Varicose vein removal webinar transcript

Louise King

Good evening. Welcome to today's webinar and thank you for joining. My name's Louise King and I’m your host this evening. Our expert presenters are Eddie Chaloner and Aaron Sweeney

Today's presentation will be followed by a Q&A session. You can ask questions throughout the webinar using the questions panel at the bottom of your screen, or you can save them up until the end. You can ask these anonymously by ticking the anonymous box. Now, if you don't, your name will be shown but I will only use your first name. But please note this is recorded, so your name will be seen for others looking at the Q&A session in future.

I will now hand over to Mr Chaloner. Thank you.

Mr Eddie Chaloner

Thanks very much, Louise, and thanks everybody for tuning in to this webinar this evening. Aaron and I have done dozens and dozens of lectures about varicose veins over the years, but we've never done one in this style, so I hope it goes okay and then you can all hear us and see the slides.

As Louise says, any questions we're happy to take at the end of the presentation.

Now let’s see if the technology will work and let me advance to the next screen!

So, here at Benenden Hospital, Aaron and I have been providing the vein service now for, I think, this is our ninth year. And during that time, we've developed the service quite substantially. The majority of our cases are done by using the Endovenous Laser which, when we started using it in 2003, was a revolutionary technique - but has now become the gold standard for treating varicose veins, not just in the UK but more or less across the world.

Being on the front of the curve as far as the technology adoption was concerned gave us a pretty good early experience and allowed us to refine the technique pretty successfully. So now more or less 90 percent of varicose vein cases can be performed using the laser or adjunctive minimally invasive techniques and the majority of cases can be done under local anaesthetic without the need to put people to sleep.

Now, that's both an advantage and a disadvantage in some respects. Most people prefer local anaesthetic but it's a bit like going to the dentist - nobody particularly enjoys having a load of injections and we do take certain steps to make that easier for people, but the benefits are substantial - being able to do walk-in, walk-out treatment without the need to keep people in hospital or put them to sleep

At Benenden, we do a lot of things. We were quite gratified to note that we're the largest single centre in the UK for doing vein surgery. We perform somewhere between 800 and 1000 cases a year, on a normal year. This year has been anything but normal, obviously, but we are slowly getting back to something like our normal practice.

Aaron will say quite a bit more about that when he does his bit, so I’m now going to talk about what varicose veins are and how they present.

So, normally veins can't really be seen when they're functioning normally in the leg. You can see small blue marks on your skin, particularly if you're pale northern European, but they're more or less invisible.

Unfortunately, when the valves in the veins start to fail, the peripheral veins - the ones that are just underneath the skin - start to swell as they become engorged with blood under high pressure and people notice that by lumpy purple or blue bulging veins visible on the surface of the skin.

As well as the cosmetic appearance, most people tend to notice symptoms of aching heaviness and swelling of the legs and ankles, particularly toward the end of the day if they've been standing up a long time - and also particularly in hot weather. And this is caused by the blood being under higher pressure in the vein as a consequence of valve failure.

Symptoms of cramp, bursting, throbbing, swelling are often reported and the next step is that the veins - if they’re varicose veins for a long period of time, and I’m talking about many years here - start to develop irritation of the skin usually around the lower part of the ankle, on the inside. And this firstly presents itself as tiny little venous blow outs and little purple veins on the surface of the skin - and then progresses to a discoloration, usually a brown discoloration of the skin, associated with dryness and itchiness.

If that goes on for long enough, it can cause skin breakdown into a thing called the venous ulcer which is something to be avoided.

So, we’ll just go through the different types - or severity - of veins in the next few slides - you'll be able to see what I mean by all that.

So, this first picture shows what we call a Type one vein, which are the little cutaneous blemishes – blue, purple or red. Sometimes called spider veins or thread veins or reticular veins. And these are mainly of cosmetic significance; they're not usually symptomatic, they don't create aching or throbbing in the same way as the larger veins do and they can be treated quite simply with injections to improve the cosmetic appearance. Aaron might say more about that later on.

