According to the scientific evidence, up to 30% of procedures performed to eliminate so-called leg “spider veins” may result in skin pigmentation that is certainly unsatisfactory from an aesthetic standpoint (European guidelines for sclerotherapy in chronic venous disorders, Phlebology Journal 2014;29(6):338–354).
The first step to be taken in order to avoid this complication is an appropriate diagnostic assessment, which MUST begin with a detailed collection of the patient’s clinical history.
Subsequently, a high-resolution duplex ultrasound examination of both legs MUST be performed, assessing in detail the ENTIRE venous circulation (deep and superficial).
Indeed, in 26% of apparently purely cosmetic cases, a careful diagnostic examination reveals alterations of the deeper venous system (Telangiectasia in the Edinburgh Vein Study: epidemiology and association with trunk varices and symptoms. Eur J Vasc Endovasc Surg 2008;36:719–724).
Failing to identify deep venous vessels that are not visible to the naked eye, yet are responsible for “feeding” the more superficial and visible vessels, inevitably leads to a lack of aesthetic improvement in the treated leg.
In order to visualise the veins that “feed” the more superficial vessels from deep within the leg, in addition to duplex ultrasound it is essential to also scan the entire area concerned with instruments known as “transilluminators” and/or “augmented reality visualisers” (Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011;53:2S-48S).
This analysis is able to reveal vessels that are visible neither to the naked eye nor on ultrasound examination, because their calibre is very small.
Only once the vessels not visible to the naked eye and responsible for the unsightly “spider veins” have been precisely identified will it be possible to proceed with their treatment.
Many strategic and technical alternatives are available today for the elimination of these cosmetic blemishes. At the same time, however, these strategies and techniques have different indications, each one intended for a different type of vein to be treated.
Sclerotherapy still represents the most frequently used tool for eliminating “spider veins”, particularly when the vessel exceeds 1 mm in calibre (Comparative study in leg telangiectasias treatment with Nd:YAG laser and sclerotherapy. Laser Med Sci 2019).
Sclerotherapy is, however, also one of the techniques requiring the greatest experience and skill, since it is as effective as it is operator-dependent. The physician must in fact choose the right drug, the right formulation – liquid or “foam” – the right concentration, the right injection volume, the right syringe, the right needle, the appropriate angle of entry into the vessel, the right infusion pressure and, above all, the right injection site. In the right hands, sclerotherapy is a tool of very great efficacy and safety in most cases of unsightly spider veins, but at the same time these qualities require an equally high level of professional skill on the part of the operator.
For vessels smaller than 1 mm in diameter, the most recent literature has shown that transdermal lasers may represent an option, provided the vessel is not too deep and the venous flow feeding the “spider vein” is not too strong (Comparative study in leg telangiectasias treatment with Nd:YAG laser and sclerotherapy. Laser Med Sci 2019).
When using the laser, particular attention must be paid to the patient’s skin colour, since the presence or absence of melanin can significantly change the absorption of the energy emitted by the laser, thereby risking permanent hyper- and hypopigmentation.
The laser too requires considerable experience on the part of the operator. Here as well, many parameters can be modified from case to case, leading to a more or less satisfactory outcome of the procedure: the wavelength emitted, the amount of energy delivered per unit of surface area, the area of the emitted energy beam, the distance between emission points, the duration of the laser pulse and, above all, the anatomical site where the treatment is performed.
Contrary to what patients too often believe, the laser is not a kind of magic wand capable of instantly “erasing” the blemish. Skin changes such as post-treatment erythema are to be considered normal and are most often transient. Follow-up visits are therefore mandatory in order to verify the optimal outcome of the treatment and to intervene early in the event of any complications.
In conclusion, in the aesthetic treatment of “spider veins” the myth of an immediate and easy solution within the reach of any physician with minimal experience in sclerotherapy and/or laser must be dispelled. Likewise, it must be made clear that the belief that aesthetic treatment of “spider veins” is ineffective because “they come back anyway” is an equally mistaken conviction when considered in the context of a centre with specialists dedicated to this type of procedure.
While it remains true that all aesthetic procedures are inevitably destined not to last forever, given the advancing age that affects everyone, an appropriate approach to the treatment of “spider veins” can lead to a significant result. This aesthetic improvement will depend largely on the physician’s skill and, to a lesser extent, on the degree to which the patient follows the advice and lifestyle recommendations duly explained by the professional. A degree of unpredictability will then be associated with individual variations in lifestyle, hormonal balance and nutrition to which each person is subject.
In order to manage this last aspect as well, an appropriate aesthetic treatment must address the patient’s care in its entirety, following the patient with the utmost professionalism before, during and after the procedure. Only with this comprehensive coverage of every aspect related to the treatment can the effective disappearance of the unsightly “spider veins” be achieved.