Rejuvenation of the aging hand

Evaluation of Platelet-rich Plasma and Microneedling for Facial Skin Rejuvenation

Background

The regenerative properties of platelet growth factors make platelet-rich-plasma (PRP) an attractive modality for treatment of aging skin. The main objective of this study was to determine efficacy and safety of PRP injections and microneedling compared with saline injections in women with aging skin of the face.

Methods

In this prospective, randomized clinical trial, 18 women with facial aging were randomized to receive either PRP injections to the unilateral face and saline injections to the contralateral side, or vice versa. Microneedling was performed after injections on the entire face. Physician assessment, photographs, and treatment satisfaction questionnaires were used for outcome assessment at baseline and 16- and 24-week follow-ups.

Results

There was no evidence of improvement and suggestion of worsening in skin laxity and rhytides from baseline to weeks 4, 16, and 24 for PRP and saline (all P ≤ 0.004) and no notable difference in skin roughness between baseline and follow-up time points for PRP or saline (all P ≥ 0.19). The degree of change in skin laxity, rhytides, and skin roughness from baseline to follow-up time points was similar for PRP and saline. All patients experienced some degree of pain/discomfort and burning/stinging sensation at treatment weeks 4, 8, and 12 for both saline and PRP.

Conclusions

PRP injections did not seem to be effective for treatment of aging skin of the face in women, with no notable macroscopic improvement in appearance when compared with baseline or saline injections. Advanced age of study participants (>45 years) and less-sensitive methods of evaluation may be potential contributing factors to the lack of detected response.

A 15% Trichloroacetic Acid + 3% Glycolic Acid Chemical Peel Series Improves Appearance of Hand Lentigines: An Evaluator-Blinded, Split-Hand Prospective Trial

BACKGROUND

Improving the appearance of lentigines on the hands is a key component to hand rejuvenation. Soft tissue fillers revolumize hands, but do not address pigmentary changes. OBJECTIVE: This study investigated the effiacy of a 15% trichloroacetic acid (TCA) + 3% glycolic acid (GA) combination peel in improvement of appearance of hand lentigines.

METHODS

A prospective evaluator-blinded, split-hand study was performed using a 15% TCA + 3% GA peel to treat patients with hand lentigines. Subjects received a total of 3 treatments at 4-week intervals on 1 hand, with the other hand serving as an untreated control. Final photographs were taken 12 weeks after the last treatment. Two blinded board-certified dermatologists graded improvement in hand lentigines using a 5-point scale.

RESULTS

Eighteen of 20 patients completed the study (90%). The mean age was 64.4 years (SE 1.6, range 51-71). The mean pain scores were 3.8 (SE 0.4) on a 10-point scale (1 = no pain, 10 = extremely painful). Blinded evaluators correctly identified the after-treatment photographs in 16 patients (88%). Physician and patient-graded mean improvement of lentigines was significant for treated versus control hands ( p < .01). No adverse events were noted.

CONCLUSION

A series of three 15% TCA + 3% GA peels are effective and safe in the treatment of hand lentigines.

Hand Rejuvenation: A Systematic Review of Techniques, Outcomes, and Complications

BACKGROUND

Hand rejuvenation is an increasingly popular cosmetic procedure for hand atrophy and aging. The objective of this study is to systematically evaluate the techniques, outcomes, and complications of surgical hand rejuvenation.

METHODS

A systematic review was undertaken using a computerized search. Publication descriptors, methodological details, techniques, outcomes, and complications were extracted. Articles were assessed using the MINORS and Cochrane instruments.

RESULTS

Thirty-one studies were included. Most studies were published in the last five years (51.6 percent) and were prospective case series (35.5 percent). The mean age of patients was 56 (range 21-82), while the mean sample size was 47 (range 10-220). The most commonly examined interventions were Radiesse (32.2 percent) and fat grafting (32.2 percent). Major complications were not observed in any study, while minor complications such as edema and pain were temporary. Injection techniques varied, however, the proximal to distal fanning technique and using a cannula was associated with a lower risk of complications. Both Radiesse and fat grafting had robust long-term esthetic outcomes.

CONCLUSIONS

Hand rejuvenation is a safe and efficacious surgical intervention to reduce dorsal hand atrophy. Further studies are needed to compare the long-term outcomes of common interventions.

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 .

