The hands, just like the face, are highly visible parts of the body. They age at a similar rate and demonstrate comparable changes with time, sun damage, and smoking. Just like in the face, volume loss in the hands is a common indicator of age.
Both intrinsic and extrinsic factors infuence aging of the hands. The epidermis of the skin thins; lentigines, dyschromia, and textural roughness appear; and seborrheic and/or actinic keratosis may develop. The quantity and quality of collagen and elastin decline in the dermis, resulting in skin laxity and thinning. Deep to the skin, atrophy of the subcutaneous fat causes underlying tendons and bony prominences to become visible.
A thorough understanding of anatomy is necessary for successful rejuvenation of the hands with fillers. Histological and ultrasound analysis of the dorsum of the hand have found three distinct fatty-areolar laminae that they called the dorsal superfcial, the dorsal intermediate, and the dorsal deep lamina. The intermediate and deep laminar layers are separated from the lamina superfcial to it by distinct fascial layers, called the dorsal superficial fascia and the dorsal intermediate fascia, respectively. The third fascial layer, the dorsal deep fascia, separates the floor of the dorsal deep lamina from the dorsal interosseous muscles and the metacarpal bones. The dorsal intermediate fascia is an extension of the antebrachial fascia of the forearm, and the dorsal deep fascia is contiguous with the periosteum overlying the metacarpals. The sensory nerves and dorsal veins are contained within the dorsal intermediate lamina and the extensor tendons reside in the dorsal deep lamina. No structures are apparent in the dorsal superfcial lamina. Adhesions between fascial layers were determined to be fascial sheaths surrounding arteries and veins running through fascial septa. These adhesions are located within the dorsal superfcial lamina, numbered 8–12 per hand, and inserted into the dermis, presumably to supply the subdermal plexus.
Patient Evaluation and Selection
The examination of hand look for changes in all component of hand. Skin for solar letigenes and actinic keratosis. dermal atrophy. subcutaneous fat atrophy with prominent veins and tendons. The ageing changes are graded on Merz Hand grading scale.
The volume loss is assessed by clenching the wrist and prominent tendons indicate more subcutaneous fat loss.
The Hand is also examined in hanging position to see distensibility of veins an increase in vein size when hand placed vertical at heart level indicate valvular weakness and benefit from vein ablation therapies.
Filler choice for hand augmentation
The injectable agents that are currently being used for hand rejuvenation are all excellent products. HA, CaHA, and PLLA are all biocompatible, simple to administer, safe, and easily tolerated with or without topical numbing cream.
In June 2015, Merz Aesthetics reported that its CaHA product (Radiesse®; Merz Aesthetics, Franksville, WI, USA) was the first FDA-approved injectable filler for hand augmentation to correct volume loss in the dorsum of the hands.
Several ﬁllers have been used for hand augmentation. Which one should be chosen? This depends on the indication. For patients with severe elastosis, at ﬁrst, a superfcial ﬁller should be used to strengthen the dermis. In the second step, the volume loss can be addressed with ﬁllers intended to increase volume. CaHA causes more swelling and bruising than HA fllers, but it replaces volume effciently, so it is still frequently used in the hands.
There are two techniques: (1) the tunneling technique and the (2) tenting technique.
The tunneling technique can be divided into superﬁcial tunneling (intradermal injections) and subdermal injections.
This technique is best used when the dorsum of the hand is stretched. For this purpose, the patient must form a ﬁst and then, for example, a hyaluronic acid preparation can be injected with a 30 gauge needle
For this technique, a blunt cannula is used. Different cannula gauges can be used at this level including 18, 21, or 25. As the blunt cannula does not allow the penetration of the dermis, a small incision with needles must be made at the dorsum of the hand. The cannula is inserted into this incision, and then the material (usually hyaluronic acid) is distributed subcutaneously by anterograde and retrograde technique. For experienced hands, this is a very fast technique. Regardless of the injection’s volume, slight massaging should be performed to produce an aesthetic and uniform result.
The tenting technique is straightforward. 0.2 ml or more is injected forming a small nodule. This nodule will then be massaged into the dorsum of the hand.
HA fillers dilute it 1:1 with 0.8 mL saline and 0.2 mL of 1% lidocaine with 1:100,000 parts epinephrine. HA gel already contains some lidocaine, the diluent is added primarily for the mild vasoconstrictive effect of the low-concentration epinephrine. Getting a smooth, dilute mixture involves connecting the fller syringe to the diluent syringe with a Luer Lock connector and mixing the products back and forth at least 20 times. Dilution improves distribution of the injected product and helps to ensure that the final contour is as smooth and natural in appearance as possible.
