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Dr. Barry Eppley

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Archive for the ‘sclerotherapy’ Category

Plastic Surgery Product Review – Asclera Sclerotherapy Solution

Monday, October 1st, 2012


The cosmetic treatment of spiders vein by injection (sclerotherapy) dates back for over fifty years. The traditional sclerotherapy agents include hypertonic saline and sodium tetradecyl sulfate. (STS) While effective, they are associated with pain on extravasation, tissue necrosis with extravasation, and a moderate risk of hyperpigmentation. A ‘new’ sclerotherapy agent, Asclera (polidocanol), was approved in 2010 that offers some advantages over the effects of saline and STS. Asclera was FDA-approved for spider veins of less than 1mm and reticular veins from 1mm to 3mm. Interestingly, Asclera has been available for more than forty years around the world but historically not in the U.S. Its effects have been well known but not was available for use until more recently.

Compared to saline and STS, what are the advantages of Asclera sclerotherapy solution? It specifically has two. First, it is much less painful to inject. Many patients would say that it is painless during injection. Secondly, it is not associated with or has much less tissue necrosis potential with extravasation. It may have less potency than STS but clinical studies show equal efficacy in spider veins of similar size. It is available in 0.5% and 1% concentrations in 2ml ampoules.

Asclera offers a new sclerotherapy solution to U.S. physicians that is an effective aesthetic leg treatment for bothersome spider veins. For small vessels 1mm or less I use the 0.5% concentration. For larger vessels the 1% concentration is more effective.

New Injectable Aesthetic Treatments

Wednesday, September 14th, 2011

The growth of injectable aesthetic treatments is largely fueled by the number of products that are available to use. Between neuromuscular paralyzing agents, volumizing fillers and sclerotherapy agents, there are over fifteen products currently available. That is about to grow by two new products and on-label indications.

Moving alongside Botox and Dysport will be Xeomin offered by Merz Aesthetics with its recent approval earlier this year. Like its predecessors, it has been approved by the FDA for temporary improvement in the appearance of moderate to severe glabellar (between the eyebrow) lines in adults. (between ages 21 to 65) What its advantages may be, if any, over Botox and Dysport remain to be forthcoming. As a different molecular structure of botulinum toxin, incobotulinumtoxin A, it is likely to have most of the working properties of the botulinum toxins such as delayed onset of action, limited zone of diffusion and a lifespan of three to four months. Its unit dosage and its pricing point will be interesting to see what the company offers and how it compares to its competitors.

While Restylane and many other injectable fillers have been around for awhile, it would surprise many that they have never been approved by the FDA for lip augmentation. This is interesting given that lip injections make up a significant percentage of the product’s use in most practices. This means that lip enhancement by fillers has been used off-label for more than a decade. Restylane, introduced initially in the U.S. in 2004 by Medicis Aesthetics, has been recommended recently by an FDA advisory panel to expand its approved indications to that of the lips. While this does not formally mean the FDA will do so, it is more likely than not. While this doesn’t provide any new benefits to injectable lip augmentation per se, it is comforting to know that its well known safety and effectiveness is scientifically recognized.

Sclerotherapy has used injectable products such as hypertonic saline and sodium sotradecol for decades without any new technology innovations. In the past year, a new sclerotherapy solution has been introduced that is widely used around the world. Asclera, pilodocanol, has been FDA-approved and released by Merz Aesthetics. This is for sclerosing uncomplicated spider veins (very small varicose veins less than 1mm in diameter) and small varicose veins (1 to 3mms) known as reticular veins. Asclera works similarly to other sclerosing agents by damaging the endothelium which is the lining inside of blood vessels. This causes blood platelets to attach to the lining of the vessels, causing the blood vessel to clot. Over time, the clotted vein will be replaced with scar tissue. Without blood flow, the spider veins ‘disappear’. With a similar mechanism of action, the question is how Acsclera may be superior to existing products. It is believed that it works more effectively and with less injection discomfort than its predecessors.

The infusion of new products like Xeomin and Asclera and expanding indications of existing products, like Restylane for lips, will continue to fuel the growing field of office-based injectable cosmetic treatments.

Dr. Barry Eppley

Indianapolis, Indiana

Polidocanol as a New Sclerotherapy Agent for the Treatment of Spider Veins

Tuesday, March 29th, 2011

Spider veins of the legs are a common concern for many women. While their main concern is usually that of a cosmetic distraction, some women will have discomfort with them as well. They often appear in patches and may have deeper blue veins in the vicinity of the spider patch. This indicates, like the leafs on a tree, that spider veins are not isolated entities and are the result of valve incompetence of the larger venous system onto which they are conbected. This suggests that the treatment of spider veins in many cases will prevent further progression of the problem.