Nanofat: A therapeutic paradigm in regenerative medicine

Adipose tissue is a compact and well-organized tissue containing a heterogeneous cellular population of progenitor cells, including mesenchymal stromal cells. Due to its availability and accessibility, adipose tissue is considered a “stem cell depot.” Adipose tissue products possess anti-inflammatory, anti-fibrotic, anti-apoptotic, and immunomodulatory effects. Nanofat, being a compact bundle of stem cells with regenerative and tissue remodeling potential, has potential in translational and regenerative medicine. Considering the wide range of applicability of its reconstructive and regenerative potential, the applications of nanofat can be used in various disciplines. Nanofat behaves on the line of adipose tissue-derived mesenchymal stromal cells. At the site of injury, these stromal cells initiate a site-specific reparative response comprised of remodeling of the extracellular matrix, enhanced and sustained angiogenesis, and immune system modulation. These properties of stromal cells provide a platform for the usage of regenerative medicine principles in curbing various diseases. Details about nanofat, including various preparation methods, characterization, delivery methods, evidence on practical applications, and ethical concerns are included in this review. However, appropriate guidelines and preparation protocols for its optimal use in a wide range of clinical applications have yet to be standardized.

Rhinoplasty with Fillers and Fat Grafting

Nonsurgical rhinoplasty is one choice for cases in which open surgery may be harmful, the deformity is not indicated to correct with open surgery, or in patients who have phobia of general anesthesia or any type of surgery. Autologous fat injection or fillers are most common materials currently available in the market. In this article, we explain the indications, contraindications, methods, and complications of this treatment.

Fat Grafting for Hand Rejuvenation

The hands are one of the most visible parts of the body, and prominent dorsal veins and extensor tendons are the most readily recognized signs of the aging process. Fat grafting has been demonstrated to be a safe and effective method of hand rejuvenation by restoration of subcutaneous fat. Despite some variability in the technical approach, fat grafting techniques are consistent in their use of low-pressure injection with standard cannula sizes, small aliquots of graft, and a total volume of graft greater than or equal to 15 mL per hand. While distribution of the fat is an area of debate and a topic of active research, published studies have shown high patient satisfaction rates, suggesting that perhaps the restoration of volume alone is paramount. In this article, we will review the applications of fat grafting to the hand, focusing primarily on its role in hand rejuvenation.

A randomized study showing improved skin quality and aesthetic appearance of dorsal hands after hyaluronic acid gel treatment in a Chinese population

BACKGROUND

Patients are increasingly aware of the aesthetic appearance of aging hands.

AIMS

To evaluate efficacy and safety of a hyaluronic acid gel for improving skin quality in aged skin of the dorsal hand.

METHODS

This was a 15-month randomized, multi-center, evaluator-blinded, split-hand, no treatment-controlled study. Three treatments with hyaluronic acid gel were administered in the same hand in adult Chinese subjects with grade 2 or 3 (mild or moderate aging) on the Hand Grading Scale (HGS). The primary objective was to evaluate the difference at 3 months between treated and untreated hands, based on the blinded evaluator's HGS assessment. Secondary assessments included the Global Aesthetic Improvement Scale (GAIS), biophysical measurements (skin elasticity, skin roughness and hydration), and subject satisfaction. Safety was evaluated by incidence of adverse events.

RESULTS

A total of 100 subjects were enrolled. Clinically relevant differences in HGS favored HA gel (P < .0001). At 15 months, 87%-96% of treated hands were still improved according to GAIS (per evaluator and subject, respectively). Objective measures of skin quality improved, confirmed by evaluators and highly satisfied subjects. Treatment was well tolerated.

CONCLUSIONS

Hyaluronic acid treatment improved skin quality and reduced the aging appearance of the hand, with high subject satisfaction.

Detailed Sonographic Anatomy of Dorsal Hand Augmentation With Hyaluronic Acid and Calcium Hydroxyapatite Fillers

BACKGROUND

Volume restoration using filler in the dorsum of the hand is a simple and effective procedure to improve wrinkles and hide veins and tendons. Currently, calcium-hydroxyapatite (CaHA) filler is the only FDA-accepted material to use in the hand dorsum. However, it is not easy to inject due to swelling and redness. In addition, hand anatomy through sonography is wrongly described in Plastic and Reconstructive Surgery® Journal. Through incorrect marking in sonographic hand anatomy, physicians will conduct erroneous procedures and surgeries.

OBJECTIVES

CaHA filler and hyaluronic acid (HA) filler were both injected into the hand to compare intra-individually the effect of each filler. Through this study, the author introduced detailed and refined sonographic anatomy. Overall, the author identified the correct injection method and depth.

