1. www.sentara.com 8/31/081 TREATMENT OF SMALL VEINS CHRISTI SILER, R.N. SENTARA COSMETIC AND LASER TREATMENT CENTER

2. www.sentara.com 8/31/082 Examples of Small Veins

3. www.sentara.com 8/31/083 Etiology of Venous Disease Heredity- Primary cause Pregnancy Obesity Standing or sitting for long periods of time Trauma Incidence- 80% female & 20% male

4. www.sentara.com 8/31/084 Microanatomy of Venous System Spider Veins Reticular Vein Perforator

5. www.sentara.com 8/31/085 Algorithm for Small Vessel Treatment Rule out truncal insufficiency- plan to correct if present Determine system involved Identify associated reticular veins Perform appropriate treatment Compression for 5-7 days Follow-up & re-treat in 4-6 weeks

6. www.sentara.com 8/31/086 Lateral Reticular Vein with associated telangiectasia

7. www.sentara.com 8/31/087 Small Vein Treatment Options Sclerotherapy- still the Gold Standard Lasers- great adjunct to treatment Non lasers- IPL, Ohmic Thermolysis, Vascutouch Microphlebectomy- for large reticular veins Combination Therapy- BEST OPTION for quickest and cosmetically superior results

8. www.sentara.com 8/31/088 The Ideal Sclerosant Non-allergenic/ Non-toxic Painless No risk of hyperpigmentation No risk of telangiectatic matting No ulceration FDA approved UNFORTUNATELY, no sclerosant meets all of this criteria

9. www.sentara.com 8/31/089 Detergent Properties Efficient sclerosant- causes intimal inflammation  thrombus formation  fibrous tissue  vein obliteration Painless Low rate of allergies Low rate of pigmentation Extravasation tolerated at low amounts

10. www.sentara.com 8/31/0810 Reticular Veins R/O truncal insufficiency/ incompetent perforators Inject reticular veins first Follow with laser/ sclerotherapy to telangiectasias Compression dressing post tx facilitates clotting

11. www.sentara.com 8/31/0811 Why Combination Therapy? Vessel damage d/t heat Laser spider veins first Decreased intimal lumen Less sclerosant needed Lower incidence of hyperpigmentation TWICE THE DAMAGE MEANS TWICE AS FAST!

12. www.sentara.com 8/31/0812 Lasers- Not All are Created Equal 940 nm and 1064 nm most common for treatment of telangiectasias Goal is to cause vessel damage without damaging surrounding tissue No sun exposure or sunless tanning prior to tx Test laser and sclerotherapy at consultation to assess response and candidacy for treatment

13. www.sentara.com 8/31/0813 Superior Cosmetic Result with Combination Therapy

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15. www.sentara.com 8/31/0815 Foam Sclerotherapy CO2 vs. Room Air –CO2 bubbles dissolves faster in arterial circulation, thus reducing the risk of adverse event Tessari Method- –1 part solution: 4 parts gas –Stopcock, 2 syringes

16. www.sentara.com 8/31/0816 Foam Sclerotherapy Advantages Disadvantages

17. www.sentara.com 8/31/0817 Advantages- Increases surface area of sclerosant, thus reducing amount of drug needed Circumferential contact with intimal wall causes more damage/ better result Displaces blood, thus avoiding dilution of drug/ increases efficacy Disadvantages- Patients with PFO may not be candidate Neurological deficits- Migraine Scotoma DVT- clear deep system with foot dorsiflexion immediately post tx and encourage ambulation

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19. www.sentara.com 8/31/0819 Before/ After Foam Sclerotherapy

20. www.sentara.com 6 Weeks After One Treatment! 8/31/0820 Sclerotherapy to reticular vein Laser to spider veins Dilute sclerotherapy to spider veins immediately following laser

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22. www.sentara.com Facial Telangiectasias 8/31/0822

23. www.sentara.com Adverse Sequelae Post Sclerotherapy Hyperpigmentation- transient Localized Urticaria d/t inflammatory response/ histamine release Angiogenesis/ Telangiectatic Matting- R/O truncal insufficiency or perforators to decrease risk Discomfort at injection site Recurrence- hereditary 8/31/0823

24. www.sentara.com Complications Cutaneous necrosis Superficial thrombophlebitis DVT Nerve Injury Allergic Reaction Migraine Scotoma 8/31/0824

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26. www.sentara.com In Summary Reticular veins & associated telangiectasia can be easily treated in the office setting R/O truncal insufficiency or incompetent perforators Microphlebectomy if needed for large reticular veins Laser/ RF first and follow with sclerotherapy Foam sclerotherapy to reticular veins if appropriate candidate Dilute sclerotherapy to telangiectasia Most patients require 3-5 treatments spaced 4-6 weeks apart for optimal results 8/31/0826