A DEMAND THAT IS OFTEN POORLY MANAGED
Jean-Marc CHARDONNEAU, MD
This article reviews all the diagnostic and therapeutic situations that require an analysis of the incidence of disorders of the phlebological and lymphological sphere that induce an alteration in the beauty of the legs, particularly in women.
It insists on the quality of this considering of the explicit or implicit request of the patients, that it is a question of taking care and treating them in the most effective way possible.
Keywords: phlebology, aesthetics, legs, telangiectasia, varicose dilatations, large legs, cellulite, varicosities, pigmentation, oedema, lipedema, cyclic oedema syndrome, lymphoedema, phlebedema; transillumination, laser, radiofrequency, foam sclerotherapy
About the close relationship between leg beauty, health
and aesthetic phlebology
"The worst enemy of fine arts is worn-out legs." Raiberti.
In the nineteenth century, in the midst of the romanticism peculiar to Victor Hugo and Lamartine, Raiberti, a doctor and poet from the city of Milan, understood, at a time when legs were nevertheless masked by long clothes, the close relationship between the beauty of the legs and health.
Many years later, far from that time when the body was hardly revealed, the third millennium saw a fashion in Western societies that did not deprive itself of showing off the body and especially the legs, playing on their grace, harmony and sensuality.
This quasi-permanent presence of the legs in our visual field explains the social role they have today, recalling the close link between leg's aesthetic and Phlebology.
The beauty of the legs (photo 1) has become a capital element of feminine aesthetics.
Having beautiful well-made legs and keeping them in their vigour and harmonious proportions is the wish of all women.
How many women give up taking advantage of certain fantasies of fashionable clothing that reveal the legs?
How many women feel uncomfortable when summer and the beach are mentioned?
There are many situations that cause complexes.
AESTHETIC AND AESTHETIC PHLEBOLOGY OF THE LEGS
Today, modern phlebology [1, 2], aware that no phlebological lesion is completely innocent from an aesthetic point of view, has assimilated this change in patient demand.
There are essentially four types of treatment requests :
varicose veins dilatations,
The demarcation between leg aesthetics and aesthetic phlebology is becoming very clear
THE REBIRTH OF LEG AESTHETICS
Aesthetics is the science that deals with beauty and the feeling that it gives rise to in us.
The criteria that can characterize beauty vary with the times, the cultures;
And within those criteria, rarity sublimates that beauty.
The works of painters and sculptors over the centuries are testimony to this.
The canons of beauty, like beauty itself, are ephemeral.
They are dependent on religious and cultural criteria and vary according to the times.
It is necessary here to reread the description of feminine beauty at the time of the Renaissance.
ABOUT THE "PSYCHOLOGY OF THE LEGS
"I spend my life looking at women's legs": this sentence is nothing exceptional, except that it comes out of a woman's mouth.
Symbolizing the dictatorship of the leg complex in some women, who spend their time looking at the possible defects of other women's legs.
According to a "SoFreS" survey, 89% of French women attach great importance to the aesthetics of their legs: too white, too oily, too many varicose veins.
A BVA survey shows that a large proportion of women are too complex to reveal their legs in the hot season.
"Le Parisien" reveals the sad results of a "BVA" survey: 40% of women are complex because they don't find their legs thin enough and a third of women prefer not to show their varicose veins. 38% of them won't trade their pants for a skirt.
In phlebology, the aesthetic demand corresponds to a request from the patient towards a transformation of the aspect of his leg. one can distinguish the conscious demand from the unconscious one.
The conscious demand is favoured by the clothing fashion which frequently reveals the lower part of the body, hence the greater frequency of aesthetic questioning in women.
The unconscious demand. Some psychiatrists have taken a close interest in the problem.
The genesis of this unconscious demand would have several sources.
The leg, organ of walking, favours movements, reduces distances and thus plays a social role by allowing rapprochement and contact, thus communication.
The foot is the extension of the leg and its symbolism is complementary to that of the leg.
The leg is today an important element of sexual symbolism.
Hence unconscious motivations favored by a desire of communication and a will to be desired.
MOTIVATIONS OF TREATMENT
Patient motivation is conveyed by 2 principles:
Aesthetic concerns for the great majority of them
And for the purpose of prevention for a more marginal segment of the population.