METHODS

In this prospective, intra-individual, comparative study, patients were injected 1 cc of CaHA filler to the left hand and 3 cc (36 mg) of microphasic hyaluronic acid to the right. Outcomes were assessed by Merz hand grading scale, skin bio-parameters, dermascopic finding, and Global Aesthetic Improvement Scale (GAIS) with follow-up at 3, 6, 9, and 12 months.

RESULTS

The average GAIS score improved in both hands and generally maintained over the course of the study. There was significantly more bruising and swelling in the CaHA-injected hands compared with the HA-injected hands. The skin roughness and appearance improved in both sets of hands on dermascope. The average Trans-Epidermal-Water-Loss decreased and the average Stratum Corneum Hydration increased in HA-injected hands. The biopsy study showed that the HA particles lasted for 9 months.

CONCLUSIONS

The author reestablished sonographic anatomy. Veins and tendons became less apparent after injections.

LEVEL OF EVIDENCE: 2

Ageing profiles of Caucasian and Chinese cohorts - focus on hands skin

OBJECTIVE

In spite of hand care being a dynamic segment of skin care, hands skin physiology has been receiving little attention in comparison to facial skin. In the present study, we aimed at gathering a comprehensive set of skin data from the dorsal part of the hand to study age related-changes in two ethnic groups (Caucasian and Chinese).

METHODS

Skin topographic, skin colour/colour heterogeneities, skin chromophores and skin biophysical measurements of 116 Caucasian and Chinese female volunteers aged 30-65 years old were collected in Ireland and in China as part of a cross-sectional study.

RESULTS

Topographic alterations happened at both micro and macro scales with a noticeable delay in the onset of 10 years for the Chinese cohort. Similar evolution of skin colour with ageing was observed between the two cohorts and strong dissimilarities were seen when it came to colour heterogeneities and melanin hyper concentration, with a 20-year delay in severity for the Chinese cohort. A similar sharp drop of skin hydration occurred when reaching the 60's regardless of the group and substantial differences were recorded for skin biomechanical properties of the skin.

CONCLUSION

These results provide additional insights about hand skin physiology in relation to ageing and ethnic differences, especially when put into perspective with what is currently known about facial ageing. This research yield additional material for hand cream product rationale and strategies for mitigating the appearance of ageing hands.

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.

Use of adipose tissue and stromal vascular fraction in hand surgery

Adipose tissue is an abundant source of various cell types including not only adipocytes, but also progenitor and endothelial cells from thestroma. Interest in adipose tissue has surged since the identification in 2001 of adipose-derived stem cells (ADSCs) and of the stromal vascular fraction (SVF) obtained from adipose tissue by enzymatic digestion and centrifugation. SVF has been proven effective in ensuring tissue regeneration, thus improving tissue trophicityand vascularisation. These effects have generated strong interest among both physicians and surgeons, particularly in the field of hand surgery. Several applications have been developed and used, for instance to treat Dupuytren's contracture, systemic sclerosis-related hand lesions, and skin ageing at the hand. Other uses are being evaluated in clinical or animal studies. The objective of this article is to review the capabilities of adipose tissue and their current and potential applications in hand surgery.

Procedure, applications, and outcomes of autologous fat grafting

OBJECTIVE

To systematically review the procedure, applications, and outcomes of autologous fat grafting, a promising technique with various clinical applications.

PATIENTS AND METHODS

Literature review of publications concerning autologous fat grafting.

RESULTS

Since its introduction, lipofilling has become increasingly popular; however, its results are variable and unpredictable. Several modifications have been made to the procedures of fat harvesting, processing, and injecting. Surgical excision and low negative-pressure aspiration with large-bore cannulas minimize adipocyte damage during fat harvesting. The "wet" method of fat harvesting involves fluid injection at the donor site and facilitates lipoaspiration while minimizing pain and ecchymosis. For fat processing, centrifugation at a low speed is preferable to high-speed centrifugation, gravity separation or filtration. Fat injection at the recipient site should be performed using small-gauge cannulas in a fanning out pattern over multiple sessions, rather than a single session. Fat grafts exhibit not only dermal filler properties but also regenerative potential owing to the presence of stem cells in fat tissue. Thus, the clinical applications of autologous fat grafting include correction of secondary contour defects after breast reconstruction, release of painful scar contractures, and treatment of burn scars and radiodermatitis. Lipofilling is also used in aesthetic surgery, such as facial and hand rejuvenation, augmentation rhinoplasty, and breast and gluteal augmentation. The complications of lipofilling are minimal and include bruising, swelling, pain, infection, necrosis, and calcification.

