Intem qti on aI D e rm at o surgery

Cosmetic Varicectomy

MAITWAL] HARAHAP,

FEATURE

of the comrrrLrncst abnormalities of tl.re civilized rvorlcl. lVith a ra;'idlv expanding r.r,or'ld population ancl increasirrg lile sf,a;rs,
varico;r rein> rr'ill Lrn,.1ouL.re .i lr c.'r'rini.. .,.' .ln \'\'L rgrou'ing problem to patient anci phlsici.rr.rlikc.
The classification of varicose veins.rc!(rrrling to
Dodd and Cockettl is briet.ly as lollorls.

Varicose veins are one

7,

Prunary farrrrlinl i,nricosr, i,cirrs. l hcsc inclucle' long

saphenous, short saphenons, arrcl arrklr ;'t'rfor-

2.
3.
4.

ators.

-l

hest' tr pes .ri!r dLre to

cleep r,ein thrombosis ilioicnror..rl l\ pe, peripheral type, or both,
Prelguittcy i,eirrs. These a|c pcculi.rr t,r \\'orlen
and are a postpregnancv phelrom('non.
Rnrt tqtcs oi i,airis (seconc-larl to .rrteriolenous
tistulas, Kiippel-l rena u nal slnelro me'. r ihlctcs'
ht,pertrophied veins, ancl cal.illan vc'irr.i. Thesc'
include spider veins, telangieclascs, .rncl burst
Scconddnl r'nrlcosc r.cirrs.

vei

n s.

Spicler veins are clusters oi blnish r('.i r essel clilatalions common on lvomcn's lt,cs antl thighs
lVhether these nranifestalions h;ir e somcihing lo
do rrrth ll-e deleloprncnr ot \.r i,' -L \r..r' :s rn
knou'n. Reticular varicosities .rre oflen Lri cslhetic
concern, but thev are asvmptorr.rtic. Cast'-i t)f urinor reticular varicosities ancl spitlcr reiris can be

Nl.rrl|ali llarahap, ivI.D., is AssLrci.ri. Irotrssrir DePartmrnr ,,f D, r.r..ri, LJe\ <.1r.r,,. .,i \1,.r... 1 . \".-r'. .
North Sumaira, Rumah Sakit Pirnge.li, \lcclarr, ln.iorre
sia.

Address reprint recluesis to Nlarrrr,ali H.rr..haP. \1.D., Dc

partment of Dernlatolog\', Unj\ crsit\' (.i

\lpd..- lScl , r \lecl.,r .rr.J r,,...,

Dr'rr,rtu)/

irJ{. O,rir,i 1l !l S.fiJrri,,r

l:i,\.:

\ortl',

SLrrllatra

lreated b\, using scleroiherapv rlith 20% sodiur.t.r

chloride solutior.r: or 0.5li soclium tetradecvl sulfate
rSotr,rrl"cr'l lrquidr. 'Fur i riectiun .' 27-giug,r'. r a
32-gauge needle is used.
N,linor primarv familial varicosis $,ithout s\.mp
toms in manv paiients, especiallv women, is of esthetic concern. The cosmetic aspect is not, impor
tani because the female leg has become a notable
seconclan, sex characterjstic, and lomc.n are more
conscioLrs of anv ', isible veins. Thel seek adi ice bccause of tlie disfigu lement.
Active treatlnent shoulcl be started in minor primarY Varicosis il the patienls insist on a cosmetic
repair.
Sclerotherapv is an old and n e ll-establi s hec{
treatment. The techniques of compression sclerotherapv have been described in detail elseu'hele.n
It has a clelinjte place as a supplemcnt to surgical
thelapv, for it can be usc'cl latcr on to obliterate
residual veins. lloi.r'ever, there can be no cloubt that
varicecto]n\: is ihc nlore precise mcthocl becausc the
varicose leins can be seen.
Ilemoving the delectable varicose veins bv varicectomv should improve the esthetic look of ihe
1eg. This goal must bc achievecl l'ithout leaving
conspicLrous scars, or e\tensjve hematonas that lnav
lead to uglv pigmentation.
I have used this surgicaltechnique on 16 palients
and iollorved up 11 patjents oi er a period of 1 to 3
vears. Recurrences have not been observed so far.
INDICAI IONS FOR VARICECTOI"IY
Further eradication of smaller \,eins that \\'ere nol
removecl at a stripping operalion ma\. be tecluesled

