Louise King

Good evening, everyone. Welcome to our webinar on varicose vein treatment. My name is Louise, and I'll be your host this evening. Our expert presenter is a consultant vascular surgeon, Mr Aaron Sweeney. You can see on the screen that this presentation will be followed by a question-and-answer session. If you'd like to ask a question during or after the presentation, please do so using the Q&A icon, which is at the bottom of your screen. This can be done with or without your name. Please note that this session is being recorded. If you do provide your name and if you'd like to book your consultation, we'll provide contact details at the end of this session and a small offer for attending the session. I'll now hand it over to Mr Sweeney, and you'll hear from me again shortly.

Mr Aaron Sweeney

Thank you. Hello everybody. My name is Aaron Sweeney. I'm one of the two consultant vascular surgeons who work here at Benenden. Our main focus of treatment is on varicose veins, and we treat quite a lot of them, so today I'm just going to start talking a little bit about what's involved, what we do, the numbers we treat per year, and some of the little bit of an explanation of what exactly varus veins are and what is available to you. As we start, I'll just say what's going to be included in this session, so I'll talk a tiny bit about myself and a little bit more about treating patients at Bennett and Hospital. I'll tell you a little bit about what varicose veins are, kind of what symptoms they produce, and then a little bit about how I check things out and then give you an overview of the different treatments that are available. We have a little video of one of our patients, and then at the end we're going to have a question-and-answer setting session. I should say that most people have specific questions they want to ask, and sometimes I answer them on my way through all these slides. Sometimes people feel a bit nervous asking questions about veins because they don't quite understand anatomy, etc. Please don't be embarrassed. It's amazing the number of people who know very little about what's going on with their vascular system. It's not unusual, and it's sometimes nice if you ask a question. I can answer it, and it's often a question that many people want to ask first.

That's me I'm a vascular surgeon so I deal mostly with our used to deal mostly with arteries and veins now I deal almost exclusively with veins I work here with Mr Eddie Chaloner and we were the guys when we were a good bit younger who saw this technique initially it started over in New York and then Eddie was the first guy to do it in London I was the junior doctor then so I saw the first one ever performed here and essentially we both looked at it and thought well that's much better than stripping vein and then it took a few years for us to actually get us up and running and working perfectly so like many new techniques you think it's going to be fantastic and it often takes three or four more years of research to actually get it to a level where you can you work out how to do it properly and safely and also to make sure that it is better than the treatment that was there before.

At Benenden Hospital, we do a lot of varicose vein surgery. We are actually the largest provider of bins in England, and just to note, the CQC, which is the government group that goes around checking things out, thinks we are outstanding. That's based on what the hospital looks like, how it works, and how patients and staff feel, so we do a lot of veins, and we get decent results. Most people are pretty happy with everything. There are always occasional patients who are a little unhappy because of an odd complication here and there, but for most people, we try our best to make it a fairly straightforward experience and fix the problem that you have.

So, what are varus veins? I'll give you a very brief insight into the anatomy of your vascular system. So, your heart is pumping away, and it'll pump into your aorta, which is an artery. Your artery then heads down through your chest through your tummy, giving you loads of branches, and then finally heads down into both legs. The artery going into your leg probably has the advantage of having a pump and gravity, so everything goes down, and your arterial blood delivers oxygen and a little of other stuff just to keep your muscles, etc., working. Your veins are trying to take all that blood and deliver it back up to your heart so it can be pumped again. I think it's helpful to think of your veins like a Christmas tree. You have one main vein that runs up the centre of your leg, and that's called your deep vein. Remember that it drains a litre, sometimes two litres per minute, when you're exercising, and there are hundreds of branches. Most of those branches are draining muscle, and they have the advantage of being surrounded by muscle so they can squeeze the blood up your leg. The ones that cause varicose veins are draining your skin.

