Featured Operative Technique

Aesthetic Treatment of Leg Veins

Victoria A. Vitale-Lewis, MD

The author’s preferred treatment for spider veins is sclerotherapy, a technique that uses irritants to obliterate
the vessel lumen. She reserves laser treatment for vessels too small to sclerose, matting, and patients who
refuse sclerotherapy. Treatment is initiated only after ruling out reflux in the larger superficial venous systems
or through the perforators. For long lasting and satisfying results, the author recommends multiple treatments,
using the lowest concentration of the most effective sclerosant to achieve vessel obliteration with minimal

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thrombus formation. She presents a guide to pretreatment evaluation, sclerosing solutions, injection tech-
nique, and posttreatment care. (Aesthetic Surg J 2008;28:573–583.)

T
he key to success in the aesthetic treatment of leg
veins is identification and control of the source of
venous reflux. Unsightly cosmetic leg veins or
“spider veins,” distinguished from varicose veins on the
basis of size, include telangiectasias, or fine red spider
veins (<1 mm); venulectasias, or slightly larger, bluish
spider veins (<2 mm); and reticular veins (2 to 4 mm;
Figure 1). The larger leg veins, including the saphenous
veins and their tributaries, become varicose as the result
of significant venous reflux. The treatment of venous
reflux is considered medically necessary compared with
the treatment of spider veins, which is viewed as purely
aesthetic.
PREOPERATIVE EVALUATION
Reflux in the larger superficial venous systems or
through the perforators must be ruled out (or treated)
before treating spider veins. Usually, reflux can be
assessed by simple circumferential clinical examination
of the entire leg, ruling out the presence of bulging vari-
cosities, especially along the paths of the long and short
saphenous veins, their major tributaries, and the sites of
the common perforators (Figure 2). Once it is deter-
mined that the problem is limited to cosmetic spider
veins, no further testing is required.1
If, on physical examination, a question of significant
venous reflux arises, noninvasive venous testing is indi-
cated. Doppler ultrasound is useful as a screening tool in
patients that demonstrate questionable reflux on clinical
exam. In a study evaluating veins that appeared appro-
priate for cosmetic treatment, 22% of patients with spi-
der veins were found to have superficial venous
incompetency, usually in the long saphenous system.2
One such patient complained of a patch of spider
veins on the calf, but was actually found to have a dilat-
Dr. Vitale-Lewis is in private practice in Melbourne, FL.
ed vein close to the saphenofemoral junction upon exam-
ination of her thigh (Figure 3A). The Doppler probe was
placed just below the saphenofemoral junction and, on
release of distal compression, augmentation of the
Doppler signal for longer than 1 second was heard, indi-
cating reflux. This finding was confirmed by augmenta-
tion of the signal with proximal compression applied by a
valsalva maneuver (Figure 3B).
A physician who is reluctant to use the Doppler ultra-
sound as a screening tool may simply order a duplex
scan to rule out significant venous reflux (in patients in
whom physical examination raises this issue). Duplex
venous imaging provides not only an audio but also a
visual picture of reflux. This software is now available
on a laptop computer and is routinely used by phlebolo-
gists who treat significant venous reflux.
A patient with significant venous reflux in the saphe-
nous systems, including tributaries or nonsaphenous
varicose veins, is referred to a vascular surgeon for
endovenous ablation with either radiofrequency or laser
or ambulatory phlebectomy. Treatment of significant
reflux in these larger veins, while providing a cosmetic
benefit to patients, is considered medically necessary.
Once significant reflux is ruled out, treatment of the
cosmetic spider veins—consisting of reticular veins,
venulectasias, and telangiectasias—is initiated. Treat-
ment depends on the diameter of the vessel; however,
typically, different diameters of veins occur together in
the same cluster (Figure 4). In fact, this association of
reticular veins with spider veins has been studied and it
has been shown that 88% of patients with thigh telang-
iectasias had incompetent reticular veins on Doppler
ultrasound and 89% on duplex scanning.3,4
SCLEROTHERAPY
The goal of the treatment is complete obliteration of
the vessel lumen. My initial approach to treatment is
sclerotherapy.