CONCLUSIONS

Lipofilling is a low-risk procedure that can be used to correct soft-tissue defects in the face, trunk, and extremities, with minimal discomfort for patients.

Hand rejuvenation with fat grafting: A 12-year single-surgeon experience

Background

Fat grafting has been successfully used for reconstructive and esthetic surgery of the breast, face, and other body parts. In this article, we present our protocol for hand fat grafting and over a decade of clinical experience.

Methods

Fat tissue is obtained from the flanks, peri-umbilical region, or internal side of the thigh or knee. No centrifuge machine is used to prevent fat damage. After decantation, fat is injected into the dorsum of the hand using a cannula from the wrist and not from the fingers. Fat is distributed gently above the dorsal deep fascia to avoid perforation of the vessels.

Results

The proposed technique was applied to 65 patients. The amount of fat injected ranged from 10 to 30 cm³. No allergic reactions were noticed. Each patient’s progress was followed-up for a minimum of 12 months. Over this period, contour changes and the effects of the procedure(s) on the skin were analyzed. Fifty-six patients (84%) were satisfied with the results during the observation period, 7 patients (12%) were somewhat satisfied and needed one more fat grafting procedure to achieve complete satisfaction, and 2 patients (4%) were dissatisfied with the results. Three cases of temporary swelling of the hands resolved naturally. No long-term complications were seen.

Conclusions

This study covers over a decade of practical experience in applying fat grafts to hands. The procedure is effective in reshaping and rejuvenating the hand as it shows long-lasting results after 1-year follow-up.

Modern trends in lipomodeling

Lipomodeling is the process of relocating autologous fat to change the shape, volume, consistency, and profile of tissues, with the aim of reconstructing, rejuvenating, and regenerating body features. There have been several important advancements in lipomodeling procedures during the last thirty years. Four clinical steps are important for the success of engraftment: fat harvesting, fat processing, fat reinjection, and preconditioning of the recipient site. With the discovery of adipose derived stem cells and dedifferentiated cells, fat cells become a major tool of regenerative medicine. This article reviews recent trends in lipomodeling trying to understand most of the issues in this field.

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.

The Importance of Hand Appearance as a Patient-Reported Outcome in Hand Surgery

Hand appearance is meaningful to patients because hands are an essential part of human interactions, communication, and social integration. Recent literature indicates that hand aesthetics is an important, measurable patient-reported outcome. In hand surgery, several outcome instruments exist that accurately measure functional outcomes, but aesthetics is often overlooked or imprecisely measured. This makes comparison of disease burden and effectiveness of therapies, as they pertain to aesthetics, difficult. This special topic article outlines the aesthetic features of the hand, how literature is evaluating the appearance of the hand in outcomes research, and proposes a novel approach to assessing hand aesthetics.

A Prospective, Comparative, Evaluator-blind Clinical Study Investigating Efficacy and Safety of Two Injection Techniques with Radiesse(®) for the Correction of Skin Changes in Aging Hands

Background:

Dermal fillers are used to correct age-related changes in hands.

Aims:

Assess efficacy and safety of two injection techniques to treat age-related changes in the hands using calcium hydroxylapatite filler, Radiesse^®.

Settings and Design:

This was a prospective, comparative, evaluator-blind, single-center study.

Materials and Methods:

Radiesse^® (0.8 mL/0.2 mL 2% lidocaine) was injected subdermally on Day (D)01, using a needle multipoint technique in one hand (N) and a fan-like cannula technique in the other (C). Assessments were made pre-injection, on D14, Month (M)02, M03 and M05 using the Merz Aesthetics Hand Grading Scale (MAS) and Global Aesthetic Improvement Scale (GAIS). Participants completed questionnaires on satisfaction, pain and adverse events (AEs).

Statistical Analysis Used:

Data distribution was tested with the Shapiro-Wilk and Levene's tests. The Wilcoxon signed-rank and Chi-square tests were employed to evaluate quantitative and qualitative data, respectively.

Results:

All 10 participants completed the study, four opted for a M03 touch-up (0.8 mL Radiesse^®). Evaluator-assessed mean GAIS scores were between 2 (significant improvement but not complete correction) and 3 (optimal cosmetic result) at each time point. The MAS score improved from D01 to M05 (N: 2.60 to 1.40; C: 2.20 to 1.30). Following treatment, participants reported skin was softer, more elastic, more youthful and less wrinkled. Other than less noticeable veins and tendons on the C hand, no differences in participant satisfaction were noted. All AEs were mild, with no serious AEs reported.

