Challenges, Considerations, and Strategies in Hand Rejuvenation
July 2016 | Volume 15 | Issue 7 | Original Article | 809 | Copyright © 2016
Ramin Fathi MD1 and Joel L. Cohen MD FAAD1,2,3
1Department of Dermatology, University of Colorado Denver, Aurora, CO
2AboutSkin Dermatology and Derm Surgery, Greenwood Village, CO
3Department of Dermatology, University of California at Irvine, Irvine, CA
Hand rejuvenation is an increasingly requested procedure in dermatology. Dorsal hand augmentation with soft tissue filler is one aspect
of hand rejuvenation. Calcium hydroxyapatite is FDA approved for this purpose, while at the present time other filler products are utilized but are considered off-label for dorsal hand augmentation. This article reviews the relevant anatomy, the general and filler-specific
techniques commonly employed, and potential complications that may arise.
J Drugs Dermatol. 2016;15(7):809-815.
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An increasing number of patients are requesting rejuvenation of the aging hand. Despite the hands being one of the first areas to show signs of aging due to their high levels of exposure (especially to ultraviolet radiation) and significant amounts of wear and tear, the vast majority of aesthetic procedures have traditionally focused on the face with little attention paid to the hands. Treating just the face can lead to a discrepancy between a rejuvenated facial appearance and the aged appearance of the hands.1
Current methods of hand rejuvenation include autologous fat injection, sclerotherapy, intense pulsed light, laser therapies, chemical peels, and microdermabrasion.2 Aside from cumulative extrinsic factors like ultraviolet radiation, microcirculation deficiency may also potentially play a role in intrinsic aging of the skin, a manifestation of diabetes mellitus and peripheral arterial occlusive disease.3 Loss of volume is believed to occur specifically because as aging occurs, the skin loses its subcutaneous fat and muscles resulting in thinning skin.4 Other than fat injections, these device-based treatments and other procedures (eg, light-based therapies or peels) do not address volume loss and focus on textural changes and dyschromia. Hand augmentation with soft tissue fillers represents an important and emerging tool in providing volume replacement.
Volume restoration of the aging dorsal hands can provide a more youthful appearance, decrease skin laxity and wrinkling, and reduce the prominence of underlying structures such as veins, bones, and tendons.5 The ideal filler for this purpose effectively adds bulk and volume, and is also durable enough to withstand repeated dynamic motion.5 This review discusses the relevant anatomy, techniques for soft tissue augmentation, and potential complications of the procedure.
The skin and soft-tissue layers of the dorsal hand from most superficial to deep include the epidermis, dermis, two fascial planes intersecting fatty lamina, tendons, and finally, the deep fascia that covers the metacarpals and the interosseous muscles.6,7 Histologic analysis of the dorsal hands reveals each of these three distinct fascial layers (Figure 1). The dorsal superficial fascia separates the superficial fatty lamina from the intermediate lamina, and the dorsal intermediate fascia separates the intermediate lamina from the deep lamina.8 The thickness of the components of the dorsal hands can vary dramatically from patient to patient. The dorsum of the hand itself has a relatively thin dermis, which becomes more attenuated with the aging process. Lefebvre-Vilardebo et al examined ultrasound images of 14 healthy volunteers aged 25-72 and found the thickness of the dermis measured from 0.2 to 0.9 mm, the fascial plane from 0.3 to 2.2 mm, and the tendon layer from 0.7 to 1.7 mm. Overall the total thickness of all dorsal hand layers ranged from 2.2 to 4.6 mm.6
The venous system of the dorsal hand is an interconnected network that can be found within different levels of the fascial layers.6 However, veins are found to be in highest concentration, along with residing sensory nerves, in the dorsal intermediate lamina.8 By contrast, the dorsal superficial lamina has no distinct structures traveling within the plane.8
Treatment success after cosmetic procedures can be measured subjectively in several specific regions with patient satisfaction questionnaires. Objective success for hand rejuvenation can be measured using the Merz Hand Grading Scale (MHGS). The MHGS is a 5-point scale used to grade appearance of the dorsum of the hand (Table 1).9 This tool has been validated for