Aesthetic Surgery Journal Volume 28 • Number 5 • September/October 2008 • 573

 Characteristics of Leg and Thigh Veins

Spider Veins

Telangiectasias < 1 mm - fine and red in color

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Venulectasias < 2 mm - larger and purple in color

Reticular veins 2-4 mm

Larger Leg Varices

Medical/surgical treatment required

Illustrations by
William M. Winn,
Atlanta, GA

Figure 1. Classification of veins based on size. Spider veins include (A) telangiectasias or fine red spider veins <1 mm; (B) venulectasias slightly
larger, bluish spider veins < 2 mm, and (C) reticular veins 2 to 4 mm. The larger varicose veins (D)—including the saphenous veins and their tribu-
taries, if present—require treatment that is usually considered medically necessary, performed before treatment of the cosmetic spider veins.

Polidocanol United States from compounding pharmacies. BioForm

Choosing a sclerosing agent may be complicated by the
fact that these agents tend to enter and leave the market.
My favorite sclerosing agent is polidocanol, which is not
approved by the US Food and Drug Administration
(FDA) but could, until recently, be obtained in the
Medical (San Mateo, CA) has now licensed United States
rights to Aethoxysklerol, a sclerosing agent containing
polidocanol, which is commonly used in Europe. I
believe this agent deserves some consideration if it once
again becomes available. It is classified by its mecha-

574 • Volume 28 • Number 5 • September/October 2008 Aesthetic Surgery Journal

 A Superficial Superficial
epigastric v. epigastric v.
B Superficial
Superficial Superficial circumflex iliac v.
circumflex external
iliac v. pudental v.
Anteriolateral v.
Long saphenous v.
Anteriolateral v.
Posterior medial v.

Hunter perforator

Boyd perforator Long saphenous v.

Anterior malleolar v.
Anterior malleolar v.

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Posterior malleolar v.

Cockett’s perforating v.
C
Dorsal venous arch
Connection
to posterio- Saphenopopliteal
medial v. junction

Intrasaphenous v. Short saphenous v.

Paraperoneal perforator

Figure 2. Physical circumferential examination of the entire lower extremity—especially along the paths of the long (A, B) and short (C) saphenous
vein, their major tributaries, and the sites of the common perforators—must be performed to rule out the presence of varicose veins.

nism of action as a detergent and is weaker than the oth-
er commonly used detergent approved by the FDA, sodi-
um tetradecyl sulfate (STS).
Basically, all sclerosing agents are irritants that injure
the endothelial surfaces, resulting in obliteration of the
vessel lumen (Figure 5).5 Polidocanol has been widely
used for sclerotherapy of spider veins in concentrations
of 0.25% to 0.75%. The concentration I have most com-
monly used is the 0.5% solution (Table 1). If a patient
has a significant number of larger spider veins, including
reticular veins, then at the first treatment, I may use a
0.75% solution in these larger spider veins or increase
the efficacy of the 0.5% solution by foaming, which I
will discuss. The maximum daily dose of polidocanol is
2 mg per kg of body weight. This dose is equivalent to
28 mL of a 0.5% solution in a 70-kg person, which well
exceeds the usual amount that would be required in a
single treatment session, even in the case of extensive
spider vein involvement.6
Because of the current unavailability of polidocanol,
and based on a study in Europe showing that chromated
glycerin is superior to polidocanol for sclerotherapy of
leg telangiectasias,7 I have recently begun using glycerin
for sclerotherapy of the very small telangiectasias (<1.0
mm in diameter). Glycerin is available in a 72% concen-
tration in the United States from compounding pharma-
cies because glycerin is used in cerebral edema and
acute glaucoma. It has been shown to be as effective as
chromated glycerin, which is more widely used in
Europe.8 I dilute the 72% glycerin 2:1 with 1% xylocaine
with epinephrine to decrease its viscosity and pain on
injection (Table 1).
Sodium Tetradecyl Sulfate
STS is approved by the FDA and has been used as a scle-
rosing detergent since the 1940s (except for the period
from 2000 to 2002 when its manufacture was discontin-
ued). However, be mindful that STS is a stronger deter-

Aesthetic Treatment of Leg Veins Volume 28 • Number 5 • September/October 2008 • 575