These are Type two veins, and you can see they're slightly raised from the skin, but they're not terribly large and they're not associated with any deeper valve malfunction. And again, they very rarely cause significant symptoms. They're relatively minor problems and they can either be treated by injections or by just physically removing them to make them look a bit better. Again, mostly type 2, mostly cosmetic significance.

Type three is the commonest type of proper varicose vein. Around about fifty percent of varicose veins are what we call Type three, and you can see here on the surface of the leg there are some quite large, twisted, tortuous bulging veins. And this is the type of vein which causes symptoms of aching, throbbing, swelling, discomfort for most patients.

There are, broadly speaking, there are two ways of treating this type of problem. You can either have an operation, which is generally the preferred option, or - if you're not keen on having an operation or not technically suitable – now these can be treated with compression stockings.

Now I mentioned compression stockings really mostly to dismiss them for most patients. They do work in the sense that if people wear them, they will compress the veins and improve the symptoms -  but they don't cure the underlying cause. And the practicality is such that they're so uncomfortable to get on and to take off and you need to wear them during the course of the day, particularly if the weather's hot, that the vast majority of patients can't really tolerate them in the long term. And the surgery is the preferred option - particularly as our techniques now are so much better than they were when Aaron and I were young surgeons.

So, for the vast majority of patients with Type three veins and above, surgery is usually preferable because the results are so good.

The next stage is stage four, and you can just see on this slide that over the bulging veins here there's a starting to become a change in the skin colour, which is usually itchy and sometimes inflamed. So, type four veins are starting to become a serious medical problem.

Type four veins are characterised by this sort of skin damage, and also by conditions such as superficial thrombophlebitis. What that means is that in each of these bulging varicosities, the wall of the vein on the inside becomes rough and this causes the blood to clot.

Patients experience that as an inflammatory condition with a sudden manifestation of a hard, tender lump on the leg which takes about two weeks to settle down on its own, but frequently recurs. And this is an independent risk factor for the more serious DVT or deep vein thrombosis, which is a much more serious medical problem

So, by the time your veins get to stage four they really need to be treated to prevent serious problems occurring in the future.

So, stage five and stage six are really getting quite gnarly. You can see on the left-hand side here - stage five - this is what we call pre-ulcerous.

So, the skin has become quite badly damaged. It's heavily pigmented, quite thin - probably itchy - and just in the middle there's the starting point of a skin breakdown which eventually, if untreated, will lead to type six which is on the right hand side where you've got a full thickness breakdown of the skin and a large venous ulcer.

Now it's important to say that this doesn't happen overnight. This progression through the stages from stage three to stage six often takes many, many years - sometimes decades. So, if you've got varicose veins which are relatively modest, you're not suddenly going to wake up one morning with a venous ulcer. You'll get plenty of advanced warning about that process and have plenty of time to get something done about it. But untreated, around about a third of patients suffering with varicose veins for a long period of time do progress to stage five or stage six.

And the problem, once you get to this point, is that whilst a venous ulcer can be healed, and we do heal lots of them, it takes a great deal of time and effort to get this thing sorted out. It requires a combination of many weeks of extensive compression bandaging, done twice a week by a skilled nurse, usually in conjunction with surgery to get the venous ulcer like this healed up. And on occasions, we need to put skin grafts on them as well - and sometimes once they've been established for a long period of time, they become so chronic that they never heal at all.

So, it's a real source of disability and for particularly older people and the solution to - or the best way of treating - a venous ulcer is not to get one in the first place.

Fortunately, prompt surgery, when it's at stage three or stage four, will prevent further progression to this sort of skin damage and eventual ulceration.

And now I’m going to hand over to Aaron, who's going to talk in a little more detail about the types of techniques we use these days in modern venous practice to prevent this sort of thing from happening, to make people's legs feel better and - let's face it - to make it look better as well.

So, I’m now going to turn my microphone off and hand over to Aaron.

Mr Aaron Sweeney

Hello there. I hope everyone can hear me!