So in certain people with usually white skin like mine you can see loads of blue veins under the surface they're called saffin veins there's hundreds of them they're nearly all like little shoelaces and about that size and they all drain about a teaspoon or so of blood per minute on their own they're not that important but altogether they drain your skin adequately your skin doesn't require an awful lot of blood but its main trouble is that these veins aren't surrounded by muscle they're going uphill and so they need some valves to keep everything going in the right direction and a varicose vein happens when that one of those valves fails so instead of the blood allowing everything to go only uphill it starts to pour back down again in the beginning your other veins work a little bit of overtime taking care of that and so you don't get any symptoms but eventually in about 75% of people or so the other veins just can't quite manage and so you start initially to get a little bit of swelling usually around your ankle subsequent to that it can get a little bit achy or sore and then very occasionally you get little clots forming in your veins that's called thrombosis and sometimes people have veins for ages and they all of a sudden get a little bit of trouble and that's nearly always because if you start some blood pressure medication that relaxes your blood vessels but if you relax the varicose vein it gets bigger and then it suddenly becomes sore some things that you might not think of when you're looking varus veins you sometimes see big huge chunky veins on certain people and that causes no trouble then other times you can see the tiniest little veins and you wonder why that person's having anything any treatment but some varicose veins you can't see very well because they're just under of the surface and they often produce swelling to begin with cramping at night with that very heavy feeling towards the end of the day most people when they lie in bed at night the veins drain so they usually feel their cure at first thing in the morning then as the day goes on your legs swell sorry your veins swell and any symptoms you get usually get worse as the day goes on so varicose veins typically cause more trouble in the evening and they also cause more trouble in hot weather because they dilate a little bit and for ladies they cause more trouble at the end of pregnancy and just before period time because you guys get a little surge of progesterone and progesterone dilates veins that's why your ankles sometimes swell and why your last trimester can be a bit miserable Pregnancy doesn't necessarily cause varicose veins, but if you have them at the beginning of your pregnancy, it makes life a little miserable.

So veins think of them like a Christmas tree hundreds of branches most of them working perfectly but it only takes one and then that fills up with blood and puts a bit of back pressure onto your skin either makes it makes it swell or itchy so how do you treat veins well first thing is you don't necessarily have to rush and do anything if you're not having much trouble you can leave them be most veins don't cause any great trouble but the older treatment used to be to do cuts and disconnect where the branches join the main vein and then you put a little wire inside and pull it out and that's called stripping and that's a pretty brutal operation it was a pretty brutal operation I used to do it as a junior doctor it worked but in half the people it veins used to come back and that it didn't matter really if you did a great job when your body was trying to heal itself it produce new veins and that's why 50% of people got recurrent veins after stripping and it's why operations for varicose veins got such a bad name because people thought it was fairly useless once you've lasered a few veins you realize that that kind of recurrence level is reduced dramatically it's probably no more than 1% and the advantage in doing laser treatment is that you can mostly do it under local anaesthetic we can treat almost everyone with a laser and the other important thing just on the slide there is that we do over a thousand of these a year that tells you that kind of we're reasonably good at doing them and everyone around us is reasonably good at dealing with them so that's the nurses etc are all used to that procedure.

Sometimes you hear about different grades of varicose veins, so I'll quickly go through this. There's what we call these grade ones; they're just little things on the surface; they're cosmetic thread veins best treated with a little bit of sclerotherapy, but they're not dangerous. Grade two means that you can actually feel them, but again, they are not necessarily dangerous. There's a whole heap of things you can do for them, but basically, you don't have to treat them at all. Troublesome nearly always they've this vein here you can see on the inside of the knee should have been the size of a thread but actually been stretched and so rather like a balloon stretching eventually reaches a size where it starts to give you some grief h of course it can't really go pop but what it does do is split a little bit and when veins start to split they produce a quite an immediate reaction that's called fits and if there's a little bit of blood inside the vein and it clots it's called thrombosis but usually it's about grade three where you start to do things grade four is when it starts we start to push it have something done and that's nearly all always when the skin starts to change colour a little bit and it's or become very itchy or you start to develop eczema and we nearly always push you a little bit to say you should have some treatment you shouldn't leave that alone and then I'll quickly go through those that's if you leave them alone your skin basically becomes so unhealthy that even minor injuries can result in the skin breaking down so sometimes people say well I developed an ulcer because my grandchild gave me a kick or banged his bike against me But actually, that's not the reason why you could have the ulcer. It's nearly always that for some years beforehand, your skin has become unhealthy because of Bar's vein, and you just didn't realise that's what was going on. So, the kind of thing I look for is: have you had itchy skin for a long time that has changed colour at all and gone a little bit red or a bit shiny because they're all signs that your skin's not healthy? Then it just takes a very minor knock and the skin breaks, and then it takes forever to heal, so treatment-wise, there are lots of different treatments. I use a laser, but there's plenty of different treatments, but they're all essentially the same.

