"The worst enemy of fine art is a frazzled leg". Raiberti

In the XIXème Raiberti, a doctor and poet from Milan, understood the close relationship between leg beauty and health at a time when legs were hidden by long clothes.

Many years later, far from that time when the body was not revealed, the 3ème The millennium brings to the fore, in Western societies, a clothing fashion that does not shy away from showing off the body and especially the legs, playing on their grace, their harmony, their sensuality.

This quasi-permanent presence of the legs in our visual field explains the social role they have today, reminding us of the close link between the aesthetics of the legs and phlebology.

The beauty of the legs (photo n°1) has become an essential element of the female aesthetic. To have beautiful legs and to keep them in their vigor and their harmonious proportions is the wish of all women.


Of the beauty of the legs.

How many women give up taking advantage of certain fashionable clothing fantasies that reveal their legs?

How many women feel uncomfortable when summer and the beach are mentioned? 

There are many situations that can create complexity.



Today, modern phlebology (1, 2), aware that no phlebological lesion is completely innocent from an aesthetic point of view, has assimilated this change in patient demand.

There are essentially 4 types of treatment requests (3): telangiectasias, varicose dilatations, fat legs and cellulite.

The demarcation between aesthetics of the legs and aesthetic phlebology becomes very tight. 



Aesthetics is the science that deals with beauty and the feeling it brings out in us. The criteria likely to characterize the beauty vary with the times, the cultures. And within these criteria, the rarity comes to sublimate this beauty.

The works of painters and sculptors through the centuries are testimony to this. The canons of beauty like beauty itself are ephemeral. They depend on religious and cultural criteria and vary according to the times.

It is necessary here to reread the description of the female beauty at the time of the renaissance. 

In "Les Dames Galantes" by Brantome (1540-1589):

"To make a woman perfect and absolute in beauty, she needs thirty beautiful sis...

Three white things: skin, teeth and hands.

Three blacks: eyes, eyebrows and eyelids.

Three reds: lips, cheeks and nails.

Three long ones: body, hair and hands.

Three short ones: teeth, ears and feet.

Three large: the chest or breast, the forehead and the eyebrow.

Three narrow ones: the mouth, the belt or waist, and the foot entrance.

Three big ones: the arm, the thigh and the big leg.

Three untied: fingers, hair and lips

Three small ones: nipples, nose and teste."



"I spend my life looking at women's legs": This sentence has nothing exceptional, except the fact that it comes out of a woman's mouth. Symbolizing the dictatorship of the legs complex in some women, who spend their time to scrutinize the possible defects of the legs... of other women.

According to a SOFRES 89 survey, % of French women attach great importance to the aesthetics of their legs: too white, too fat, too many varicose veins: a BVA survey shows that a large proportion of women are too complexed to reveal their legs in hot season.

Le Parisien "reveals the sad results of a BVA survey : 40% of them are complexed because they do not find their legs fine enough and a third of the women prefer not to show their varicose veins. 38% of them will thus not exchange their pants for a skirt.

In phlebology, the aesthetic request corresponds to a request from the patient for a transformation of the appearance of his leg. 

We can distinguish between conscious and unconscious demand.

  • The conscious request is favored by the fashion of clothing which frequently reveals the lower part of the body, hence the greater frequency of aesthetic questioning in women.

  • The unconscious demand. Some psychiatrists have taken a close interest in the problem.

The genesis of this unconscious demand would have several sources.

  • The leg, the organ of walking, favors displacements, decreases distances and thus plays a social role by allowing approach and contact, thus a communication.

  • The foot is its extension and its symbolism is complementary to that of the leg.

  • The leg is today an important sexual symbol.

Hence unconscious motivations favored by a desire for communication and a desire to be desired.


Patient motivation is conveyed by 2 principles:

    • Aesthetic concerns for the vast majority of them

    • And for prevention purposes for a more marginal segment.

The aesthetic demands are focused on 2 axes:

    • Skin color anomalies (varicosities, varicose veins and pigmentation)

    • Shape abnormalities (cellulite, edema and fat legs).


The beauty of the legs depends mainly on 3 criteria: length, circumference and shape.