A
Figure 3. A, This patient has clinical findings suggestive of reflux at
the saphenofemoral junction. B, The patient is undergoing Doppler
ultrasound screening for reflux at the saphenofemoral junction. With
the probe placed just below the saphenofemoral junction, a loud sig-
nal, audible for longer than a second on release of distal compres-
sion, is indicative of reflux.
gent than polidocanol and carries an increased risk of
adverse sequelae, such as hyperpigmentation and telang-
iectatic matting.9 STS in concentrations of 0.1% to
0.15% can be used for sclerotherapy of telangiectasias
less than 1 mm in diameter as an alternative to the 72%
glycerin diluted 2:1 (if the use of only one agent is
desired). For vessels 1 to 3 mm in size, I recommend
0.15% to 0.25% foamed STS solution and 0.25% to
0.5% foamed solution for 3- to 6-mm veins (Table 1).
The maximum amount that can be injected at a single
treatment session is 10 mL of a 3% solution which, at
the low concentrations used for treating spider veins,
would rarely be approached in a single session.
Foaming With Air
In patients undergoing sclerotherapy of venulectasias
and reticular veins, the efficacy of the detergent can be
increased by foaming with air. A 3-mL syringe filled with
0.25 mL of detergent is attached to a second 3-mL
syringe filled with 1.25 mL of air, using a double or 3-
way stopcock. The amount of air in the syringe is impor-
tant because the ratio of gas to air is ideally 4:1 to 5:1.
The sclerosant is then pushed between the 2 syringes
several times until the detergent appears as white foam
576 • Volume 28 • Number 5 • September/October 2008
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B
with tiny bubbles (Figure 6). The bubbles of the lipid
micelles provide a larger surface area of contact with the
endothelium, thus increasing the sclerosing efficacy of
the detergent. Foaming also increases effectiveness by
inducing vasospasm of the injected vessel so that there
is less backflow of blood and dilution of the agent before
it can have its sclerosing effect. Because foaming
increases the effectiveness of the sclerosing agent, it
allows for lower concentrations to be used.
Preparation
Patients usually require 3 30-minute sclerotherapy ses-
sions at 4- to 6-week intervals. This time interval
between sessions is optimal for the sclerosant effect to
accomplish vessel obliteration. The patient is instructed
to avoid applying leg creams on the day of the procedure
and to purchase and bring with them 10 to 20 mm Hg
graduated compression pantyhose. Photographic docu-
mentation of the spider veins is mandatory before treat-
ment. It is difficult to standardize photographic views
because the number and locations of the spider veins
vary among patients. However, inclusion of a recogniza-
ble joint, such as a portion of knee or ankle, helps in ori-
enting the image for later postoperative comparison.
Aesthetic Surgery Journal
 Telangiectasias

Venulectasias

Reticular vein

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B C
Figure 4. A, Common arborizing pattern of spider veins with feeding reticular vein and branching
venulectasias and fine telangiectasias. B, Typical lateral thigh cartwheel pattern with feeding reticular
vein. C, Typical cluster of spider veins including telangiectasias, venulectasias, and reticular vein.

Sclerosing agent

Vein wall

Endothelium

Endothelial damage

Endofibrosis with
obliteration of lumen

Figure 5. All sclerosing agents damage the endothelial surfaces, causing fibrosis, which results in the
obliteration of the vessel lumen.

Aesthetic Treatment of Leg Veins Volume 28 • Number 5 • September/October 2008 • 577

