In addition to the face and neck, the hands can show signs of age before the rest of the body. Hand rejuvenation with fillers has become an increasingly popular minimally invasive cosmetic procedure that can be offered to restore the signs of aging hands.
Aging of the hands is due to a combination of dermal and subcutaneous thinning, resorption of bone, increased skin sagging, laxity, and pigmentation and textural changes. As the dermis quality and quantity diminishes, veins, bones, and tendons become more prominent.1,2 Many factors can influence the appearance of these changes such as genetics, smoking, alcohol abuse, exposure to UV radiation, patient’s occupation, and associated diseases that can affect the hand structures such as rheumatologic disorders.3
One of the best ways to improve the appearance of the dorsal hands is to re-volumize and minimize the appearance of prominent veins and tendons with fillers in an easy, in-office, 1-day procedure. Radiesse—a calcium hydroxylapatite product—is the only FDA-approved injectable filler for hand augmentation to correct volume loss in the dorsum of the hands.4 This article discusses the use of calcium hydroxylapatite to rejuvenate and restore youthful volume to the dorsal hands in 1 of our patients.
Case
A 63-year-old woman presented to our office inquiring about procedures to enhance the appearance of her dorsal hands. Her past medical history was noncontributory, and she has had multiple facial cosmetic procedures but none on her hands. Upon physical examination, the patient’s hands showed thinning of her skin with pronounced veins, tendons, and bony prominences (Figures 1A-C). Different options, risks and benefits, and expected outcomes were discussed with the patient and she agreed to proceed with injection of calcium hydroxylapatite for hand rejuvenation.
The procedure began with application of cold compresses to the area for 10 minutes. After this, clorhexidine scrubs where applied to both dorsal hands that were comfortably placed on a flat surface with the fingers extended. Initially, calcium hydroxylapatite was mixed with lidocaine 1% using a 2-sided syringe connector. Calcium hydroxylapatite was injected in the depressions along side the bony prominences and veins with a retrograde technique, inserting the needle on the most proximal part of the dorsal hand and always aspirating before injecting. Before injecting, the skin was pinched and retracted to make sure the injection was on the superficial lamina. The area was massaged and a second set of injections was done in a fanning technique on the areas where the depressions were still present for a total of 1.3cc of calcium hydroxylapatite. The areas were massaged again followed by cold compresses for comfort measures. The patient tolerated the procedure well and no adverse effects were observed. At the 3-week follow-up, the patient was extremely satisfied with the results and denied any side effects. The same procedure was performed on the contralateral hand (Figures 2A-C).
Article continues on page 2
{{pagebreak}}
Discussion
For effective hand rejuvenation 2 major issues must be addressed: loss of soft tissue volume and problems with skin tone and texture. Dermal fillers can help restore volume while light-based technologies and laser treatment can improve pigmentation problems and sun damaged skin.
In the histologic and ultrasound study of cadaveric dissections of the hand from Bidic and colleagues5, they found 3 fatty laminae that were superficial, intermediate, and deep, separated by thin fascia. The fascia that separates the last 2 is an extension of the antebrachial fascia of the forearm and the floor of the deep lamina is contiguous with the periostium of the metacarpals. The deep lamina contains the extensor tendons and the intermediate lamina contains the sensory nerves and the dorsal veins.5 The superficial lamina does not contain any structures, thus would be the ideal plane for the injections and it is opened when the skin is tented.3
An efficacious way to volumize the hand is with calcium hydroxylapatite.4 Composed of 30% calcium hydroxylapatite microparticles in 70% aqueous carboxymethyl cellulose gel carrier, its material is identical to the one on the bones and teeth, making it very biocompatible. These particles are large (25-45µm), which impedes phagocytosis and makes it more durable. After the injection, the gel is broken down by the body and the calcium hydroxylapatite stays, stimulating formation of collagen around it.6-8 When injected into the hands, calcium hydroxylapatite lasts an average of 12 to 18 months,1,9 but there are reports of patient satisfaction up to 3 years after the first application.8,10
The potential side effects off this procedure such as swelling, pain, erythema, bruising, itching, loss of sensation, and nodules are minor and transient.3 Calcium hydroxylapatite has a positive safety profile and has not shown any calcification or foreign-body reaction.11 The injection of the filler into a vessel is a potential adverse complication.12,13 To avoid this complication, the needle should be advanced through the skin in a retrograde fashion, always aspirating first, while the needle is moving toward the epidermis.3
This case presents a patient who achieved excellent results with hand rejuvenation with a treatment of calcium hydroxylapatite. She experienced no complications. For this in-office procedure, it is very important to master the technique and have a thorough understanding of the anatomy of the hands. In the hands of an expert cosmetic injector, this is a relatively simple procedure that provides high satisfaction to the patient.
Dr Correa-Selm is a micrographic surgery and procedural dermatology fellow at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr. Rogachefsky is a practicing dermatologist at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ.