When you come and see us we normally will do an ultrasound scan, and that's really to see inside your leg - because it is often quite surprising that very small veins on the surface can actually be fed by a much larger vein that normally runs up the inside of your leg, and it can be the size of your thumb.

It should be a very small thing that's smaller than a shoelace. However, if the valves break this vein gets a little bit bigger and, at various parts of your leg, the little branches come up on the surface and then you see some varicose veins.

There are loads of treatments available. It used to be that people had cuts in their legs and their veins pulled out. That was called ‘stripping’. That was a reasonable treatment when there was nothing else available but, for the past 20 years or so, new techniques have appeared.

We commonly use a laser - and that's not a James Bond type procedure that you may have seen in Goldfinger - this is a small laser. It looks like a little wire, we thread it up the inside of your vein and we use the heat from the laser to seal the vein so, instead of pulling veins out, we damage them from the inside - and this essentially stops the problem.

There are a number of different ways - different techniques - and when you look online normally huge numbers of different techniques. But they're more or less the same.

There are treatments where you pass something up the inside of a vein and you use heat to damage the vein -  and that can be a laser, it could be electricity or a microwave treatment - and various companies describe that in different ways; they call it radio frequency ablation, for example. But most of these either use laser heat or electricity as a heat source.

There are some chemical techniques as well; they're generally not quite so good and they involve - instead of giving a heat injury to the inside of the vein - we pass a small chemical up the inside and that gives a chemical damage to the inside lining of the vein. We prefer to use a laser because its results are really quite impressive for most people.

The recurrence rate is really tiny; we would normally tell people that after having their vein treated with a laser the risk of a recurrence is about one percent. However, you do have approximately a ten percent chance of another vein on that leg or the other leg becoming varicosed over the following decades usually. So, for most people, when they have their veins treated with a laser, that's the end of their problem.

But it does involve a little bit of discomfort. Again, online, people often focus on the lack of pain involved in having varicose veins treated. I would say that it is a little bit like going to the dentist. It's probably as stressful! The injections that we use for local anaesthesia are much less painful than those the dentists give.

The operation itself may take 20 to 30 minutes and afterwards I think most people feel like they've pulled a muscle. For guys we usually tell them it's like the first football match of the year and often people will take Nurofen or whatever your favourite painkiller is just to keep things going for the first few days.

In general, people can go back to work the next day, but I would say most people take it easy for a day or two. And afterwards we put you in a bandage and that stays on normally for between three and five days. It sometimes can be a little uncomfortable, so people take it off a little earlier; it's not a great problem taking the bandage off - it's a non-stick type bandage, it's a bit like Velcro.

And we don't ask people to wear compression stockings afterwards because we find that either people find them too hard to put on, or they they're too tight or too inconvenient and they often produce far more trouble than if you just leave them off completely.

When you come and see us, as I say, we do an ultrasound scan in clinic. The consultation takes about 20 minutes or so. When we talk to you about the various techniques that you can have, we're really trying to tailor it to you and to make sure that it produces a minimum amount of discomfort. And, of course, our main priority is never to give you a complication that causes you trouble in the future.

As we have said already the surgery is usually done as a day case, so you walk in, walk out. You do need a lift home afterwards.

Sometimes people have, for various reasons, difficulties and that so occasionally people will have a general anaesthetic. That's for people who maybe find it very difficult or stressful, but for most people they come in, go out.

And if we happen to do two legs, they are often a little stressed with the first leg but in general when they come back for the second treatment, they are much more relaxed, and realise it’s not quite as troublesome as they may have expected.

So, this picture is kind of the best picture we could produce really. So, if you could see on the left-hand side of the screen it's a typical varicose vein. When we do treatment, after lasering we don't necessarily remove every single vein in your leg and it normally takes a couple of weeks for the veins just to go flat. About six weeks afterwards though, you get the full effect. So that this is kind of the best picture we have. So, if you have larger veins it sometimes takes a little longer.