So the stripping malarky we've kind of stopped doing that and then we've worked out that if you thread something up the inside of the vein that and it's a heat based treatment you can sort of heat up the vein on the inside and it seals itself as I mentioned on this Slide the veins you see on the surface are not the only thing that's going on nearly always you have a little column of blood so this on this slide this is looking at the inside of the right thigh of a slim leg and the top part is the groin so just at the groin crease is where there's a vein that joins in to the big vein so think of the big vein like the trunk of the Christmas tree and the vein you can see running down the inside of the leg is one of the branches and that's a nice little picture of how we thread the laser up and basically seal and get rid of the vein we use an ultrasound just to check where that watch vein is not working as sometimes you can be surprised and we just make sure that it's sealed.

Now that there are quite a few different treatments available, I would say the heat-based treatments are the best. EVLT is the laser treatment that's Endovenous laser treatment within a vein laser treatment there is another thing called radio frequency ablation and that's essentially electricity but it doesn't sound quite so catchy as a laser so in order to differentiate it you call it radio frequency ablation then there are a few other treatments where you inject something into the vein so with a laser or radio frequency ablation or even a microwave therapy you're threading a little tiny wire up the inside of the vein to damage it and there other treatments involve using a chemical to damage the inside lining of the vein we tend not to do that I mention glue in it because some people have thought it was a good idea to inject a glue up the inside of veins in I can see why but it does leave the glue inside so one of the bigger advantages I think of Endovenous laser treatment or the other heat treatments is all you're doing is heating up the vein you're not leaving any chemicals inside so when you come to me the important bit is although you have a varicose vein or you have some leg ache I just like to make sure that the varicose vein is the cause of your leg ache or the cause of your swelling so it's really important to be seen by I think a consultant surgeon I like to do the scan myself that's to make sure that I can actually treat your vein and also I it's pretty obvious to me if the symptoms you're getting are caused by the vein I can see when I chat with you I give you a couple of options I try my best not to push you into having something done, and really, I just give you the choice and tell you exactly what the score is, so to speak.

Most surgery we do here is day case I would say it's pretty close to 99% and virtually all of it is under local anaesthetic and it's bit like going to the dentist it's not exactly the most pleasant experience but it's not that bad most people are pretty stressed having operations and I think in terms of varicose vein surgery EVLT in terms of stress is a bit like going to the dentist it's not like root canal work and I think most people afterwards think of it as being yeah it was okay not particularly want to have they don't particularly want to have it done every day but it's a 20- minute procedure of which about two or three minutes is me administering local anaesthetic and the anaesthetic is not the same as the jab in your mouth from a dentist so we show you a few pictures of what happens this is somebody who's had treatment to the vein in their thigh now obviously these are quite good pictures so it's almost like an advert but if you look at the leg on the far left you can see the bumpy bits so this patient actually had a vein running the entire length of his leg so 40 cm vein you can't see it but you can see a branch of that vein so the branch comes up onto the surface so what we did here was we lasered the vein running up the inside of the leg and that's it we didn't touch the bumpy bits and that relieves the symptoms fairly quickly and as you can see two weeks or so afterwards the vein is deflated and about 6 weeks it looks okay but I think there's a few little bits there so sometimes people just want to get rid of the ache and pain which case we thread a little laser up and down and other times people say know I want it looking perfect so would you sort of sort me out and that nearly always involves a couple of little tiny nicks in the skin and they're and again it's done under local anaesthetic and essentially we break up the little branch of that main vein so I hope I've explained that reasonably well so just think of your veins like a Christmas tree one branch is not working correctly we thread a little laser up that Branch damage it with heat you need to do a bit of local anaesthetic to make sure you don't feel that and then you end up in a bandage for a few days you're not quite perfect because you can't have a proper shower with the bandage on but you could walk the dog the next day I think it takes about two weeks before you're back to full speed and not thinking about your leg so people who go to the gym normally go to the gym at two weeks people who walk the dog walk the dog the next day everyone after the surgery says you can feel that I've done something most people say it's a bit like a pulled muscle not much worse than that most people take a painkiller of some sort whether that's paracetamol or a little bit of neurophen I prefer neurophen, but if you can't take that, paracetamol works pretty well.

