Roman ŠMUCLER^a,c, Ladislav HORÁK^b, Jiří MAZÁNEK^a
aDept. of Maxillofacial Surgery, 1^st Medical School of Charles University, Prague, CZ
^bDept. of Surgery, 3^rd Medical School of Charles University, Prague, CZ
^cASKLEPION-Laser Center, Prague, CZ

More than 2 500 leg veins patients have been treated with a dye laser successfully by our team and this therapy has become a basical cosmetic treatment. However, its limiting factor is mainly the diameter of leg veins. Very often we have to treat some cases that are not ideal for classical surgical or for dye laser methods. We have decided to apply invasive paravenous laser coagulation and adapted a 1064/1319 nm Nd:YAG laser for invasive applications. Having penetrated the cutis with laser fiber we coagulate leg veins during slow paravenous motion. Perfect preoperative examination is the main condition of success. After 15 months we have got very interesting results. Fifteen per-cent of patients have been treated perfectly with this method only, but excellent results have been reached with combination of Nd:YAG and dye lasers. 

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INTRODUCTION

Removal of minor leg veins lesions, namely venectasia, with the use of a laser equipment became a standard therapy. Gradual development shows that the most successful is the dye laser with optional wavelength and pulse period longer than 1 ms. Patients appreciate this method especially because of the considerable number of lesions that can be coagulated during one therapy (as opposed to classical injection sclerotisation), lowered pain factor and considerably lower regime limitations. Physicians appreciate the simplicity of the method that requires practically no special manual skill, while it can be mastered very quickly. Our results of dye laser therapy evaluated after 21 months are given in the following table.

1. Complications after Leg Veins Treatment with Dye Laser Only

After mastering the method and utilising all opportunities it offers, we obviously hit the indication limits of laser sclerotisation. It is indicated without any doubt that this method is suitable only for minor lesions up to the diameter of 1.2 - 1.6 mm (according to the nature and pigmentation of the surrounding skin). As we have ascertained ourselves, should we use a simpler laser, for example a KTP laser, the safe lesion diameter we can coagulate, is found under the limit of one millimetre. The key factor of the therapy result is undoubtedly the differential diagnosis of leg vessel disseases using all available examination methods, namely sonography. The complex of phlebologic therapy states laser coagulation as the last one. It is fully indicated only with patients who either are in for not serious leg vessel system disease treatment (especially insufficiency of deep vessel system), or patients who had these symptoms treated already. Patients very often ask for a certain compromise consisting of a cosmetic intervention without full treatment of the fundamental disease. However, this often leads to frequent relapses, if the source can actually be treated temporarily at all. Nevertheless, the physician and the patient face a big dilemma upon one or two unwanted vessels, supplying small vessels, to be removed by laser. And it is exactly here, where by admitting a certain amount of risk, the most frequent relapses originate, which can, to a certain degree, discredit laser therapy. Our aim was to develop a laser method enabling treatment of these particular patients.

MATERIAL AND METHODS

The base of our solution was our experience in tissue contact coagulation using Nd:YAG laser (1064/1379 nm). We followed a long research of this laser effects on various tissues. Satisfactory experience with thermal necrosis of rather big quantities of tissue near the surface skin layer provided a chance of safe coagulation of considerably more gracile vessel structures.

The principle of our method is penetration of laser fibre under the skin with a following paravenous preparation. Double passage of laser beam along the vessel, upon insertion and extraction of the fibre, causes coagulation of the given vessel. We focused on converting this idea to a procedure as simple as possible, which, upon maintaining the method safe, would require minimum purchase and operation costs. Our basic tool was the Nd:YAG laser, however, the principle is usable with certain modification by any laser with a major coagulation element (Ho:YAG, diode laser...). 

We started our research with a laser enabling us to work in both wavelengths. A model has been manufactured, beam interactions were examined in various modes of resonator setting with tissue and certain indications were determined and examined especially in the thoracic and abdominal surgery. These results have created a basis for further examination in the area of maxillofacial surgery and leg veins surgery as well. Despite of separate experimental studies no systematic evaluation has been available as to the utilization of Nd:YAG laser in paravenal surgery of leg vein yet. 

Patient selection system was as follows: Patients were treated in a private medical institute. Therefore we could not fully randomise our study and we had to accommodate the evaluation method to this fact, too. During 15 months 65 patients were gradually treated. Regarding the low number of patients, the results are considered preliminary. Physicians for the programme were selected by dermatologists who evaluated the patients before and after the given operation. The actual examinations took place in two groups the effectiveness of which was then compared. 

Patients A. Examined by a general surgery expert. The examination included only past history of each patient, aspection, palpation, Trendelenburg's test and Perthes's test. We tried to prove whether the method can be effective without a specialist in the given field or not, i.e. in conditions typical of many laser centres.

Patients B. In the second case, both the examination and final indication were performed by a phlebologist experienced in classical and minimally-invasive methods. In this case, all modern imaging methods were used including sonography. 

Prior to the actual operation, and based on the appropriate examination, the location of separate vessels to be coagulated is drawn. Special attention is paid to the structure of vessel anastomoses. Then we select access points in such a way to minimise the number of punctures. This plan is modified with regard to the selected anaesthesia so that the entire path of the fibre be safely insensitive tissue.