873

-l
INTERNAT]ONAL DERMATOSURCEITY

FIGURE 1. The varicose veiits are eas\,

pJlienl standing on .l r.,is(J

to

serl \\

ilh

ihe

pJ.rtf(,r.nr.

by women who desire treatment o{ r,aricose veins

for cosme rjc pu rpose.
Varicectomr.ai>o lrr: arr oic,r.itrn.r. plac|
i: rrr...
ing trivial. isolatecl. :uperficr.rl r ar'irl- lr j: r-r.
quested b\ wonren Ior estltetic re,rsJ.-s
J,.b\ _,.,llc
people \.\ ho need to be tit ,ur m jliran -,
i ;.
cmigration.
Incompeleni perforatint veins cJn a,{o bp
r(.
moved_
ligated n ifh the Vari.,-, Io r\. Iuii,nrque. '^and
Howe\ er, if erther lne Iorrg ur >horr 5.r_
vein is involrecl. it shuulcl E' t g.,,"c .,n.t
li-"i"",t
tne sdphenou5 trunl rcrnored by stril,pins
,

PREOPERATIVE PREPARAlION
The operation ior cosmetic vrricer rorn\
carr L.e I,cr._
l911ed ln tltc ourpatient clcpirtnrc r rr irtrrr.rr rl r

trcultv. The ieg> mLrst bc c.ricILrlli. er.anincc] jtl.

t|e Fahe.rrt standirrg on a Iajsecl p..rlt,,rir -u rrtrr,r
lne phvslct.tn i> curnlot.table rFig. I r.
. It is importitnt to mar\ triLlr rnl ervIr r..in t,r.rL
ls to be rem(,\ ecl prior to
Il.rcing lhe p.ttie.,r o r t.r,
cPer.rtin8 rablc. I u:e an ordinarv rclr_t,ppc.r
,rr.,-,,..,
(Pentel pen). The marks macle
bv tt,,, p"n o.",n
delible and are not washed off Uy spirits or othe,r
iiquids, Lr.ed,[or sterili,,int rhe s(jrr rt
of,efariul)
lhe rnk nldrk ntu.t bc placeJ tlirc.rtr ,,r.r. _rrr.r_l
874

2. Preoperati\.e rtiarktng ol thc \'aricose vetn5 \vrth

an ordinary felt-tipped marker (Peniel pen).
FIGURE

veins, so that an incision through ihe ink mark t.ill

(\po.e the vein:1Fig.21. ll rhe ink rnark i. rnaLle
Ddr.lllei to the \'ein, ihe r.ein maI elsilr. he mi,seJ.
The
placetl on the operatrng table, ancl
, legsp.rtieniis
the
are elevated abor.e lreart level to reclLrce
b,i,-'od loss and to increlse deep r enr,u.
flow.r: The
is prepared and Lhe legs torveled. The oper_
:\m r5 perlormed under
.:rt'on
local dnc,thesid.

OPERATIVE TECHNIQUE
I use a very_sharp

pointed knife (#11 blade) to make

-r.rb r,r'ounds 2 or 3 mm in length or
er Ihe carerullv
marked \eins {Fjgs. I dnd 4;. lnci:ions
of the ,lin
mL-t lullo\\ rhe skin lines to pre\ cnt rrglr >cars.

line-ended [orceps is rhnrst intu ihe sm.rll

jce ro hur_
"nd closrd once ur trr
rorv into the subcutaneous
tissue r-rntil the,,,ein rvall
is sighted (Figs. 5-g). These veins can then be
grasped with a small hemostat and teasecl
out qLrite
c.rreiulll . Wirh a side-to-sidc mo\ ement, ouiie lone
\\ ou nd dnd ope n ed

