Clinical experience with complications of hand rejuvenation

Revitalizing Hands: A Comprehensive Review of Anatomy and Treatment Options for Hand Rejuvenation

Dorsal hand rejuvenation is gaining popularity as a solitary procedure and adjunct to face and neck rejuvenation treatments. As the hands age, the skin loses elasticity and becomes more translucent, the veins, joints, and tendons appear more prominent, and the bones become more noticeable. These changes are due to intrinsic and extrinsic factors. Current treatment methods include the injection of dermal fillers and autologous fat grafting. Anatomic studies to ensure the successful implementation of rejuvenation procedures identified three separate fascial layers in the dorsum, from superficial to deep. More recent re-evaluations revealed a less distinct, inseparable, sponge-like fascial layer. All authors agree that the superficial dermal layer is probably the optimal location for the injection of volumizing materials because it is free of anatomical structures. Many methods for harvesting, preparing, and injecting fat grafts to the dorsum of the hand have been described in the past three decades. Both filler and fat-graft procedures are performed on an ambulatory basis under local anesthesia. Good results with low postoperative and long-term complication rates and high patient satisfaction have been reported.

LGBTQ+ Perspective in Hand Surgery: Surgeon and Patient

Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) individuals and patients face high levels of discrimination both in the workplace and in the clinic setting, with more than 25% of LGBTQ+ people experiencing discrimination in the workplace due to their sexual orientation. Hand Surgery stands to continue to advance by encouraging the brightest students into the field no matter their background. LGBTQ+ patients also have specific needs within the field of Hand Surgery, where we are uniquely positioned to treat them or guide them by being well versed in the needs of the community.

Clinical characteristics of and therapeutic approach to complications due to the injection of foreign material in the face: a retrospective study

Background Soft tissue fillers are increasingly used to rejuvenate and beautify the body and face. Unknown foreign materials that have not always been proven to be safe for human use have been used for injections in the past. Various commercial injectable materials have since been developed and are used; however, the number of complications has increased as soft tissue fillers have increased in use.Methods A retrospective study of 39 patients with facial foreign body complications who underwent surgical treatment between March 2012 and February 2021 was conducted. Patient information was analyzed, and patient satisfaction was evaluated using a questionnaire after surgical treatment. A comparative statistical analysis was undertaken.Results Patients who underwent procedures performed by unlicensed practitioners tended to be older at the time of presenting to the hospital (P=0.004). The degree of satisfaction after surgical repair was significantly lower following the direct approach than after the indirect approach using a bypass incision (P=0.044). The degree of satisfaction significantly decreased (P=0.001) as the number of operations the patient received increased.Conclusions When treating complications caused by foreign material injections, surgical removal is a more reliable method than treatment with medication or further injections; however, treatment decisions should be made thoughtfully, and many factors must be considered. Patient satisfaction can be improved by reducing the number of operations and making the appropriate corresponding incisions or excisions to treat the full range of symptoms caused by foreign substances and by indirectly using bypass incisions to mitigate post-surgery scars.

Autologous fat transfer for hand rejuvenation: systematic review on technique and outcome

Background

Age-related changes to the dorsum of the hand present as dyschromia, soft-tissue atrophy, and volume loss, resulting in wrinkles and prominent deep structures. Volume augmentation by means of autologous fat transfer (AFT) is one of the options to rejuvenate the hand; theoretically, autologous fat is the ideal filler because of durability and biocompatibility.

Objective

This systematic review aims to summarize and describe the current evidence on the technique, effectiveness, and safety of AFT in hand rejuvenation.

Methods

Three major databases, PubMed, Embase, and Web of Science, were systematically searched up to November 2020 for studies reporting on AFT and hand rejuvenation.

Results

A total of 10 articles were included, reporting on a total of 320 patients treated by AFT to improve the aesthetic appearance of the dorsum of the hand. Some degree of postoperative oedema was present in nearly all patients. Other complications were infection (0.67%), cysts/irregularities (1.3%), temporary dysesthesia (5.3%), and ecchymosis (7%). There were no major complications. Of all patients, 97.6% self-reported to be satisfied with the result.

Conclusions

Overall, by combining the current evidence, AFT is considered a promising and safe technique to rejuvenate the aging hand with very high patient satisfaction. Future research, using validated patient questionnaires, objective volumetric measurements, and longer follow-up, is needed to confirm these results.

Level of Evidence

3

A Review of Hand Feminization and Masculinization Techniques in Gender Affirming Therapy

INTRODUCTION

Anatomical characteristics that are incongruent with an individual's gender identity can cause significant gender dysphoria. Hands exhibit prominent dimorphic sexual features, but despite their visibility, there are limited studies examining gender affirming procedures for the hands. This review is intended to cover the anatomical features that define masculine and feminine hands, the surgical and non-surgical approaches for feminization and masculinization of the hand, and to adapt established aesthetic hand techniques for gender affirming care.

