**6.8. Surgical management**

Surgical procedures are often applied when dressings and compression therapies fail in the venous ulcer treatment [76]. There are two approaches in surgical treatment of venous ulcers: ameliorating the cause of the ulcer and treating the ulcer itself by surgical procedures [4].

Superficial venous insufficiency is present in about forty to fifty percent of patients with venous ulcer [2]. Superficial vein surgery, simply comprised of ligation or sclerosis of the long and short saphenous systems, with or without communicating vein ligation or sclerosis, may be useful in patients with superficial venous insufficiency but only when deep veins are compe‐ tent [120]. Although superficial vein surgery does not affect the success of improvement in venous ulcers, ulcer recurrence has shown to be reduced by the procedure [120]. Subfascial endoscopic perforating vein surgery, a new surgical technique, has proven to be effective in patients with perforator vein insufficiency [8]. In this technique, perforator veins are ligated by an endoscopic camera system through a small incision. This procedure has low complica‐ tion rates and morbidity [121]. As mentioned above, it has been shown that venous surgery does not seem to improve the healing but delays or reduces the recurrences [76].

Radical excision of the diseased area including the whole ulcer bed, the fibrotic suprafascial tissues, and the abnormal superficial and perforating veins, and flapping this large soft tissue defect have been shown to be successful in a few cases. However, highly invasive character of this procedure limits its application [122].

Skin grafting has proven beneficial to heal large‐size recalcitrant ulcers [120]. Contamination with microorganisms and risk of trauma are the main factors that should be kept in mind when grafting for ulcer [123]. Split‐thickness skin grafts, punch grafting, and meshed grafts are some of the grafting methods used in venous leg ulcers. While pinched grafts are suitable for small ulcers, meshed grafts are useful for large highly exudative ulcers [4].

### **6.9. Prevention**

In the period that patient has no venous ulcers, it is important to keep in cooperation with and offer some simple lifestyle changes to the patient. Leg elevation is thought to provide venous return, reduce edema, and improve cutaneous circulation [98]. Elevation of the legs above heart level for 30 minutes three or four times a day is a simple and effective method in reducing edema and improving the cutaneous microcirculation in patients with chronic venous insufficiency [87]. Calf muscle pump dysfunction is usually present in venous insufficiency and venous ulcers. Appropriate calf exercise regimes have shown to be useful to improve muscular endurance and may even provide proper functioning of the muscle pump [124]. Even in the first stages of chronic venous disease, starting the effective treatment of symptoms will help for preventing progression to ulcer. The most important step is to persuade the patient, with risk factors or early signs of venous insufficiency, to apply the appropriate compression. It is important to make the patients understand that compression therapy will be a lifelong therapy. The elastic bandages with the appropriate length and strength of compression must be worn daily. Moreover, weight management of obesity, regular exercise programs (with the aim of improving the efficiency of calf muscle pump), and treatment of varicosities (endove‐ nous laser ablation, radiofrequency ablation, and other approaches to repair veins and valves) should be planned. Thrombophilia is increasingly recognized as a major risk factor for DVT, which is the most common identifiable risk factor for the development of chronic venous ulcer. More than 40% of patients with CVU have at least one thrombophilia and chronic venous ulcer patients with post‐thrombotic disease are shown to have lower response rates to medical and surgical therapy. Thrombophilia screening is suggested to be performed in patients who have venous ulcer before the age of 50 to stratify the thrombotic risk and start the appropriate prophylactic and therapeutic management. Good nutrition is important in venous ulcer patients as protein deficiency is associated with impaired wound healing. Also smoking affects healing via decreasing the fibroblast proliferation [76]. All these factors together will help to prevent the progression of chronic venous disease to ulceration. Commitment to lifelong exercise programs, weight control, and protection against skin injury is necessary for the prevention of venous leg ulcers [31, 125].