Table 1. Most commonly used dilutions for sclerotherapy
solutions
Polidocanol usually diluted for injection in a 30-mL vial of 0.9%
sodium chloride
Preparation 1: 0.5% Polidocanol
5 mL 3% Polidocanol
25 mL 0.9% sodium chloride (for injection)
Preparation 2: 0.75% Polidocanol
7.5 mL 3% Polidocanol
22.5 mL 0.9% sodium chloride (for injection)
72% glycerin (usually diluted for injection in 3-mL syringes)
Diluted 2:1:
1 mL 72% glycerin.
0.5 mL 1% xylocaine with epinephrine
STS (usually diluted for injection in a 30-mL vial of 0.9% sodium
chloride)
Preparation 1: 0.15% STS
1 mL 3% STS
19 mL 0.9% sodium chloride (for injection)
Preparation 2: 0.25% STS
2 mL 3% STS
22 mL 0.9% sodium chloride (for injection)
Preparation 3: 0.5% STS
4 mL 3% STS
20 mL 0.9% sodium chloride (for injection)
STS = sodium tetradecyl sulfate.
INJECTIONS
Injections are performed with the patient in the supine
position. The legs are prepped with alcohol, which is
used not only as an antiseptic, but also to improve
visualization of the veins by changing the index of skin
refraction. Optimal lighting and magnification are need-
ed. Several different types of transillumination lighting
are available to facilitate visualizing the vessels, partic-
ularly the reticular veins.
The injections are performed with 30 gauge 0.5-inch
disposable needles and 3-mL syringes. The needle is
bent to a 30° to 45° angle so that it is parallel to the
skin upon entry. Also, the bevel of the needle is turned
upward so that the needle may sometimes actually be
seen in the lumen of the spider vein (Figure 7). The 3-
mL syringes are filled with only 1 to 1.5 mL of the scle-
rosant so that the syringe can be held and the plunger
pushed with the same hand, freeing the opposite hand
for retraction of the skin. The site of entry into the spi-
der vein is at the source of the reflux if identifiable. A
feeding reticular vein, if present, is sclerosed first
(Figure 8). Along a reticular vein, 0.5 mL of sclerosant
is injected at 5.0-cm intervals. The skin is punctured
approximately 1 mm from the desired location of entry
into the spider vein. The needle is then guided into the
spider vein with a gentle but bold puncture. It is not
necessary or productive to obtain a blood return except
578 • Volume 28 • Number 5 • September/October 2008
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Figure 6. The detergent is foamed to increase efficacy. One 3-mL
syringe is filled with 0.25 mL of 0.5% polidocanol, and the second 3-
mL syringe is filled with 1.25 mL of air. Pushing the sclerosant
between the 2 syringes several times foams the detergent with a gas
to liquid ratio of 5:1, appearing as white foam with tiny bubbles.
in the deeper reticular veins where the depth is less
obvious than the more superficial spider veins. Using
low injection pressure and stopping the injection at a
particular site when a 1 to 2 cm area is empty of blood
are recommended techniques. Continuing the injection
beyond this point is likely to increase the incidence of
extravasation and telangiectatic matting.10 Injections
are limited to 0.5 mL of the sclerosant at any one site
for the same reason.
If a wheal starts to develop at the injection site as
the sclerosant is injected, indicating extravasation, then
I abort the injection at that site and digitally compress
the injection site. This will dilute the extravasated scle-
rosant by diffusion and, hopefully, avert significant
injury to the skin. Only if there is a significant extrava-
sation would I inject a solution of 75 units of
hyaluronidase in 3 mL of saline.11 One of the reasons I
prefer polidocanol is that the chance of inducing signif-
icant necrosis on extravasation is minimal when 0.5%
to 0.75% concentrations are used. For very tiny telang-
iectasias, 72% glycerin in a 2:1 dilution with lidocaine
has become popular because it is even more innocuous
upon extravasation, which is difficult to avoid with
these very tiny vessels.8 In most cases of missing a
lumen on injection, the needle is deep to the vein.
Maintaining digital pressure on this failed site, I would
select a second injection site into the spider vein, mak-
ing sure that the needle is properly bent and as parallel
to the skin as possible in order to ensure more superfi-
cial placement. The procedure can be tedious, but per-
severance is necessary for a good result.
Cotton balls and tape are applied to the injection
sites as the treatment progresses. This provides com-
pression and hides the hyperemic reaction in the scle-
rosed spider vein that develops 30 seconds after the
sclerotherapy, which can be perceived by the patient as
persistence of the spider vein (Figure 9).
Aesthetic Surgery Journal
 Digital pressure on pre-
vious injection site

Low injection pressure

30-45 angle

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Skin
1-2 cm area emptied of blood
Fat

Sclerosing agent
< 0.5mL at each site

30 gauge 1/2⬙ needle, bevel up

(facing toward skin)

Figure 7. A, The injections are performed with 30-gauge half-inch disposable needles and 3-mL syringes filled with only 1 to 1.5 mL of the scle-
rosant. The needle is bent at a 30° to 45° angle, to be parallel to the skin, with the bevel turned upward. Digital pressure is applied at the previ-
ous injection site. B, Using low injection pressure, injecting less than 0.5 mL at each site, and stopping the injection when a 1 to 2 cm area is
empty of blood are recommended techniques to decrease the incidence of extravasation and telangiectatic matting.