Dr Lee is director of the ACGME-approved micrographic surgery and procedural dermatology fellowship and practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Disclosure: The authors report no relevant financial relationships.
References
1. Lim A, Mulcahy A. Hand rejuvenation: combining dorsal veins foam sclerotherapy and calcium hydroxylapatite filler injections [published online June 24, 2016]. Phlebology. doi:10.1177/0268355516655684
2. Riyaz FR, Ozog D. Hand rejuvenation. Semin Cutan Med Surg. 2015;34(3):147-152.
3. Rivkin AZ. Volume correction in the aging hand: role of dermal fillers. Clin Cosmet Investig Dermatol. 2016;9:225-232.
4. Merz North America announces FDA approval of Radiesse® for use in the hands [press release]. Raleigh, NC; June 4, 2015. https://www.merzusa.com/wp-content/uploads/Merz-North-America-Announces-Radiesse-Hands-Approval-FINAL.pdf. Accessed March 24, 2017.
5. Bidic SM, Hatef DA, Rohrich RJ. Dorsal hand anatomy relevant to volumetric rejuvenation. Plast Reconstr Surg. 2010;126(1):163-168.
6. Berlin AL, Hussain M, Goldberg DJ. Calcium hydroxylapatite filler for facial rejuvenation: a histologic and immunohistochemical analysis. Dermatol Surg. 2008;34(suppl 1):S64-S67.
7. Jansen DA, Graivier MH. Evaluation of a calcium hydroxylapatite-based implant (Radiesse) for facial soft-tissue augmentation. Plast Reconstr Surg. 2006;118(3 suppl):22S-30S, discussion, 31S-33S.
8. Emer J, Sundaram H. Aesthetic applications of calcium hydroxylapatite volumizing filler: an evidence-based review and discussion of current concepts: (part 1 of 2). J Drugs Dermatol. 2013;12(12):1345-1354.
9. Moers-Carpi M, Vogt S, Santos BM, Planas J, Vallve SR, Howell DJ. A multicenter, randomized trial comparing calcium hydroxylapatite to two hyaluronic acids for treatment of nasolabial folds. Dermatol Surg. 2007;33(suppl 2):S144-S1451.
10. Bass LS, Smith S, Busso M, McClaren M. Calcium hydroxylapatite (Radiesse) for treatment of nasolabial folds: long-term safety and efficacy results. Aesthet Surg J. 2010;30(2):235-238.
11. Jacovella PF. Use of calcium hydroxylapatite (Radiesse) for facial augmentation. Clin Interv Aging. 2008;3(1):161-174.
12. Tracy L, Ridgway J, Nelson JS, Lowe N, Wong B. Calcium hydroxylapatite associated soft tissue necrosis: a case report and treatment guideline. J Plast Reconstr Aesthet Surg. 2014;67(4):564-568.
13. Sung MS, Kim HG, Woo KI, Kim YD. Ocular ischemia and ischemic oculomotor nerve palsy after vascular embolization of injectable calcium hydroxylapatite filler. Ophthal Plast Reconstr Surg. 2010;26(4):289-291.
In addition to the face and neck, the hands can show signs of age before the rest of the body. Hand rejuvenation with fillers has become an increasingly popular minimally invasive cosmetic procedure that can be offered to restore the signs of aging hands.
Aging of the hands is due to a combination of dermal and subcutaneous thinning, resorption of bone, increased skin sagging, laxity, and pigmentation and textural changes. As the dermis quality and quantity diminishes, veins, bones, and tendons become more prominent.1,2 Many factors can influence the appearance of these changes such as genetics, smoking, alcohol abuse, exposure to UV radiation, patient’s occupation, and associated diseases that can affect the hand structures such as rheumatologic disorders.3
One of the best ways to improve the appearance of the dorsal hands is to re-volumize and minimize the appearance of prominent veins and tendons with fillers in an easy, in-office, 1-day procedure. Radiesse—a calcium hydroxylapatite product—is the only FDA-approved injectable filler for hand augmentation to correct volume loss in the dorsum of the hands.4 This article discusses the use of calcium hydroxylapatite to rejuvenate and restore youthful volume to the dorsal hands in 1 of our patients.
Case
A 63-year-old woman presented to our office inquiring about procedures to enhance the appearance of her dorsal hands. Her past medical history was noncontributory, and she has had multiple facial cosmetic procedures but none on her hands. Upon physical examination, the patient’s hands showed thinning of her skin with pronounced veins, tendons, and bony prominences (Figures 1A-C). Different options, risks and benefits, and expected outcomes were discussed with the patient and she agreed to proceed with injection of calcium hydroxylapatite for hand rejuvenation.
