Challenges, Considerations, and Strategies in Hand Rejuvenation

of the authors (JLC) preps the skin with two passes of isopropyl alcohol followed by two passes with Chlorhexidine scrub.

The boundaries of the area treated are usually the fifth metacarpal laterally, the second metacarpal medially, and the dorsal wrist crease proximally.⁵ Filler agents have typically been injected with a 27-30 gauge ½ inch needle into the subdermal and subfascial plane, but superficial (dorsal) to the deep fascia.^10,13 The thumb and the forefinger of the non-injecting hand are used to lift the skin over the dorsal aspect of the hand being treated.⁵ This type of skin tenting can be used to separate the superficial fascial layers from the deep lamina, which contains vascular and tendinous structures. The patient’s hand should be held loosely in a resting position as the filler is injected subcutaneously at an oblique angle adjacent to the dorsal veins of the hand.² Some injectors now prefer to use a 25 gauge 1.5 inch cannula to inject filler into the dorsal hand, making the initial entrance nick into the skin with an 18-22 gauge needle. Whether using a needle or cannula, a distal approach (more common) or proximal approach may be employed in order to place the filler volume in the appropriate places alongside tendons and veins. Distinct differences and volumes for each filler are discussed below.

The most commonly used technique is with a needle. However, some providers are more comfortable using a cannula. With a cannula, usually there are less entrance sites (often 2-3 total) that can be used for the cannula to be fanned-out in order to access areas of volume depletion. Especially when using a cannula, tenting the skin can help provide an easier passage to reach areas of volume loss.¹⁴ In 2012, a double-blinded, randomized controlled trial compared a metallic cannula to a standard needle for soft tissue augmentation of the nasolabial folds. The authors reported less pain, edema, bruising, and redness with a metallic cannula.¹⁵

Performing gentle hand massage after injection (usually with the hand in complete flexion) is quite common. Chlorhexidine prep, ultrasound gel, vitamin K cream, or a mild lotion can be used to massage out visible lumps or bumps in a smooth fashion.¹⁴ Patients often ice the treated area in the office for at least 10 minutes. Some physicians then prefer for the treated areas to be bandaged with a compression, non-stick wrap, and patients are sometimes even instructed to sit on their hands immediately post procedure in an effort to try to minimize swelling. Patients are usually recommended to avoid workouts for a day or two and also elevate their hands above the level of their heart several times that day for at least 15-20 minutes, also in an effort to try to minimize swelling.

In general, no massage by the patient is required or encouraged unless specified for the particular filler below.⁵ Patients may return to normal activities as soon as they are comfortable. Mild swelling and bruising may be expected and can often last about 1 to 2 weeks. Some physicians prefer that some patients (especially those less known to the practice from a history of other procedures) be seen 14 days after initial injection for follow-up, and to reassess. More augmentation can occur at this re-check visit if needed or desired.¹³

Autologous fat transfer has been used for a variety of reasons since 1889.¹⁶ In the late 1980s, autologous fat grafts showed promise as a means of rejuvenation by restoring a youthful fullness to the dorsum of the hand.¹⁷ Autologous fat treatment involves aspiration and harvesting of fat from a donor site and injection into the treated area through small incisions or 18-gauge needle holes with a micro cannula.¹² In 2002, Coleman described his technique of delivering fat in a structured fashion with many minuscule tunnels, thus advancing our knowledge of dorsal hand injection.¹⁸ Additionally, reported complications of fat grafting, including infection, cyst formation, temporary dysesthesia, and significant edema, provided a benchmark of comparison for soft tissue fillers.¹⁷ While autologous fat grafting is the earliest described technique for hand augmentation, it is more invasive (especially with the need for sites of harvesting) and time-consuming and has somewhat unpredictable results.¹⁹ While it is still performed and popular in some aesthetic practices today, the scope of this article will focus on soft tissue fillers.

Hyaluronic acid products are commonly used off-label to restore lost dorsal hand volume. Examples of HA fillers include