Dear Dr. A \u201cI have ugly spider veins, so I went to a vein clinic. Before I met the doctor an ultrasound was done of my legs by the ultrasound tech. After waiting 40 minutes I got to meet the doctor who told me that I have varicose veins. I asked the doctor what about my spider veins? The doctor told me that unless I have the varicose veins treated my spider veins will not go away.\u201d https:\/\/youtu.be\/e7Phv9RWZj8 This has become a common complaint of patients when they come see us for a second opinion. The following is my answer to the patients: I ask my patients if they are having symptoms that interfere with their quality of life. I ask them if their primary concern is how the leg looks or how the legs feel. I look at their legs to see if they have ropy varicose veins or smaller spider veins. After collecting the above information, I divide the patients to the following 3 categories \tThere are patients that have spider veins with no symptoms (leg pain, leg ache, leg swelling, restless leg syndrome ect.) I tell them there is no need to look at their larger deeper veins with an ultrasound. I recommend cosmetic sclerotherapy for these patients. I also tell them that they should not have more aggressive treatment done (EVLT, EVLA, RFA, VNUS, vein stripping ect.) \tThere are patients that have ropy varicose veins and spider veins with no symptoms symptoms (leg pain, leg ache, leg swelling, restless leg syndrome ect.) I tell them if they want spider veins treated and don\u2019t care for the ropy veins they should do that. If they want the ropy veins treated, we offer them various cash options for the extent of just pulling the vein out to treating the underlying varicose veins. Patients ask me, \u201cisn\u2019t it better that we fix all the vein problem\u201d. My answer is, we should not fix what is not a problem. These patients don\u2019t like the way their vein looks and that can be fixed without spending an arm and a leg. \tThere are patients who have symptoms with or without visible spider veins\/ varicose veins. I will do the ultrasound myself and work with the patient, our patient care coordinator and insurance company to get all or part of the treatment covered. These are the only patients who need to have ultrasound regardless of presence or absence of visible veins.