Abstract
As minimally invasive rejuvenation of the face has become commonplace, awareness of other aging anatomical areas has increased. The discrepancy between a youthful appearing face and aged appearing hands is a particular concern since hands, unlike other parts of the body, are visible in almost all circumstances. Resurfacing techniques, from chemical peels to lasers, can improve skin color and texture, but fail to address contour. In recent years, the injection of autologous fat and off-the-shelf dermal filling agents have become standard of care to restore volume loss. This chapter reviews best practices for hand rejuvenation including how to navigate the complex hand anatomy to provide safe and effective results.
59 Filler Finesse: Hands—The Role of Hyaluronic Acid, Calcium Hydroxyapatite, and Autologous Fat
Key Points
Similar to the face, hand aging is a result of intrinsic and extrinsic factors. However, the tendency for even the aesthetically oriented to ignore hand care and protection means that age tends to show on the hands sooner.
Intrinsic aging consists of atrophy of the skin dermis, muscles, and subcutaneous fat. Extrinsic aging from photoaging and the use of the hands for activities of daily living like exposure to water, cleansers, and extreme temperatures speed changes in skin texture, density, and color. Thus, aged hands are characterized by lax, wrinkled, and heterogeneously pigmented skin covering hollow dorsal web spaces, prominent bones, tendons, and veins. In addition to discoloration from photoaging, visible veins can produce a blue hue.
Restoration of a smooth appearing hand requires a combined approach to improve the skin surface and contour. Techniques used include improvement of texture and color utilizing cryosurgery, chemical peels, and energy-based devices. Restoration of a youthful smooth contour include the injection of fat, fillers, biostimulators, and in select cases sclerotherapy to reduce the appearance of prominent vessels.
The first filler to gain Food and Drug Administration (FDA) approval for hand rejuvenation was Radiesse, calcium hydroxyapatite (Merz, Frankfurt, Germany), in 2015. Calcium hydroxyapatite provides long-term improvement in contour and its opaque nature acts to camouflage prominent veins. Restylane Lyft (Galderma, Texas) became the first hyaluronic acid gel filler approved by FDA for age-related volume loss of the hands in 2018. As a hyaluronic acid, Restylane Lyft can be reversed.
59.1 Pertinent Anatomy (Fig. 59.1)
Bidic et al described the anatomy of the hand in distinct layers transitioning from superficial to deep: skin, dorsal superficial lamina, dorsal superficial fascia, dorsal intermediate lamina, dorsal intermediate fascia, dorsal deep lamina, and dorsal deep fascia.
The dorsal superficial lamina is a fatty layer deep to the skin, which lacks sensory nerves and major veins, making it a desirable plane for injections.
59.2 Technique
See Video 59.1 and Video 59.2.
59.2.1 Antiseptic Preparation
Wipe fingers, web spaces, and dorsal hands and wrists with ChloraPrepTM (70% isopropyl alcohol/3.15% chlorhexidine gluconate) or 70% alcohol followed by LasercynTM Dermal Spray (sodium chloride, sodium sulfate, monobasic sodium phosphate, hypochlorous acid [0.009%], water).
59.2.2 Anesthesia
Although topical anesthesia with a lidocaine preparation may be used, it is generally not necessary. When using a cannula for injection, small intradermal blebs of 1% lidocaine without epinephrine are placed at the planned insertion sites.
59.2.3 Injection Technique
When utilizing a disposable blunt tipped cannula, the approach may be distal or proximal. The most common protocols are use of two or three insertion sites between dorsal web spaces or a single insertion site at the junction of the hand and the wrist. Cannula size of 25 gauge, 50 mm or 22 gauge, 70 mm is appropriate and can be passed easily above critical structures.
When using a needle, filler can be placed via micropuncture of multiple dorsal injections of 0.05 to 0.1 cc, four small bolus injections of 0.2 to 0.5 cc, a single bolus centrally, or by linear threading. Injection is performed by tenting the skin and injecting the filler perpendicular to the skin for bolus technique or parallel for threading technique.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