The procedure began with application of cold compresses to the area for 10 minutes. After this, clorhexidine scrubs where applied to both dorsal hands that were comfortably placed on a flat surface with the fingers extended. Initially, calcium hydroxylapatite was mixed with lidocaine 1% using a 2-sided syringe connector. Calcium hydroxylapatite was injected in the depressions along side the bony prominences and veins with a retrograde technique, inserting the needle on the most proximal part of the dorsal hand and always aspirating before injecting. Before injecting, the skin was pinched and retracted to make sure the injection was on the superficial lamina. The area was massaged and a second set of injections was done in a fanning technique on the areas where the depressions were still present for a total of 1.3cc of calcium hydroxylapatite. The areas were massaged again followed by cold compresses for comfort measures. The patient tolerated the procedure well and no adverse effects were observed. At the 3-week follow-up, the patient was extremely satisfied with the results and denied any side effects. The same procedure was performed on the contralateral hand (Figures 2A-C).
Discussion
For effective hand rejuvenation 2 major issues must be addressed: loss of soft tissue volume and problems with skin tone and texture. Dermal fillers can help restore volume while light-based technologies and laser treatment can improve pigmentation problems and sun damaged skin.
In the histologic and ultrasound study of cadaveric dissections of the hand from Bidic and colleagues5, they found 3 fatty laminae that were superficial, intermediate, and deep, separated by thin fascia. The fascia that separates the last 2 is an extension of the antebrachial fascia of the forearm and the floor of the deep lamina is contiguous with the periostium of the metacarpals. The deep lamina contains the extensor tendons and the intermediate lamina contains the sensory nerves and the dorsal veins.5 The superficial lamina does not contain any structures, thus would be the ideal plane for the injections and it is opened when the skin is tented.3
An efficacious way to volumize the hand is with calcium hydroxylapatite.4 Composed of 30% calcium hydroxylapatite microparticles in 70% aqueous carboxymethyl cellulose gel carrier, its material is identical to the one on the bones and teeth, making it very biocompatible. These particles are large (25-45µm), which impedes phagocytosis and makes it more durable. After the injection, the gel is broken down by the body and the calcium hydroxylapatite stays, stimulating formation of collagen around it.6-8 When injected into the hands, calcium hydroxylapatite lasts an average of 12 to 18 months,1,9 but there are reports of patient satisfaction up to 3 years after the first application.8,10
The potential side effects off this procedure such as swelling, pain, erythema, bruising, itching, loss of sensation, and nodules are minor and transient.3 Calcium hydroxylapatite has a positive safety profile and has not shown any calcification or foreign-body reaction.11 The injection of the filler into a vessel is a potential adverse complication.12,13 To avoid this complication, the needle should be advanced through the skin in a retrograde fashion, always aspirating first, while the needle is moving toward the epidermis.3
This case presents a patient who achieved excellent results with hand rejuvenation with a treatment of calcium hydroxylapatite. She experienced no complications. For this in-office procedure, it is very important to master the technique and have a thorough understanding of the anatomy of the hands. In the hands of an expert cosmetic injector, this is a relatively simple procedure that provides high satisfaction to the patient.
Dr Correa-Selm is a micrographic surgery and procedural dermatology fellow at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr. Rogachefsky is a practicing dermatologist at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ.
Dr Lee is director of the ACGME-approved micrographic surgery and procedural dermatology fellowship and practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Disclosure: The authors report no relevant financial relationships.
References
1. Lim A, Mulcahy A. Hand rejuvenation: combining dorsal veins foam sclerotherapy and calcium hydroxylapatite filler injections [published online June 24, 2016]. Phlebology. doi:10.1177/0268355516655684
2. Riyaz FR, Ozog D. Hand rejuvenation. Semin Cutan Med Surg. 2015;34(3):147-152.
3. Rivkin AZ. Volume correction in the aging hand: role of dermal fillers. Clin Cosmet Investig Dermatol. 2016;9:225-232.
4. Merz North America announces FDA approval of Radiesse® for use in the hands [press release]. Raleigh, NC; June 4, 2015. https://www.merzusa.com/wp-content/uploads/Merz-North-America-Announces-Radiesse-Hands-Approval-FINAL.pdf. Accessed March 24, 2017.
5. Bidic SM, Hatef DA, Rohrich RJ. Dorsal hand anatomy relevant to volumetric rejuvenation. Plast Reconstr Surg. 2010;126(1):163-168.
6. Berlin AL, Hussain M, Goldberg DJ. Calcium hydroxylapatite filler for facial rejuvenation: a histologic and immunohistochemical analysis. Dermatol Surg. 2008;34(suppl 1):S64-S67.
7. Jansen DA, Graivier MH. Evaluation of a calcium hydroxylapatite-based implant (Radiesse) for facial soft-tissue augmentation. Plast Reconstr Surg. 2006;118(3 suppl):22S-30S, discussion, 31S-33S.
8. Emer J, Sundaram H. Aesthetic applications of calcium hydroxylapatite volumizing filler: an evidence-based review and discussion of current concepts: (part 1 of 2). J Drugs Dermatol. 2013;12(12):1345-1354.
9. Moers-Carpi M, Vogt S, Santos BM, Planas J, Vallve SR, Howell DJ. A multicenter, randomized trial comparing calcium hydroxylapatite to two hyaluronic acids for treatment of nasolabial folds. Dermatol Surg. 2007;33(suppl 2):S144-S1451.