The intervention is performed in infiltration anaesthesia, in our case using 2% trimecaine (Mesocain inj., Léčiva) or 2% lidocaine (Xylocaine, Astra). Less frequently, namely with more extensive interventions and with psychically more unstable patients, the intervention is performed in sedation using Dormicum, Roche. 

The intervention is performed under strictly aseptic conditions, sterilisation of laser fibres is performed in an autoclave. A strong injection needle secures skin penetration. Skin penetration by laser is avoided for collateral necrosis, which threatens by complicating the following cure. After needle extraction, the subcutaneous area is penetrated into by the given laser fibre and strictly paravenous procedure is performed. Penetration through the subcutaneous area required skills and experience. The first risk, which fortunately remains only theoretical so far, is breaking the fibre tip. This danger is minimised by the fact that only the minimum possible part of the glass fibre remains without plastic cover. The second risk is the speed of the process. When it is too slow, it necessitates a cure of an extensive necrosis. Too quick a process may decrease the effectiveness of the method and moreover increase the creation of subcutaneous extravasations from small vessels that were torn by the fibre, however, not coagulated. At the beginning, we measured in a standard way during the therapy the temperature on the skin surface. First by digital thermometer, then by strip contact thermometer. The measured values did not reach the values necessary for irreversible thermal damage. For that reason we consider per-operation measurement of skin surface temperature excessive and decided not to refrain from it. 

We used 13 watts in continuous mode or 10 watts in pulsed mode. Energy depends from individual surgical technique. 1064 nm wavelength was preferrably utilized for slow coagulation of bigger vessels, whilst 1319 nm advanced quickly in non problematic areas.

After finishing coagulation, we apply plaster pressure bandage on the point of puncture. Our main recommendation is to perform regime measures common for phlebologic interventions and wear pressure stockings of the compression factor of 2 for the period of 10-14 days. After 6 weeks, minor lesions are treated additionally by dye laser as per the standard method. If there are crossed vessels on several levels, this treatment is repeated.

RESULTS

2. Physitians` Evaluation of Operated Patients

3. Complications in case of combined therapy

DISCUSSION

Our work has shown that the method we proposed provides a relatively satisfactory amount of success. No patients were damaged by this operation intervention. No fiber was damaged, no festering complication occurred. Patients accepted the method very well, infiltration anaesthesia is very satisfactory. If the given vessel was removed, the following pigment laser therapy had 100% effectiveness during no more than two sessions. We believe that this combination is the future and sense of this method. The limits of vessel diameter of vessels that can be treated by laser were shifted further. As regards vascular laser, after the preparatory therapy the risk of repeated or unsuccessful intervention drops considerably. 

Our study further proves that an inter-discipline co-operation is necessary in the area of laser therapy. Our method itself was originated by application of our experience namely in the area of maxillo-facial and general surgery. The most important result seems to be the transparency of the all-inclusive approach to diagnostics and treatment of leg vessel system diseases. Laser centers, provided these are not linked with at least phlebologic diagnostics, even better if these have no complete surgical support, should not attempt such therapy at all, which is a frequent bad habit. The method is sensitive to exact treatment of vessels and knowledge of the entire vessel system, otherwise the success of any intervention is a matter of coincidence. The effort to keep a lucrative patient leads to crossing the indication limits and failures.

An interesting phenomenon is the higher patient satisfaction than indicated by objective results according to physicians. While at the same time, patients with cosmetic defects are usually rather hyper-critical. We explain this fact by a general dislike of classic, however mini-invasive methods and a certain fashion of laser surgery. Patients, slightly in a contradiction to reality, see this intervention an undoubted progress they do not want to give up. 

The method requires exact training which is, however, for physicians experienced in the field of surgical laser and surgery as such it is a matter of days. Repeated training of several physicians confirmed this fact. The method can certainly be made more exact by connection of thermal sensors with a feedback etc.. However, we think, based on the given resource studies that these modifications have no clinical effect and actually make the system more expensive, which is then vulnerable. Problems of this method lie in the area of exact indication, damage of the surrounding tissue by non-exact energy dosage were to our surprise minimal. As regards further development of the method, we are trying to use larger energy doses through which we might be able to cure bigger vessels and more complicated vessel systems. However, the development of the method, e.g. towards coagulation v. saphena magna is considered unreal for the time being. The truth is that much larger structures beyond comparison are now coagulated by means of the hyper-thermal method, however, that is the case of a static process. Nevertheless, a vessel is a very complicated space intra-cooled system with its connections. 

A major advantage of this method is basically the variable laser equipment as the only key fact is the high ratio between coagulation and vaporisation, which can be handled by a number of systems. We used Nd:YAG laser. It is much easier to work with it, which is a commonplace, if the device is in the pulse mode. The future of this method is, however, as generally applies to this category of hyper-thermic laser interventions, a diode laser. The interventions we used are today reachable through these devices, however, upon lower operation and purchase costs and a much higher system mobility. We intend, as a further direction of our work, to test this option. 

Conclusions:

1. the method is functional and upon proper indication brings satisfactory results

2. the method is very sensitive for exact diagnostics

3. the method has a narrow indication spectrum - solitaire vv. perforantes

4. the method is very well accepted by patients

5. the method is suitable for combining cure with a vascular laser

6. the method is very simple and not very sensitive to technological risks

7. the method is easily reproducible

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Acknowledgements:
The authors would like to thank IGA MH, Czech Republic, for financial support (IGA 4191-3)