GreatSkin Medispas

Ambulatory phlebectomy permits removal of incompetent veins below the saphenofemoral and saphenopopliteal junctions, not including the proximal great or short saphenous veins. The junctions themselves cannot be treated with simple phlebectomy as junctional reflux must be addressed by endovenous ablation methods or rarely by surgical ligation and stripping. Veins that may be removed by ambulatory phlebectomy primarily include major tributaries; perforators; and reticular veins, including small reticular veins associated with telangiectasias.

Skin incisions or needle punctures as small as 1 mm are used to extract veins with a phlebectomy hook. The procedure is well tolerated by patients and produces good cosmetic results. Long-term results are excellent as long as the most proximal source of reflux is eliminated by endovenous ablation techniques. In contrast to sclerotherapy of large varicose veins, ambulatory phlebectomy minimizes the risks of intra-arterial injection, skin necrosis, and residual hyperpigmentation.

In contrast to traditional venous ligation, the small size of the skin incision or puncture usually results in little or no scarring. Performed with the patient under local anesthesia, ambulatory phlebectomy leads to greatly reduced surgical risks compared with traditional surgery for truncal (axial), reticular varicose veins and incompetent perforators. In contrast, for these larger veins, sclerotherapy involves risks including intra-arterial injection, iatrogenic phlebitis, deep vein thrombosis and pulmonary embolism, skin necrosis, and most of all, residual hyperpigmentation.

History of the Procedure

Cornelius Celsus first described phlebectomy in 45 CE. The earliest phlebectomy hooks were described in 1545, as illustrated in the Textbook of Surgery authored by W.H. Ryff. Dr Robert Muller, a Swiss dermatologist in private practice in Neuchâtel, Switzerland, rediscovered the technique in 1956. He developed his own technique and instruments and taught the technique to hundreds of physicians. Dr A.A. Ramelet, former president of the Swiss Society of Phlebology, was one of Dr Muller’s students who further advanced the technique for smaller reticular veins with his own hooks. Today the technique is practiced by thousands of phlebologists around the world.

Pathophysiology

Venous insufficiency is caused by a refluxing circuit that results from failure of the primary valves at the saphenofemoral junction typically leads to superficial varicose veins. Varicose veins that branch off an incompetent saphenous vein are called branch veins or secondary varicosities. The typical signs and symptoms of venous insufficiency, including ankle edema, stasis dermatitis, and possibly ulceration, may occur when varicose veins are untreated. The most important aspect of pathophysiology is the origin point of reflux and its elimination. Only then can branch varicosities be treated.

Clinical

Detailed general and phlebologic examination is mandatory before any phlebologic treatment is administered. Careful attention must be paid to the patient’s medical history and to the general state of the patient, and any contraindications to local anesthesia or the surgical procedure itself must be identified.

The integrity of the deep venous system and the proper function of the calf muscle pump should be ensured. Also, preoperative clinical and ultrasonographic examinations are essential to detect and map all types of the varicosities and their origins. Duplex ultrasonography mapping of the source of reverse flow or reflux is typically performed. Important sources of reflux (eg, saphenofemoral or saphenopopliteal junctions) should be corrected before any effort is made to address end-branch disease.

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