VENOUS and VASCULAR

What are varicose veins?
Varicose veins are raised ropey, enlarged veins. They usually appear on the legs and can cause the leg to swell, itch, ache, and in severe cases, can cause ulcers. Normal vein valves close after blood travels up the vein, preventing blood from moving backward (refluxing) down the vein. Varicose veins form when valves in the vein fail (become incompetent). Valves become incompetent for a variety of reasons, including trauma and pregnancy. Once a valve becomes incompetent, the vein below the valve is exposed to higher pressure and becomes dilated. This causes other valves to fail and other veins to dilate.

What are the symptoms of varicose veins?
Varicose veins are dark blue in color and commonly appear on the backs of the calves or on the inside of the legs. But they can form anywhere on your legs, from your groin to your ankle. They protrude or bulge from under the skin and feel ropey. Varicose veins cause an achy or heavy feeling in the legs and burning, itching, throbbing, muscle cramping and swelling in your legs. Prolonged sitting or standing makes your legs feel worse while elevating your legs makes them feel better. Varicose veins can also cause skin ulcers near your ankle.

How are varicose veins treated?
Both invasive and non-invasive methods are available to treat varicose veins. Non-invasive methods include wearing compression stockings, exercising, leg elevation, losing weight, not wearing tight clothes, avoiding long periods of standing or sitting and not crossing your legs while seated. Invasive treatments include endovenous therapy, ligation, and phlebectomy. Endovenous therapy is treatment from inside the vein using heat generated by lasers, radiofrequency devices or chemicals to irritate the vein walls and cause the vein to close and then be reabsorbed by the body. Ligation is tying off a vein to cause it to shrink. Phlebectomy is the removal of varicose veins.

Is varicose vein treatment painful?
Patients report feeling little, if any, pain during and after our procedures. Tumescent solution is local anesthetic used to desensitize the treatment area.

Is there any scarring, bruising, or swelling after the procedure?
Patients may experience some bruising or swelling following varicose vein procedures. Long term, our patients report little to no scarring.

How quickly can I resume normal activity?
Patients are walking immediately following the procedure; they typically resume normal activities within one day. Strenuous activities should be avoided for 7-10 days.

What is venous reflux disease?
Venous reflux disease is a condition that develops in the superficial venous system when the valves in your veins that keep blood flowing out of your legs and back to your heart becomes damaged or diseased. This causes blood to pool in your legs. Common symptoms of superficial venous reflux disease include leg restlessness, pain, swelling, and heaviness and fatigue as well as varicose veins.

Do varicose vein procedures require any anesthesia?
All varicose vein procedures are performed in our office using only local anesthesia allowing patients to literally walk out of their procedure; thus, avoiding the need for extended recovery and the side effects associated with general anesthesia.

How soon after treatment will my symptoms improve?
Most patients report a noticeable improvement in their symptoms within 1-2 weeks following the procedure.

What happens to the treated vein left behind in the leg?
The vein simply becomes fibrous tissue after treatment. Over time, the vein will gradually incorporate into surrounding tissue. One study reported that 89% of treated veins are indistinguishable from other body tissue one year after the Closure procedure was performed.

What is endovenous laser therapy?
Endovenous laser therapy is a new technique that uses a laser to destroy the vein. It is an outpatient procedure and may be done under local anesthesia. It takes about 45 minutes. A laser fiber is inserted into the vein under ultrasound guidance. Next, the vein is anesthetized using local anesthesia. The fiber is then connected to the laser generator and slowly withdrawn from the vein, sealing it and stopping the venous reflux. Possible adverse reactions are numbness and tingling, and venous thrombosis (blood clots) in the legs. Patients may have bruising and mild pain for up to 4 weeks.

What is radiofrequency ablation of varicose veins?
Radiofrequency ablation – the Closure Procedure – is similar to endovenous laser therapy. A radiofrequency probe is placed in the vein under ultrasound guidance. Then the vein is anesthetized using local anesthesia. Next, the vein is heated along its entire length by slowly withdrawing the probe from the vein. This causes the vein to clot and close, stopping the reflux. Radiofrequency ablation is an outpatient procedure, can be performed under local anesthesia, and takes about 45 minutes. Possible complications are numbness, tingling, and blood clots in the legs. Patients may have bruising and mild pain for up to 4 weeks.

How does the VNUS Closure® and ClosureRFS™ procedure actually work?
Radio-frequency energy delivers heat to the vein walls causing them to collapse and seal closed so that blood can no longer flow through the diseased vein.

How is EVLT different from VNUS Closure®?
EVLT delivers heat to the vein walls with laser energy where Closure® uses radio-frequency energy. It is typically based on the physician’s preference, as both are highly effective procedures.

