Anatomy & hand medical rejuvenation

AIMS OF REJUVENATION

Ageing and implications for rejuvenation 

The ageing of the hand has generated much attention lately. 

Hands may age quickly due to mechanical use and exposure to the environment. Hand ageing is caused by skin changes and volume loss.

Despite not being seen as a primary symbol of beauty, hands are important for the overall appearance.

Prior to proposing treatments to improve the appearance of hands, ideal hand aesthetics and changes during the ageing process need to be defined. This is what this chapter is about.

Rafael Jakubietz, MD

Anatomy ! Anatomy ! Anatomy ! 

THREE IMPORTANT FACTS YOU NEED TO KNOW

A soft-tipped cannula

Lifting the skin between two fingers and inserting a needle at the centre of the resultant triangle is unsafe because veins are pulled up into this space and the risk of vessel damage is real. The best instrument for injecting filler product into the back of the hand is therefore a soft-tipped cannula.

Lifting the skin when injecting 

Lifting the skin raises the entire fascial sheet without creating space for the injected product, the positioning of which is therefore blind and impossible to predict.

The Scrape Skin Threading Technique 

The only layer that is unattached to the fascial septa and tendons is the interface between the dermis and the fascial plane. Although this plane seems to be virtual in anatomical dissections, it has been shown to be ideal for the injection of filler. To find and follow this plane, the undersurface of the dermis had to be scraped with the cannula.

Injecting too little is better than injecting too much.

Marc Lefebvre-Vilardebo, MD

Hand rejuvenation with fillers allows for volume replacement. 

The ideal filler for hand rejuvenation should be safe, non-allergenic, easy to inject into the subdermal plane of the dorsum of the hand, should produce a natural and smooth looking clinical end-point and should have a long duration of effect.

Volume loss of the dorsal aspect of the hand falls within the intrinsic ageing factor bracket. It is best managed with injectable fillers. Several injectable fillers may be used for volumising augmentation of the hands. The most clinically effective and long-lasting results have been recently reported with calcium hydroxylapatite.  Hyaluronic acid is also a suitable filler for hand rejuvenation, although more research and studies are required, especially regarding longevity and distribution within the tissue structures of the dorsal hand.

Rejuvenation of the volume loss within the deeper structures relies upon subdermal filler injections.

Volume replacement can be successfully accomplished using a variety of filler product, ranging from the surgical option of autologous fat transplantation, to the newer form of fillers.

However, it is important to bear in mind that to achieve successful hand rejuvenation, each ageing feature should be addressed with appropriate treatment modalities. Importantly, more often than not a combination technique is necessary.

Looking forward, there is a need for more studies to support our clinical practice and empower our clinical decision-making. Importantly, longevity of the different fillers needs to be explored further in future research.

Luitgard Wiest, MD

Dorsal volumising of the hand does not work for many patients with very prominent veins, either because there is no volume loss; the volumising option is rejected by the patient ; there is a high risk of an unsighlty cosmetic outcome. 

CAN ALL DORSAL HAND VEINS BE TREATED? 

Some patients ask for specific treatment of one or two very dilated veins but most want all of their visible veins to be dealt with.  Even when you explain to patients that veins and tendons are visible on beautiful, young hands, it is always difficult to make them appreciate and accept this fact.

So can all veins be treated?

In our opinion the answer is no, because of anatomical and haemodynamic constraints.

The choice of treatment will mainly depend on characteristics of the venous network, but the patient’s psychology and distance from the clinic also need to be taken into account.

Some patients will be more open to a radical strategy with immediate results whereas others will prefer a non-surgical treatment even if its effects are slower or even delayed.

If there are just one or two very dilated veins with the other veins being moderately visible, phlebectomy is the best option.  If there are many dilated veins or if the whole venous network is too much visible and aesthetically displeasing, “soft” slcerotherapy will be more suitable.

The size of the veins does not affect this choice but the larger the vein, the greater the number of sessions that will be required.

Some patients do not want to see any veins at all after treatment and these should be offered a combination of “soft” sclerotherapy and volumising filling, either with a synthetic filler or with autologous fat tissue.  But the sclerotherapy should be performed first !

Marc Lefebvre-Vilardebo, MD

Pain represents a major obstacle to seeking treatments. 

Pain-free procedures will encourage patients to come back for further treatments. 

Technical understanding of local anaesthesia is indispensable for phlebectomy and preferable for volumising filler injections of the hand also.

The back of the hand is relatively insensitive, but the technique of subdermal injection using a cannula tends to induce more stimulation of receptors within and below the dermis and the procedure can be painful, especially when repeated.

Knowledge of basic anatomical and technical fundamentals is now making it possible to conduct painless procedures, thereby increasing patient satisfaction.

Regional anaesthesia of the back of the hand is safe and effective, even with simple subcutaneous infiltration. It does not alter tissue structure and usually covers the entire area to be treated.

Nabila Azib, MD

This chapter focuses on the cutaneous signs which are associated the loss of both adipose tissue and muscle bulk, alongside vascular changes, and deformation of the bones which all contribute to the general appearance of the ageing hand. 

It is important to perform a good analysis both qualitative and quantitative of the signs of ageing on the hands to determine a treatment strategy with prioritisation of malignant and premalignant lesions. Laser treatment, IPL and PDT can be used to manage the various signs of ageing of the skin of the hands.  Diverse physical and chemical modalities can be combines to ensure a comprehensive result, possibly followed by maintenance treatment with topical products (sunscreen, moisturisers, or retinoids).

Jacques Savary, MD , Veronique Gassia, MD