Reticular veins are blood vessels that are over 2mm in diameter which a 30 gauge needle can safely enter into the vein without collapsing the vein. The reticular veins we can inject for cosmetic sclerotherapy need to be seen and thus above the fascia.  In addition, bulging veins or veins with greater diameters tend to be high pressure veins and should not be attempted using the standard dilutions for sclerosants and require greater intervention.  Cosmetic sclerotherapy allows for us to destroy reticular veins easily as we are able to directly inject FDA approved sclerosants (POL/STS) into the vein to achieve ultimate closure of the vein. The injection technique for successful injection of reticular veins is as follows:

• The needle needs to be bent at a 20 degree angle with the bevel point up.
• Find a straight segment of the reticular vein to inject always try to inject the straightest segment of reticular veins. The flow of blood in larger veins trend always to be in the direction back to the heart.
• Leave a small amount of air in the hub of the needle so that the flash can be seen when entering into the vein.  It is also recommended that you aspirate slowly to confirm being within the vein.
•  If you are unsure whether you are in the vein or not, re-aspirate. Develop a (2) Handed Technique to keep the needle stable throughout the injection. 
• Slowly infiltrate the medicine into the reticular vein and track its progress throughout the vein.  Stay in the vein and keep infiltrating until you feel back pressure or a wheal develops.
•  Stop injection if you start to form a wheal at the injection site.
•  If using liquid, use a 1cc or 3cc syringe – with liquid it is acceptable if the sclerosant enters into telangiectasis.
•  If using foam, a 3cc syringe works well, do not allow the sclerosant to travel to adjacent vein segments especially telangiectasias.  The issue is that you will not have entirely sclerosed the adjacent vein segments and may increase the chance of matting or standing.
•  If the vein blows, try an adjacent segment.
•  Only if you are using foam, if you see sclerosant flowing into adjacent telangiectasias, STOP YOUR INJECTION (if using liquid it is ok for the sclerosant to flow into smaller telangiectasias).
• Veins around the kneecap and behind the knee are especially prone to rupture. Use gentle injection pressure and smaller volumes.
•  For kneecap reticular veins, bend the knee at a 45 degree angle to stretch the skin.  This will allow for a smoother injection.
• Reticular veins that are seen above the fascia need to be injected before the smaller telangiectasias (spider veins, thread veins) as they may be the source for the smaller veins. 
• Remember, before any cosmetic sclerotherapy treatment a cursory medical review (history, prior treatments) and physical observation of the patient’s lower extremities is recommended.

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