Features
How liposuction has advanced vein treatments
Advances made in one area of medicine often find application in other specialisations. Dr Haroun Gajraj writes about how he has changed his vein procedures following advances in liposuction
At first, you might think that liposuction has little to do with varicose vein treatment and removal. In fact, the modern era of vein treatments was made possible by Dr Jeffery Klein, a Californian dermatologist. In 1997, he invented a new local anaesthetic technique for liposuction, tumescent local anaesthetic (TLA).
In a matter of just a few years, TLA changed a dangerous, brutal operation performed under general anaesthetic with big cannulas into a gentle, precise outpatient procedure performed under local anaesthetic. Dr Klein introduced microcannulas so that the excess fat could be removed through tiny punctures only a few millimetres in size.
In 1995, the first reports of vein removal with TLA were published in the medical literature. Again, dermatologists were at the forefront of this development. But the powerful advantages of TLA were soon recognised by vein specialists worldwide, and now modern phlebologists can treat all vein problems under local anaesthetic as a walk in, walk out procedure in a clinic rather than in a hospital and without general anaesthesia.
So what is TLA? Dr Klein invented the use of large volumes of dilute local anaesthetic to which adrenaline has been added. The words “tumescent”, “tumescence” and “tumesce” are derived from the Latin tumere (v) meaning “to swell”; the adjectives reflect the swelling that occurs with the infiltration of large volumes of local anaesthetic fluid.
The addition of adrenaline causes the blood vessels to constrict so that the action of the anaesthetic is prolonged (lasting 10 hours or more) and there is no bleeding during the operative procedures. In vein treatments, TLA causes the veins to collapse and they are easier to remove.
As with liposuction, TLA has revolutionised vein treatments from a brutal surgical operation, into a precise, gentle procedure performed in a few hours without the need for a hospital.
Local anaesthetic
I first used TLA in my vein practice in 2002. As a vascular surgeon, I was used to performing vein procedures in a hospital operating theatre under general anaesthetic, so TLA took getting used to.
However, within a few months, the advantages were clear. In the last eight years, I have performed a vein treatment under general anaesthetic only once and this was for a lad of 18 years old, who was too nervous for TLA. I am amazed that most vascular surgeons in the UK still treat people with varicose veins under a general anaesthetic.
There are many advantages of TLA for varicose vein removal and here are a few:
• faster recovery
• safer
• less bruising
• more precise technique
• fewer complications
• no need for hospital
• less risk of infection
• highly cost effective, and
• applicable to people with medical conditions that preclude general anaesthesia.
So why don’t all vein specialists use TLA? With an impressive list of advantages, you would think that all vein treatments would be performed under local. Well, there are some disadvantages and they all relate to the surgeon.
First, patience and extra time are needed for the local anaesthetic to take effect. Second, the patient is awake and the surgeon may need to talk to him or her. Third, not all surgeons have the right temperament for TLA. Fourth, a gentle technique is needed. Fifth, a
nervous patient will need reassurance and kindness.
General anaesthetics for vein procedures are really for the benefit of the surgeon, not for the benefit of the patient.
My technique
Klein recommends TLA solutions of different formulations for different parts of the body. My TLA solution is one litre of normal saline (0.9% sodium chloride) to which 1mg of adrenaline, 10 mEq of sodium bicarbonate and 1g of lidocaine have been added. This formulation works well for removal of leg veins. The concentration of lidocaine provides excellent analgesia, the adrenaline provides vasoconstriction and bloodless vein extraction and the bicarbonate neutralises the slightly acidic pH and so minimises the stinging and discomfort when the local anaesthetic solution is infiltrated.
Originally, I made a small linear incision for phlebectomy with a scalpel blade, but since 2008, I now use a 1mm circular dermal punch to introduce the phlebectomy instrument, and once the resulting skin defect has healed it is virtually invisible.
Skin is elastic, so the circular defect easily stretches when removing large veins. Once the vein has been extracted, the defect returns to 1mm in size. Previously, my experience has been that linear incisions tend to tear and enlarge when large veins are extracted and the resulting scar can be unsightly. The dermal punch is well known to dermatologists for performing small skin biopsies for histological examination and Klein recommends dermal punches to enable the introduction of microcannulas for liposuction.
Using TLA, only a few instruments are needed for vein extraction and the technique is simple. In my practice, the cosmetic results of vein extraction using TLA and a dermal punch are excellent.
Nowadays, many patients wish to avoid admission to hospital and general anaesthesia and use the internet to find specialists who provide vein treatments under TLA. Patient choice is the driver and I see this trend increasing. It is likely that most vein treatments will performed under TLA within the next two to five years and vascular surgeons will need to embrace this change.
Advances in liposuction and vein surgery have resulted from a cross-fertilisation of ideas from different specialties, namely dermatology and vascular surgery. Sometimes it is difficult to predict where the next “big idea” might come from, which is why I enjoy reading Body Language and attending conferences that expose me to a variety of specialists outside my own field.
Dr Haroun Gajraj is director of the VeinCare Centre W: theveincarecentre.co.uk
