ORIGINAL ARTICLE Management of the Primary Varicose Veins With Venous Ulceration With Assistance of Endoscopic Surgery Sin-Daw Lin, MD,* Kai-Hung Cheng, MD,† Tsai-Ming Lin, MD,* Kao-Ping Chang, MD,* Su-Shin Lee, MD,* I-Feng Sun, MD,* Wen-Her Wang, MD,* and Chung-Sheng Lai, MD* Abstract: Two hundred sixty-two cases of primary varicose veins in which the lesions extended to the areas of the lower third of the leg and/or the ankle were treated with the assistance of endoscopic surgery. The conditions of varicose veins were classified by the reporting standards in venous disease. The number of cases in lesions of C2, C4, C5, and C6 were 60, 156, 31, and 15, respectively. They were also classified into 4 clinicoanatomic types according to varicositic changes in normal veins. The number of cases in types I, II, III, and IV were 57, 88, 42, and 75, respectively. The incidence of skin changes resulting from varicosity were 100%, 90.5%, 53%, and 50% in types I, II, III, and IV, respectively. The incidence of skin changes in this series was 77.6%. About one fourth of the cases having skin changes progressed to C5 and/or C6 lesions. Early and radical treatment of varicose veins could prevent the occurrence of skin changes and subsequently avoid the incidence of C5 and/or C6 lesions. The mean number of incisions in each limb was 2.9. With good illumination and magnified monitor view, the varicose veins and incompetent perforating veins were radically excised, but the normal veins were preserved. Forty-six cases of C5 and C6 lesions were followed up at least 1 year postoperatively. Four cases were lost from follow-up. In all cases except 1, there has been no recurrence. The conditions of skin changes improved subsequently. The recurrent rate of ulceration was 2.4%. In treatment of primary varicose veins with or without ulceration, surgery with assistance of endoscopic surgery achieved a low recurrence of ulcerations and minimal operative scarring. Key Words: varicose vein, venous ulceration, endoscopic surgery (Ann Plast Surg 2006;56: 289 –294) V enous ulceration of the lower limb may occur in the presence of varicose veins and may be simply a conse- quence of varicose veins. 1,2 There are 2 types of varicose veins: primary and secondary. The abnormal deep venous hemodynamics in postphlebitis veins resulted in secondary type varicose veins. Homans 3 divided venous ulceration into 2 groups: that associated with varicose veins and “postphle- bitic” venous ulcers. Darke and Penfold 4 divided the venous ulceration into 4 types based on underlying abnormalities and the type IV of patients with postphlebitic damage occupied 22%. The other (78%) patients were associated with primary varicose veins. Gloviczki et al 5 also reported that primary valvular incompetence (70%) and secondary postthrombotic venous insufficiency (30%) were the causes of chronic ve- nous disease in their study of 103 patients. Blair and Homsho, 6 in their study of venous ulceration, demonstrated that 87% of limbs had superficial venous disease and 38% of limbs had deep venous disease. The reported incidence of patients with coexist- ing venous ulceration and varicose veins varies from 30% to 67%. 7,8 Varicose veins causing leg ulceration was described by Hippocrates more than 2000 years ago. 9 Linton 10 and Cockett 11,12 also emphasized the potential cause of varicose veins of venous ulceration. Although the progression from the inflammatory reaction of the skin to ulceration remains poorly understood, venous hypertension, whether caused by superficial or deep reflux, is the main cause of venous ulceration. 6,10 –14 The recurrent rate of venous ulceration is high, and the reported incidence of recurrence within 1 year varies from 26% to 69%. 15,16 As early as in 1938, Linton 10 developed an operation to correct all the venous pathophys- iological dysfunction, which included perforating veins liga- tion. Complete removal of diseased veins and incompetent perforating veins should eradicate the venous hypertension and reduce recurrence of the ulceration. 6,10,17 With the superior illumination and magnified monitor view offered by the surgical endoscope, the varicositic trunk, varicositic tributaries, incompetent perforating veins, and normal veins can be clearly visualized and identified. Lin and colleagues 18 –21 have managed primary varicose veins with the assistance of endoscopic surgery. Adequate removal of varicositic veins and ligation of the incompetent perforating veins can be achieved and have encouraging results, with very low incidence of recurrence. In this study, primary Received September 5, 2005 and accepted for publication November 11, 2005. From the *Division of Plastic and Reconstructive Surgery, Department of Surgery, and the †Division of Cardiology, Department of Internal Med- icine, Chung-Ho Memorial Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan. Reprints: Sin-Daw Lin, MD, Professor, Division of Plastic and Reconstruc- tive Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical Univer- sity, 100 Tzyou 1st Road, Kaohsiung 807, Taiwan. E-mail: sidalin@kmu. edu.tw. Copyright © 2006 by Lippincott Williams & Wilkins ISSN: 0148-7043/06/5603-0289 DOI: 10.1097/01.sap.0000197641.18499.b9 Annals of Plastic Surgery • Volume 56, Number 3, March 2006 289