Ieirglhs of the tortrrou> r ein can

L,e ,, ltharjrtn t-fi

*".:f, lilrl*. incision in a very shori space ol rrme
\\itjrout bleeding rFigs. 9 -rnd 10r. Bleeding is pre_
\ crtcd l.r elevaling the lcg and local
c.,mpi.es,'ion.
(Jne c.1n miss llre veins ii Ilrer
harc noi bern

Dtr

ntil

Sllr.9. O)r.01. t1r9 Scftr)r1,,,r. t9n"j

HARAHAP

ob

rb
F-.

FIGURE 3. A verv sharp pointecl

to make stab \\ ounds 2 or 3

fullv marked i'eins.

krliie i#11 blacit') is used

nm in lcngth or't'r lhe

e,'1

t,. ::?'

FlCl. RE 4. 5cher alic

drrrring.rf

Fip,ure

f igurc

i.

car-e-

I
;

t
,l

FIGURE

5, A fine encied curver-l forceps is thrLr5t

ir-rto lhc

ft(,URt- b. (cr'emrtr, Jr,

r,in;.'f

snrall \\'ound.

marked n'ith great care. If the incision is kept ven.

small bv r-rsing delicate instruments, the nLrrrber of
incisions need noi be considered, as the\ becone
/. Drrrrrrrloi irrrt. LJtco/ 1lr, Siirlttrlr.r

l9r"a

practically invisible later.

Smal1, well-placed incisions are less painful, heal
rapidly, and leave virtualll'no residuai scarring.
875

INTEItNA

IiO\AL

DFR\ IATOSU RC L,It\

w
';-;c

IIGLRL 7.

lhc.ur.e.r tL,r(vt15 :...r,.t..l\. \\.. .1r.,\\r t.J

\(tn i. ,,;lrt..o.rrrJ .-.,-1.. .. .1,.,

the ou{siot rirllllt(

slrlal] henlust.rt

FIGURE 8. Schematic

draiving of Figure

7.

.''

i"1,?^"il,ll,

Blind burrorving in subcutaneous tissue \\,ith coarse

instruments from large incisions is to be avoiciccj.
With this method, lvmphatics and nerves are un_

876

Long lengths or small iortuous veins after

necessarily destroved, and the cosmetic resull

be poor.

l,ill

After all the veins have been renoved, the clerI. Denwlal.

SrrrE. O,r.o1. 11:g S.pte tuer'LgSj

HARAHAP

$rsr.

FIGURE 11.

fhe skin

rror-Lnd is closccl

nith 5 ll

nr lon

FICURE 12. A sterile

filrn 6-inch crepe barciage ]s applieci

fron foot to thigh.

\!iih Dexon 5-0 and thc skin is cLosed

with 5-0 nvlon (Fig. 11).
As soon as the nouncls are closecl ancl tht skirt
cleansecl from blood stains, a flat l-ricc!'oi gar.rze is
mis is closed

put over each incision, and a sierjlc iirr.n 6-inclr clepe

bandage is appliecl fron foot to thigh (Fig. 12r Ihis

bandage is left until the sevenih clar', ivht'n the

stitches are removed.
The cosmetic result depends in ihe first inst.rrrce
on the sr.n.rll size of the incision, ;incl lhe skin eclges
being undamaged as far as possible. Scarring is cottsiderablv less if baths are prohibitecl for 6 rveeks
and by correct bandaging.
POSTOPERA f IVE CARE

lhal lhe\. are n.rainlainecl

htart lrrel. Orr lne rlr\l \r.t,. Jll!r op!r ,l., rr

The iegs are elevated so

above

the Patienl is encouraged to n alk as cleemetl necessarv, ol to renain in bed, if this is preterrecl. Sitting in a chair and;rbsolute bedresl are forbiriclcn.
I give all paiients 0.5 g acetr-l salicr.lic acicl three
times a da\'. Prophy'laxis ot thror.nbosis antl lighi
anaigesic effect are thus combinecl. Figurc 13 s ho$ s
the result of the operatior.r after.l nronths.

ffi

,ru&

ffi

COMPLICATIONS

The most fre.luent complication js ecchvmosis.