Despite the widespread availability and marketing of laser treatments, sclerotherapy is the gold standard in the treatment of spider veins. In the United States, the use of hypertonic saline and sodium tetradecyl sulphate (Sotradecol) are the two injectable agents available for use. While each has its proponents, there is no clear evidence that one is more effective than the other in experienced hands. Outside the United States, however, polidocanol (POL) is more commonly used.

Recently, POL has become approved for spider vein sclerotherapy in the United States and is now widely available. POL has had the reputation for years that it more effective than hypertonic saline or Sotradecol and has fewer potential skin and soft tissue complications should some of the solution get outside of the vessels. Is POL a better option for sclerotherapy and, if so, is it actually more safe?

In a 2010 issue of the journal Phlebology, a double-blind randomized comparative clinical trial of polidocanol, sodium tetradecyl sulphate and isotonic saline was published. In 316 patients, 160 spider veins and 156 larger reticular veins were treated with one of the tested injections. Digital images were taken prior to injection and at 12 and 26 weeks after the last injection. The study showed that more patients were satisfied with POL at 12 and 26 weeks (84%, 88%) compared to Sotradecol (64%, 63%) and isotonic saline. (14%, 11%) Injection site reactions (irritation, discoloration, necrosis) were significantly more frequent in patients treated with Sotradecol as compared with POL.

Requests for spider vein treatment are common in a plastic surgery practice. However, most plastic surgeons do not treat them for a variety of reasons including the lack of glamor in so doing and the tedious nature of providing the service. In my Indianapolis plastic surgery practice I do perform sclerotherapy and, under 2.5X loupe magnification, it is fairly easy to cannulate small vessels for the injections. Even though I have a laser that can treat spider veins, sclerotherapy in my hands is more effective, less painful and more economical for patients. POL is a welcome new agent for sclerotherapy, particularly if it has a higher safety profile.

Dr. Barry Eppley

Indianapolis, Indiana

Dual Laser and Sclerotherapy for Spider Veins of the Leg

Monday, May 31st, 2010

One of the most common cosmetic leg concerns is that of spider veins. The use of the term ‘spider veins’ is a bit contradictory as the vessel size one refers to with this term is the size of spider legs. But a true vein, in vessel terms, would be much larger. Medically speaking, spider veins are known as telangectasias. That refers to a vessel size that is somewhere between minute end capillaries and small reticular veins, usually 1 to 3 mms in diameter.

The treatment of spider veins can be done with either sclerotherapy or laser coagulation. Both can work and there are some specific advantages and disadvantages to either approach.

Sclerotherapy is the injection of a chemical solution into the spider vein. It is simple to do but requires skill to introduce the needle into the small vessel and not get the solution into the surrounding tissues. The solution irritates the vessel and causes it to clot off in the next several weeks. Once there is no blood flow into the spider vein, it is no longer visible. The spider vein will look red and raised over the week following the injections. The injected area is wrapped until the next day after the injections. Compressing the vein for a short period of time after helps the injected solution stay in the vessel and squeezes the sides of the vessel together. The success of sclerotherapy is often touted as being between 90% and 100%. In my Indianapolis plastic surgery experience, I tell patients to expect about 70% improvement or elimination of visible spider veins. Most patients will need a second or touch-up session for optimal clearing.

There are different sclerotherapy solutions and concentrations for use. These include concentrated or hypertonic saline and sodium sotradecol. A newer sclerotherapy solution has just been released by the FDA. Asclera, known generically as pilodocanal, is actually used around the world and is the preferred solution outside of the United States. It is reported to be more effective and comfortable to inject than what we historically have used here in the states. It is likely to replace these older agents in the near future as its use becomes more familiar.

The use of laser for the treatment of spider veins has become more popular than sclerotherapy, particularly for those that own a laser that has that capability. The laser is easier to hit the spider vein as it is a ‘point and shoot’ method rather than actually cannulating the vessel. Adjusting the settings on the laser is key as the power and depth of penetration of the laser light will determine both effectiveness and the avoidance of skin burns. The laser settings are a bit of an art form as the size and exact location of the spider veins in the skin or subcutaneous levels differs in every patient and level of the leg. I find that the laser is more more expensive and painful but not necessarily more effective over sclerotherapy.

My historic approach to spider veins of the legs is that ‘if you can stick it successfully with a needle, sclerotherapy is better than the laser.’ It is less expensive, less painful, and more consistently effective. To capture the benefits of both spider vein treatments, I will often combine the two in a technique known as Laser-Assisted Sclerotherapy. (LAS) Initially the spider vein is injected and then the laser is used to treat over the top of it. Since I use a Sciton laser, the settings are typically 70 joules and 50 milliseconds for a 6 to 8mm spot size. While these settings would be ineffective if done alone, they are adequate when combined with sclerotherapy. In my experience, this raises the effectiveness of the treatment closer to 90% which is better than sclerotherapy or laser alone.  

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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