Conclusions:

Both injection techniques (needle and cannula) demonstrated equivalent clinical efficacy with a comparable safety profile for the correction of age-related changes in hands with Radiesse^®.

Nonanimal stabilized hyaluronic acid for tissue augmentation of the dorsal hands: a prospective study on 38 patients

BACKGROUND

Often ignored, hands are one of the most telltale signs of aging. This prospective study was initiated to evaluate the effect of subcutaneous hyaluronic acid (HA) injections in aging hands, with special attention to complications and long-term outcomes.

METHODS

Between January 2010 and December 2010, a total of 38 patients with skin phototypes II-IV and between 58 and 76 years old were treated with HA injection for aging hands. The quantity of injection never exceeded 1.0-1.5 ml HA per hand. A clinical follow-up was performed at 2 weeks, 4 weeks, 3 months, and 6 months after injection. Complications were reviewed for the whole series. At the first follow-up, 2 weeks after the procedure, ultrasound was carried out to determine if additional filling material was required. At each follow-up, patients were asked to fill out a satisfaction questionnaire.

RESULTS

Nine patients developed slight ecchymosis that disappeared after 1 week. No other complications were seen in the series. Pain during the injection and discomfort after the procedure were minimal. At the 2-week follow-up, after ultrasound control, nine patients received a complementary injection. At each follow-up, overall patient satisfaction was high and was validated by clearance of rhytids, veins, bony prominences, and dermal and subcutaneous atrophy.

CONCLUSION

Skin revitalization with injectable HA can improve the clinical appearance of the back of the hands. However, this therapy requires knowledge of the possible complications and their remediation as well as knowledge and respect of injected doses. Moreover, despite excellent results at each follow-up, the results of our series are not as good after 6 months, and a longer follow-up would be needed to determine if this procedure provides long-lasting benefit.

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 .

Treatment of the ageing hand with dermal fillers

Following the trend in facial cosmetic procedures, patients are now increasingly requesting hand rejuvenation treatments. Intrinsic ageing of the hands is characterized by loss of dermal elasticity and atrophy of the subcutaneous tissue. Thus, veins, tendons and bony structures become apparent. Among the available procedures, intrinsic ageing of the hands is best improved by restoring the volume of soft tissue. Volume restoration can be achieved with a number of long-lasting dermal fillers with varying degrees of improvement and treatment longevity. The dermal fillers used in hand rejuvenation include autologous fat, collagen, hyaluronic acid, calcium hydroxylapatite and poly-L-lactic acid. Here, we describe our preferred injection method for hand rejuvenation using calcium hydroxylapatite and a single-bolus injection.

Techniques for the optimization of facial and nonfacial volumization with injectable poly-l-lactic acid

With the recognition of the key role of volume loss in the facial aging process, injectable dermal fillers and volumizers have become increasingly important treatment options for recontouring and rejuvenating the aging face. While replacement fillers effectively correct individual lines and wrinkles, volumizing agents that replace collagen provide a longer-lasting, volume-based alternative. Poly-L-lactic acid (PLLA) has been shown to increase dermal thickness and volume for up to 2 years and beyond. Although early clinical use of this agent in patients with HIV-associated facial lipoatrophy was associated with a significant rate of nodule or papule formation, subsequent experience has helped define the proper reconstitution volumes and injection techniques for optimizing results and minimizing nodule/papule formation. While injectable PLLA has been used successfully for rejuvenation of most facial areas, increasing experience suggests that it is a versatile agent capable of providing aesthetic enhancement in multiple areas of the body, including the dorsum of the hands, the décolleté, the neck, the buttocks, the medial ankles, and acne scars. Although the current published experience in these areas is limited, further studies and clinical use of injectable PLLA will clarify the potential of this agent as a minimally invasive alternative and/or adjunct to surgery for restoring volume loss in multiple anatomic areas.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article.

Complications related to Artecoll injections for soft tissue augmentation of the hand: 3 case reports

Rejuvenation of the aging hand has gained recent popularity. I report on 3 cases with complications related to the use of Artecoll (a permanent filler composed of polymethylmethacrylate) in soft tissue augmentation of the hand. All 3 patients had late-onset granuloma reactions, and the acute attacks were successfully treated with local injections of triamcinolone. However, recurrent reactions and hypopigmentation at the injection sites were noted.