METHODS

The authors performed a comprehensive database search of PubMed, Embase OVID and SCOPUS to identify articles on the characterization of masculine or feminine hands, hand treatments related to gender affirmation, and articles related to techniques for hand masculinization and feminization in the non-transgender population.

RESULTS

From 656 possibly relevant articles, 42 met the inclusion criteria for the current literature search. There is currently no medical literature specifically exploring the surgical or non-surgical options for hand gender affirmation. The available techniques for gender affirming procedures discussed in this paper are appropriated from those more commonly used for hand rejuvenation.

CONCLUSION

There is a dearth of literature addressing the options for transgender individuals seeking gender affirming procedures of the hand. Though established procedures used for hand rejuvenation may be utilized in gender affirming care, further study is required to determine relative salience of various hand features to gender dysphoria in transgender patients of various identities, as well as development of novel techniques to meet these needs.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. .

Multiple Knoten am Handrücken infolge einer kosmetischen Behandlung mit Hyaluronsäure

Bei einer 47-jährigen Frau erfolgte eine kosmetische Behandlung zur Faltenreduktion beider Handrücken in Form einer Unterspritzung der Falten mit Hyaluronsäure. Wenige Tage später trat eine Schwellung beider Handrücken mit Hitze- und Spannungsgefühl auf. Unter Kühlung und topischer Pharmakotherapie war die Schwellung rückläufig, jedoch traten deutliche Knötchen im Bereich beider Handrücken an den vorher injizierten Arealen auf, die trotz regelmäßiger Unterspritzungen über mehr als 2 Jahre nicht abheilten. In einer dermatologischen Begutachtung wurden Fremdkörpergranulome diagnostiziert, deren Auftreten nach Fillerinjektionen mit Hyaluronsäure in die Handrücken, wenn auch selten, beschrieben wurde. Ein Behandlungsfehler konnte daher nicht bejaht werden, da es sich bei den Granulomen um die Verwirklichung eines seltenen, aber typischen Risikos des Eingriffs handelte. Jedoch blieb offen, ob eine rechtswirksame Einwilligung auf der Basis einer Aufklärung über sämtliche für die Einwilligung wesentlichen Umstände vorlag. Im Falle kosmetischer Eingriffe stellt die Rechtsprechung an die Aufklärung besonders hohe Anforderungen; sie sollte „schonungslos“ sein, damit der Patient entscheiden kann, ob er ggf. bleibende Entstellungen oder gesundheitliche Beeinträchtigungen in Kauf nehmen will, selbst wenn diese auch nur entfernt als eine Folge des Eingriffs in Betracht kommen. Die Beweispflicht für die Aufklärung trägt der Arzt; kann er dieser Pflicht nicht genügen, tritt für die Folgen der Behandlung eine Beweislastumkehr ein, d. h. dem Arzt werden eventuelle Schäden zugerechnet, auch wenn der Eingriff lege artis erfolgte.

Hand Rejuvenation by Targeted Volume Restoration of the Dorsal Fat Compartments

BACKGROUND

Recent anatomic findings suggest aging-related changes of the complex fat distribution in the hand.

OBJECTIVES

To rejuvenate the aging hand, we developed a targeted fat grafting technique based on the physiologic fat distribution of the hand.

METHODS

The dorsum of both hands was examined in 30 healthy volunteers of different age utilizing B-mode ultrasound to determine physiological changes of the aging hand. Additional anatomic dissection was performed in 10 hands of five fresh cadavers to establish the anatomic basis for the targeted restoration technique. A total of 17 patients were treated for hand rejuvenation utilizing this technique and followed up for at least 6 months. The posttreatment outcome was assessed through B-mode ultrasound, 3-dimensional (3D) topography scanning, and a patient satisfaction survey.

RESULTS

According to the fat distribution of the dorsum, hand aging was divided into three grades: (1) mild atrophy with rhytides; (2) moderate atrophy with exposed veins; and (3) serious atrophy with exposed tendons. Anatomic findings showed the existence of distinct superficial and deep fat compartments. The average fat grafting volume was 25.5 ml per hand dorsum administered in one or two procedures. Patients were monitored for 8.3 ± 2.6 months. After 6 months, a volume gain was found in all patients. The degree of aging was significantly reduced. The majority of patients (94.1%) were satisfied with their results.

CONCLUSIONS

This study provides the anatomic and clinical basis for targeted restoration of the physiological fat volume in the hand dorsum with high satisfaction rates.

LEVEL OF EVIDENCE

4.

Hand rejuvenation: Combining dorsal veins foam sclerotherapy and calcium hydroxylapatite filler injections

Background

The hands are an important aesthetic feature that can reveal aging through surface pigmentary changes, loss of skin thickness and ectatic dorsal hand veins. Techniques addressing these changes already exists but are not routinely combined for optimum results.