10. Bass LS, Smith S, Busso M, McClaren M. Calcium hydroxylapatite (Radiesse) for treatment of nasolabial folds: long-term safety and efficacy results. Aesthet Surg J. 2010;30(2):235-238.
11. Jacovella PF. Use of calcium hydroxylapatite (Radiesse) for facial augmentation. Clin Interv Aging. 2008;3(1):161-174.
12. Tracy L, Ridgway J, Nelson JS, Lowe N, Wong B. Calcium hydroxylapatite associated soft tissue necrosis: a case report and treatment guideline. J Plast Reconstr Aesthet Surg. 2014;67(4):564-568.
13. Sung MS, Kim HG, Woo KI, Kim YD. Ocular ischemia and ischemic oculomotor nerve palsy after vascular embolization of injectable calcium hydroxylapatite filler. Ophthal Plast Reconstr Surg. 2010;26(4):289-291.
In addition to the face and neck, the hands can show signs of age before the rest of the body. Hand rejuvenation with fillers has become an increasingly popular minimally invasive cosmetic procedure that can be offered to restore the signs of aging hands.
Aging of the hands is due to a combination of dermal and subcutaneous thinning, resorption of bone, increased skin sagging, laxity, and pigmentation and textural changes. As the dermis quality and quantity diminishes, veins, bones, and tendons become more prominent.1,2 Many factors can influence the appearance of these changes such as genetics, smoking, alcohol abuse, exposure to UV radiation, patient’s occupation, and associated diseases that can affect the hand structures such as rheumatologic disorders.3
One of the best ways to improve the appearance of the dorsal hands is to re-volumize and minimize the appearance of prominent veins and tendons with fillers in an easy, in-office, 1-day procedure. Radiesse—a calcium hydroxylapatite product—is the only FDA-approved injectable filler for hand augmentation to correct volume loss in the dorsum of the hands.4 This article discusses the use of calcium hydroxylapatite to rejuvenate and restore youthful volume to the dorsal hands in 1 of our patients.
Case
A 63-year-old woman presented to our office inquiring about procedures to enhance the appearance of her dorsal hands. Her past medical history was noncontributory, and she has had multiple facial cosmetic procedures but none on her hands. Upon physical examination, the patient’s hands showed thinning of her skin with pronounced veins, tendons, and bony prominences (Figures 1A-C). Different options, risks and benefits, and expected outcomes were discussed with the patient and she agreed to proceed with injection of calcium hydroxylapatite for hand rejuvenation.
The procedure began with application of cold compresses to the area for 10 minutes. After this, clorhexidine scrubs where applied to both dorsal hands that were comfortably placed on a flat surface with the fingers extended. Initially, calcium hydroxylapatite was mixed with lidocaine 1% using a 2-sided syringe connector. Calcium hydroxylapatite was injected in the depressions along side the bony prominences and veins with a retrograde technique, inserting the needle on the most proximal part of the dorsal hand and always aspirating before injecting. Before injecting, the skin was pinched and retracted to make sure the injection was on the superficial lamina. The area was massaged and a second set of injections was done in a fanning technique on the areas where the depressions were still present for a total of 1.3cc of calcium hydroxylapatite. The areas were massaged again followed by cold compresses for comfort measures. The patient tolerated the procedure well and no adverse effects were observed. At the 3-week follow-up, the patient was extremely satisfied with the results and denied any side effects. The same procedure was performed on the contralateral hand (Figures 2A-C).
,
In addition to the face and neck, the hands can show signs of age before the rest of the body. Hand rejuvenation with fillers has become an increasingly popular minimally invasive cosmetic procedure that can be offered to restore the signs of aging hands.
Aging of the hands is due to a combination of dermal and subcutaneous thinning, resorption of bone, increased skin sagging, laxity, and pigmentation and textural changes. As the dermis quality and quantity diminishes, veins, bones, and tendons become more prominent.1,2 Many factors can influence the appearance of these changes such as genetics, smoking, alcohol abuse, exposure to UV radiation, patient’s occupation, and associated diseases that can affect the hand structures such as rheumatologic disorders.3
One of the best ways to improve the appearance of the dorsal hands is to re-volumize and minimize the appearance of prominent veins and tendons with fillers in an easy, in-office, 1-day procedure. Radiesse—a calcium hydroxylapatite product—is the only FDA-approved injectable filler for hand augmentation to correct volume loss in the dorsum of the hands.4 This article discusses the use of calcium hydroxylapatite to rejuvenate and restore youthful volume to the dorsal hands in 1 of our patients.
Case
A 63-year-old woman presented to our office inquiring about procedures to enhance the appearance of her dorsal hands. Her past medical history was noncontributory, and she has had multiple facial cosmetic procedures but none on her hands. Upon physical examination, the patient’s hands showed thinning of her skin with pronounced veins, tendons, and bony prominences (Figures 1A-C). Different options, risks and benefits, and expected outcomes were discussed with the patient and she agreed to proceed with injection of calcium hydroxylapatite for hand rejuvenation.
