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Questions and answers for patients Questions and answers for medical professionals From sclerotherapy to T.R.A.P. |
The Question of “Matting""The matting treated in phlebology As an experienced operator, I am prompted to express my views on the question of “matting” (the formation of microtelangiectasias), not least because in the national and international literature and at congresses there is a great deal of confusion on the issue. This confusion often stems from ignorance and superficiality, though in some cases it is aimed at promoting the use of the laser or pulsed light, techniques which are abysmal in the field of phlebology and others. First of all, it should be realised that there is not just one type of matting; there are at least three: miopragic matting, inflammatory matting and haemodynamic matting. Miopragic matting is encountered (fortunately not frequently) in patients in whom miopragia (a congenital weakness) is also manifested in the capillary vessel walls (which dilate at the slightest injury). Miopragic matting is characterised by the presence of ectatic capillary vessels that splay out into capillaries that are so fine as to lose their visual identity. In such patients, it is difficult to achieve the same aesthetic result as is normally achieved in other patients, since the mere pressure due to injection can cause other capillaries to dilate. In these patients, therefore, we can improve the venous circulation in the lower limbs, but we cannot guarantee an immediate aesthetic result unless a series of treatment trials with T.R.A.P. is carried out. Matting of inflammatory origin very often follows sclerotherapy. Fine telangiectasias form along the route of the injected vessels when the sclerosing solution is too inflammatory; that is to say, when the vessel wall is damaged in depth and the blood gathers in the vessel. Haemoglobin is highly inflammatory for the tissues, and this inflammation leads to melanocytic cutaneous hyperpigmentation. This type of matting is therefore almost always accompanied by hyperpigmentation. Inflammatory matting is clearly visible when timedsurgical de-epithelialisation at 1 Watt is performed on sites of recent hyperpigmentation, as this reveals the dilated capillary-papillary plexus. Treatment for inflammatory matting is conservative. The patient must apply products that are anti-inflammatory, chelating and inhibitory of melanogenesis. Oral venotropics and chelators are also useful. Inflammatory matting resolves with time and does not require “phlebological” intervention. Haemodynamic matting is the manifestation of haemodynamic hypertension caused by trauma or by therapeutic procedures themselves. Haemodynamic matting mainly stems from untreated perforating vessels, which may even originate at a distance from the site of the matting. How does it arise? When superficial vessels are obliterated, ablated or reduced in diameter, this eliminates the natural escape of the hypertension caused by the valvular insufficiency of one or more perforating vessels. This pressure, which is not compensated for by a reduction in the calibre of the non-visible vessels, dilates the capillary-papillary plexus in the tributary area. Fine ectatic capillaries can also form as a result of a pressure increase in a single perforating vein. In this case, the hypertension is caused by the obliteration or reduction in diameter of the other previously incontinent perforating vessels. Areas of matting very often form following saphenectomy, phlebectomy and laser coagulation, as these procedures disrupt the normal physiology of the venous circulation and eliminate the “gateways” that allow us progressively to treat the non-visible vessels that are responsible for the disorder. I am not totally against traditional sclerotherapy; on rare occasions, I use it myself. However, we must not imagine that sclerotherapy can cure the circulation. For example, obliterating the telangiectasias of matting with small amounts of concentrated sclerosing solution, or worse, coagulating the small vessels by means of laser is a strategic error, in that it eliminates the “gateways” through which a regenerating solution can be brought into contact with the dilated or dilatable vessels that cause the disorder. This brings us back once again to a concept that I will never tire of repeating “A three-dimensional disorder like venous insufficiency cannot be treated by means of a two-dimensional method”. Phlebectomy is a two-dimensional method. The sole raison d’être of this technique was that it did not result in the hyperpigmentation associated with traditional sclerotherapy; now, with the availability of regenerative phlebotherapy, which does not give rise to hyperpigmentation, phlebectomy no longer has any reason to exist. Obliterative sclerotherapy is also two-dimensional; small quantities of sclerosing solution close the superficial veins, which are both the result of, and the outlet for, valvular insufficiency. Even saphenectomy is largely two-dimensional, and irreparably damages a venous system that should be treated. This issue, however, merits a section apart. Another rule that must always be borne in mind is this: “We cannot treat a miopragic circulation, which suffers from a global weakness, by operating only on a small part of it, as the traditional methods do.” The “regenerative” solution is injected at several sites in the area of matting. To strengthen vessel walls and reduce the diameter of the dilated or dilatable non-visible vessels, a large quantity of solution must be used. The aim is to reduce superficial hypertension, which is the cause of both the onset and recurrence of the matting. After the regenerative solution has been injected, a smaller amount of solution at a higher concentration (10% sodium salicylate in a buffered hydroglycerin vehicle) can be injected. What characterises haemodynamic matting?
Haemodynamic matting is characterised by the rapid outflow of blood from the injection sites. It can be resolved only by reducing the calibre of the tributary perforating veins in the area. The operator notices the improvement in this visual parameter: the outflow speed of the blood. The treatment must therefore be three-dimensional. All two-dimensional treatments, such as laser therapy, are irrational and are bound to be followed by recurrence. How is haemodynamic matting treated?
Haemodynamic matting arising after saphenectomy and sclerotherapy. Treatment with three-dimensional regenerative phlebotherapy using large amounts of solution. |
Three-dimensional Regenerative Phlebotherapy Fleboterapia tridimensional Regenerativa |