Aesthetic demands focus on 2 axes:
Abnormalities in skin color (varicosities, varicose veins and pigmentation)
Anomalies of the shape (cellulite, oedema and big legs).
WHAT IS A BEAUTIFUL LEG?
The beauty of the legs depends mainly on 3 criteria: length, circumference, shape.
The shape depends on 2 factors:
The muscular mass.
The location of fat.
The important element is the muscular body of the solear and twin muscles.
According to some authors, the ideal circumference is between 31 and 36 cm.
Certain aspects are considered as beauty criteria: long, straight and thin legs.
As soon as the axis of the legs diverges from the vertical axis, it deviates from our perception of beauty.
The curves of the legs are very delicate.
The convex curve inside the leg is short and very pronounced, followed by a long concavity.
On the outside of the leg, the convexity is longer and smoother. It is followed by a short gentle concavity that ends at the outer part of the ankle.
Can we define the scientific criteria for a beautiful leg (photo 3)?
A number of objective criteria make it possible to define what is called a beautiful leg and to refine the therapeutic result.
The length of the leg h: on the diagram below (foot - knee) it must represent 26% of the height of the individual.
We can schematically divide the leg into 4 cylinders with delicate curves:
> The upper part of the calf (75% of the height of the leg),
> The lower part of the calf (50% of the height of the leg),
> The transitional part and the ankle.
3 cases of figure arise:
1. e is > 50% of C: in case of lipoedema, lymphoedema and various oedemas.
2. e is > 50% of C: this is amyotrophy.
3. C > 50% of e: this is muscle hypertrophy.
HOW DO YOU DEAL WITH THEM BIG LEGS?
30% of women consider that their legs are too big.
The repercussions of large legs are aesthetic, but also functional with sensations of pain, skin tension and heavy legs.
The chronic big leg [4, 5] is a frequently encountered clinical picture.
Under this name, very diverse pathologies are hidden.
The chapter of the big legs  is very vast and complex.
This morphological abnormality is a daily challenge for the therapist who treats them.
Etiological challenge, requiring a fine clinical acuity and often the help of high-resolution ultrasound. C1 & C2: define the ¼ upper calf.
d: defines the middle of the calf.
e: defines the entry of the ankle is the lower ¼ of the leg.
In posterior vision:
The width of e must be 50% of C.
The width of B must be 50% of C + e. In lateral vision :
The width of e is 70% of the width of C.
The width of B must be 50% of C + e.
The curve is thus more marked in posterior vision and more progressive in lateral vision.
Therapeutic challenge, as the treatment may require knowledge of various technicalities and equipment.
6 clinical situations are encountered:
Lipedema (picture 4) [6, 7],
Cyclic edema syndrome,
Lymphedema [8, 9],
Edema of general cause (iatrogenic, endocrine, kidney and heart failure),
Today's assessment of venous disease is based on the Echo-doppler examination.
This examination has totally revolutionized the understanding of varicose vein disease and its corollary treatment.
Today, it allows us to carry out an "à la carte" treatment according to the origin of the refluxes.
Crossectomy and stripping , which until recently were still considered by some to be a quasi-religious therapeutic dogma, have gradually been abandoned.
However, endovenous treatments which are carried out under ultrasound become the reference treatments.
They are done on an outpatient basis and are not very disabling.
A catheter is introduced into the varicose vein.
3 procedures are possible:
Endovenous laser ,
Radio frequency ,
Microfoam echosclerotherapy [13, 14] which revolutionized the chemical ablation of varicose veins. Microfoam echosclerotherapy allows a high concentration of sclerosing agent (mainly in France polidocanol and sodium tetradecyl sulphate) to be applied to the surface of air microbubbles.
Their sclerosing action is maximal.
The foam is produced by a vortex effect obtained by connecting 2 syringes to a 2 or 3 way connection system.
It can also be used in microsclerotherapy to treat telangiectasia, but caution is required, because pigmentation is always present.
Finally, phlebectomy [15, 16] remains an excellent alternative to remove collateral varicose veins and varicose veins of the feet and hands.