Is losing the vein and vein’s function a problem?
No. These veins are part of the superficial venous system, which is comprised of a number of veins. When a vein’s valves become damaged or diseased, it inhibits the proper blood flow out of the leg. In turn, the vein is no longer useful and cannot be repaired. When the diseased vein is ablated (closed) or removed, the blood is rerouted to healthy veins, restoring the proper blood flow. Damaged veins are no longer candidates for vein harvesting used in other procedures, i.e., open-heart surgery. However, as previously stated, our superficial venous system is comprised of a number of veins. For this reason, there are other healthy veins that can be used for vein harvesting used in other procedures.

What are the potential complications of the procedure?
No serious complications have been reported in well over 2000 cases through March 2009. A small number of treated patients have had transient paresthesia (numbness) and even fewer have had superficial clotting or DVT (

Am I at risk from exposure to laser/RF energy?
No. You will be given a special pair of glasses to protect your eyes in case of an accidental firing of the equipment outside the body.

Why does it occur more in the legs?
Gravity is the culprit. The distance from the feet to the heart is the furthest blood has to travel in the body. Consequently, those vessels experience a great deal of pressure. If vein walls and valves weaken, the reflux of blood can cause superficial veins to become varicose.

What are venous stasis ulcers?
Venous ulcers are areas of the lower leg where the skin has broken down exposing the tissue. Typically, skin discoloration, as well as itching, will occur around the ankle before a venous ulcer will form. Ulcers can range from the size of a penny to completely encircling the leg. They are painful, open wounds, which weep fluid and can last for months or even years if left untreated.

What is the short-term treatment for varicose veins?
ESES (pronounced SS) is an easy way to remember the conservative approach. It stands for Exercise Stockings Elevation and Still. Exercise, compression hose/stockings, elevation and rest will not make the veins go away or necessarily prevent them from worsening due to the underlying venous reflux disease not being addressed; however, it may provide temporary relief of the symptoms associated with varicose veins. Weight reduction is also helpful. If there are inflamed areas or an infection, topical and/or oral antibiotics may be prescribed.

What is sclerotherapy?
Sclerotherapy is commonly used for treating spider veins and small varicose veins. It involves the injection of an FDA-approved foamed sclerosing solution (a mixture of saline and Sotradecol®), which causes chemical endovenous ablation of the vein, which collapses and diminishes in appearance.

What is the main difference between arteries and veins?
In simplest terms, arteries take oxygen-rich blood FROM the heart; veins return oxygen-depleted blood TO the heart.

What are the three main categories of veins?
The deep venous system returns blood directly to the heart and is in the center of the leg, near the bones. The superficial venous system is just beneath the skin; it has less support from surrounding muscles and bones than the deep venous system. Perforator veins serve as connectors between the superficial and the deep systems.

Are all bluish surface veins varicose veins?
People should not be too quick to identify any blue veins as being varicose veins. Fair-skinned and/or thin individuals are prone to slightly more prominent veins. Varicose veins are slightly raised and typically more noticeable upon standing.

Does pregnancy cause varicose veins?
Pregnancy does not cause varicose veins; rather, it can aggravate an existing tendency toward the condition. More blood circulates in the body during pregnancy to meet the demands of the developing baby. This increased blood flow can burden an already weakened venous system. The growing fetus can also press on the pelvic veins and hinder the passage of blood. Finally, some researchers speculate that hormones present during pregnancy may contribute to dilated vessels. Prominent, uncomfortable veins that do not diminish postpartum should be evaluated by a vascular surgeon; though, some insurance providers require a six-month waiting period postpartum be observed before treatment is a covered benefit.

My legs often ache or throb if I am on them too long. Is this related to my varicose veins?
It depends. Leg aching and/or throbbing are symptoms of varicose veins and are most likely related to them. However, since there may be other conditions related to your leg discomfort, it is recommended that anyone experiencing leg pain should have an evaluation by a vein specialist. Temporary relief of these symptoms may be achieved by avoiding prolonged sitting and/ or standing If you have a standing profession or if you find yourself standing for an extended amount of time, shift your weight from leg to leg. When sitting for more than 30 minutes, try to elevate the legs above heart level. If that is not possible, stand up and walk around for a few minutes before sitting again. In either case, wearing compression hose is recommended.

What are medical grade compression stockings?
These are either knee-high or thigh-high elastic stockings, which are designed to compress most at the feet and ankles and least at the top. The lessening of compression from the ankle to the upper end of the stocking happens gradually. This maintains the flow of blood upwards towards the heart. These stockings come in 4 compression grades, depending on the requirement of the patient, guided by the physician.

