Challenges, Considerations, and Strategies in Hand Rejuvenation

approximately one bottle of reconstiututed PLLA each session into the intermetacarpal space using a threading or retrograde fanning technique has been described.¹⁷

Applying a moisturizing cream and then diligent massage to try to ensure even distribution is believed to be particularly important when specifically using PLLA. Instructing the patient as well to massage the injected areas of each hand for 5 minutes, 5 times a day, for 5 days is often employed after PLLA injections to try to avoid product clumping and promote a natural-looking correction. This technique helps minimize the chance of nodule formation.^17-23

CaHA was approved by the FDA in June 2015 for soft tissue augmentation of the dorsal hands^12,24 after obtaining original FDA approval for facial augmentation in 2006. This product consists of CaHA microspheres (25-45 μm) suspended in a gel composed of water, glycerin, and sodium carboxymethlycellulose, in a 30% microspheres to 70% carrier gel composition. CaHA is the inorganic component of bone and teeth, and is inert, biocompatible as well as non-antigenic.⁴ CaHA is considered to be non-permanent filler.

Before treatment, 0.2 to 0.3 mL of 1% or 2% lidocaine HCL is frequently mixed with each 1.5 ml syringe of CaHA. To achieve this, use a Luer-Lok-to-Luer-Lok connector and a 1 ml syringe with Luer-Lok. To avoid clogging, introduce CaHA into the syringe containing the anesthetic first. Then push the newly combined CaHA and lidocaine back and forth from syringe to syringe until it becomes a homogeneous mixture.⁵

The filler can be injected into the hand using a multi-bolus technique (0.2 to 0.5 ml per injection) evenly distributed on the dorsal hand.¹⁰ Alternatively, CaHA can also be injected using a pauci-bolus technique (0.5-1.4 ml per injection),⁵ with one to two injections per hand between the first and fifth metacarpals using a 27-gauge needle. With the pauci-bolus technique, a single bolus can be injected midway between the dorsal crease of the wrist and the metacarpophalangeal joints¹⁷ (Figure 2). It is recommended that not more than 3 ml per hand should be injected per visit.¹⁰ Total volume injected should be at the discretion of the treating physician to achieve the optimal cosmetic result. Figure 3 and Figure 4 show examples of patients treated with CaHA. Figure 5 compares treated hands with non- treated hands. While a 27-gauge needle was used for the FDA study, some physicians prefer to use a cannula off-label for CaHA injections in the dorsal hand.

Patients often experience temporary swelling as well as occasional areas of bruising after treatment. Adverse events