CaHA is an FDA-approved product for the indication and consider the opaque color of the fller an advantage in avoiding the Tyndall effect. Another advantage to CaHA is its high G’ (or stiffness), giving it the best lifting ability of any fller. This makes CaHA economically advantageous because less amount of the product is needed to produce signifcant lift for patients with advanced volume loss. When injecting CaHA, most practitioners will dilute the product 1:1 with lidocaine or a mixture of lidocaine and saline. Most patients will get good correction with 1–3 mL of HA or CaHA per hand. After injection, the hands are massaged to evenly distribute the fller throughout the dorsum.
After injection, the patient should ice her hands for the rest of the day. She should also elevate her hands as much as possible (day and night) and try to avoid salty food for the next 2–3 days. Most swelling occurs immediately, persists for a few days, and then resolves. Occasionally, some patients experience delayed swelling several days to a week after injection. For swelling that persists for longer than 2 weeks, a short, tapered dose of oral methylprednisolone will usually resolve the issue. Bruising after hand rejuvenation by filler injection is common, but is usually mild and short lived. More signifcant bruising can be treated with a pulsed dye laser.
Treatment of Solar lentigines and actinic keratosis
With actinic keratoses considered a precancerous disease state, treatment is not only cosmetically appealing but also medically pertinent. Treatment is often unrewarding using conventional approaches for facial lesions such as cryotherapy, topical fuorouracil, topical hydroquinone, and lasers due to discomfort, scarring, dyspigmentation, lack of effcacy, healing time, and cost. Fortunately, two relatively old treatments for this situation, photodynamic therapy (PDT) and chemical peels, have been revisited with surprising success, offering good clearance and relative ease of application and most importantly excellent patient satisfaction.
PDT is useful in the treatment of photodamage and actinic keratoses (AK). Scaliness and redness of the hands may resolve after 1–3 treatments. The skin is first scrubbed with acetone to remove the lipid layer barrier. Second, a gentle (1–2 pass) microdermabrasion procedure might be done if the facility is available to allow penetration. Application of the sensitizing agent, topical 5-aminolevulinic acid (ALA), is completed first with varying time before treatment. Its recommended that 20% ALA with initially a 2 h incubation time. This is in contrast to the face, where even a 30 min incubation allows enough diffusion of the medication. If a patient has not had signifcant response to this protocol, then the subsequent procedure may use an emollient applied after the ALA to maintain the ALA in solution and to facilitate penetration. The incubation time may also be expanded to overnight.
The choice light source then becomes another decision. Most decisions are obviously to use whatever equipment the clinician may already possess. The peak absorption curves occur at wavelengths in the 410 nm (blue) range . However, additional minor absorption peaks can be found in the green, yellow, and red portions of the color spectra. Thus, light in these wave lengths can, in theory, activate. Blue light offers more extensive absorption (20-fold) and thus the most “potent” activation of PPIX. It also is not as deeply penetrating as the red light.
If the goal is to target epidermal changes (keratoses, lentigos, epidermal atrophy), this is optimal. However, if the goal is to stimulate dermal remodeling then longer wavelengths are ideal. To this end, a continuous wave red light source might be ideal. The devices readily available and used to target other wavelengths are “pulsed” and thus are less likely to activate the PPIX. Long pulsed pulse dye laser (585–595 nm), with the nonpurpuric setting, can be used. In addition, intense pulse light (IPL) may be used and is frequently one of the choices since it is present in many cosmetic offices, it alone is able to treat lentigenes, and various filters can be used to treat. Because of the extremely short pulse time, there might not be enough oxygen available to produce a true “photodynamic” response, but might rather produce a “photothermal” effect to good benefit. The standard treatment is to use the laser or IPL as if one were treating with out the ALA. Immediately following, the patient must practice total avoidance of visible (not just UV) light, because the ALA remains in the skin and can be metabolized to PPIX for up to 48 h. Inadvertent light exposure, such as a 20 min drive home after the procedure, may be enough to produce a brisk phototoxic reaction manifested by excess erythema, swelling, and pain.
Chemical peeling on the hands and arms is more of a challenge because of the uneven nature of the skin thickness and the dramatic hyperkeratosis seen on some portions of the hand. Depending on patient medical history, pertinent prophylactic antimicrobial therapy should be instituted, especially for impetigo and herpetic infections. Prior to peeling, one needs to decide whether superfcial peeling (Jessner’s solution, glycolic acid, low percentage of trichloroacetic acid (TCA) that targets epidermis is the goal or if deeper medium depth (35% TCA pretreated by Jessner’s solution) is to be performed. While a superfcial chemical peel is optimal for patients with mild photodamage and color abnormalities, a medium depth chemical peel is effective for patients with lots of pigment alterations, especially brown and tan pigmentations and seborrheic keratoses.
