INTRODUCTION
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.
Anatomy
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
