Sun-mottled, wrinkled, veiny hands shout one’s true age despite how young the face might look. Surgical hand-lifts are not an option, but aesthetic practitioners can subtly hide telltale signs of hand aging with a range of products and procedures.
"Two main factors have led to an increase in patients requesting hand rejuvenation,” says Neil Sadick, MD, founder of Sadick Dermatology in New York City. He has written several articles on hand rejuvenation and regularly lectures on the topic at dermatologic congresses. “First, patients are now familiar with devices and fillers for the face and feel comfortable and confident with them. Secondly, a plethora of new types of treatments can quickly, safely and effectively restore volume, smoothness and softness in the hands.”
Chemical peels, intense pulsed light (IPL), broad-band light (BBL, Sciton) and laser therapies can improve lentigines and uneven skin tone, while autologous fat and dermal fillers can help remedy soft tissue loss. Many of the same dermal fillers routinely used in the face are also effective for hands, but currently only two products have FDA approval specifically for hands. The first, Radiesse (Merz Aesthetics), a calcium hydroxylapatite (CaHA) dermal filler, was approved in June 2015 to treat volume loss in hands. The second, Restylane Lyft (Galderma), became the first hyaluronic acid (HA) filler to gain FDA approval for hand rejuvenation in May 2018.
“Since the approval of Radiesse, we have had a consistent number of patients asking about this procedure,” says Joel L. Cohen, MD, clinical educator and director of About Skin Dermatology and DermSurgery serving patients in Denver. “With the approval of Restylane Lyft, I hope the marketing efforts of the two companies will be much more effective at growing the hand filler market.”
His typical hand rejuvenation patients are those who have successfully received fillers for facial concerns and want to similarly improve the appearance of volume loss in their hands. Dr. Cohen uses the five-point Merz Hand Grading Scale that he helped to develop to show patients how their hands rate. He then shows them before-and-after photos of patients he has personally treated to demonstrate how fillers can improve volume loss.
Miguel Angel Aristizabál Torres, MD, an aesthetic medicine specialist who practices in Bogotá, Colombia, regularly trains other doctors around the world in aesthetic techniques. He says that increased awareness of the aging process of the hands has led to an increased interest in hand rejuvenation. “Women and men today are less tolerant of the contrasts between youthful facial skin and hands with wrinkles, and visible veins and tendons. We create social media campaigns specifically showcasing hands before and after volume correction or before and after solar lentigines removal,” says Dr. Torres.
New Orleans dermatologist Mary P. Lupo, MD, agrees that today’s patients show more interest in hand rejuvenation, but the number of hand rejuvenation procedures in her practice has increased only slightly. “The barrier is that people often run out of discretionary income after completing the face,” she says.
While most hand rejuvenation patients come from among those who have successfully used fillers for facial rejuvenation, Phil Werschler, MD, of Werschler Aesthetics in Spokane, Washington, reports attracting another patient group as well: “Recently, we have been seeing male-to-female transgender patients for hand ‘softening,’” he says. “And it makes sense: Adding volume increases the appearance of ‘softness’ and beautifies the backs of hands to complement fingernail grooming.”
“Hands start to lose volume due to fat atrophy around age 40, leading to thinning skin, fine lines and bulging veins,” says Dr. Sadick. “Moreover, as one of the most exposed-to-the-elements body parts, hands are likely to have more photodamage.”
For pigmentation complaints, Dr. Werschler recommends topical tretinoin, TCA peels, intense pulsed light (IPL) and lasers. For volume loss, he suggests dermal fillers or fat transfer, and for general skin aging, platelet-rich plasma (PRP) therapy.
“My favorite combination is Radiesse followed by Fraxel (Solta Medical) and continued home care including tretinoin/hydroquinone and daily sunscreen use,” he says.
Dr. Sadick uses a three-step combination approach. “First, I perform liquid or foam sclerotherapy to remove bulging veins and smooth the surface of the dorsal hand. About a month post sclerotherapy, I restore lost volume with a dermal filler. I prefer Radiesse as it has a great safety profile, lasts two to three years and has biostimulatory properties that promote new collagen formation. Finally, usually the same day that I do the filler injections, I treat the area with either a Fraxel (Solta Medical) or Enlighten Picosecond (Cutera) laser to remove brown spots, stimulate epidermal turnover and even skin tone,” he says.
Dr. Lupo successfully used Sculptra to rejuvenate hands until encountering a “severe delayed nodule” in 2007. “Since then I have used Radiesse,” she says. “For age spots, I like Fraxel Dual (thulium wavelength) best. I no longer do sclerotherapy since Radiesse hides the veins too.”
Dr. Torres uses Q-switched and picosecond lasers to treat brown spots. Two weeks before the laser treatment, he starts patients on topicals to prevent post-inflammatory hyperpigmentation. He prefers CaHA for volume loss because of its rheological properties (High G) and duration.
Dr. Cohen treats lentigines with a BBL or Q-switched laser just prior to injecting filler and performs both treatments during the same appointment.
For the filler procedure, Dr. Cohen often uses a 25g cannula to deliver Restylane Lyft or Radiesse. “I generally use two entry sites about 2cm below the wrist, injecting from proximal to distal towards the fingers to deliver volume to the entire dorsal hand,” he explains. “This is easier than using multiple needle entries, and many patients prefer fewer needle punctures.” He notes, however, that using cannulas is an off-label delivery technique for hand augmentation at this point.