The procedure began with application of cold compresses to the area for 10 minutes. After this, clorhexidine scrubs where applied to both dorsal hands that were comfortably placed on a flat surface with the fingers extended. Initially, calcium hydroxylapatite was mixed with lidocaine 1% using a 2-sided syringe connector. Calcium hydroxylapatite was injected in the depressions along side the bony prominences and veins with a retrograde technique, inserting the needle on the most proximal part of the dorsal hand and always aspirating before injecting. Before injecting, the skin was pinched and retracted to make sure the injection was on the superficial lamina. The area was massaged and a second set of injections was done in a fanning technique on the areas where the depressions were still present for a total of 1.3cc of calcium hydroxylapatite. The areas were massaged again followed by cold compresses for comfort measures. The patient tolerated the procedure well and no adverse effects were observed. At the 3-week follow-up, the patient was extremely satisfied with the results and denied any side effects. The same procedure was performed on the contralateral hand (Figures 2A-C).
Article continues on page 2
{{pagebreak}}
Discussion
For effective hand rejuvenation 2 major issues must be addressed: loss of soft tissue volume and problems with skin tone and texture. Dermal fillers can help restore volume while light-based technologies and laser treatment can improve pigmentation problems and sun damaged skin.
In the histologic and ultrasound study of cadaveric dissections of the hand from Bidic and colleagues5, they found 3 fatty laminae that were superficial, intermediate, and deep, separated by thin fascia. The fascia that separates the last 2 is an extension of the antebrachial fascia of the forearm and the floor of the deep lamina is contiguous with the periostium of the metacarpals. The deep lamina contains the extensor tendons and the intermediate lamina contains the sensory nerves and the dorsal veins.5 The superficial lamina does not contain any structures, thus would be the ideal plane for the injections and it is opened when the skin is tented.3
An efficacious way to volumize the hand is with calcium hydroxylapatite.4 Composed of 30% calcium hydroxylapatite microparticles in 70% aqueous carboxymethyl cellulose gel carrier, its material is identical to the one on the bones and teeth, making it very biocompatible. These particles are large (25-45µm), which impedes phagocytosis and makes it more durable. After the injection, the gel is broken down by the body and the calcium hydroxylapatite stays, stimulating formation of collagen around it.6-8 When injected into the hands, calcium hydroxylapatite lasts an average of 12 to 18 months,1,9 but there are reports of patient satisfaction up to 3 years after the first application.8,10
The potential side effects off this procedure such as swelling, pain, erythema, bruising, itching, loss of sensation, and nodules are minor and transient.3 Calcium hydroxylapatite has a positive safety profile and has not shown any calcification or foreign-body reaction.11 The injection of the filler into a vessel is a potential adverse complication.12,13 To avoid this complication, the needle should be advanced through the skin in a retrograde fashion, always aspirating first, while the needle is moving toward the epidermis.3
This case presents a patient who achieved excellent results with hand rejuvenation with a treatment of calcium hydroxylapatite. She experienced no complications. For this in-office procedure, it is very important to master the technique and have a thorough understanding of the anatomy of the hands. In the hands of an expert cosmetic injector, this is a relatively simple procedure that provides high satisfaction to the patient.
Dr Correa-Selm is a micrographic surgery and procedural dermatology fellow at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr. Rogachefsky is a practicing dermatologist at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ.
Dr Lee is director of the ACGME-approved micrographic surgery and procedural dermatology fellowship and practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Disclosure: The authors report no relevant financial relationships.
References
1. Lim A, Mulcahy A. Hand rejuvenation: combining dorsal veins foam sclerotherapy and calcium hydroxylapatite filler injections [published online June 24, 2016]. Phlebology. doi:10.1177/0268355516655684
2. Riyaz FR, Ozog D. Hand rejuvenation. Semin Cutan Med Surg. 2015;34(3):147-152.
3. Rivkin AZ. Volume correction in the aging hand: role of dermal fillers. Clin Cosmet Investig Dermatol. 2016;9:225-232.
4. Merz North America announces FDA approval of Radiesse® for use in the hands [press release]. Raleigh, NC; June 4, 2015. https://www.merzusa.com/wp-content/uploads/Merz-North-America-Announces-Radiesse-Hands-Approval-FINAL.pdf. Accessed March 24, 2017.
5. Bidic SM, Hatef DA, Rohrich RJ. Dorsal hand anatomy relevant to volumetric rejuvenation. Plast Reconstr Surg. 2010;126(1):163-168.
6. Berlin AL, Hussain M, Goldberg DJ. Calcium hydroxylapatite filler for facial rejuvenation: a histologic and immunohistochemical analysis. Dermatol Surg. 2008;34(suppl 1):S64-S67.