Ablative fractional CO2 resurfacing for photoaging of the hands: pilot study of 10 patients

Extrinsic aging of the hands involves alterations in pigmentation, wrinkling, and texture as a result of chronic ultraviolet and environmental exposures. Inherent tissue properties of the skin of the dorsal hand have made it challenging to safely and effectively improve all three parameters of photoaging with a single device. Recent successes with non-ablative fractional lasers on the hands, as well as success of ablative fractional lasers on the neck and chest, raise the question of potential efficacy of ablative lasers for photorejuvenation of the hands. This was a prospective pilot study of ablative fractional CO(2) laser in 10 participants, each receiving three treatments to one hand at 4-6-week intervals. Subjective assessments by investigator and participants were performed 1 month after each treatment. At 1-month follow-up after final treatment, investigators rated mean improvement of 26-50% for wrinkles, 51-75% for pigment, and 26-50% for texture. Participants rated mean improvement after final treatment as 26-50% for wrinkles, 51-75% for pigment, and 51-75% for texture. Other than significant edema noted in one participant after the first treatment, side effects were limited to transient erythema and edema, with no long-term scarring or pigmentary alteration. In this pilot study, ablative fractional resurfacing was safe and effective for the treatment of all markers of extrinsic aging of the hands. A high degree of improvement was achieved in two to three treatments with no long-term sequelae.

Treatment of the aged hand with injectable poly-l-lactic acid

We report the use of injectable poly-l-lactic acid (PLLA) for volume restoration in a 45-year-old white female who was concerned about the appearance of her hands. The patient expressed a desire for long-term restoration, and selected injectable PLLA because of its known 2-year duration of effect, although she was informed that injectable PLLA is not FDA-approved for use in the hands. After reconstitution with 8 ml of diluent plus lidocaine, 0.1-0.2-ml aliquots of injectable PLLA were injected into selected sites, up to 5 ml per hand. The patient underwent three identical treatments, followed by postinjection use of moisturizing cream and massage; improvement in appearance was noted by the patient between the second and third treatments. Correction was maintained for at least 18 months, with no adverse events. We have also briefly reviewed the literature on the use of injectable PLLA for volume restoration in the hand.

Dorsal hand anatomy relevant to volumetric rejuvenation

BACKGROUND

In recent years, plastic surgeons have performed volumetric hand rejuvenation with either structural fat grafts or injectable fillers; however, the relevant anatomy has not been examined. The authors undertook a cadaveric investigation of the hand dorsum to elucidate anatomical guides that may eventually lead to improved hand rejuvenation techniques.

METHODS

Samples were obtained from 10 fresh cadaveric hands. Specimens were evaluated microscopically after histologic staining. Doppler ultrasound was used on eight living hands to further explore the lamination of the dorsal hand fat. A lead oxide injection of eight fresh cadaveric hands permitted examination of the vascularity of perforating septa.

RESULTS

Histologic examination revealed three distinct fatty laminae separated by thin fascia. No structures that traversed the subcutaneous, superficial fatty lamina were identified. The large dorsal veins and dorsal sensory nerves resided within the intermediate lamina. The extensor tendons were found within the deep lamina. Doppler ultrasonography confirmed the compartmentalized ultrastructure of the hand dorsum, clearly elucidating the distinct fascial layers, gliding tendons, and compressible veins. Eight to 10 perforating vessels travel within fascial septa that perpendicularly traverse the three laminae.

CONCLUSIONS

The subcutaneous tissue of the dorsal hand is divided into three fatty laminae separated by fascia layers with multiple vessel-containing septal perforations. An injection technique that addresses the fatty laminae and the perforating septa may yield improved and consistent rejuvenation results.

Changes in skin physiology and clinical appearance after microdroplet placement of hyaluronic acid in aging hands

BACKGROUND

Up to now rejuvenating treatment of the hands has been challenging and results often disappointing.

AIMS

To determine whether hyaluronic acid (HA) microdroplet placement into the dorsal hands has an impact on skin physiology and clinical appearance and whether there is any difference between stabilized HA (S-HA) and nonstabilized HA (NS-HA).

PATIENTS/METHODS

The intra-individual comparison in 15 volunteers involved injection sessions at week 0, 4, and 8 with random assignment of left and right hand to either S-HA or NS-HA. Skin physiology parameters cutaneous elasticity, surface roughness, hydration, and transepidermal water loss (TEWL) were measured in vivo at weeks 0 (before treatment), 4 (before subsequent treatment), 12, and 24. Clinical hand assessment was carried out at weeks 0 and 12 by a blinded dermatologist.

