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Page 2 of 8 García Botero et al. Plast Aesthet Res 2018;5:15 I http://dx.doi.org/10.20517/2347-9264.2018.09

INTRODUCTION
Venous disease is a pathological chronic condition that causes significant morbidity and decreases quality
of life in affected patients. The incidence of chronic venous insufficiency (CVI) varies within a range of 1%
to 40% in women and 1% to 17% in men with a higher prevalence in western industrialized countries.
[1]
However, there is a low registration of cases due to the lack of reporting . Patients with chronic peripheral
[2]
vascular disease of venous origin exhibit secondary ulcer complications in skin and soft tissues of the lower
limbs, with recurrence rates of 45% to 70% per year during the course of the patient´s disease, which makes
it difficult to manage .
[2]
The pathophysiology of the venous ulcers is explained by the venous hypertension which lead to increased
pressure in the distal veins of the leg; fibrin cuff theory in which the fibrin gets excessively deposited
around capillary beds leading to elevated intravascular pressure causing enlargement of endothelial pores
resulting in a further interstitial fibrinogen deposition increase. There is also an inflammatory trap theory
in which various growth factors and inflammatory cells are trapped in the fibrin cuff promoting severe
uncontrolled inflammation in surrounding tissue, thus preventing proper regeneration of wounds. Finally,
the dysregulation of various pro-inflammatory cytokines and growth factors like tumor necrosis factor-
alpha, transforming growth factor (TGF) beta and matrix metalloproteinases lead to chronicity of the ulcers.

In order to determine the type of ulcer, it is very important to rule out arterial etiology. The clinical history
may suggest the venous etiology. Additionally, the physical examination should describe the location, the
measure of the size, the characteristics of the ulcer, the amount and type of exudate, the appearance of the
ulcer bed, the odor of the ulcer and the pain associated with the ulcer.

Ankle brachial pressure index (ABPI) is a noninvasive test to determine the origin of the ulcer, which is
evidence level B. This test uses the handheld doppler ultrasound, which identifies peripheral arterial disease
in the leg. Systolic BP is measured at the brachial artery and at the ankle level.

ABPI = highest systolic foot pressure (dorsalis pedis/posterior tibial artery)/highest systolic brachial BP
a. ABPI 0.8-1.2: indicative of good arterial flow. Suggestive of venous etiology if an ulcer is present
b. ABPI < 0.8: with the clinical picture of arterial disease-arterial insufficiency
c. ABPI > 1.2: suggestive of possible arterial calcification

A meta-analysis study of venous ulcers in an adult population reported a prevalence of 0.12% to 1.1% . In the
[1]
USA, seven million people suffer from CVI, which may be the underlying cause of 70% to 90% of ulcers in lower
limbs . The overall incidence of venous ulcers is considered to increase with age. In this regard, Evans et al.
[3]
[1]
reported a prevalence of venous ulcers of 56% in patients from 55 to 64 years of age, in comparison to 12%
in patients from 18 to 24 years old.

Venous ulcers in lower limbs are one of the 10 most common medical problems in western countries with
a substantial socioeconomic impact due to frequent disabilities . In 1992, The American Venous Forum
[2]
estimated that, in the USA at any point in time, one person/1000 has an unhealed venous ulcer that becomes
[4]
a disability factor in multiple aspects of daily life, including the number of work days on the job. Ulcers in
lower limbs not only affects older people but it also affects actively working people , resulting in two million
[5]
working days lost in USA . Ulcers also diminish the quality of life since they can cause health consequences
[6]
to the patient and to the social security health system as well. The treatment cost to patients with chronic
[3]
venous ulcers in the USA is about three billion dollars per year, therefore it becomes a significant public
health problem . The elevated costs for treating this pathology has resulted in the development of new
[7,8]
treatments with the objectives of reducing healing time, morbidity and associated costs.