7. Jansen DA, Graivier MH. Evaluation of a calcium hydroxylapatite-based implant (Radiesse) for facial soft-tissue augmentation. Plast Reconstr Surg. 2006;118(3 suppl):22S-30S, discussion, 31S-33S.
8. Emer J, Sundaram H. Aesthetic applications of calcium hydroxylapatite volumizing filler: an evidence-based review and discussion of current concepts: (part 1 of 2). J Drugs Dermatol. 2013;12(12):1345-1354.
9. Moers-Carpi M, Vogt S, Santos BM, Planas J, Vallve SR, Howell DJ. A multicenter, randomized trial comparing calcium hydroxylapatite to two hyaluronic acids for treatment of nasolabial folds. Dermatol Surg. 2007;33(suppl 2):S144-S1451.
10. Bass LS, Smith S, Busso M, McClaren M. Calcium hydroxylapatite (Radiesse) for treatment of nasolabial folds: long-term safety and efficacy results. Aesthet Surg J. 2010;30(2):235-238.
11. Jacovella PF. Use of calcium hydroxylapatite (Radiesse) for facial augmentation. Clin Interv Aging. 2008;3(1):161-174.
12. Tracy L, Ridgway J, Nelson JS, Lowe N, Wong B. Calcium hydroxylapatite associated soft tissue necrosis: a case report and treatment guideline. J Plast Reconstr Aesthet Surg. 2014;67(4):564-568.
13. Sung MS, Kim HG, Woo KI, Kim YD. Ocular ischemia and ischemic oculomotor nerve palsy after vascular embolization of injectable calcium hydroxylapatite filler. Ophthal Plast Reconstr Surg. 2010;26(4):289-291.
In addition to the face and neck, the hands can show signs of age before the rest of the body. Hand rejuvenation with fillers has become an increasingly popular minimally invasive cosmetic procedure that can be offered to restore the signs of aging hands.
Aging of the hands is due to a combination of dermal and subcutaneous thinning, resorption of bone, increased skin sagging, laxity, and pigmentation and textural changes. As the dermis quality and quantity diminishes, veins, bones, and tendons become more prominent.1,2 Many factors can influence the appearance of these changes such as genetics, smoking, alcohol abuse, exposure to UV radiation, patient’s occupation, and associated diseases that can affect the hand structures such as rheumatologic disorders.3
One of the best ways to improve the appearance of the dorsal hands is to re-volumize and minimize the appearance of prominent veins and tendons with fillers in an easy, in-office, 1-day procedure. Radiesse—a calcium hydroxylapatite product—is the only FDA-approved injectable filler for hand augmentation to correct volume loss in the dorsum of the hands.4 This article discusses the use of calcium hydroxylapatite to rejuvenate and restore youthful volume to the dorsal hands in 1 of our patients.
Case
A 63-year-old woman presented to our office inquiring about procedures to enhance the appearance of her dorsal hands. Her past medical history was noncontributory, and she has had multiple facial cosmetic procedures but none on her hands. Upon physical examination, the patient’s hands showed thinning of her skin with pronounced veins, tendons, and bony prominences (Figures 1A-C). Different options, risks and benefits, and expected outcomes were discussed with the patient and she agreed to proceed with injection of calcium hydroxylapatite for hand rejuvenation.
The procedure began with application of cold compresses to the area for 10 minutes. After this, clorhexidine scrubs where applied to both dorsal hands that were comfortably placed on a flat surface with the fingers extended. Initially, calcium hydroxylapatite was mixed with lidocaine 1% using a 2-sided syringe connector. Calcium hydroxylapatite was injected in the depressions along side the bony prominences and veins with a retrograde technique, inserting the needle on the most proximal part of the dorsal hand and always aspirating before injecting. Before injecting, the skin was pinched and retracted to make sure the injection was on the superficial lamina. The area was massaged and a second set of injections was done in a fanning technique on the areas where the depressions were still present for a total of 1.3cc of calcium hydroxylapatite. The areas were massaged again followed by cold compresses for comfort measures. The patient tolerated the procedure well and no adverse effects were observed. At the 3-week follow-up, the patient was extremely satisfied with the results and denied any side effects. The same procedure was performed on the contralateral hand (Figures 2A-C).
Discussion
For effective hand rejuvenation 2 major issues must be addressed: loss of soft tissue volume and problems with skin tone and texture. Dermal fillers can help restore volume while light-based technologies and laser treatment can improve pigmentation problems and sun damaged skin.
