vessels were
then treated with CG mixed 1 : 1 with lidocaine 1% with
Case Study 12
epinephrine, 1 mL, with resolution occurring in approximately 4
weeks. When the woman was examined 1 year later, the
telangiectasia and leg pain had both resolved (Fig. 12.2C).
Treatment of facial telangiectasia
A 65-year-old man presented with prominent perinasal red
telangiectasia (Fig. 12.29A). A slow infusion of POL 0.5% was
given into the telangiectasia, and the solution was held in place
Case Study 11
until the vessel went into spasm. A total of 0.5 mL of solution
was given in a single treatment session into nasal vessels. Three
Treatment of facial telangiectasia
A 40-year-old man with a 20-year history of a prominent
periorbital vein requested treatment (Fig. 12.28A). Physical
examination showed a 2-mm venule in the lateral infraorbital
330
weeks after treatment, the vessels had resolved (Fig. 12.29B).
When the patient was seen in follow-up 15 years later, the
treated vessels were not present. New red telangiectasias were
present but not as prominent as before treatment (Fig. 12.29C).
Conclusion
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A
A
B
C
B
Figure 12.26 Case Study 9. A, Scattered telangiectasia in patches without
obvious feeding reticular veins on the anterior thigh. B, Presentation
10 years later with persistent resolution of the treated veins.
Figure 12.28 Case Study 11. A, Periorbital vein prior to treatment.
B, Appearance 8 weeks after treatment. C, Continued elimination of the
vein 12 years after treatment.
J Dermatol Surg Oncol 19:899, 1993.)
(From Goldman MP, Weiss RA, Brody HJ, et al:
A C
Figure 12.27 Case Study 10. A, Clinical appearance before sclerotherapy. B, Developmental of telangiectatic matting after sclerotherapy. C, Resolution of
telangiectasia 1 year after treatment (see text for details).
B
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Chapter
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12
A
Clinical Methods for Sclerotherapy of Telangiectasias
C
Figure 12.29 Case Study 12. A, Perinasal telangiectasia before treatment. B, Appearance 3 weeks after one treatment with 0.5 mL of polidocanol 0.5%.
C, Appearance 15 years after initial treatment. Note persistent resolution of treated telangiectasia with appearance of new telangiectasia.
B
A
Figure 12.30 Case Study 13. Facial telangiectasias and venous malformation: A, before, and, B, after treatment with polidocanol foam.
Case Study 13
Facial telangiectasias and venous malformation
An 8-year-old boy had been treated 4 years before for an
extensive venous malformation of the right cheek. The initial
treatment had included embolization with Ethiblock and
subsequent surgical removal of remaining material. A
perilesional network of spider veins outlining the remaining scar
was still present (Fig. 12.30A)
foam in three different points was challenging since the patient
332
. Injection of 1 mL of 0.5% POL
B
had also requested local anesthesia with EMLA cream, inducing
a venous spasm. Two sessions gave a nice improvement, and
patient satisfaction.
Case Study 14
Sclerotherapy of telangiectasias on venous malformation
A 12-year-old girl presented with an extensive venous
malformation of the left limb. Lesions were present at birth. One
can observe the development of large competent superficial
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veins: great saphenous vein and accessory anteromedial
extrafascial tributary (Fig. 12.31). A wide but light-pink portwine stain extended the length of the limb, but both legs had
the same length and circumferences. The girl was mainly
concerned with the development of telangiectatic and reticular
veins on the anterior, medial, and lateral aspects of the limb.
Since reflux had not been detected, neither in the deep nor in
the superficial venous networks, careful microsclerotherapy with
POL 0.5% foam was carried out, improving the lesions with
patient satisfaction after four sessions.
Case Study 15
Treatment of reticular chest veins
A 40-year-old woman developed dilated reticulated veins on
her chest shortly after breast augmentation (Fig. 12.32A).
Sclerotherapy was performed using STS 0.25% foam made by
using 1 mL of STS and 4 mL of air. A total of 8 cm3 of foam
(2 mL of solution) was used to infiltrate the entire anterior
chest venous network. Figure 12.32B, shows the appearance
3 months after treatment.
Conclusion
Figure 12.31 Case Study 14. Telangiectasias on venous malformation.
A
C
Figure 12.32 Case Study 15. A, Dilated reticulated veins on the chest. B, Appearance 3 months after sclerotherapy using sodium tetradecyl sulfate 0.25%
foam. C, Appearance 5 years after treatment. Note persistent resolution of the treated veins.
B
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