I would say that when you see me or Eddie and have a consultation our whole thing is to work out what you actually want because if you come with a medical problems such as skin that's quite raw we will tailor your operation to fix that other times people come saying well they want everything to look perfect and I happy very happy to treat that as well it just involve a slightly different treatment plan but the most important thing we find is that because we do over a thousand people per year normally the most important thing to me is that people don't have complications that if you come for a problem you fix the problem and the patient goes away and forgets about you a few weeks later we don't overtreat people and likewise we don't undertreat you so we just basically I think it's really important having consultations because you work out what the problem is can you fix it and what's the safest way of sorting that out.

So, we do have a patient testimonial, just a lady who has had treatment here. It's just a few minutes, and sometimes I may have forgotten to mention a few things, so if so, I'll tell you just afterwards, but we'll just start that now.

Jo Crossey

My name is Jo Crossey. I'm 58 years old well it did it was making my legs more uncomfortable as the years went on feeling very heavy and tired especially in the hot weather my feet would swell and just generally feeling achy most of the time I did start working part time and part of that reason was probably unconsciously thinking actually I can't keep on my feet all day long every day we thought it was worth the drive to go and especially when it was a beautifully new Hospital it was it was a very pleasant experience and I wouldn't hesitate to go back again if I needed to in the future my GP referred me on the 22nd of January and I had my consultation with Benenden on the 31st of January so I was quite impressed by that the operation was very straightforward you are given a booklet to explain what the procedure is Mr Chaloner who I saw also talked me through it but obviously when you're in consultation it's a lot of information to take in so I came home and read the leaflet I also looked online for him, and he gave a very good explanation online. Everything that was in the booklet is exactly what happened on the day you were talking through it, and the staff were very helpful, supportive, and talked to you through every process. I felt as if I'm walking into a lovely environment like that that everything was going to be okay that it would be state-of-the-art technology and processes so I felt very confident that I was in good hands my recovery was again like it said on the Tim you know I had to wear my bandages for 5 days and then take those off I couldn't drive for 5 days obviously because they saved for insurance purposes if I had to stop quickly and I or if I was in an accident Insurance might not be so happy if I was work wearing bandages and then I was back to work in a week it was a bit achy and a bit sore but they give you advice about putting your feet up whenever you can putting in local anaesthetics sorry rubbing in local anaesthetic gels wearing a support bandage if I needed to and I did that a few times because the weather was quite warm post-surgery so I made use of those devices and advice and it certainly helped my life now has changed in that I I'm not feeling the heaviness in my legs and I have been wearing shorts I about which I hadn't done before so it certainly boosted my confidence in terms of that and yes getting back to running after two grandchildren if anybody was thinking about having the varicose veins done I would recommend the Benenden Hospital their technology and the process as they do is it's just laser treatment is the way forward in terms of not making you lie in a bed getting you up and getting you mobile certainly Benenden Hospital is highly recommended as far as I'm concerned.

Mr Aaron Sweeney

Okay, so I think we're going to just do a little Q&A session, and I hope if anyone has any questions, whether you think they're stupid or not, don't worry, just ask them, because often, in answering one question, I answer quite a few questions in one go.

Louise King

So, we have some questions already. The first one says I believe my varicose veins would be classified as grade one to two if I did not treat them. How quickly would they get worse?