RESULTS

Intradermal injection of S-HA generated significant improvement in skin elasticity and surface roughness at week 12 compared to baseline. On the hands treated with NS-HA, there was a trend for improvement (not significant). While there was no significant difference in hydration and TEWL between both hands before treatment, at week 12 hands treated with S-HA displayed a significantly higher hydration level and lower TEWL compared to NS-HA treatment. Clinically S-HA proved to be significantly superior to NS-HA. At week 24 the observed effects started to return back toward baseline, with S-HA treatment still offering better results compared to the NS-HA.

CONCLUSIONS

Skin revitalization with injectable HA can improve clinical appearance and skin physiology parameters on the back of the hands. It has been shown that S-HA has better effects when compared with NS-HA.

Hand augmentation with stabilized hyaluronic acid (Macrolane VRF20 and Restylane Vital, Restylane Vital Light)

Volume augmentation of the back of the hand is a new technique which is not yet often employed. We describe the treatment of two patients who received hyaluronic acid products produced by Q-Med (Macrolane VRF20, Restylane Vital and Vital Light). The injections of Macrolane VRF 20 were done by feathering technique using a long and blunt 18 gauge canula while Restylane was injected by tunneling or tenting technique with a 30 gauge needle. Significant adverse events did not occur. After injection of the hyaluronic acid fillers, the appearance of the back of the hands was improved. Both patients were very satisfied with the result.

Addressing volume loss in hand rejuvenation: a report of clinical experience

BACKGROUND

Current options for treating the aging hand include microdermabrasion, fractional thermolysis, chemical peeling, intense light sources and laser therapy (such as pigment lasers and ablative resurfacing), as well as injectable fillers and volumizers to correct soft tissue atrophy.

OBJECTIVE

This article reviews the latest technologies in hand rejuvenation and provides data from three clinical practices using injectable poly-l-lactic acid (PLLA) for soft tissue augmentation.

METHODS

Patient data from three clinical practices were retrospectively collected and tabulated. This included baseline patient data, the number of injections and vials of product used, and adverse events.

RESULTS

PLLA was used to improve volume loss in the hand to the satisfaction of a majority of patients. The most commonly reported adverse events, such as bruising, swelling and pain, were injection-related and resolved within a few days of treatment. No papules or nodules were reported in any patients and there were no serious adverse events.

CONCLUSION

The overall results from the three clinics presented here show that patients were very satisfied with the results of PLLA treatment for the hands, and experienced only minor and short-term injection-related adverse events.

Cosmetic use of polylactic acid for hand rejuvenation: report on 27 patients

OBJECTIVE

Polylactic acid (PLA) is effectively used on the face. In the Author's opinion it can also be applied successfully to other body areas. The aim of the present retrospective study is to estimate the safety and results of this new technique in order to improve the hand skeletal status in old patients.

MATERIALS AND METHODS

Twenty-seven patients were treated in the period from January 2004 to April 2005 (a total of 109 sessions). Their age averaged 65.9 years. In all cases the hand treatment was associated with a face or neck treatment. 150 mg polylactic acid was diluted with 0.5 mL of 3% Carbocain and water for injectable preparations (from 5 to 8 mL). Intermetacarpal spaces were injected with this solution in dosages ranging from 2 to 4 mL with a particular and rigorous technique. The protocol, consisting of 3-6 consecutive sessions, is discussed below.

RESULTS

The results have been evaluated by a Definitive Graduated Score (DGS) based on the patient's and doctor's satisfaction scores (from 1 to 10) and by the photograph score. They have ranged from 4 to 9 (average of 6.55). No important side effects have been detected. There has been one case of fine unnoticeable nodulations. In six cases the result has not been satisfactory. In seven cases the DGS was higher than 8.

CONCLUSION

The fibro-connectival restoration of hands is an important step in the global aesthetic treatment of old patients. This technique can give good results, particularly if associated with peelings and sclerotherapy. Side effects have been acceptable.

A double-blind, comparative study of nonanimal-stabilized hyaluronic acid versus human collagen for tissue augmentation of the dorsal hands

BACKGROUND AND OBJECTIVE

Cosmetic surgery to counteract the aging process is an evolving field. Most procedures have concentrated on the face; however, the hands are an often-neglected area. Current methods of hand rejuvenation include autologous fat injection, sclerotherapy, intense pulsed light, chemical peel, and microdermabrasion. Only autologous fat injection restores dermal thinning. We compare the use of hyaluronic acid (Restylane, Medicis Aesthetics Inc.) versus collagen (Cosmoplast, INAMED Aesthetics) for soft tissue augmentation of the dorsal hands.

