Hand Rejuvenation

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.

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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.

 

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Anatomy

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.

hand anatomy

hand Rejuvenation

 

Patient  Evaluation and Selection

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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.

Merz-Hand-Grading-Scale

 

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The volume loss is assessed by clenching the wrist and prominent tendons indicate more subcutaneous fat loss.

 

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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.

Fillers

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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.

   Techniques

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.

  Superficial Tunneling

Technique

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

  Deep  Tunneling

Technique

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.

Tenting  Technique

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.

Photodynamic Therapy

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.

Hand rejuvenation

Chemical Peeling

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.

 

Lasers

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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.

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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.

Sclerotherapy

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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.

Fat grafting

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One thought on “

  1. MiaST Sage says:

    I can’t stop myself from reading and checking all the videos! You can really tell what my age is just by looking at my hands. After reading this, I realized that filler treatment is a need for me. Looking forward to have this treatment soon!

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