TELANGIECTASIAS: A TAILOR-MADE TREATMENT
According to studies, between 67 and 80% of women [17, 18] have varicosities.
They increase with age and vary according to ethnicity: higher frequency in Caucasians and lower in Blacks.
In addition to the visual approach and doppler ultrasound, which have their limitations, other means of exploration are useful in the diagnosis and therapeutic procedure of telangiectasias.
Transilumination is the GPS of the aesthetic phlebologist.
Transilumination (photo 5) [19, 20] is certainly the most useful (almost indispensable) observation technique for the therapist who wants to take an interest in the treatment of telangiectasias.
This procedure consists of sending a light beam emitted by an optical fibre onto the skin. It diffuses through the subcutaneous tissue and reflects off the fascia.
The reflected beam is stopped by the subcutaneous formations forming a shadow on the skin.
The viewing depth is less than 4 mm.
It allows the reticular networks, reticular varicose veins and possible connections between telangiectasia and reticular varicose veins to be seen.
It should allow us to answer 2 questions:
1. Is there a reticular vein in the vicinity of the telangiectasia?
2. If yes, is this reticular vein pathological or not? In other words, does it feed (reticular varicose vein) or not the telangiectasia?
The semiology of transillumination  makes it possible to decide: in the case of reticular veins feeding the telangiectasias, the supply networks are then injected as a first-line treatment, with an increase in efficiency, speed and stability of results over time.
The therapeutic approach mainly involves 3 procedures:
Microsclerotherapy [21, 22, 23, 24], grade 1 C recommendation, is often the first-line treatment for telangiectasias.
Reticular varicose veins (diameter between 1 and 3 mm) and telangiectasias (diameter < 1 mm) can be treated.
Theoretically up to 0.3 mm diameter (needle diameter 30 G) can be treated, but with a little experience almost all telangiectasias can be treated.
It consists of depositing active principles in contact with the wall of a dilated vein (small calibre less than 2 mm) in order to trigger a controlled reaction leading to fibrosis of the vessel.
The intravenous injection of a sclerosing product, in liquid or foam form [19, 20, 21], dissipates the film of fibrogen which protects the intima and alters the venous endothelium.
The fibrin invades the venous wall causing an inflammatory reaction that will lead to fibrosis in several months.
Many parameters must be defined before each treatment.
It is a treatment that is not insignificant and therefore the respect of the treatment rules and the therapeutic strategy must be well thought out.
With microsclerotherapy one can treat almost all types of telangiectasia. Many variations are possible:
Use of several needles left in place,
The micro foam [25, 26],
The laser sclerotherapy,
Injections of hyaluronic acid which do not close the vessel but restore it to a quasi-normal size.
The laser [27, 28] is an indispensable technology in a technical platform of aesthetic phlebology.
Even if microsclerotherapy is the reference treatment, it cannot have an absolute monopoly.
There are patients who do not respond to microsclerotherapy , patients with allergies or when the diameter of the telangiectasia is less than 0.3 mm (size of the smallest needle).
There is therefore room for the laser.
Two wavelengths are mainly used: 534 nm (KTP) and 1064 nm (NdYAG).
Schematically the KTP for very thin and superficial vessels
And nd Yag for deeper, more dilated vessels.
From a pragmatic point of view, the adjustment of the parameters is very important:
The smaller the vessel, the greater the fluence, the shorter the pulse time and the smaller the collimation diameter.
Conversely for larger vessels.
The principle of thermocoagulation is based on the action of a radiofrequency current, of the order of 4 million Hertz, causing a thermal lesion on the wall of the varicosities.
The thermal effect is due to the vibration of the atoms around the tip of the needle. Technically, the needle passes perpendicularly through the skin to come into contact with the telangiectasia.
The punctures are made every 2-3 mm along the vessel.
The disappearance of the vessel is instantaneous and is replaced after a few hours by microscopic crusts which will disappear in a few weeks.
No lasting side effects are to be reported, except exceptionally pigmentations.
This treatment [24, 25] developed by the author [29, 30] and available to most doctors gives interesting results, but only on small vessels and bony areas (malleolus, foot, upper lateral leg).