So, the main thing to take from this is that it's a relatively straightforward procedure. It is a little stressful; most people walk in, walk out the door. In general, people go back to work as quickly as they wish. I would say that most people don't drive for the first few days, most people find the bandage a little uncomfortable and I think it takes around about a week to go back to the gym and maybe two weeks to run.

I only tell people it takes between two and three weeks for you to forget that you've ever had an operation and for your legs to feel much better.

Louise King

Great thank you, Mr Chaloner and Mr Sweeney, thank you very much - it's really interesting.

OK, so we have a couple of questions that have already come in, but please everyone listening please do ask any question you have - no matter how silly you might think they are, I’m sure they're not. Any questions?

So, the first question I have is:

I’ve had two operations in the 1980s. Does this affect further treatment?

Mr Eddie Chaloner

Yeah, I’ll take that one. The answer is, it depends. For primary patient cases - so veins that haven't been operated on before - the sort of treatments that Aaron was describing – EVLT laser and so on - are almost applicable in almost 100% of patients. And for people who've had previous surgery - and so have what we call recurrent veins - now that changes slightly. And it's very difficult to tell without examining the patient - and most importantly, doing an ultrasound scan.

Having said that, over the years the proportion of patients with recurrent veins who are suitable for minimally invasive treatments has increased substantially. When we started out doing this operation, only around about 50% of people with recurrent veins could be treated with lasering or similar techniques. Now it's more like 80%, so - and the other thing is - we've got more options now in our in our techniques.

So it's very, very unusual that a patient - even with recurrent varicose veins after multiple previous surgeries - can't have a minimally invasive style of treatment (usually under local anaesthetic, without the need to have a massive cut in the leg or go through prolonged surgical treatment like you used to have in the past).

So, in general terms, we can usually do something beneficial. We can rarely make it perfect, but we can improve it in almost all cases. And, for the vast majority of people, we can do it with minimally invasive methods.

Louise King

Okay, next question. What are the benefits of varicose vein treatment at a hospital instead of a clinic?

Mr Aaron Sweeney

I might answer that one. Really, it's - we feel - it's a safety issue actually. We find that in many clinics, I think, push for a particular type of surgery and sometimes you can be in a clinic that's really just a simple room in a building. And I think it is much nicer to be in a hospital setting, and that's really for any kind of reactions you might have to a drug and also from a sterility and cleanliness point of view.

I know in Benenden everyone is checked (including the staff) for COVID before any treatments begin, but also there's a great deal of expertise in a hospital and there's often a larger number of people. So, I would always prefer to - if I’m doing operations – I would much prefer to do it in a hospital rather than in a room in a clinic, for example.

Louise King

I guess also a hospital like ours is rated Outstanding by the CQC so, especially right now, it's really nice to know that we do have such cleanliness state you know – regimens - in place and we do have a zero percent MRSA as well. That's always very good to know. Next question.

Can I exercise or walk the dog soon after an operation?

Mr Eddie Chaloner

Yes, more or less directly actually. Most people can walk the dog the next day. The majority of patients are surprised, in the day or two after laser treatment, how little pain they have, and part of that’s because of the bandage that's put on - which is a bit inconvenient - but most people can walk pretty normally more or less straight away.

The worst bit after surgery is usually when the bandage comes off at about five days. And that's when patients usually get a bit of tightness in the thigh or the lower part of the leg. And, as Aaron was saying, that will stop you going to the gym or riding a bike for a few days but - for the majority of patients - that feeling of tightness and soreness lasts from about day five maybe to day ten.

By day ten it’s more or less resolved, and most people are pretty much back to normal. So, yeah, the straight answer as far as the dog is concerned that you can walk the dog pretty much straight away.

Louise King

Excellent, thank you. Okay, Susan asked why would you be offered chemical rather than laser treatment?

Mr Aaron Sweeney

It depends really. Usually it's because - I can't say usually - sometimes it's because the person offering the treatment hasn't done many laser treatments. The other reason is that chemical, which is normally foam injected up your leg, is actually a very easy treatment. It can be done in outpatients - you don't need to go to a hospital necessarily to have that done.