How long do I have to wear compression stockings after the procedure?
Compression stockings are essential to a successful recovery and prevent adverse side effects after surgery. You must wear compression stockings for the first 24 hours after the procedure. After that time, you should continue to wear them for the next 7 – 10 days at all times, except when sleeping.

Is treatment covered by insurance?
One of the questions I am most often asked when doing screenings for vein disease is “Is treatment covered by insurance?” As usual, most medical questions are not easily answered and so the answer is yes, and no. All insurance companies consider varicose vein disease treatments medically necessary, and will, therefore, cover it, if there are complications such as bleeding or ulceration. Most consider treatment medically necessary if there are symptoms and reflux can be demonstrated on a Doppler exam. Of course, some of the newer treatments are considered “experimental” and therefore not covered. Spider vein treatments are considered cosmetic and no longer covered by any insurance plans of which we are aware. Lastly, not only does each insurance company have its own requirements but each individual policy can vary within the general guidelines of the company. Sounds confusing and it is. The best way to find out if your particular situation meets the requirements necessary for insurance coverage is to come in for an evaluation.

Can my symptoms e.g. pain, swelling etc. be caused by other conditions?
Yes, there are a number of conditions that can mimic venous disease in one or more of its manifestations. Nerve compression from back problems as well as arterial disease is the commonest. However, there are many other conditions that can cause swelling, pain, discoloration, and ulceration etc. Your experienced physician would be able to diagnose your condition and/or rule out many of the other conditions.

AESTHETICS

What is Botox®?
Botox®(toxin from bacterium Clostridium Botulinum) is a very safe neurotoxin, used in minute amounts for many conditions, including treating facial wrinkles, defiant migraine headaches and excessive sweating of the hands etc. In the face, it is used to weaken the voluntary muscle of expression around the eyes, forehead, and mouth, which pull on the skin and cause wrinkling. This can improve the wrinkles, depending on the dose of Botox and severity of wrinkles, and may eliminate the mild to moderate ones until the effect wears off months later. Thus, touch-ups are recommended 3-4 months later.

What are Fillers?
Fillers are either temporary or permanent. It is unwise to use permanent fillers in the face of a younger person, since changes with age may not match the previous, satisfactory result. Permanent fillers stay permanently. Temporary fillers are derived from harmless substances (e.g. hyaluronic acid) that eventually get degraded and absorbed. They are great fillers because they are forgiving, in lending themselves to removal with an enzyme. They last about 6-8 months. Fillers (Juvederm®, Voluma®, and others) fill low areas and dips in the face and also help to “iron out” wrinkles. We believe in minimal use of these fillers so that the result will enhance beauty and not be too obvious.

What causes wrinkles & what does the procedure involve?
The repeated pulling of the muscles of expression in the face on the skin, over years, causes wrinkling. Botulinum is injected into voluntary muscles of the face to relax them, preventing pulling and wrinkling of the overlying skin.

How long do the treatments with Botox® and fillers last?
Botox: Effects of Botox® treatment last between 3-5 months. If the sites are re-treated in 3 months, the effect may last more than 5 months. Moderately severe and severe wrinkling is not suitable for Botox and may require plastic surgery. Fillers: The fillers used at Spring of Youth Medical Group are temporary. They degrade and are absorbed by the body within 5-8 months. If fillers are re-applied before the effects of the initial treatment have worn out, it results in a longer-lasting effect for follow up treatments, especially if combined with Botox®. Fillers and Botox® can be reapplied as needed.

What areas are treated with Botox®?
For aesthetics, Botox® is used mostly relax the muscles of expression in the forehead, and around and between the eyes. It is also used around the mouth and in the neck.

How long does the procedure take?
It takes half an hour to complete a consult, which includes photographs. So you’ll be on your way in no time at all!

Can I see the change in my face immediately?
For Botox®, a favorable visual change may take 2-3 days to develop, and it is full within 1-2 weeks. Normally, before/after photos are taken before the procedure and 2 weeks after the procedure. For Fillers, a favorable result is seen immediately.

What is the recovery like after these procedures?
There is minimal to no bruising. After the procedure, we ask people to stay upright for about 4 hours to prevent facial congestion. Otherwise, there is zero recovery time and no down time. People can eat 2-3 hours after a nerve block, just like a dental treatment.

Are dermal fillers painful?
Fillers are prepared with a local anesthetic. In addition, a tropical numbing agent is applied to the treatment area. We often use nerve blocks with a tiny needle, for larger areas. So the treatment is relatively painless.

How much is treatment going to cost?
Consultation costs $95, which will be credited towards the price of the procedure. Payments for Botox are typically calculated per units of Botox® used, and for FILLERs, per amount used (tube). After the initial consultation with Dr. Barmada, a plan for the treatment will be outlined and discussed with the patient. In the plan, the number of units needed for completion of the service be calculated.