types of sclerosants, sclerosing agent, how a cosmetic sclerosant should be.

1. Cosmetic Sclerotherapy
Rodrigo Kikuchi
Vascular Surgeon
Venous Disease Comission - Brazilian Society of Angiology andVascular Surgery
Member SBACV, SBLMC,ABFL,AVF,ACP, SVS,AFI,ASLMS
Vascular Excellence Institute - Londrina/PR - Brazil
Vascular Excellence São Paulo - São Paulo/SP - Brazil
10 min

2. • Disclosure:
No potential conflict of interest regarding this presentation

3. Cosmetic Sclerotherapy
pain
thrombosis
swelling
It’s unattractive…

4. J Vasc Surg 2011;53:2S-48S
• Recomendation 12.1
12.1 We recommend liquid or foam sclerotherapy for telangiectasia,
reticular veins, and varicose veins.
• Grade 1 (strong)
• Level of evidence B (moderate)

5. Cosmetic Sclerotherapy

7. Microcirculation1997; 4:329-340.
Cutaneous microcirculation has two horizontal lines:
1-1,5 mm of skin
junction between the dermis and
subcutaneous
valve system
arteriolar smooth muscle cells
controlling flow

8. - May explain failure
- May explain other treatment needs

9. Possible algorithm approach to leg vein
Mann, M. Clin Plastic Surg 38 (2011) 475–487

10. Cosmetic Sclerotherapy - Principle
Zone 1: irreversible damage
Zone 2: reversible damage
Zone 3: no damage
Goldman M, ed. Sclerotherapy: Treatment of Varicose
and Telangiectatic Leg Veins. St Louis, MO: Mosby Year
Book; 1995.

11. • Hyperosmolar
- mechanism of action: cellullar dehydration in both blood
components and the cell wall
- Examples: Hypertonic saline 23%, 75% hypertonic glucose/
dextrose, Sclerodex (25% glucose, 10% hypertonic saline)
- Hypoallergenic
- Unwanted effects: hemolysis and pain
Dietzek CL. Perspec Vasc Surg and Endov SurgTherapy, 2007.
Types of Sclerosants

12. • Detergents
- produces endothelial damage by mul5ple
mechanisms
- decreased cell surface tension
- interferes with the lipids of cell surface
- extrac5on of cell surface proteins
- STS (Sodium tetradecyl sulfate), Polidocanol
- greater 5ssue necrosis index
Types of Sclerosants
Dietzek CL. Perspec Vasc Surg and Endov SurgTherapy, 2007.

13. • Chemical
- produces direct corrosive effect
- It produces immediate effect chemical bonds of the
cell wall
- examples: glycerin chrome
- Pain and pigmenta5on
Dietzek CL. Perspec Vasc Surg and Endov SurgTherapy, 2007.
Types of Sclerosants

14. Dermatol Surg 2010;36:1010–1025

15. • Polidocanol is an insurance agent and comparatively
better than the STS
Rabe E, et al
Phlebology, 2010
• Both polidocanol and STS improved rates and
unwanted effects
Rao J, et al. Derm Surg, 2005
Goldman MP. Derm Surg, 2002
• Polidocanol has fewer unwanted effects and greater
patient comfort Carlin MC, J Derm Surg Oncol, 1987

16. • Polidocanol is the best material for the realiza5on of
small veins sclerotherapy
• Editorial 5tled: Polidocanol: "the perfect solu5on"
Weiss RA. J Derm Surg Oncol, 1994

17. - May 30, 2010
• FDA Approves Asclera 0.5% and 1% for use in
telangiectasias and re5cular up to 3mm
• Sclerotherapy: it is back and beQer
Mann MW. Clin Plast Surg, 2011
• Polidocanol is beQer hypertonic saline because it
causes less pain and necrosis
Peterson JD, Goldman MP, Weiss RA, Duffy DM.
Dermatol Surg, 2012 (Epub ahead of print)

18. J Vasc Bras. 2013 Mar; 12(1):10-15

20. • Medical literature
PolidocanolGlucose 75%

21. Phlebology 2012;27:383–389

22. - Experimental study in rabbits
- polidocanol injec5on (liquid and foam) in subcutaneous 5ssue in
concentra5ons of 0.5%, 1%, 2% and 3%, and volume 0,1-0,5ml
- There were no necrosis with volumes <0.5 mL
- Necrosis only with foam 2% and liquid 1%
JEADV 2010, Sep (7)

23. - ulcer is caused by an occlusion of arteriole due to an arteriovenous shunt
(liquid goes from venulae to arteriole)
- doppler performed in 155 telangiectasias
- pulsed sound detected in 112 cases
- 22 cases were inves5gated histologically and found 19 microshunts
- authors suggest not perform injec5ons with volumes greater than 0.2 ml in
each puncture
Dermatol Surg 2001; 27: 133-136

24. Sclerosing Agent

25. • Choice of Glucose 75%
- More viscous
- Lower flow
- Less possibility of venulo capillary reflux
- Less possibility of post-sclerotherapy ulcers
- Increased safety
Sclerosing Agent
BUT…

26. This never happened
with me…
Dextrose is not a
powerful sclerosing agent

27. Dextrose
Polidocanol
dextrose + polidocanol
Progressive Management
Sotradecol
Increase polidocanol
concentration

28. Foam sclerotherapy?
Mann, M. Clin Plastic Surg 38 (2011) 475–487
Breu. VASA 2008; S/71: 3–29

31. After sessions with dextrose
75%
Next session: dextrose 67.5%
+ polidocanol 0.3%

32. polidocanol 0.5% foam + polidocanol 0.25% liquid

33. Patient: Angelica Siviero
Date of Birth: Aug. 27, 1957
Date: 09/16/2014
L Lateral Shin
July 23, 2014
L Lateral Shin
Sept. 16, 2014
Dextrose 75%

34. Dextrose 75%
Polidocanol foam 0.25%
Polidocanol liquid 0.25%

35. - Choose the right case (ultrasound, examination)
- Pressure on the plunger should suit the sclerosant viscosity in order
to avoid reflux from venulae to arteriole
- Low volume and multiple punctures
- Use liquid for telangiectasia, foam for reticular veins
- Use low concentrations of polidocanol / STS and progress as
needed (0.125% - 0.25% - 0.5% - 1%)
How should a cosmeEc sclerotherapy be?
First: do not harm, than treat

36. Information aboutVascular Excellence Group
www.excelenciavascular.com.br
area for physicians
- more than 50 events in Brazil and South America
- specific training for liquid sclerotherapy, radiofrequency, laser transdermal, endovenous
laser and foam sclerotherapy
- more than 400 physicians trained
- more than 1500 attendees in the events organized by EVAS Group
- database with more than 3200 papers revised and commented

38. Hands on Training Courses
Foam sclerotherapy

39. kikuchi@excelenciavascular.com.br
+55 (11) 98111-9901
www.excelenciavascular.com.br
area for physicians