Mr Aaron Sweeney

There's no guarantee they will, so I think it takes up to 10 years from the time somebody sees a little varicose to when they become quite easily visible or sore. So you might say varicose veins are often thought of as purely cosmetic, but I would say that's not really true. So my plastic surgery colleagues busiest time of the year is January, where everyone decides this year they're going to fix things. For vascular surgeons and vein surgeons, their busiest time of year is at the end of summer. That's not because people don't like to look with their legs; it's because they become painful, and when you ask people when they started being painful, it's nearly always taken many years to get there. most people who have varicose veins have other things to worry about so if they're not that sore they often wait and wait and if you little kids or whatever you're just too busy but when you actually ask how long they've had them often it's 10 plus years from when they first noticed a vein to when it actually became when they actually came to have a consultation to get it treated so if your veins are relatively small there's absolutely no rush I would never push should have something done and I would say to you though that in treating your vein whenever you treat it it's all exactly the same quite often the veins are much the same size when they just start it's just the branches of the vein that's not working get a little bit bigger often the vein running up the inside of your leg or sometimes in the back of your calf is moderately large but the bits you see on the outside are only quite small so and to answer your question it can often take many years before your veins get big enough to bug you.

Louise King

Thank you. This person says they've developed varicose veins after pregnancy, and now they're not putting so much weight on their legs. Will it get better without treatment?

Mr Aaron Sweeney

Kind of so when you in the last trimester your progesterone levels went really high so that didn't cause your varicose veins your varicose veins were probably there beforehand but the hormones made things a lot worse and a baby's head in your pelvis puts a bit of extra pressure on you so veins are often really big post in the immediate few weeks post pregnancy and then they actually get smaller because your progesterone level drops but you still have varicose veins so what normally happens is you're a bit too busy to begin with then you go through a summer period where you notice that your legs are a bit swollen but it's rare for somebody who has varicose vein at the end of pregnancy not to unfortunately keep them The little veins that keep everything going uphill are really flimsy, and the moment they break, they don't repair themselves, so it's just a case of waiting until the vein gets a little bit bigger. Unfortunately, post-pregnancy, if you have varus veins, I think you'll keep them, and it's just a matter of time before they get a bit bigger.

Louise King

Thank you. This person asked, Should they try to walk and exercise less before having them treated so they don't get worse?

Mr Aaron Sweeney

No was the answer so when you walk many varicose veins feel better because you get a type of siphoning effect so if you're cycling a bike or walking the blood has being pumped around your leg so most people when they for example go for a walk the blood supply to their leg will increase twofold at least so often varicose vein blood which is kind of hanging around a little bit it just gets caught up in the rush of blood flowing in and out of your of your leg so I would say you should continue to exercise I can't see any problem with that sometimes if your skin is sore because of a varicose vein exercising can be a bit Troublesome because sometimes makes your skin worse and lastly I didn't mention too much about compression stockings because that's often what everyone is told to wear a compression stocking I don't know how anyone wears a compression stocking for longer than a flight I think they're miserable and if you have to wear a stocking up to the top of your leg you need a suspender belt to keep it up that's just not a reasonable long-term solution to a varicose vein but sometimes people who have varicose veins who are exercising they wear skins or a type of compression stocking and that can make the leg feel quite a lot better afterwards.

Louise King

Thank you, and Derek says he has a visible varicose vein that is not too pronounced, but it can be very itchy, particularly in the winter.

Mr Aaron Sweeney

Yes that's not unusual and the important thing to remember there is what you see on the surface is often just the tip of the iceberg so some people have little tiny veins and visible on the surface and you're wondering how can they possibly complain about that but when I do a scan I sometimes show them that they can have a 50 or a 60 cm vein running from their ankle right the way up to their groin which is not working it's a bit like a yard of Ale sitting under the surface with one little Point that's coming up onto the surface so you see the small vein but there's quite a lot of pressure behind and what's happening is your skin which is trying its best to drain the stuff that's left over um like lactic acid and stuff like that it's just not able to clear quickly enough and sometimes that produces that reaction where you start to get itchy skin so it's a sign itchy skin is a sign your skin has been damaged and nearly always is quite a large vein under the surface which you just can't see especially so because our skin is a bit thicker because we have testosterone girls have nice female hormones which cause lots of trouble in other ways but it give you soft skin but that soft skin is means that veins are much more easy to see so bloke hard hairy skin can hide an awful lot

Louise King

Great, thank you. I never knew that I had only thread veins and no clear varicose veins. Can these be treated more easily than the EVLT procedure?