Patients are pretreated with topical retinoids at least 14 days before the procedure to help with even penetration and this is particularly important for the thicker areas of skin such as the hands. The retinoid is stopped 5 days prior to treatment. Acetone scrub is done to degrease the area. This is followed by one even application of Jessner’s solution. Subsequently, 25–35% TCA is applied in an even pattern in perpendicular directions to maximize even coverage. The chemical should be layered cautiously and before starting a new application, waiting for frost to appear. TCA and Jessner’s solution are “self neutralizing” and the frost is the endpoint. The procedure should not be painful. An even frost demonstrates a successful application. Spot treating diffcult lesions such as hyperkeratotic actinic keratosis with increased number of applications may be necessary. If a patient has not responded to this protocol, it may be repeated in 1–2 months with additional “spot” touching of 50% TCA after the application of the 35% TCA.
The QS ruby and 532 nm QS Nd:YAG lasers have been found to be effective in the removal of lentigines on the dorsal hands. When compared, the QS ruby laser produced slightly better treatment results, but caused more discomfort during treatment. However, the 532 nm QS Nd:YAG laser produced more posttreatment discomfort. Treatment technique is similar to on-face treatment. It should be emphasized that using subtherapeutic fuences in patients with darker skin types may cause posttreatment hyperpigmentation, lasting weeks to months. Aggressive fuences may cause skin sloughing and postinflammatory hypo- or hyperpigmentation. The clinical endpoint of whitening should be sought during treatment and used to adjust laser settings. Wound healing is fastest when the lowest therapeutic fuencies are used. One to three treatment sessions every 3–4 weeks are generally recommended, but adjusted to patient’s clinical response. Laser-mediated PDT may be used for keratoses, lentigines, and photorejuvenation.
IPL laser can also be used advantage being lesser degree of post procedure hyperpigmentation. Protocol used is The 560 nm filter was chosen first to improve not only senile lentigines and diffuse melanin pigmentation but also wrinkles . The parameters most common is emitted spectrum, 560 – 1200 nm; double pulse mode;pulse duration 4.0 ms each pulse with a delay of 30 ms); spot size 8 × 35 mm; and fluence 12 J/cm2. A single shot was delivered to each target area, and the handpiece moved on to eliminate overlap. The clinical end point was slight erythema of the entire dorsum. The filter was then changed to the 515 nm cut-off, at which wavelength there is better absorption by melanin. The parameters were: emission spectrum, 515 – 1200 nm; single pulse mode, pulse duration 3.0 ms; spot size 8 × 15 mm; and fluence 13 J/cm2. Only the lentigines were targeted with a single shot, or two shots if required. The end point was a dark change in the lentigines.
In sclerotherapy, a sterile “sclerosing” solution is injected into the target vessels that induce infammation of the intima layers and destroys the endothelial cells, causing the vessels to collapse and dissolve. Sodium tetradecyl sulfate (STS 0.25%) is the only FDA-cleared sclerosing solution available and is administered by traditional injection technique.
A newer option is foam sclerotherapy. Since commercial preparations of the foam are not available, STS (0.2%) foam, fuid or viscous, must be made in the physician’s offce by either the Tessari or doublesyringe technique. The sclerosing solution (STS, 0.25%) is prepared by diluting 2 mL STS (3%) with 22 mL bacteriostatic water. A 3-way stopcock, sclerosing solution, 3-mL disposable plastic syringe, and 30-gauge needle are needed. First, a syringe containing liquid is connected to a similar air-containing syringe via the 3-way stopcock. Then, for fluid foam, the liquid and air are pumped back and forth 20 times and for viscous foam, five times with additional pressure and seven times without additional pressure. When the foam sclerosing solution is injected into the vein, the foam forces blood from the vein, oxygen bubbles dissolve, and the vein defates.Foam sclerotherapy is currently safe, effective, rapid, sterile, and reproducible. Compared with traditional sclerotherapy, foam sclerotherapy is associated with fewer adverse effects, fewer required treatments, and superior overall beneft. The sclerosing solution and blood have greater contact with each other as the air presses the blood cells against the wall of the vein. Other advantages are that the foam, rather than mixing with the blood, actually replaces the blood and is in contact with the vein for a longer period.
Sclerotherapy causes less trauma than surgical procedures. It is also safe, effective, economical, and less dependent on technique than other procedures. On the downside, sclerotherapy may cause bruising, require several sessions to achieve maximum clinical beneft, and may result in extravasation of the sclerosing solution into the perivascular tissue, leading to localized cutaneous ulcers. (Even the most experienced physician may accidentally inject a small amount of sclerosing solution into the perivascular tissue.