Restylane, Belotero, and Juvederm.12 Streptococcus species of
bacteria generate HA. All three of these families of HA products
available for use in the US are approved for facial soft tissue
augmentation specific indications and not for hand rejuvenation.
It is known that HA, in general, binds and retains water
and can thereby increase turgor and tissue volume. HA is also
thought to stimulate collagen production.20,21 Although hyaluronic
acid is biodegradable, crosslinking of HA improves its
durability. A distinct advantage of HA is that imperfections or
undesired product can usually be reversed in the short term
using hyaluronidase enzyme.19 There are two commercially
available formulations of hyaluronidase, including Vitrase
(ovine derived and requires skin testing) and Hylenex (human
derived and does not require any skin testing).
Man et al compared HA versus human collagen. While this human
collagen (Cosmoplast), which is no longer available,19 was better tolerated overall with regards to adverse effects, patient satisfaction was higher with hyaluronic acid. Additionally, blinded
independent board-certified investigators found the results of hyaluronic acid to be superior to human collagen injections.2
Brandt et al evaluated small gel particle HA in a prospective open-
label study of 16 patients in the dorsal hand. Two weeks after treatment, vascular, tendon, bony prominence, and skin turgor were improved by 60.9%, 65.2%, 73.7%, and 26.3%, respectively. Substantial or complete global aesthetic improvement was
rated in 75% of patients by investigators and in 56% by patient self-report; 81% of patients were satisfied or very satisfied.19 In
this study, the authors describe a threading technique using 2-4 ml of filler into the proximal hand and subsequently massaging distally using an anti-bruising cream, with subsequent melting
ice application.19
Dallara described 99 patients in Europe who received combined
HA (Juvederm Ultra 3 and Juvederm Hydrate) treatment. The
mean volume injected was 1.02 ml of the former HA per hand
at day 0 (minimum = 0.8 ml and maximum = 1.6 ml) and 0.91
ml of the latter HA per side at day 15 (minimum = 0.5 ml and
maximum = 1 ml). The mean grade at baseline, according to the
hand grading scale (named the Carruthers Aging Hand Scale in
the study), was 3.18 (3.20 for the left hand and 3.16 for the right
hand). This decreased at day 15 to 1.97 (1.96 and 1.99 for left and
right hands, respectively) and at day 30 the mean score was
1.73 (1.71 for the left hand and 1.74 for the right hand).1
Poly-L-Lactic Acid
PLLA (Sculptra) is a synthetic, biocompatible, biodegradable
filler associated with a low risk of allergic reaction.22 It
is thought to stimulate the production of collagen in areas of
volume loss.12 The use of injectable PLLA for dorsal hand augmentation
has not been evaluated or approved by the US Food
Drug Administration and is considered off-label.23 Redaelli
described 27 patients with an average age of 65.9 years who
were treated with PLLA for augmentation of the dorsal hands.22
His study found a measurable decrease in vein tortuosity and
extensor tendon visibility. For the evaluation of the results, a
patient’s satisfaction score (PSS) and a physician’s satisfaction
score (PhSS) was calculated from the second to the last treatment
session (minimum 3, maximum 6, average 4.03 sessions
per patient). A definitive (composite) graduated score (DGS)
was then calculated for each patient. The DGS was the average
of the PSS and PhSS (scores from 1 to 10). The PSS relevant
to hands ranged from 4 to 9 (two patients scored 4 and two
patients scored 9) averaging 6.59. The PhSS ranged from 4
(three patients) to 9 (two patients), averaging 6.4. In 6 patients
(22.2%), the DGS was less than 5, in 14 patients (51.8%), it was 6
to 7, and in 7 patients (25.9%), it was greater than 8.22
PLLA can be reconstituted with bacteriostatic water with or without lidocaine 1%.22,23 This reconstitution is recommended to stand for at least several hours, but usually a minimum of overnight is preferred by most injectors and, specifically, a higher-volume reconstitution (with 7-10 cc’s) is preferred by most.17 Injections of reconstituted PLLA are most frequently
performed with a 25-27 gauge needle at an angle of 30-40 degrees into the deep dermis. Some physicians advocate aspirating
back on the syringe to try to ensure that the needle (or cannula) is not in a vessel. Placement of subcutaneous
aliquots of 0.1-0.2 ml per site is commonplace. Use of
