Your legs aren't likely to get a lot of public display over the winter--which makes it the ideal time to change how they look.
Whether you have stray squiggles of noticeable veins or a road map on your calves, the treatment you choose probably will cause bruising that takes several weeks to disappear--and may require multiple treatments.
"Fall and winter is our most popular time," says Dr. James Laredo, a vascular surgeon and associate professor of surgery at George Washington University Medical Center. "People time it before shorts season."
The timing also is ideal because you want your legs as pale as possible. Tanned skin reduces vein visibility during the procedures and also increases the risk of side effects, such as discoloration. (Women will also want to avoid treatments before or during menstruation because of heightened sensitivity.)
No one knows exactly what causes visible veins, but experts agree that genetics and hormones play a role--and that obesity as well as standing or sitting for long periods may increase the pooling of blood in the legs, which causes some veins to swell and rise to the surface of the skin.
About 55 percent of women and 45 percent of men in the US suffer from some type of vein problem, according to the Department of Health and Human Services. Thanks to the number of men now seeking treatment--a jump of more than 200 percent in the past five years--vein removal is now the second-most performed cosmetic surgical procedure in the nation, says the American Academy of Cosmetic Surgery. Only liposuction is more common.
Part of the reason for the popularity: "Treatment is now more effective and less invasive," says Dr. Mitchel Goldman, a volunteer clinical professor of dermatology at the University of California-San Diego and a founder of the American College of Phlebology.
Depending on the size of your veins, the problem may be more than cosmetic. Spider veins, the gossamer-thin red and blue ones, probably pain you only when you look at them. But more serious varicose veins--big dark blue or purple ones that bulge above the skin's surface--can cause pain and swelling. Because treating them will relieve those symptoms, insurance pays for treatment in most cases.
It used to be that the only solution for varicose veins was surgery under general anesthesia. But that mostly has been replaced by less invasive options that include injections (called sclerotherapy), laser, and radiofrequency energy. The approach that's best for you depends on the size and type of vein problem.
With the Food and Drug Administration's approval last year of a new injection agent called polidocanol, the $44-million sclerotherapy market is expected to nearly triple by 2015, according to the forecasting firm Millennium Research Group. The moneymaking potential means you'll want to choose your provider carefully. Once upon a time, vascular surgeons and dermatologists performed most of these treatments, but a four-to-six-hour course from an organization such as the American College of Phlebology allows everyone from nurse practitioners to emergency-room doctors to do them.
Even if your spider veins are small and you think the only issue is cosmetic, some doctors recommend an ultrasound to check for underlying problems in deeper leg veins. You may prefer to start with a physician who specializes in "venous diseases"--vein problems--so he or she can address complications or unexpected findings, says Laredo, though other doctors can refer you to a specialist if needed.
Experience also counts. Says Dr. Elizabeth Tanzi, codirector of laser surgery at the Washington Institute for Dermatologic Laser Surgery: "Someone who's done this a lot can do a whole leg in 15 minutes"--meaning that any pain is over faster.
Here, in increasing order of the vein size each treatment is designed for, are the ways to tackle varicose veins.
Quick and Easy: Radiofrequency
Red spider veins, the tiniest of visible veins, may be treated with the VeinGogh, which the FDA approved last year. A burst of high-frequency energy is delivered through a hair-thin probe. The heat collapses the vein wall and shuts it down.
The pain is similar to that of a rubber-band snap against the skin. Treatment takes about 15 minutes--though redness may persist for a couple of hours--and starts at about $350. You should see improvement within six weeks.
Light Touch: Lasers
Purple and blue spider veins--and any other veins smaller than the thickness of a ballpoint-pen line--can be zapped with light. The beam destroys the blood vessels, which are then absorbed by the body.
The treatment takes a few minutes to a half hour, depending on the size of the treatment area. Side effects? "It may look like a cat has scratched you for a few days," says Dr. Tanzi.
You won't need to wear support stockings. You will, however, need several treatments, because a single one--it costs about $300 a leg--at best will resolve 75 percent of the problem, says Tanzi. And sometimes vessels shut down initially and then reopen.
If you're choosing the laser because of needle-phobia, beware that it's considered slightly more painful--and that there's a small chance the laser won't resolve the problem, at which point you may end up trying sclerotherapy. Dr. Laredo, who doesn't perform laser treatments, says patients get better results, with fewer treatments, using sclerotherapy.
If you have larger varicose veins, you may choose treatment by endovenous laser, a half-hour office procedure that requires local anesthesia. The doctor, usually a vascular surgeon, will insert a catheter and tiny laser fibers that use 70 joules of energy per centimeter to heat the vein. (Startling as that sounds, your chances of a skin burn are less than 0.5 percent.) You may feel pain for about a week afterward, and you'll need to wear support stockings ("not as ugly as they used to be," says Tanzi) for several weeks.
A British study presented at the European Vascular Society in September found that foam injections, a kind of sclerotherapy not approved by the FDA, are as effective as the endovenous laser but are faster and less painful and had people back at normal activity more quickly. But in cases of large veins, sclerotherapy can require multiple treatments and has a much higher and faster recurrence rate than the five to ten years of relief offered by the laser.
Gold Standard: Sclerotherapy
Sclerotherapy works by injecting solutions that destroy the lining of the vein, causing it to shrivel slowly to an invisible thread of scar tissue. "It really is the gold standard of treating leg veins," says Tanzi. "It can be faster than laser and can treat a wider range of blood vessels."
The stinging saline solution of yore has been replaced with better, less painful injectables such as glycerine (the same as in soap) and the newly approved polidocanol (originally developed as a local anesthetic in eczema creams, thus virtually painless). Not all providers have the latter, and it's more expensive, though you may not see the cost: Many offices charge just for time units of treatment.
No anesthesia is required; you may receive topical numbing cream plus a concentrated blast of cold air, and you'll be able to walk out of the doctor's office and go about your day. You'll need to wear bandages and compression stockings for up to two weeks, and "legs could look worse before they look better, because of the bruising while the body shuts the vein down," says Laredo.
You should see improvement in six to eight weeks. More than one treatment--prices start at about $350--may be required, and you'll need at least six to eight weeks between them. A potential side effect is that the solution can escape the vein, causing a skin ulcer. And in up to 15 percent of patients, a brown line--caused by iron in the blood--appears on the skin, though often it fades within a year.
Gone for Good: Surgery
The advantage of surgery to strip the veins--known as phlebectomy--is that it's a one-shot deal that offers a low chance that the problem will recur. It's typically performed in a doctor's office under local anesthesia, though Laredo says if the veins are very big, he prefers to do it in the operating room under general anesthesia. It doesn't require an overnight stay.
There can be scarring, and blood clots are a rare, though serious, complication. You'll need to wear support stockings for a couple of weeks. It's $600 to $2,000 a leg, not including hospital and anesthesia costs.
This article appears in the December 2011 issue of The Washingtonian.