I find, though, that it produces quite a lot of complications, such as skin damage and sometimes skin staining. So, when people use a chemical, I’m always a little bit careful because you are injecting something inside, it is producing a reaction inside your leg and so - for that reason - I tend not to favour it.

When you use a laser or an electric wire, you're actually just producing heat. There are no chemicals going into your body as such. But in certain circumstances, chemical treatments are actually very good. So sometimes with recurrent veins we use a foam or another chemical to treat them, so the whole idea with us is to stop us doing lots of incisions and pulling veins out.

So, most times we can treat the vein with a laser. Sometimes we do use a chemical as well, so it is quite nice to - when you see whoever you see - that they are able to offer everything rather than push you one way or the other. I hope that answers that.

Louise King

I think so. Okay, thank you. I have a question from Sonia. She asks: do you do treatment for just spider veins?

Mr Eddie Chaloner

Yes, we do. We do quite a lot of that and there are several different treatments you can use for spider veins or thread veins.

The commonest one, and the one we prefer, is using injection sclerotherapy which is a chemical-based technique, as Aaron was just saying, and it's one of the indications we think that’s the best option for the little thread veins to get them to shrivel up and eventually go away.

It's important to say though that it's rare to make somebody's leg look like a marble statue. Again, when you read, well some people write about injection sclerotherapy the thread veins you'd think it was some sort of magic trick. It isn't. It's a very useful technique - done properly in the right way - but it does give you a certain amount of bruising and brown marks on the skin where the vein was for somewhere between eight to 12 weeks.

So, for that reason, patients who are coming for the thread vein treatment often like to have it in the autumn or wintertime. And, if they turn up in June asking to get rid of their veins so they can go on the beach in July, I’m afraid that's unrealistic.

So, the short answer to the question is yes, we do an awful lot of injection sclerotherapy. It works pretty well; most people get a good result, but unfortunately, we're unlikely to be able to put you back on the catwalk or turn you into a marble statue.

Louise King

Okay, that's a good answer, and also quite relevant for me. Thank you. Okay we have an anonymous question and the question is: can varicose veins come back after treatment?

Mr Aaron Sweeney

Yes, they can, and it all depends what treatment you have - so some are better than others - but also, we don't actually know the reason why people develop varicose veins in the first place. We know it's to do with gravity and standing all day and humans are the only people who - only animal who - gets varicose veins, but we don't actually know the exact cause.

Now that means that whatever treatment you have - and it can be wonderful, work wonderfully - but another vein in your body can actually become varicosed, so you can develop new varicose veins.

One of the problems in the past was that, when people had their veins stripped, they nearly always recurred and that was because - when you pull the vein out - your body tried to heal itself and produce new veins that weren't normal. And they often became varicosed and sometimes you would hear stories of your granny having an operation and then having worse veins a few months later. That kind of scenario doesn't really happen with laser treatments; the vein, once you laser it, absolutely disappears so you can tell people that it's 100% successful or almost, but that doesn't stop new varicose veins appearing.

And most people we see, they come to us the first time and they say ‘Will I be back to see you again?’ and I say there's a probable 10% chance that another vein will go in either that leg or the other leg - but it's very unlikely to be the vein that you come to see us with.

Louise King

That makes sense. Okay, Karen asks: please can you give me approximate cost for treatment of varicose veins if they're not advanced?

Mr Eddie Chaloner

Well that rather depends on the circumstances. Benenden Members, I think as provided by the society, similarly were for people who are insured with other providers. For patients who are self-funding, it really depends on the size of the problem - and in order to assess that, one needs to do a proper consultation and scan. And then following on from that, the hospital can give people a quote as to the cost for whatever treatment is required.

As a rough guide (and don't hold me to this because I’m pretty bad at these types of estimates) as a rough guide, it's somewhere between two and a half to three thousand pounds I think, to get one leg done. But the hospital costs it up on an individual basis, once a patient's seen Aaron or myself and we've interpreted what we need to do. And then the hospital translates that into a cost for a self-paid package. Am I right in that Louise?