1. Proper hand position for traction

2. Inject reticular vein first at 5 cm
intervals

Figure 8. Proper position of the hands, syringe, and needle for injection with optimal retraction. The syringe is half-full, the
needle is bent, and the bevel faces upward. If the reticular vein is present, inject it first at 5.0-cm intervals.

Aesthetic Treatment of Leg Veins Volume 28 • Number 5 • September/October 2008 • 579

 A B

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Figure 9. A, Pretreatment view. B, Posttreatment view about 30 seconds after the initial blanching—as the vein is cleared of blood, an intense
hyperemic reaction develops.

A B C
Figure 10. Evacuation of microthrombi, if present, 1 week following sclerotherapy, is recommended to decrease the incidence of adverse seque-
lae, including hyperpigmentation and telangiectatic matting. Microthrombi appear as ink-like deposits in the vein. A, The skin is punctured over
the microthrombus with a 25-gauge needle. B, The liquefied coagulum is expressed. C, Typical appearance of the removed clot. A few other
thrombi still required declotting.

POSTOPERATIVE MANAGEMENT
Compression
When treatment is completed, 10- to 20-mm Hg graduated
compression stockings are applied before the patient
hangs their legs downward to minimize the backflow of
blood. The patient is instructed to wear the support hose
for a minimum of 72 hours. There is debate in the litera-
ture about the effectiveness of compression and the opti-
mal degree of compression and length of compression
time.12-14 I advise the patient that continuous wear for 3
weeks provides less chance of adverse sequelae than 3
days of wear with even less chance of adverse sequelae if
worn for 6 weeks.15 Based on the 2007 study by Kern,12
many practitioners are recommending 20-mm Hg graduat-
ed compression stockings for 3 weeks postsclerotherapy.
However, other practitioners believe that 30- to 40-mm Hg
is the ideal degree of compression.14,16 I have found my
patients to be noncompliant with this higher degree of
graduated compression stockings.
Ambulation
The patient is encouraged to walk posttreatment to avoid
deep vein thrombosis which, although exceedingly rare,
has been reported in 2 patients following sclerotherapy
of spider veins.17,18
Follow-Up Care
Hyperpigmentation and telangiectatic matting are two of
the most common adverse sequelae following sclerother-
apy. The goal of the treatment is successful obliteration
of the vessel lumen with minimal thrombus formation.
A higher incidence of the most common adverse seque-