“I use cannulas virtually all the time,” says Dr. Werschler. “They are safer, hurt less, bruise less and are exceptional for hand injections. My favorite is the 25g, 2-inch size. A single pilot hole placement at the extensor crease on the wrist allows placement throughout the entire dorsum down to the base of the phalanges. Additionally, the cannula will help prevent inadvertent placement of product into the extensor tendon sheath, which is where lumps, bumps and nodules occur, regardless of the product used.”
Dr. Torres emphasizes the safety aspects of cannula delivery. “It is important to remember that the dorsal hand vein network that gives rise to the cephalic and basilar veins over the forearm is located superficial to the fascia, just below the skin; hence, the risk of vascular or structural damage is high,” he says. “I recommend cannulas with a gauge of 24 or 22. Small gauge cannulas behave as needles and can penetrate these structures.”
Dr. Werschler also prefers Radiesse to Restylane Lyft and other HA fillers for most patients. “Since dermal thinning is usually the primary concern and Radiesse has proven collagen-stimulating properties, it more directly addresses the actual concern than an HA-based filler,” he explains. “I’ve used Restylane Lyft for hands, and it does work nicely. However, I’ve had patients come back with complaints of discoloration. In fair-skinned patients (who are the most likely to request hand rejuvenation) there seems to be a predilection for the Tyndall/Rayleigh response, resulting in a blue to gray discoloration, especially when [the hands are exposed to] bright sunlight. I suspect this is because of the hands’ more horizontal positioning, combined with the refractive aspects of the loose aerolar tissue between the skin and underlying aponeurosis.”
While Dr. Werschler considers cannulas the most significant technique improvement, he also offers several other tips to improve safety and outcomes. “I like to use the AccuVein viewer to help identify the vascular network on the backs of hands, especially if the patient has particular social concerns over bruising,” he says. “I have the patient hold a squeeze ball, or similar object in the hand being injected with slight (~ 30 degrees from horizontal) flexion. This allows the long cannula to glide easily in the loose aerolar space and is ergonomic for the injector. I like the patient to be sitting upright with her hands on a pillow over an absorbent disposable pad for the injection. Immediately after the injections we use ultrasound gel (or something similar) and manual massage to evenly distribute the product. We then place a gauze pad followed by a cold pack over the dorsum and ask the patient to place her hand under her buttock.”
“Swelling and bruising are the most common side effects of delivering fillers to improve volume loss in hands, as well as discomfort,” says Dr. Cohen. “Bruising is usually gone in five days or so, but swelling can persist eight to 10 days in some cases. The accompanying soreness can be an issue for those with professions that focus on the hands, such as pianists or surgeons.
“We are always looking at how we can make these procedures even safer,” he continues. “One way is to be diligent about aseptic techniques. We go beyond just a rubbing alcohol skin prep and use a chlorhexidine scrub to minimize infection risk.”
Contraindications include any active infection or skin disease, a history of keloids or irregular wound healing, allergies to any of the products used, Raynaud’s and bleeding disorders.
“Relative contraindications include recent use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or herbal supplements known to affect coagulation and hemostasis,” says Dr. Torres. “Patients with autoimmune diseases are treated on a case-to-case basis, taking into consideration prior treatments. Finally, I do not recommend volume correction in patients with a history of carpal tunnel syndrome or other conditions affecting the radiocarpal joint, because of the risk of post-procedural pain that can later be attributed to the procedure.”
Make sure patients remove rings and agree to leave them off for at least 24 hours, says Dr. Lupo. Failing to do so could result in an emergency room trip and the need to cut the rings off—an embarrassing outcome for the doctor and one the patient won’t easily forgive.
“Because of the functional nature of hands, it’s important to take a careful history of any range-of-motion limitations, work type, unusual swelling, neuropathies or other medical or occupational conditions that could be affected,” notes Dr. Werschler. “Post-injection swelling, edema, bruising, tightness and stiffness are common in patients with a history of arthritis, those who are on anti-platelet or anti-thrombotic therapies, and those with vocations that require excessive use of hands or practice martial arts. You can still treat most of these patients after a discussion of the risks and benefits, but they need to be aware that dermal filler treatments of hands are not without potential complications.”
Dr. Werschler and Dr. Torres are monitoring developments in regenerative medicine that could lead to breakthroughs in hand rejuvenation.
“Stem cells, PRP, PRF (platelet-rich fibrin), SVF (stromal vascular fraction)—these are where the future lies, not just for hands but for aesthetic medicine in general,” says Dr. Werschler. “While we are getting close, we haven’t yet arrived from a technology and technique perspective.”
Dr. Torres is looking forward to a new protocol created in Spain using an autologous gel composed of platelet-rich fibrin plus growth factors. “This gel provides an acceptable lifting capacity and has an important collagen stimulatory effect even though its volume correction lasts up to four months,” he says. “This product will not replace tradition-al fillers but is another valuable tool in the aesthetic medicine/cosmetic dermatology armamentarium.”
Linda W. Lewis is the contributing editor of MedEsthetics.
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