Hor'r,ever, in the majoritv of patienis, ecchvmosis is
slight. It is alr.r'avs gradua)lv resr:rbed withor-rt per'
manent sequelae.
I. Dcnnatol.5r,,\, O,r.o1 1i:9 Srfk'rl'i1 l9d'j

FIGURE 13. The result

of the operation after 3 months.

877

INTER\AT]ONAL DER\IATOSURGER\

CONTRAINDICA'fIO NS
T]]e most important contr.rindication to surgen,is
chronic arterial occlusion. Acute cellr-rlitis and inabilitv to u.alk because oi other cliseases are alsit

co:rtrairrdrratt,'rrs. Il trlc pJti. nr

j l(tj

ar.e

i.tr. ir

i,

also verr diiiicLrlt ro r'irrrl the I t.n. \rr.h t,Lrr-c

l.J
tients aie advisecl to lose. lejghl beiote ire.rtntent
is begun.rr

REFERE,\CES

1. Dodcl, H.,.1n.1 Cockeit, F.

B. The patholog\-.1nd Surgert of

the Veins oI the Lo!\'er Limb, 2ncl erl. Edinburgh anci Lon-

don, Churchill Li\.ingstone, 1926, pp. 59_6rr, 7-1.

S. J., dnLl Tromo\.itch, L A. Cosmetic Dern]nro-

2. Stegnan,

logic Sr.Lree' . Chicago, Year Book \1cdic.1l pLrblishers, 19t.l,

pp. 192 196.
3. Shields, J. L.. anct.lanser-r, G. T. lht,raprr for suprriicial
telanEieciasias oi thc lorver !,xtrrnitiL,s. I. Dernratol. Surg.
Oncol. 6r857-8b0, 1962.
.1. Weissb'rS, D. Treatrrlent of \'.rricosc
\cini b\ conlpressjL,n
sclerotherapv. Surg. Gr|rrcol. OLrstet ti1 :]j3_356, 1980.
5. tVaibel, P. Oprratjre tredtnent oi vancosc \.ins. pro!1. Surs.

112-1.

1973.

Fegdn C \'d
dun. llcllrunta

.,'i- \',.ill-: C,,pp1,,.-1,.1.5..ltrr.rhrr.rp.

_r,n_

n. lr./r);
7. Linr.'n R.R Irrc.r,ntrrunr..trinq\cl11\.,t t,.. lorrr.r lr;an.r

the

olrrru\(

r,r'hnr,rrrq

ri,r th,..r

iig.rtl,,r

. \nn

cu,c.

107r582.19:ls

8. Dodd, H.

The dingnosis.rnd li8.rtion oi incumpetent nnll!

pertoratins veins. Ann. R. Coll. Surg. En{l 3l:161, I961.

l\ '. .\ r.rw nr(,1r,,(l r.,-.:rril,, rrn- rn. int(.. ., ..,

phenous veins in v.rricose conditions. A pr;liminar\.rr,port

9. Kelltr

NY State I. N1ecl. 82:365. 19rt;.

10. Babcock, lV. \\J. A nerv operation lor ihe extirpation of var_
rcose !erns ot l!'g. NY Stat J. Nled. S6:1a3, 1907.
I L Il,,r-an, J. ThL. r,lcr.,ri\e trr,nrnr!nL ,,r r.r,.i.,ce verrr:. \
Engl. J. Med. :00:965. 1929.
12. Dale, !V. A. Ligation, stripping, and excisron oi varictrsr,
veins. Surger\ 67:389, 1970.
13. Abr.lmson, D. l. \'ascul.1r disorrlers of the c.\tremitii,s 2ncl
ed. Hagersk)\r'n, Harper & Ro\\, t9;.1, p. lli.

878