In the histologic and ultrasound study of cadaveric dissections of the hand from Bidic and colleagues5, they found 3 fatty laminae that were superficial, intermediate, and deep, separated by thin fascia. The fascia that separates the last 2 is an extension of the antebrachial fascia of the forearm and the floor of the deep lamina is contiguous with the periostium of the metacarpals. The deep lamina contains the extensor tendons and the intermediate lamina contains the sensory nerves and the dorsal veins.5 The superficial lamina does not contain any structures, thus would be the ideal plane for the injections and it is opened when the skin is tented.3
An efficacious way to volumize the hand is with calcium hydroxylapatite.4 Composed of 30% calcium hydroxylapatite microparticles in 70% aqueous carboxymethyl cellulose gel carrier, its material is identical to the one on the bones and teeth, making it very biocompatible. These particles are large (25-45µm), which impedes phagocytosis and makes it more durable. After the injection, the gel is broken down by the body and the calcium hydroxylapatite stays, stimulating formation of collagen around it.6-8 When injected into the hands, calcium hydroxylapatite lasts an average of 12 to 18 months,1,9 but there are reports of patient satisfaction up to 3 years after the first application.8,10
The potential side effects off this procedure such as swelling, pain, erythema, bruising, itching, loss of sensation, and nodules are minor and transient.3 Calcium hydroxylapatite has a positive safety profile and has not shown any calcification or foreign-body reaction.11 The injection of the filler into a vessel is a potential adverse complication.12,13 To avoid this complication, the needle should be advanced through the skin in a retrograde fashion, always aspirating first, while the needle is moving toward the epidermis.3
This case presents a patient who achieved excellent results with hand rejuvenation with a treatment of calcium hydroxylapatite. She experienced no complications. For this in-office procedure, it is very important to master the technique and have a thorough understanding of the anatomy of the hands. In the hands of an expert cosmetic injector, this is a relatively simple procedure that provides high satisfaction to the patient.
Dr Correa-Selm is a micrographic surgery and procedural dermatology fellow at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr. Rogachefsky is a practicing dermatologist at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ.
Dr Lee is director of the ACGME-approved micrographic surgery and procedural dermatology fellowship and practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Disclosure: The authors report no relevant financial relationships.
References
1. Lim A, Mulcahy A. Hand rejuvenation: combining dorsal veins foam sclerotherapy and calcium hydroxylapatite filler injections [published online June 24, 2016]. Phlebology. doi:10.1177/0268355516655684
2. Riyaz FR, Ozog D. Hand rejuvenation. Semin Cutan Med Surg. 2015;34(3):147-152.
3. Rivkin AZ. Volume correction in the aging hand: role of dermal fillers. Clin Cosmet Investig Dermatol. 2016;9:225-232.
4. Merz North America announces FDA approval of Radiesse® for use in the hands [press release]. Raleigh, NC; June 4, 2015. https://www.merzusa.com/wp-content/uploads/Merz-North-America-Announces-Radiesse-Hands-Approval-FINAL.pdf. Accessed March 24, 2017.
5. Bidic SM, Hatef DA, Rohrich RJ. Dorsal hand anatomy relevant to volumetric rejuvenation. Plast Reconstr Surg. 2010;126(1):163-168.
6. Berlin AL, Hussain M, Goldberg DJ. Calcium hydroxylapatite filler for facial rejuvenation: a histologic and immunohistochemical analysis. Dermatol Surg. 2008;34(suppl 1):S64-S67.
7. Jansen DA, Graivier MH. Evaluation of a calcium hydroxylapatite-based implant (Radiesse) for facial soft-tissue augmentation. Plast Reconstr Surg. 2006;118(3 suppl):22S-30S, discussion, 31S-33S.
8. Emer J, Sundaram H. Aesthetic applications of calcium hydroxylapatite volumizing filler: an evidence-based review and discussion of current concepts: (part 1 of 2). J Drugs Dermatol. 2013;12(12):1345-1354.
9. Moers-Carpi M, Vogt S, Santos BM, Planas J, Vallve SR, Howell DJ. A multicenter, randomized trial comparing calcium hydroxylapatite to two hyaluronic acids for treatment of nasolabial folds. Dermatol Surg. 2007;33(suppl 2):S144-S1451.
10. Bass LS, Smith S, Busso M, McClaren M. Calcium hydroxylapatite (Radiesse) for treatment of nasolabial folds: long-term safety and efficacy results. Aesthet Surg J. 2010;30(2):235-238.
11. Jacovella PF. Use of calcium hydroxylapatite (Radiesse) for facial augmentation. Clin Interv Aging. 2008;3(1):161-174.
12. Tracy L, Ridgway J, Nelson JS, Lowe N, Wong B. Calcium hydroxylapatite associated soft tissue necrosis: a case report and treatment guideline. J Plast Reconstr Aesthet Surg. 2014;67(4):564-568.
13. Sung MS, Kim HG, Woo KI, Kim YD. Ocular ischemia and ischemic oculomotor nerve palsy after vascular embolization of injectable calcium hydroxylapatite filler. Ophthal Plast Reconstr Surg. 2010;26(4):289-291.
Discussion
For effective hand rejuvenation 2 major issues must be addressed: loss of soft tissue volume and problems with skin tone and texture. Dermal fillers can help restore volume while light-based technologies and laser treatment can improve pigmentation problems and sun damaged skin.
