A hook instrument is then used to capture the varicosity, such as the Oesch-style hook or a crochet hook (Figure9.2). Once captured, the vein will appear pearly white6 (Figure9.3). Although smaller subdermal varicosities can simply be avulsed, longer and larger varicosities should be grasped with pointed clamp, such as a Halsted mosquito hemostat. Once the vein is doubly clamped, it is sharply divided between the two clamps. Each end is slowly and gently pulled from the adhering subcutaneous fat and slowly rolled onto the clamp in the direction of the vein (Figure9.3). Successive clamps can be applied to improve traction. Effort should be directed toward preventing premature avulsion of the vein; if this occurs, a separate inci­sion can be made proximally or distally to recapture the vein and maximize length of vein removed.9 It is important to remove as much of the varicosity as possible as this will reduce the potential inflammation that arises from the thrombosis of a retained segment.4 This should be repeated as many times as necessary, commonly requiring in excess of 20 or more phlebecto­mies.9 Following each phlebectomy, pressure can be held over the site to ensure hemostasis.