The shape depends on 2 factors:

    • Muscle mass.

    • The location of the fat.

The important element is the muscular body of the soleus and twins.

According to some authors, the ideal circumference is between 31 and 36 cm. Certain aspects are considered as beauty criteria: long, straight and thin legs. As soon as the axis of the legs diverges from the vertical axis, it deviates from our perception of beauty.

The curves of the legs are very delicate.

  • The convex curve inside the leg is short and very pronounced, followed by a long concavity.

  • On the outside of the leg, the convexity is longer and smoother. It is followed by a short, smooth concavity that ends at the outer part of the ankle.

Can we define the scientific criteria of a beautiful leg (photo 3)?

A certain number of objective criteria allow us to define what we call a pretty leg and to refine the therapeutic result.

  • The length of the leg H: on the diagram below (foot - knee) it must represent 26 % of the individual's height.

We can schematically divide the leg into 4 cylinders with delicate curves:

  • The upper part of the calf (75 % of the leg height),

  • The lower part of the calf (50 % of the height of the leg),

  • The transitional part and the ankle.

  • C1 & C2: define the upper ¼ of the calf. D: defines the middle of the calf. E: defines the entrance to the ankle that is the lower ¼ of the leg.

Photo 3: scientific criteria for a beautiful leg.

In posterior vision:

  • The width of E must be 50 % of C .

  • The width of B must be 50 % of C + E.

In side view :

  • The width of E is 70 % that of C.

  • The width of B must be 50 % of C + E.

The curve is thus more marked in posterior vision and more progressive in lateral vision.

There are 3 possible scenarios:

  1. E is > 50 % of C: in cases of lipoedema, lymphedema and various edemas.

  2. E is > 50 % of C: this is amyotrophy

  3. C > 50 % of E: this is muscle hypertrophy


30 % of women consider that their legs are too big.

The repercussions of fat legs are aesthetic, but also functional with sensations of pain, skin tension and heavy legs.

  • The chronic fat leg (4,5) is a frequently encountered clinical picture.

  • This name covers a wide range of pathologies.

  • The chapter of the big legs (32) is very broad and complex.

This morphological anomaly is a daily challenge for the therapist who takes care of them.

  • Etiological challenge, requiring a fine clinical acuity and often the help of high resolution ultrasound.

  • Therapeutic challenge, because the treatment may require knowledge of various techniques and equipment.

6 clinical situations are encountered:

  • Lipoedema (photo 4)  (6,7)

  • Cyclic edema syndrome,

  • Lymphedema (8, 9),

  • Phlebedema,

  • Edema of general cause (iatrogenic, endocrine, renal and cardiac insufficiency),

  • Mixed forms.


The assessment of venous disease today is based on the Echo-doppler examination.

This examination has completely revolutionized the understanding of varicose disease and its corollary treatment.

It allows today to make an à la carte treatment according to the origin of the reflux.

  • Crossectomy and stripping were gradually abandoned (10) which, until recently, was a quasi-religious therapeutic dogma for some.

  • But endovenous treatments, which are performed under ultrasound, are becoming the reference treatments.

They are done on an outpatient basis and are not very disabling.

A catheter is introduced into the varicose vein.

3 processes are possible:

- the endovenous laser (11)

- radio frequency (12),

- echosclerotherapy with micro-foam (13,14) which revolutionized the chemical ablation of varicose veins.

  • Microfoam echosclerotherapy allows a high concentration of sclerosing agent (mainly polidocanol and sodium tetradecyl sulfate in France) on the surface of air microbubbles. Their sclerosing action is maximal.

The foam is produced by a vortex effect obtained by connecting 2 syringes to a 2 or 3 way connection system.

A syringe contains 1/4 of sclerosing solution and 3 quarts of air.

A dozen of stirring back and forth between the 2 syringes allows to obtain the foam.

Its stability is about 60 seconds. Its big advantage is to be able to treat all types of varicose veins: truncal and collateral.

  • It can also be used in microsclerotherapy to treat telangiectasias, but caution is advised, as pigmentation is a concern.

  • Finally the phlebectomy (15,16) remains an excellent alternative for removing collateral varicose veins and varicose veins of the feet and hands.