Louise King

Okay, our next question is from Oliver. How quickly could I be seen and how would I book an appointment?

Mr Aaron Sweeney

Well, there are two or three clinics per week available in Benenden, so the simple answer to that is you can be seen either the same week you ring up or the following week afterwards.

In terms of operations, it really depends when you want to have it done. Most people, I think, have their procedures done within a few weeks - I think - so very rare; there's no waiting list as such so there's always gaps in the clinic who when people ring up they can be immediately put on a on a clinic list.

You can, I believe, ring directly Benenden Hospital and be put through to the person who is dedicated at giving you an outpatient appointment.

Louise King

Okay thank you. We have another anonymous question and it seems to be someone who has some understanding of the way veins work. The question is: after removing the function of a part of a vein (an affected vein) is there any way to prevent extra stress on the collateral veins or is it considered that the varicose vein is so affected that it can't safely deal with blood traveling through it anyway?

Mr Eddie Chaloner

Yeah, there's no real downside to getting rid of a varicose vein; they're not functional, they're not contributing anything to the flow of blood out of the leg and sometimes we're asked “Would it be a problem if we needed a vein for a heart bypass if you'd had them removed because they were varicose?”

And the answer to that is no because the varicose vein itself, because it's so damaged by being stretched, is unsuitable for use as a coronary graft or as a conduit for any other type of surgical bypass procedure.

So, as my mother used to say ‘It's neither use nor ornament’ and, you know, it's functionally irrelevant and it doesn't look very nice, so getting rid of it doesn't inconvenience you.

There are one or two technical exceptions to that general rule and that usually is where a patient has had very extensive DVT - deep vein thrombosis - in the past. Because sometimes patients who've had very, very extensive deep vein damage actually rely on varicose veins to allow the blood to get out of the leg.

And that's one of the important reasons that the cases are properly assessed by a surgeon who is familiar with vein surgery in the widest sense, because that's the sole and relatively rare occasion where you can actually make somebody worse by operating on their veins - rather than making them better. So that's really to be avoided and the best way of avoiding that pitfall is to know about it, to consider it when you see the patient.

Louise King

I’ve got a few more questions - another anonymous one. If varicose veins reappear after treatment, do they tend to be as severe as the ones that have already been treated?

Mr Aaron Sweeney

No, is the usual answer to that. We would normally tell people less than one percent of people come back within the first year with a varicose vein, where they had one previously.

Occasionally people do develop one nearby, and they're normally really small and can be treated with a small amount of foam or an injection. On the very rare occasions when veins come back quickly, that's because we haven't done it correctly and haven't given you enough laser energy for example. And that is incredibly rare. So, when you have a scan - before you have your operation - we work out which vein is not working correctly - that's the one that we treat.

We don't treat veins that look normal so, very occasionally, one of those can start to appear within a few months of an operation but normally it's small and can be treated with simple injection. It's really rare for us to have to bring someone back to an operating theatre twice within a year.

Louise King

Okay thank you. If, after the ultrasound, you find the veins are larger than they appear from the outside - would you suggest a general anaesthetic?

Mr Eddie Chaloner

That really rather depends on the circumstances. The run of the mill condition is that’s not necessary. The criteria for suggesting a general anaesthetic is usually more on patient preference than on technical aspects around the anatomy of the case. So, and then as Aaron said, that’s often patients who are very, very nervous about having a local anaesthetic and just prefer to be asleep and there's nothing wrong with that, and some patients are more comfortable doing it that way.

There are one or two technical circumstances where we recommend a general anaesthetic, based on the ultrasound and clinical assessment; and that's usually in quite complicated cases where we're going to have to do quite a lot of work and probably make some small incisions - and on the basis of what we know we can safely and comfortably do under local anaesthetic, for a technically very difficult case, sometimes we think we're going to push the envelope there, and rather than have a patient be uncomfortable on the local anaesthetic table, we think it's preferable to go for general anaesthetic in the first instance.