In the histologic and ultrasound study of cadaveric dissections of the hand from Bidic and colleagues5, they found 3 fatty laminae that were superficial, intermediate, and deep, separated by thin fascia. The fascia that separates the last 2 is an extension of the antebrachial fascia of the forearm and the floor of the deep lamina is contiguous with the periostium of the metacarpals. The deep lamina contains the extensor tendons and the intermediate lamina contains the sensory nerves and the dorsal veins.5 The superficial lamina does not contain any structures, thus would be the ideal plane for the injections and it is opened when the skin is tented.3
An efficacious way to volumize the hand is with calcium hydroxylapatite.4 Composed of 30% calcium hydroxylapatite microparticles in 70% aqueous carboxymethyl cellulose gel carrier, its material is identical to the one on the bones and teeth, making it very biocompatible. These particles are large (25-45µm), which impedes phagocytosis and makes it more durable. After the injection, the gel is broken down by the body and the calcium hydroxylapatite stays, stimulating formation of collagen around it.6-8 When injected into the hands, calcium hydroxylapatite lasts an average of 12 to 18 months,1,9 but there are reports of patient satisfaction up to 3 years after the first application.8,10
The potential side effects off this procedure such as swelling, pain, erythema, bruising, itching, loss of sensation, and nodules are minor and transient.3 Calcium hydroxylapatite has a positive safety profile and has not shown any calcification or foreign-body reaction.11 The injection of the filler into a vessel is a potential adverse complication.12,13 To avoid this complication, the needle should be advanced through the skin in a retrograde fashion, always aspirating first, while the needle is moving toward the epidermis.3
This case presents a patient who achieved excellent results with hand rejuvenation with a treatment of calcium hydroxylapatite. She experienced no complications. For this in-office procedure, it is very important to master the technique and have a thorough understanding of the anatomy of the hands. In the hands of an expert cosmetic injector, this is a relatively simple procedure that provides high satisfaction to the patient.
Dr Correa-Selm is a micrographic surgery and procedural dermatology fellow at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr. Rogachefsky is a practicing dermatologist at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ.
Dr Lee is director of the ACGME-approved micrographic surgery and procedural dermatology fellowship and practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Disclosure: The authors report no relevant financial relationships.
References
1. Lim A, Mulcahy A. Hand rejuvenation: combining dorsal veins foam sclerotherapy and calcium hydroxylapatite filler injections [published online June 24, 2016]. Phlebology. doi:10.1177/0268355516655684
2. Riyaz FR, Ozog D. Hand rejuvenation. Semin Cutan Med Surg. 2015;34(3):147-152.
3. Rivkin AZ. Volume correction in the aging hand: role of dermal fillers. Clin Cosmet Investig Dermatol. 2016;9:225-232.
4. Merz North America announces FDA approval of Radiesse® for use in the hands [press release]. Raleigh, NC; June 4, 2015. https://www.merzusa.com/wp-content/uploads/Merz-North-America-Announces-Radiesse-Hands-Approval-FINAL.pdf. Accessed March 24, 2017.
5. Bidic SM, Hatef DA, Rohrich RJ. Dorsal hand anatomy relevant to volumetric rejuvenation. Plast Reconstr Surg. 2010;126(1):163-168.
6. Berlin AL, Hussain M, Goldberg DJ. Calcium hydroxylapatite filler for facial rejuvenation: a histologic and immunohistochemical analysis. Dermatol Surg. 2008;34(suppl 1):S64-S67.
7. Jansen DA, Graivier MH. Evaluation of a calcium hydroxylapatite-based implant (Radiesse) for facial soft-tissue augmentation. Plast Reconstr Surg. 2006;118(3 suppl):22S-30S, discussion, 31S-33S.
8. Emer J, Sundaram H. Aesthetic applications of calcium hydroxylapatite volumizing filler: an evidence-based review and discussion of current concepts: (part 1 of 2). J Drugs Dermatol. 2013;12(12):1345-1354.
9. Moers-Carpi M, Vogt S, Santos BM, Planas J, Vallve SR, Howell DJ. A multicenter, randomized trial comparing calcium hydroxylapatite to two hyaluronic acids for treatment of nasolabial folds. Dermatol Surg. 2007;33(suppl 2):S144-S1451.
10. Bass LS, Smith S, Busso M, McClaren M. Calcium hydroxylapatite (Radiesse) for treatment of nasolabial folds: long-term safety and efficacy results. Aesthet Surg J. 2010;30(2):235-238.
11. Jacovella PF. Use of calcium hydroxylapatite (Radiesse) for facial augmentation. Clin Interv Aging. 2008;3(1):161-174.
12. Tracy L, Ridgway J, Nelson JS, Lowe N, Wong B. Calcium hydroxylapatite associated soft tissue necrosis: a case report and treatment guideline. J Plast Reconstr Aesthet Surg. 2014;67(4):564-568.
13. Sung MS, Kim HG, Woo KI, Kim YD. Ocular ischemia and ischemic oculomotor nerve palsy after vascular embolization of injectable calcium hydroxylapatite filler. Ophthal Plast Reconstr Surg. 2010;26(4):289-291.
