The rise of CLaCS and aesthetic phlebology

Kasuo Miyake

Kasuo Miyake is a leader in Cryo-Laser and Cryo-Sclerotherapy (CLaCS) treatments for varicose veins. Based in Sāo Paulo, Brazil, Miyake heads the vein clinic founded by his late father, Hiroshi Miyake, a pioneer in the field of CLaCS and aesthetic phlebology. In this article, he writes about the developments seen since his father started his career, and outlines where we are today.

One of the studies by Dr Hiroshi Miyake, who passed away in 2018, was based on the surgical treatment of telangiectasias, especially when the telangiectasias are grouped together. Hiroshi Miyake performed microphlebographies in the 1970s, and he found, having injected veins with contrast, that the grouped telangiectasias were connected to some deep veins. Some were found to be connected to the saphenous veins. So, he began to perform phlebectomies with crochet hooks in order to disconnect the telangiectasias from these deep veins, which then facilitated the treatment of veins that had not responded to other treatments.

As time went by, new technologies began to emerge. Augmented reality, which came about in 2005, quickly became a subject of study. The Clínica Miyake team was the first institution to study augmented reality and its application to varicose vein treatment— using the technology to look for feeder veins. They were the same feeder veins that Hiroshi Miyake studied in the 1970s. The only product that introduced augmented reality and its practical applications in the medical field was VeinViewer (Christie Medical Holdings). The equipment was developed in order to better locate veins in the arm, and with no comparable devices available on the market, there were no competitors.

At Clínica Miyake, we studied augmented reality and its use in the treatment of those telangiectasias which strayed from its original purpose. Since we were able to see where the feeder veins were located, we were able to use the CLaCS technique in order to treat the feeder veins directly. We also used augmented reality in order to classify veins and to mark the location of the veins for surgical procedures.

At that time, we thought this was a revolutionary thing, but unfortunately, the vascular surgeon community was very sceptical towards it. Now, 14 years later, this technology is finally becoming more popular, even becoming a discussion topic at many conferences. It is interesting to observe how the same thing happened with ultrasound. Due to a matter of low-definition ultrasound imaging and scepticism, it took a long time for ultrasound to be used in the field of aesthetic phlebology. Not to mention the cost, but nowadays for those who have their own clinic and have specialised in phlebology with aesthetic ends in mind, it is almost mandatory to have an ultrasound and augmented reality for diagnosis and treatment.

Therefore I think all of aesthetic phlebology will lean towards centralisation. The doctor will likely have all of the equipment in order to diagnose and treat, including an operating room, all in one clinic. Gravitating towards “de-hospitalisation” will reduce dependency on a hospital structure for surgeries or treatment.

Another facet which is on the rise is photo-documentation. When discussing aesthetic treatments, the government or the healthcare insurance should not pay. Aesthetic phlebology is a private treatment and, being a private treatment, the cost is much more elevated. It is an elective treatment and is therefore regarded as superfluous. Because of this, it is extremely important to perform photo-documentation. If a patient is not satisfied, he or she may return to complain, especially for a treatment with such a high cost. Similarly, if the patient thinks the treatment was not effective, it is important for the doctor to have proof of what the affected area looked like prior to treatment. It is for both the doctor and the patient: the doctor may know if the treatment method was effective and the patient can see the gradual improvements. Furthermore, if a patient’s case truly does not improve, then the doctor will know that he or she needs to alter the treatment plan.

In other news, as the founder and president of the International Meeting on Aesthetic Phlebology (IMAP), we are very excited about our 9th edition on May 3rd to 5th in Sāo Paulo, Brazil. The first IMAP was executed in 2011 with the objective of contributing to the development of Aesthetic Phlebology in the world. Since then, all eight editions have had renowned professionals from more than 30 countries. At IMAP 2018, we received more than 350 doctors, and IMAP has established its place as a global reference in the advancement of venous treatments. We already have the esteemed Alun H Davies as our keynote speaker, along with an extensive list of international speakers and sponsors. IMAP’s official language is English, and we welcome all vascular surgeons/physicians.

Kasuo Miyake is a vascular surgeon and owner of Clínica Miyake in Sāo Paulo, Brazil.


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