But that's quite uncommon. I’d say, as a rough guide, maybe that's one case a year out of - I don't know - somewhere between 800 and a thousand that we do at Benenden.

So, the majority of cases that we do under general anaesthetic are on the basis of patient choice rather than surgery choice

Louise King

Okay, interesting, thank you. Just two more questions now. One from Irina. Are there any dietary and lifestyle advice, I guess, before or after surgery and how much do hormones and therefore pregnancy affect the formation of varicose veins?

Mr Aaron Sweeney

Well the pregnancy issue - it's quite interesting. Girls produce a hormone called progesterone; it goes very high in the last three months of pregnancy and it also gets a spike just before a period time. And progesterone relaxes things to allow a baby to pop out, but it also relaxes varicose veins, so it is why some poor girls have a truly miserable time with varicose veins and haemorrhoids and swollen ankles during the last trimester and – indeed - why sometimes people notice their ankles will swell just before they're having a period.

It doesn't necessarily mean that you have varicose veins, but it's just your veins have become more relaxed. So, what that means is that hormones play a role in the symptoms of varicose veins. Heat plays a role, so in summertime people often get much more painful veins, because they've dilated.

This time here, especially this week, most people with varicose veins have no trouble at all because there's not much blood going to their skin, so their veins tend to be a little smaller.

And there are treatments in Holland and Barrett, for example, where you can get red vine leaf and – I think - it's horse chestnut and they do seem to reduce a little symptoms people get with varicose veins, but there's no real medication that's going to cure them. They're a mechanical problem; there's a valve that's broken - it's allowing blood to go in the wrong direction down your leg, filling up the vein under the skin. And it's that filling of the vein that gives you the throbbing and the ache and fills up your skin and makes it a little bit more itchy than it should be.

But, in general, if you look at when people come to us - girls tend to come slightly quicker than guys (although you know it's still a 50/50 split more or less) but girls tend to come because they have had a miserable time either in the last few months of pregnancy or around period time. And that ache is what prompts them to come - usually ten years before men come. But they come with the same symptoms (throbbing) and it just happens to be a little bit later in life.

Louise King

Thank you. Our last question is from Jenny and she asked: would thread veins be treated at the same time as the fat, bobbly ones?

Mr Eddie Chaloner

Well, the answer to that is they can be - but we usually don't. And the reason for that is that thread veins are often seen in in conjunction with ‘fat bobbly veins’ or what we would call proper varicose veins. And normally when you've treated the underlying - what we call ‘venous reflux’ - the damaged valves, the whole system decompresses, and quite a few of the thread veins will just recede just having done that.

So generally with the way we do it is that we treat the big problem first and then we let everything settle down for a few weeks and you sometimes find that, when you're then going into the tidying up phase of dealing with the thread veins, you've got a lot less to do than you would have otherwise.

And there's very little point in treating thread veins on their own if varicose veins are already present, because you just don't get a good enough result then the thread veins keep coming back.

So, the order of batting, if you like, is to deal with the big problem first that will - in turn - reduce the number of thread veins. And then you don't have to do quite so much sclerotherapy treatment afterwards to arrive at the optimal cosmetic result

Louise King

Thanks. Thank you very much, that's the end of today's presentation and Q&A session.

So, I’d just like to say thank you very much, Mr Chaloner and Mr Sweeney, it's been really interesting. I hope everyone watching has found it of use so thank you to our audience.

You will receive a short survey afterwards; really grateful if you could spare a few minutes to just respond to that. It just helps shape our future webinars.

Our next event will be on the 6th of March and that's with Mr Liam Stapleton and it'll be on podiatry.

And so, on behalf of Mr Chaloner and Mr Sweeney and everyone at Benenden Hospital and everyone on our technical team behind the scenes, I’d like to say thank you this evening and thank you for joining us and we'll see you soon. Thanks very much. Goodbye.