Mr Aaron Sweeney

Thread veins are actually more difficult to treat than varicose veins and the reason is that thread vein treatments there's quite a few of them the reason is quite a few is because none works perfectly you can use lasers to treat thread veins and have but I found it to be fairly useless so I treat thread veins with sclerotherapy which is an injection but I'm injecting something into a vein to damage it to stop it working and then to allow your body to dissolve it away for big varicose veins when you laser it basically the vein blocks off goes into mush and gets dissolved quite easily but the skin ones thread veins on the skin are more visible so it sometimes takes more effort in terms of coming to Clinic to get rid of thread veins because you have to be very careful you don't damage the good skin around them and also when you damage them it's really obvious to see so they look quite dark or bruised and it sometimes takes three or four goes to treat thread veins sometimes just one but I would say that whilst there are two kind of separate things and I'm always very careful with thread veins to tell people that first of all it's almost never works with just one goes clear therapy and the second thing is it often takes months for your skin to look good enough for you to wear shorts and not to have to explain what the bruises are in your leg so there is a period so from my point of view I've always find thread veins slightly more difficult to treat just because I'm telling people that it takes months to get a good look whereas varicose veins I would treat them and two weeks later they're back in the gym doing their stuff feeling better they may have some bruising but they're back to normal so to speak thread veins because they're not particularly painful and they may annoy you when I treat them they may annoy you a little bit more because they become bruised and battered and then you come back to see me a few weeks later and I do the same thing again so often that treatment episode stretches into many weeks and then we just wait and let everything settle down and that can take another few weeks so it's very important to manage not so much expectations but the time scale Varicose veins quickly return to normal and feel great. Thread veins can be a little bit frustrating. I normally tell people that thread veins are a bit like watching paint dry. You know eventually it'll work, but it just takes forever, and what often happens is that you have treatments. I tell you to wait a month or two, then you look down and realise they're all gone, but the initial bruising is quite significant. It can be quite annoying.

Louise King

Okay, thank you. I guess this time of year is the right time of year to get your spider veins done.

Mr Aaron Sweeney

Yeah, it is, but most people don't look at their legs in the winter because they're too cold, and then the time they do look at them is in the summer when it gets warm, and then I usually say to be a bit careful because I could ruin your whole summer by leaving you with bruise marks everywhere. Of course, remember that once people look at your legs, they ask what happened, and then you're giving the same tutorial on thread vein treatments for the whole summer, so you have to be careful about timing.

Louise King

Okay, we have a few more questions. This person says they're quite hesitant about having the treatment as they feel very faint easily. For example, just having blood tests, how would EVLT compare, and would they see anything unpleasant?

Mr Aaron Sweeney

You can avoid seeing anything because I usually have you lying flat so therefore you don't usually faint we always have the room quite cold because I found that if you warm up the room to make it Pleasant people tend to feel a little bit ill or can faint so I keep the room a little bit cold you don't have to see anything you might be surprised that the lack of blood in a EVLT treatment it's usually kind of minimal but essentially you don't have to look at anything I would say if you people who do faint occasionally people do get a little bit queasy one of the good thing is I don't like it to f beforehand so I' like you to eat normally have your coffee do your normal stuff arrive in and have it done and sometimes people who faint don't have Brey before they come to have things done because they're nervous about it and that can occasionally make a little bit worse the other thing is blood tests are a bit weird they do stick in decent old needles into you the stuff I the needles I use are much smaller than that I couldn't do a blood sample test on the needle I use to um inject local anaesthetic into you in fact I have to use a pump to get the local anaesthetic in because I it hurts my hand because I have to put so much pressure on the needle because it's so it's so small so we use a little pump to help me so you don't have to look at it and most people who are prone to fainting we have them lying flat so at the moment if you feel a bit queasy you let me know we hold off but it's not unusual for people to be queasy with blood samples in fact people often faint when I'm doing a scan on them just because when you stand up looking at something occasionally you can feel a bit weird it's usually very tall heavy Blokes rather than girls surprisingly.