MATERIALS AND METHODS

Ten female patients who demonstrated dermal thinning of the dorsal hands were randomized to receive 1.4 mL of hyaluronic acid or 2.0 cm(3) collagen to alternate interphalangeal spaces of dorsal hands. Patients returned at 1 week, 1 month, 3 months, and 6 months for digital photography and completion of a patient/physician questionnaire.

RESULTS

Hands were scored by two separate blinded physicians on scales of 1 to 5 for clearance of veins. Patients scored both tolerability and satisfaction on a scale of 1 to 5. Analysis showed a mean difference of 0.95 (0.004), median difference of 0.9 (0.008) for clearance, and a mean difference of 0.90 (0.010) with a median difference of 1.0 (0.031). The satisfaction difference was not significant with a mean difference of 0.80 (0.070) and median difference of 1.0 (0.117).

CONCLUSION

Aging of the hands is a common problem that is often overlooked. The use of soft tissue fillers is a viable tool in hand rejuvenation. In this study hyaluronic acid proved to be superior in efficacy to collagen.

Hand augmentation with Radiesse (Calcium hydroxylapatite)

The hand has remained a considerable treatment challenge, as new soft tissue fillers have arrived in the esthetic marketplace. The challenge has been the result of both the multiple visits required for treatment in, for example, autologous fat grafting and the simple management of pain in the innervated areas of the hand between the bones. This paper introduces a novel, noticeably less painful approach to treatment of the hand with calcium hydroxylapatite (CaHA; Radiesse, BioForm Medical, San Mateo, CA). Anesthetic is added to the compound prior to injection, resulting in a homogenous admixture of CaHA and anesthetic. A bolus of the mixture is injected into the skin, using tenting, and then spread throughout the hand. The result of this approach - mixing anesthetic with CaHA - is treatment that is easier to massage and disseminate, less painful to the patient than conventional hand injection, and characterized by less swelling and bruising, with minimal post-treatment downtime.

Laser ablation of unwanted hand veins

BACKGROUND

Many patients express dissatisfaction with prominent and bulging hand veins. Abolishing these veins with sclerotherapy requires higher concentrations of sclerosing agents than are used for leg veins and often results in a tender, phlebitic cord. Phlebectomy is another treatment option. Endovenous occlusion and shrinkage techniques have been used successfully to treat varicose veins of the lower extremities. The authors demonstrate a new and unique endovenous laser technique to abolish unwanted hand veins.

METHODS

Fifty-four hands (28 patients) with prominent hand veins were treated using a 600-microm laser fiber. The Dornier MedTech 940-nm diode laser system was used. The laser fiber was introduced through a 4-French sheath, which tracked as a coaxial system over an 0.018-inch guidewire. Initial entry into the treated vein was accomplished with a 20-gauge angiocatheter percutaneously. On average, four veins were treated in each hand. Tumescent anesthesia was infiltrated around the laser fiber/sheath unit before activating the laser, and all procedures were performed in an office setting. A compressive dressing was used postoperatively.

RESULTS

All but one of the unwanted hand veins were cannulated successfully. The uncannulated vein was treated with sclerotherapy and eventually required phlebectomy. Hand swelling occurred in all treated hands and lasted 2 weeks or less. There was one skin burn of approximately 3 mm at a laser exit site. All 28 patients were satisfied with their results during follow-up, which ranged from 2 weeks to 31 months.

CONCLUSIONS

This is the first report of endovenous treatment of unwanted hand veins. Laser ablation of unwanted hand veins can be performed in an office setting. These cosmetically conscious patients were satisfied with their results.

Hyaluronic Acid Fillers: Restylane and Perlane

The list of injectable skin fillers available for soft-tissue augmentation is constantly growing, giving aesthetic surgeons more options in the treatment of scars, lines, and wrinkles. Various products for soft-tissue augmentation are currently available in the United States based on hyaluronic acid. One should keep in mind that for these hyaluronic acid gel to have the desired longevity they must have repeating chemical bridges to withstand the constant mechanical and chemical enzymatic degradation to which they are subjected once implanted. Restylane and Perlane have proved to be safe, effective, and liked by patients. The Restylane family of products is currently expanding and soon practitioners will be able to have a diversified arsenal of cross-linked hyaluronic acid products to rejuvenate the aging face.