Needles are not only for injection

Stefano Ricci

In phlebologist's armamentarium needles, of different calibers, connected to a syringe, are commonly employed for the injection of sclerosing agents in varicose veins and treatment of telangiectasias; for local anaesthetics infiltration as a preliminary stage of phlebectomy or any other surgical ambulatory procedures ( thrombi removal, biopsy).
A needle may be used also for direct aspiration of haematoma, a lymphatic collection or joint sinovial fluid.
A needle is helpful in an exploration manoeuvre of an unknown fluid swelling or in testing the presence of a subcutaneous calcification, or in any other possible situation in an every day clinical practice.
But a needle may be employed in several other phlebological acts because of the particular shape of its point, presenting two extremel ysharp laterally placed blades.
Initially needles were created just bevelling a thin steel cylinder. The point was sharp but rounded and not edged at all, so that skin penetration was traumatic and painful.
When the be-bevel treatment to the lateral sides of the point was developed which, the tip became much more penetrating ( so called"painless"). In this way, unwillingly, were created two laterally sited micro-blades, so sharp that any tissue can be easily cut ( holding a sheet of paper with the left hand, it is possible divide it in two pieces just passing the point of the needle with the right).
Thinking to a needle like being a very sharp double blade, absolutely non expensive, and very easily available, other uses have been developed.

Needle for skin incision
Muller's technique of Ambulatory Phlebectomy has in limited skin incisions one of the reasons of his popularity, particularly if traditional stripping incisions are compared. Initial 1-2 mm incisions are narrowed by time and experience to 0,5 mm, which is the size of the phlebectomy hook. The size of the varix is relatively less important since a varicose vein can be avulsed through a skin hole 3 to 4 times smaller than its diameter ( with exclusion of truncal varices, abnormal dilatations and post-sclerosis ricanalizations ).
But it is not easy to do so small incisions.
In 1989 Trauchessec et Chaukroun ( 10° World Congress of U.I.P., Strasbourg. Phlébologie 1989 A.Davy,R.Stemmer eds, 1989. John Libbey Eurotext Ltd 1081-1082 )popularise the needle-bisturi idea for phlebectomy incisions, looking for an easy way of limiting the size of skin scars. The needle produces not a hole, like could be thought, but an incision , but has the great advantage of maintaining the same shape while it deepens under the dermic layer, in opposition to N.11 bisturi blade which enlarges while penetrating in the skin.
A French inquiry through 80 of the members of French Society of Phlebectomy concerning skin incision showed that 15% uses exclusively the needle, 17% needle and bisturi, 66% only bisturi. The needle size the most employed is microlance black 17G type, but all the other sizes are, more rarely, employed too. Half of needles users do not need to close wounds in any way ( neither stitches nor strips ).
Personally I use the needle, associated with N.1Muller's hook, for reticular varices. When the vein avulsion needs a bigger hook, then I prefer a N. 11 blade with a wider but less traumatised skin lesion. In any case the skin feature will suggest the best solution. As a general rule if the incisions remain under the size of 2 mm, there will generally be a good heeling with invisible scars at 6months, so that there is no utility in trying to perform at any price too small incisions nor limiting their number. Trauma of the incision's edges is, in fact, the major cause of visible scars.

Needle for vein section
When a vein is pulled out from the skin incision, if a vigorous traction is applied to one end, the vein is easily felt through the skin as a cord , particularly if it is a saphenous trunk, i.e. solid and straight. It is then possible to cut that vein at a variable distance and to pull it out without further skin incisions. A 22G needle is inserted laterally to the vein course in the chosen point and with its point the vessel is clearly felt. This manoeuvre is enhanced by an appropriate traction on the vein. The needle is hold by1¡ and 3¡ finger of the operating hand, grasping the cylindrical part at skin level. The vein section is achieved by a transverse pression of the needle tip over the vein. Two or three motions may be needed , the section being felt by the pulling hand .
The motion of the needle must be limited in the site where the section is performed to avoid lesions to perivenous structures ( partially protected by not being under traction ). The holding fingers must in part exert a constant pressure on the skin to avoid needle slipping out , with consequent awkward scratching marks.
A good indication for this technique is saphenous section under the knee while performing a groin-to-knee saphenectomy with the external ring Mayo stripper, avoiding in this way the distal incision ( Ambulatory Phlebectomy- A practical guide for treating varicose veins. Stefano Ricci, Mihael Georgiev. - Mosby Ed. 1995), During phlebectomy procedures many occasions will occur in which needle section will become helpful.
Post-operative selective compression must overlap also the site where needle-section has bee performed to avoid haematoma formation: the incision not being visible, sometimes the site may be forgotten.

Needle for depressed scars correction
This needle appliance has been called "Subcision" by the suggesting Authors (Orentreich D.S., Orentreich N.,Subcutaneous Incisions (Subcision) Surgery for the Correction of Depressed Scars and Wrinkles - Dermatologic Surgery 1995;21:543-549) and fits perfectly to the correction of phlebectomy micro-incision scar retraction.
This non frequent inconvenience may be secondary to the inclusion in the scar tissue of few connective peri-venous fibres, pulled out during venous avulsion and not sufficiently repositioned at the end of the procedure. This happens more frequently where subcutaneous tissues are smooth and thick ( like at tight) or when a perforator ligature is done ( that's why Muller discourages ligatures ). Another mechanism may be when a wound infection or an inflammatory reaction occur on a micro-incision.
The retraction may be put in evidence by pulling up the skin by non operating hand. Afterlocal anesthesia, the needle is introduced in the skin at 1 cm from the lesion, while the tip is placed under it. BY a transversal movement all the retracting fibres are freed. Additional procedures may be needed in some instances.
Ideal recovery without haematic collections will be supported by a week adhesive bandage compression.
Ugly retracting scars secondary to traditional stripping operations can be improved with this simple procedure too. Sometimes these scars may remain painful for the inclusion in the scar of nervous fibres. Subcision may eliminate this problem.
If the scar is very old, a lymphatic collection may more easily develop, which may need an aspiration treatment; it may be painful for a while but recovers regularly without any problem.

- By pemission: Phlebectomy Newsletter Vol. 1, N.1 1997 -Editor; J.A.Olivencia

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