© 1999 by the American Society for Dermatologic Surgery, Inc. • Published by Blackwell Science, Inc.ISSN: 1076-0521/99/ • Dermatol Surg 1999;25:145–147

A Visit to the Office of Drs. Margaret and Robert Weiss

William P. Coleman III, MD

Metairie, Louisiana

This is one of an occasional series of articles about visitations tothe offices of prominent dermatologic surgeons. There are anumber of highly skilled and innovative members of our fieldfrom whom we can all learn. Unfortunately, it is impossible for

everyone to visit their facilities and observe their work firsthand. The purpose of this series is to provide a behind-the-scenes look at the day-to-day workings of the offices of promi-nent dermatologic surgeons.

DOCTORS ROBERT AND MARGARET WEISS arewell-known leaders in dermatologic surgery. They havedeveloped a high-profile private practice in suburbanMaryland near Baltimore. Since both have a strong in-terest in teaching and research, they enjoy a locationnear Johns Hopkins Medical Center and the offices ofthe Food and Drug Administration (FDA). They areboth extremely bright and innovative and have man-aged to blend their practice preferences seamlessly, afeat not always possible with a physician husband andwife partnership.

The hallmark of the Weiss’ practice is high technol-ogy. Advanced technologic devices abound in their of-fice: there is a laser in each examination room; com-puters are everywhere; and even the photography isdigital. Drs. Margaret and Robert Weiss are knowninternationally for their work in phlebology and lasersurgery, but they also perform a wide range of cos-metic procedures from chemical peels to liposuction.

In addition to high technology vascular procedures,the Weiss’ perform a great deal of sclerotherapy. Theirsclerosant of choice is sodium tetradecyl sulfate (STS).They prefer using this agent because it is FDA-approved,very safe, and a potent sclerosant. Robert Weiss believesthat the occasional cases of anaphylactic shock reportedhave been due to storing STS in syringes for long periodsof time prior to use. Latex in the syringe plunger may beabsorbed into the stored solutions and initiate allergicreactions in patients sensitive to rubber compounds. Hereports that he has never seen a case of anaphylaxis inusing this agent in thousands of patients.

The Weiss’ use STS in concentrations of 0.1%, 0.2%,and 0.5% for sclerosing telangiectasia and small retic-ular veins. These dilutions are mixed by only one nursein the office who carefully labels each syringe prior touse. The surgery tray for sclerotherapy contains sy-

ringes of each of these concentrations along with nu-merous cotton balls and precut tape attached to thesides (Figure 1). They use special 30-gauge needlesmanufactured in Germany which are more uniform insharpness. However, they are very quick to discard anyneedle that does not pierce the vein smoothly.

Sclerotherapy is carried out with a 3cc syringe andthe needle bent about 30 degrees. Their technique issmooth and methodical. They allocate appointments of15 minutes duration for each patient. After each vein isinjected, Dr. Weiss massages the solution in and the as-sistant immediately covers it with a cotton ball and apiece of tape. Treatment is abandoned at any sign ofextravasation.

Patients are instructed to wear medium supporthose (20–30 mm Hg) postoperatively while upright forat least three days. Ambulation postoperatively is en-couraged. Follow-up treatments depend on the numberof telangiectasia but patients are not encouraged to re-turn for treatment of the same vein for several monthsto adequately assess the effect of sclerotherapy.

Larger vessels are sclerosed with 1–3% STS. TheWeiss’ office is equipped with duplex ultrasonography.This equipment allows the surgeon to precisely locatethe pathologic components of the venous system (Fig-ure 2). Incompetent valves, leaking perforators, andbulging veins can easily be identified and treated. Thistechnology is far superior to the more widely usedhandheld Doppler. However, it is much more expen-sive, costing nearly $90,000 and requiring a special-ized technician. Duplex ultrasonography allows thephysician to precisely sclerose veins under direct obser-vation. One can observe both the needle entering thevein and the flow of the sclerosant through the vein.Postoperatively, the degree of vein wall thickening canbe used to assess the effects of treatment.

Duplex scanning in the Weiss’ opinion is a must forthe logical treatment of varicose veins. New technol-ogy promises three dimensional scanning of veins at areduced price. These new devices will cost about$50,000. Blindly treating large varicose veins runs the

Address correspondence and reprint requests to: William P. Coleman,III, MD, 4425 Conlin Street, Metairie, LA 70006.

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risk of missing high pressure flow points which, if leftuntreated, will allow the varicose vein to recur aftersclerotherapy.

Dr. Robert Weiss is also considered to be one of theworld’s experts in ambulatory phlebectomy. He prefersthis approach to sclerotherapy for varicose veins be-cause it avoids postoperative pigmentation and is moreprecise. All of his ambulatory phlebectomy cases areperformed after careful duplex scanning to ascertainany high pressure inflow points. When these are identi-fied, they are sclerosed to prevent the reappearance of

new varicose veins, except in the case of reflux at thesapheno-femoral junction which is referred for surgicalligation. He favors the use of 3% STS for sclerosing in-competent perforators or segments with leaky valvesabove the portion to be removed. After sclerosing theback flow points he verifies the effectiveness using du-plex scanning and then proceeds with the ambulatoryphlebectomy.