Louise King

Okay, and she says, Can the lumpy purplish veins around the feet and ankles be treated? How soon after total knee replacement can treatment for varicose veins be done?

Mr Aaron Sweeney

Okay so the ones around the ankles they are the most difficult veins to treat by Miles and the reason is your skin is very thin and any treatment you do there you have to be absolutely certain that you don't cause a complication where the skin breaks down and you get a little tiny what I call little spot ulcers and they can be really painful and annoying for everyone so what I usually say to people is if you have a varicose vein have the varicose vein done first that usually deflates everything if there's a big varicose vein I'd of course remove that around your ankle big ones are easy the small ones I usually wait very occasionally if people have an enormous number of thread veins around their ankle I just tell them there's no way I'm going to get rid of all of those that I can make them better but I certainly can't make them go back to the way they were when you're were 16 and there is no amount of treatment that will get rid of those safely but for a lot of them just getting rid of the bigger varus veins they go back to looking what I would call as normal ankles so not lumpy and it is not unusual for people to come saying I just want to wear flip flops again because I'm fed up with all these marks and you that usually you can get people back to wearing flipflops but getting rid of every single thread bin particularly around the ankle can be prone to problems so it can be quite difficult. The second question about the post-knee replacement more or less whenever you like is the answer to that, but I would say the most important thing after an operation is that you're mobile, so if after a knee surgery often people are more mobile than they were beforehand, once you're mobile, it's fine. You can have anything done. Everyone talks about this six-week rule that you should wait six weeks before a flight. Six weeks before an operation, I don't know where people get that. I would say that once you're mobile and feeling okay, I'm happy to get rid of your pain.

Louise King

We need to wiggle the screen. I think it's locked.

While you're doing that, we have our final question. I have early signs of varicose veins, which I'm worried about on one leg. Does it always affect both legs eventually?

Mr Aaron Sweeney

Yeah no so when you come to me and I'm chapping away telling you what's available to you I will say if we treat your right leg you're a chance of that vein coming back is about 1% that doesn't mean that that vein is going to come back because when you laser a vein it's gone so some people will advertise that they have no recurrence rate recurrence rate of zero which is kind of can be true I think about 1% of veins pop back and that's usually an extra vein near where the one you've treated that's pretty rare but what I really tell people is that depending on their age group but if you're in your 30s and you have a varicose vein on one side I think you have a 10% chance of coming back with another vein that's nearly always the other side so 10% probably is the risk of developing a varicose vein on the other leg you might say but I know loads of people who've had vein operations and then you know they've had to go back and have a second operation and then the other went I would say if you had your vein stripped your recurrence ratees much higher than that with a laser treating the vein itself that's causing you trouble that that's not really going to come back to bug you but I think for whatever reason you got veins in the first place which can be genetic or whatever loads of people have tried to work out what the cause is you basically other than gravity we haven't really found the actual cause but I think statistically it's about 10% chance you're going to get a ban the other leg to give you a bit of grief later on.

Louise King

Great, thank you. So that's all of our questions, so thank you very much to everyone who did post a question. It's really good to talk about these things through Mr Sweeny. Could you go on to the last slide? Please thank you. As a thank you for joining this session, we are offering 50% off the value of your consultation. a call back from your dedicated private patient adviser, and we have on the line right now and an email tomorrow with a recording of this session and further information and updates on news and future events, so if you'd like to discuss or book your consultation, our private patient team can take your call until 8:00 pm this evening or between 8am and 6pm Monday to Friday, using the number on the screen on the right-hand side, we'd be grateful for you to complete the survey when this session closes, as it helps improve our future events. If you're interested in other webinars, our next webinar is on new replacement surgery next week, and you can sign up for that via our website. Finally, on behalf of myself, Mr Sweeny, and our expert team at Benenden Hospital, I'd like to say thank you very much for joining us today, and we hope to hear from you soon, so thank you very much and goodbye.