In practice: 3 main types of telangiectasias are encountered:
Fed by a reticular varicose vein,
In the case of reticular varicose veins, microsclerotherapy is necessary.
In the case of isolated telangiectasias (photo 9) 2 parameters intervene: the diameter of the vessel and its location.
If the telangiectasia is very fine and close to the bone (ankle, foot) thermocoagulation is the first- line treatment.
In other cases, laser is strongly recommended.
In the case of angiomatous layers (photo 10), microsclerotherapy is indicated.
CELLULITE AND CIRCULATION
Numerous studies and observations suggest that cellulite (orange peel skin) is the result of an imbalance between 2 mechanical forces:
The dermal resistance,
And the intralobular pressure of the superficial hypodermis.
High resolution ultrasound (picture 8) defines 2 hypoderms:
A superficial seat of cellulite (anechogenic space under the dermis)
And a deeper, echogenic space in the deep hypodermis.
When the intra-lobular pressure of the superficial hypodermis becomes higher than the dermal resistance, cellulitis clinically occurs.
This increase in pressure in the interlobular spaces is related to the presence of edema and fibrosis .
Fibrosis often complicates the development of chronic edema.
Lymphatic stasis feeds this oedema.
Compressive events explain this stasis:
The accumulation of fat
Or the presence of edema in the deep hypodermis.
The therapeutic approach has two aims: to increase dermal resistance and to reduce edema of the interlobular space.
Various therapeutic procedures claim a dermal stimulation action via the fibroblasts; others have a vascular tropism and participate in the reduction of oedema.
Thus 2 vascular targets: the lymphatic and the capillaries.
A NEW PARTNER FOR BEAUTIFUL LEGS:
THE "ENDOSPHERE THERAPY" ( AND ).
THE PROBLEM OF BEAUTIFUL LEGS
In a socio-economic environment where the image of the body exercises a real dictatorship, the presence of generous shapes and/or cellulite is often badly experienced.
The local accumulation of adipose tissue, is a secondary sexual character which concerns many areas: the hips, thighs and buttocks (saddlebags), the upper medial face of the thighs, the medial face of the knees.
Lipoedema sometimes only affects the legs and ankles.
A NEW THERAPEUTIC APPROACH: " THE THERAPY ENDOSPHERES " or " MICRO-VIBRATION COMPRESSION THERAPY" :
Numerous therapeutic solutions are at our disposal. Not all of them are of real interest. The trend is towards the least traumatic treatments possible, while having a recognized effectiveness.
Micro-vibration, an innovative and relevant technology, fits this equation perfectly. Developed by a team of Italian researchers and supported by numerous studies, this therapy has undeniable potential in the treatment of cellulite. The rotation of a cylinder of 55 hypoallergenic silicone spheres produces a low frequency vibration on the skin. At the same time, the direction of rotation and the pressure exerted cause a pumping effect.
"AND" restores the balance of the extracellular matrix and microcirculation, activates the metabolism and stimulates the lymph flow. In lipoedema, a cellulite form that is difficult to treat, according to the work of Arezzo, more than 50% reduction in hypodermic thickness is achieved in addition to medial malleolar thickness.
THE FIELDS OF APPLICATION OF " ENDOSPHERE THERAPY " ARE MULTIPLE
" AND " in aesthetic medicine can treat cellulite, localised adiposis, and is of real interest for facial rejuvenation, for the treatment of scars, lymphoedemas, lipoedemas and venous oedemas. In sports medicine the indications are numerous.
Aesthetic phlebology was born out of the evolution of therapeutic care of our patients.
The demand for treatment in aesthetic phlebology is exponential. It concerns a younger and younger population that is often very concerned about its image and its aesthetic representation, be it on the legs, the body or the face.
The doctor must respond to this subjective quest with a structured and scientific approach.
Possessing a phlebological culture and having specific training are essential to satisfy this important treatment potential.
Therapists sometimes tend to overlook this demand (due to lack of training).
The angiologists in their university hospital curriculum are well trained in major pathologies, but only give a brief overview of superficial venous disease.
The creation of a University diploma in Phlebology in France is quite recent.
Abroad, depending on the country, it is often the vascular surgeon or the aesthetic doctor or the dermatologist who takes care of it.
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