580 • Volume 28 • Number 5 • September/October 2008 Aesthetic Surgery Journal


Figure 11. Demonstrates telangiectatic matting around a previously
sclerosed spider vein. It is recommended to look for and sclerose any
previously unidentified sources of reflux, such as a feeding reticular
vein. Following this, the matting will usually fade.
lae is felt to occur following excess thrombus forma-
tion.19,20 I see patients 1 week posttreatment, at which
time any coagulum is liquefied, making evacuation pos-
sible. Microthrombi appear as ink-like deposits in the
vein. If there are any such areas seen, I puncture the
skin using a 25-gauge needle and express the clot
(Figure 10). If hyperpigmentation develops, I reassure
the patient that substantial lightening usually occurs in
the first 6 months, although gradual lightening will
A B
Figure 12. A, Pretreatment view of a 52-year-old woman. B, Posttreatment view 2.5 years following 3 sclerotherapy treatments with 0.5% sodium
tetradecyl sulfate. C, Posttreatment view after 10 years.
Aesthetic Treatment of Leg Veins
occur over 24 months.21-23 I recommend a topical agent
for the treatment of hyperpigmentation, Hiruval-35
(Vimex Pharma), which may be effective in decreasing
the hemosiderin deposits that are the primary cause of
postsclerotherapy hyperpigmentation. Minocycline should
be discontinued during the course of sclerotherapy to
avoid minocycline-aggravated postsclerotherapy pigmen-
tation, which may persist for years.24 I have not used the
Q-switched ruby laser or weekly subcutaneous injections
with deferoxamine mesylate, both of which have been
suggested in the literature for treatment of postscle-
rotherapy hyperpigmentation.25,26
If matting occurs, I first check and sclerose any previ-
ously unidentified sources of reflux, such as a feeding
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reticular vein (Figure 11). Once the source of the reflux
is controlled, the matting usually will fade. The matting
itself may be sclerosed with 0.25% polidocanol or 72%
glycerin diluted 2:1, but it will require many treatments.
If treatment is unsuccessful, I would then resort to laser
treatments with a potassium titanyl phosphate or
pulsed-dye laser.
LASER
I reserve use of the laser for 3 indications: (1) cleanup
after sclerotherapy for vessels too small to sclerose, (2)
matting, and (3) a patient who refuses sclerotherapy.
Patients who fear injection pain need to be told that the
laser is not painless, especially if they have larger blue
spider veins. Although a variety of vascular lasers have
been used in the past, the 1064-nm Nd:YAG laser is
presently the most widely used, especially for vessels
greater than 1 mm in diameter and depth.27 In general,
spider veins of less than 1 to 4 mm respond best to spot
sizes of 2.5 to 6.0 mm with fluences of 100 to 22 J/cm2
and pulse durations of 20 to 60 ms, using larger spot
sizes, lower fluences, and longer pulse durations for the
larger vessels; and smaller spot sizes, higher fluences
and shorter pulse durations for the smaller vessels. 28 In
some instances 2 passes over the vessel may be needed
for closure. Although some practitioners believe that
laser treatment is just as successful as sclerotherapy in
the obliteration of spider veins,29 I agree with the major-
ity of practitioners who have had better clinical success
with sclerotherapy than laser treatments.30, 31
C
Volume 28 • Number 5 • September/October 2008 • 581
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A B
Figure 13. A, Pretreatment view of a 62-year-old woman. B, Posttreatment view 6 months following 2 sclerotherapy treatments with 0.5%
polidocanol.

A B
Figure 14. A, Pretreatment view of a 46-year-old woman. B, Posttreatment view 1 year following 3 sclerotherapy treatments with 0.5% polidocanol.

582 • Volume 28 • Number 5 • September/October 2008 Aesthetic Surgery Journal

CONCLUSIONS
Successful treatment of leg veins, whether by laser or
sclerotherapy, requires the identification and treatment
of the highest point of reflux. Multiple treatments using
the lowest concentration of the most effective sclerosant
to achieve vessel obliteration with minimal thrombus
formation will lead to long-lasting and satisfying results
(Figures 12 to 14). The current available option of 2
treatment modalities, sclerotherapy and laser, or a com-
bination of both, can help to achieve even greater suc-
cess and satisfy more patients. ◗
DISCLOSURES
18. Reid RG, Rothnie MG. Treatment of varicose veins by compression scle-
rotherapy. Br J Surg 1968;55:889–895.
19. Orbach EJ. Hazards of sclerotherapy of varicose veins—Their preven-
tion and treatment of complications. Vasa 1979;8:170–173.
20. Goldman MP, Bennett RG. Treatment of telangiectasias: A review. J Am
Acad Dermatol 1987;17:167–182.
21. Goldman MP, Kaplan RP, Duffy DM. Post-sclerotherapy hyperpigmenta-
tion: A histological evaluation. J Dermatol Surg Oncol 1987;13:547–550.
22. Goldman PM. Sclerotherapy of superficial veins and telangiectasias of
the lower extremities. Dermatol Clin 1987;5:369–379.
23. Georgiev M. Post-sclerotherapy hyperpigmentations: A 1-year follow-
up. J Dermatol Surg Oncol 1990;16:608–610.
24. Green D. Persistent post-sclerotherapy pigmentation due to minocy-
cline: Three cases and a review of post-sclerotherapy pigmentation. J
Cosmet Dermatol 2002;1:173–182.
25. Tafazzoli A, Rostan EF, Goldman MP. Q-switched ruby laser treatment
for post- sclerotherapy hyperpigmentation. Dermatol Surg

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The author has no financial interest in and receives no compensa- 2000;26:653–656.
tion from the manufacturers of products mentioned in this article. 26. Lopez L, Dilley RB, Henriquez JA. Cutaneous hyperpigmentation fol-
lowing venous sclerotherapy treated with deferoxamine mesylate.
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