Objective

The combination techniques of dorsal hand veins sclerotherapy and sub-dermal filler injections are described.

Methods

The dorsal hand veins are treated with sclerotherapy (0.5% Sodium tetradecyl sulphate). This is then followed by subdermal injection of 0.75 mL–1.5 mL calcium hydroxylapatite (Radiesse, Merz) per hand, in conjunction with tumescent anaesthetic. The dorsal hands should be gently massaged for 2 min (per hand), twice a day for two days. If necessary, the procedure can be repeated after one month for further improvement.

Results

The techniques of sclerotherapy and filler injections complement each other well in hand rejuvenation. Calcium hydroxylapatite is safe and effective for hands and associated with high patient satisfaction. In suitable patients, the reduction in ectatic veins from sclerotherapy results in a longstanding improvement that complements volume restoration with fillers.

Conclusion

Aging hands with ectatic dorsal hand veins and skin atrophy/wrinkling not fully responsive to filler correction alone can further improve with the combination of sclerotherapy and filler injections.

Hand Rejuvenation: A Comprehensive Review of Fat Grafting

Dermal atrophy, bulging reticular veins, and prominent bones and tendons are characteristic of the aging hand. Demand for cosmetic procedures to restore a youthful appearance to the dorsum of the hand has risen in recent years. A review of the literature reveals that of the many options for hand restoration, autologous fat grafting stands out as the most promising choice compared with many available alternative options such as microdermabrasion, peeling agents, and dermal fillers. This article details the surgical technique and relevant anatomy necessary for successful hand rejuvenation. Future advancements may rely on further study into adipose-derived stem cells.

Lipomodeling: An Innovative Approach to Global Volumetric Rejuvenation of the Hand

BACKGROUND

Rejuvenation of the hand, particularly the dorsum, has garnered increased attention because of its unique aesthetic importance. Various methods have been advocated for achieving optimal aesthetic results.

OBJECTIVES

The authors describe their experience applying lipotransfer to total hand rejuvenation, including rejuvenation of the radial and ulnar aspects of the fingers.

METHODS

The authors conducted a retrospective review of 22 women who underwent global hand rejuvenation by lipotransfer. Aesthetic outcomes were assessed objectively by serial photography and subjectively by patient self-assessments.

RESULTS

No major postoperative complications were observed. Of 22 patients, 21 indicated that they were "satisfied" or "very satisfied" with the procedure. Plastic surgeons noted improvement in the aesthetic appearance of the hands after treatment.

CONCLUSIONS

Global hand rejuvenation should aim to restore volume and reduce skin laxity to reverse the signs of extrinsic aging. The fingers represent almost 50% of the length of the hand and should be included in treatments to achieve optimal aesthetic outcomes.

LEVEL OF EVIDENCE

4 Therapeutic.

Delayed immune mediated adverse effects to hyaluronic Acid fillers: report of five cases and review of the literature

Hyaluronic acid (HA) fillers in cosmetic medicine have been considered relatively safe, though fillers used in European countries and throughout the world are not necessarily approved by the Food and Drug Administration. As their use continues to expand worldwide, physicians in a wide range of medical specialties are authorized to perform HA injections, including general medicine practitioners and even dentists. An increasing number of reports have appeared regarding side effects to these products. It is now known that reactions to Hyaluronic acid are related not only to technical faults of the injections, but also to immune responses, including delayed hypersensitivity and granulomatous reactions. Herein, we describe five cases treated by a variety of treatment modalities, all with delayed reactions to different brands of hyaluronic acid fillers. As there is currently no standardization of treatment options of adverse effects, these cases accentuate the debate regarding the approach to the individual patient and the possible need for pre-testing in patients with an atopic tendency.

Inflammatory nodules following soft tissue filler use: a review of causative agents, pathology and treatment options

Nodule development is a common complication following the use of fillers for soft tissue augmentation and is commonly categorized as inflammatory or non-inflammatory in nature. Inflammatory nodules may appear anywhere from days to years after treatment, whereas non-inflammatory nodules are typically seen immediately following implantation and are usually secondary to improper placement of the filler. Although inflammatory nodules are more common with permanent fillers such as silicone, inflammatory nodule development following administration of temporary fillers such as hyaluronic acid and collagen has also been reported. Treated many times with corticosteroids due to their anti-inflammatory properties, inflammatory nodules may be secondary to infection or biofilm formation, warranting the use of alternative agents. Appropriate and prompt diagnosis is important in avoiding delay of treatment or long-term complications for the patient. This paper addresses the etiology, development, and studied treatment options available for inflammatory nodules secondary to each of the major classes of fillers. With this knowledge, practitioners may expeditiously recognize and manage this common side effect and thus maximize functional and aesthetic benefit.