Depending on the study, between 67 and 80 % of women (17,18 ) have varicosities.

They increase with age and vary by ethnicity: higher frequency in Caucasians and lower in blacks.

In addition to the visual approach and Doppler ultrasound, which have their limitations, other means of exploration are useful in the diagnosis and therapeutic procedure of telangiectasia.

Transilumination is the GPS of the aesthetic phlebologist.

Transilumination (photo 7)

Transilumination (photo 7,8) (19,20) is certainly the most useful (almost indispensable) observation technique for the therapist interested in the treatment of telangiectasia.

This process consists of sending a light beam emitted by an optical fiber onto the skin. It diffuses through the subcutaneous tissue and is reflected on the fascia.

The reflected beam is stopped by the subcutaneous formations forming a shadow on the skin.

The depth of visualization is less than 4 mm. It allows the demonstration of reticular networks, reticular varicose veins and possible connections between telangiectasias and reticular varicose veins.

  • It must allow us to answer 2 questions:

    1. Is there a reticular vein near the telangiectasias?

    2. If yes, is this reticular vein pathological or not? In other words, does it feed (reticular varicose vein) or not the telangiectasias?

The semiology of transilumination (15) allows to decide: in case of reticular veins feeding the telangiectasias, the feeding networks are then injected in first intention with increased efficiency, rapidity and stability of the results in time.

Photo 8. Transillumination with reticular varicose vein.

The therapeutic approach mainly uses 3 processes:

  • microsclerotherapy,

  • thermocoagulation,

  • the laser.

Microsclerotherapy (21, 22, 23, 24)This is often the first-line treatment for telangiectasias, a grade 1 C recommendation.

Reticular varicose veins (diameter between 1 and 3 mm) and telangiectasias (diameter < 1 mm) can be treated.

In theory, we can treat up to 0.3 mm in diameter (diameter of the 30 G needle) but with a little experience we can treat almost all telangiectasias. It consists of depositing active principles in contact with the wall of a dilated vein (small caliber less than 2 mm) in order to trigger a controlled reaction leading to fibrosis of the vessel.

The intravenous injection of a sclerosing product, in liquid or foam form (19, 20 , 21), dissipates the fibrogenic film that protects the intima and alters the venous endothelium. The fibrin invades the venous wall causing an inflammatory reaction that will lead to fibrosis in several months. Many parameters must be defined before each treatment.

It is a treatment that is not trivial and therefore the respect of the rules of treatment and the therapeutic strategy must be well thought out.

Microsclerotherapy can be used to treat almost all types of telangiectasias.

Many variations are possible :

  • use of several needles left in place,

  • the micro foam (25, 26)

  • the liquid,

  • the sclerolaser,

  • Hyaluronic acid injections which do not close the vessel but restore it to an almost normal size.

The laser (27, 28) is an essential technology in a technical platform of aesthetic phlebology.

Even if microsclerotherapy is the reference treatment, it cannot have an absolute monopoly.

Some patients have little or no response to microsclerosis (12), patients with allergies or when the diameter of the telangiectasia is less than 0.3 mm (size of the smallest needle). There is therefore a place for laser treatment.

We mainly use 2 wavelengths: 534 nm ( KTP ) and 1064 nm ( NdYAG ).

  • Schematically the KTP for very fine and superficial vessels

  • and Nd Yag for deeper and more dilated vessels.

From a pragmatic point of view, setting the parameters is very important:

  • the smaller the vessel, the higher the fluence, the shorter the pulse time and the smaller the collimation diameter.

  • Conversely for larger vessels.

The principle of thermocoagulation is based on the action of a radiofrequency current, of the order of 4 million Hertz, producing a thermal lesion on the wall of the varicosities.

The thermal effect is due to the vibration of the atoms around the tip of the needle. Technically, the needle crosses the skin perpendicularly to come into contact with the telangiectasia. The needles are placed every 2-3 mm along the vessel.

The disappearance of the vessel is instantaneous and is replaced after a few hours by microcrustellations that will disappear in a few weeks.

There are no lasting side effects to report, apart from the occasional pigmentation.