Dr. Robert Weiss performs ambulatory phlebectomyusing tumescent anesthesia, usually 0.25% lidocainewith 1:400,000,000 epinephrine. For a typical case, heemploys about 100cc of this solution which is injectedmanually using a syringe and a 22-gauge spinal needle.Prior to infiltrating, the vein is carefully outlined usingthe duplex scanner. He also verifies the position of thevein with transillumination while the patient is stand-ing. This intense halogen light accurately identifies theposition of the vein and its depth. Reticular and vari-cose veins which absorb red and near infrared light ap-pear dark against a red background. When the patientlies down for the procedure, transillumination can berepeated to be sure that the veins have not shifted. Theexact position of the vein can then be drawn on the skinsurface with a permanent marker.

The ambulatory phlebectomy procedure is performedby Dr. Robert Weiss using a variety of vein hooks.Small punctures are made over the vein every severalcentimeters using a 16- or 18-gauge needle or a #11blade. A loop of vein is then gradually teased to thesurface using a vein hook and then clamped with asmall hemostat. Using the vein hook as a dissector, hethen gently exteriorizes small segments of the vein (Fig-ure 3). Some veins are quite easy to remove in one pieceand others come out in small segments. Postoperatively,

Figure 1. Dr. Weiss’ sclerotherapy tray includes various dilutionsof STS as well as cotton balls and a tube of nitrol ointment in caseof intraarterial injection.

Figure 2. A duplex ultrasonography device.Figure 3. Ambulatory phlebectomy: The vein is exteriorized usinga vein hook after dissecting it free from surrounding tissue.

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the small punctures are closed using a skin adhesive andsmall sterile strips. The leg is then wrapped with a selfadhesive bandage and then covered with surgical sup-port hose exerting 30–40 Hg of pressure. The patient isinstructed to have a quiet evening although some ambu-lation is allowed.

Dr. Robert Weiss checks his patients the next dayand removes the pressure dressing. The effect of thesclerotherapy is verified using duplex scanning. Theambulatory phlebectomy site is observed for bleedingor extensive bruising. A self adhesive dressing is thenreapplied and remains on for 24 more hours. The pa-tient is encouraged to wear support hose for 2 weekspostoperatively except while sleeping.

The doctor reports that most of his patients tolerateambulatory phlebectomy quite well and usually do notrequire postoperative pain medication. Bruising is typi-cal, lasting 1 to 2 weeks. Long term, the small punc-tures leave minimal scars and ambulatory phlebectomyappears preferable to traditional vein stripping.

For smaller spider veins which are difficult to scle-rose and for arteriolar telangiectasia, the doctors pre-fer to use intense pulsed light such as Photoderm VL(ESC Medical Systems, Haifa, Israel) or a long pulse532mm laser with skin cooling (Versapulse, CoherentMedical Group, Santa Clara, CA). Dr. Robert Weiss incooperation with Dr. Brian Zelickson (Minneapolis,MN) has aided in the development of a new coolingdevice for the Photoderm VL which allows him to in-crease the energy levels applied without injuring theskin. He also finds these treatments help in needle-phobic patients although they are most useful only for

smaller caliber vessels. It is not uncommon to observeDr. Weiss performing a variety of procedures on thesame patient: ambulatory phlebectomy, sclerotherapy,and photoderm VL, or Versapulse. All of the latesttechnology is available in this office for each differenttype of phlebology problem.

Drs. Margaret and Robert Weiss are actively in-volved in laser research for hair removal, tattoo andpigmented lesion removal, and cutaneous resurfacing.They currently have seven lasers in their facility. Dr.Robert Weiss prefers using a high powered Erbium:YAG laser for skin resurfacing. Using 1.7 joules (25J/cm2), his goal is to remove the epidermis in only onepass. He employs a scanner with a 30% overlap in a3mm spot size. With this approach he is able to resur-face an entire face employing only topical anesthesia.The small spot size and low pulse rate allow him to re-surface without infiltration anesthesia. He feels stronglythat Erbium:YAG laser resurfacing using higher energyand 2 to 3 passes adds additional thermal effect. Usingone pass with higher energy reminds him of dermabra-sion as the epidermis is literally “blown off” by the la-ser. This of course necessitates a powerful smoke evacu-ator. This is especially important in light of recentfindings that live viruses may exist in the plume fromErbium:YAG laser resurfacing.

The Weiss’ are also involved in a variety of investi-gational protocols evaluating and developing new tech-nologic devices. They are enthusiastic and tireless intheir pursuit of new technology for cosmetic surgery.Their office is a working research lab for the future ofthis specialty.