This treatment (24, 25) developed by the author (29, 30), which is accessible to most physicians, gives interesting results, but only on small-caliber vessels and on areas that are more bony (malleolus, foot, high lateral leg). 

In practice: there are 3 main types of telangiectasias:

  • fed by a reticular varicose vein,

  • isolated,

  • angiomatous (sheet-like).

In case of reticular varicose veins, microsclerotherapy is necessary.

In case of isolated telangiectasias (photo 9) 2 parameters are involved: the diameter of the vessel and its location.

Photo 9. Isolated telangiectasias.

If the telangiectasia is very thin and close to the bone (ankle, foot) thermocoagulation is the first-line treatment.

In other cases, laser treatment is highly recommended.

In case of angiomatous layers (photo 10), microsclerotherapy is indicated.

Photo 10. Angiomatous layer.


Numerous studies and observations suggest that cellulite (orange peel skin) is the result of an imbalance between 2 mechanical forces: dermal resistance and the intra-lobular pressure of the superficial hypodermis.

High resolution ultrasound (photo 8) defines 2 hypodermas:

  • a superficial cellulite site (anechoic space under the dermis)

  • and a deeper, echogenic space the deep hypodermis.

When the intra-lobular pressure of the superficial hypodermis becomes greater than the dermal resistance, cellulitis appears clinically.

This increase in pressure in the interlobular spaces is related to the presence of edema and fibrosis.(31)

Fibrosis often complicates the evolution of chronic edema.

Lymphatic stasis feeds this edema.

Photo 11. Ultrasound of the dermis and the 2 hypoderms (superficial and deep).

2 compressive events explain this stasis: the accumulation of fat or the presence of edema in the deep hypodermis.

The therapeutic approach has two purposes: to increase dermal resistance and to decrease the edema of the interlobular space.

Various therapeutic procedures claim a dermal stimulation action via fibroblasts; others have a vascular tropism and participate in the reduction of edema.

So 2 vascular targets: the lymphatic and the capillaries.






In a socio-economic environment where body image is a real dictatorship, the presence of generous shapes and/or cellulite is often frowned upon. The local accumulation of adipose tissue is a secondary sexual characteristic that concerns many areas: the hips, thighs and buttocks (saddlebags)It can occur on the upper medial side of the thighs and on the medial side of the knees. Lipoedema sometimes only affects the legs and ankles.

A new therapeutic approach: 


Many therapeutic solutions are available to us. Not all of them have a real interest. The trend is towards treatments that are the least traumatic possible, while still having proven effectiveness.  Micro-vibration, an innovative and relevant technology, perfectly matches this equation. Developed by a team of Italian researchers and confirmed by numerous studies, this therapy has an indisputable potential in the treatment of cellulite.


The rotation of a cylinder of 55 hypoallergenic silicone spheres produces a low frequency vibration on the skin. The direction of rotation as well as the pressure exerted cause a parallel pump effect. ET restores the balance of the extracellular matrix and microcirculation, activates the metabolism and stimulates the lymphatic flow. In the case of lipoedema, a cellulite form that is difficult to treat, according to the work of Arezzo, more than 50 % of reduction in hypodermic thickness is obtained in the medial supramalleolar region.


THE ET In aesthetic medicine, it can treat cellulite, localized adipose tissue, and is of real interest for facial rejuvenation, for the treatment of scars, lymphoedema, lipoedema and venous oedema. In sports medicine the indications are numerous.


Aesthetic phlebology was born from the evolution of the therapeutic management of our patients. The demand for aesthetic phlebology treatment is exponential.

It concerns an increasingly young population that is often very concerned about its image and its aesthetic representation, whether it be on the legs, the body or the face.

The physician must respond to this subjective quest with a structured and scientific approach.  

Having a phlebological culture and specific training are essential to satisfy this important treatment potential.

  • Therapists sometimes tend to hide this demand (due to lack of training).

  • Angiologists in their university hospital curriculum are well trained in heavy pathologies, but they only briefly review superficial venous disease.

  • The creation of a university diploma in Phlebology in France is quite recent.

  • In other countries, depending on the country, it is often the vascular surgeon, the cosmetic doctor or the dermatologist who does the treatment.


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Aesthetic health based on scientific evidence

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