Treatment for the dorsal hands may involve a variety of fillers including hyaluronic acids, collagens, poly L lactic acid and calcium hydroxylapatite, each of which offers advantages and disadvantages, including variation in duration and cost of correction. Here, Dr. Beer offers recommendations on how to handle hand injections. The use of various fillers to treat the signs of facial aging is well-established in dermatology and plastic surgery. Its history dates back to the early part of the 20th century when paraffin was used to change the appearance of the face. More recently, a real plastic-type material, Artefill, was FDA-approved for cosmetic use. And now in 2009, despite challenging economic times, physicians and patients alike are interested in ways to treat signs of aging on nonfacial, as well as facial skin. One area garnering interest is the hands. Injections for Hands Unlike the soles of the feet, which may be treated with a variety of fillers for therapeutic indications, the dorsal hands are injected for primarily cosmetic reasons. Treatment for the dorsal hands may involve a variety of fillers including hyaluronic acids, collagens, poly L lactic acid and calcium hydroxylapatite. Each of these offers some advantages and some disadvantages and also varies in the duration and cost of correction. Here, we discuss some of the main issues and injection methods. Patient Selection Considerations It is true with most surgical procedures — but is especially the case with elective cosmetic procedures — that patient selection can make all the difference in both actual and perceived results. With that in mind, in our practice, we restrict the hand rejuvnenation approaches described below to patients with moderate, not severe, hand aging. Hyalurons One of the most common materials used for treating dorsal hand atrophy is hyaluronic acid. The hyalurons have various commercial products available, including Perlane, Restylane and Juvederm. They vary in their cross linkage, effective hyaluronic acid concentration — that is, total hyaluronic minus free hyaluronic — as well as their anesthetic content, the resistance of the gel to flow, duration and cost. Volume Since volume is a primary consideration for the correction of dorsal hand atrophy, one consideration for product selection is the volume of the products available. Perlane and Restylane, which are supplied in syringes that are filled to approximately 1.2 mL, provide adequate volume for treating an average hand with 1.5-mL syringes. Juvederm 24 has about 0.9 mL of product per syringe and may require more syringes per hand. Calcium Hydroxylapatite Radiesse is a calcium hydroxlyapatite (CAHA) filler approved for cosmetic indications. Although used primarily in the face, it has also been used in the hands. Volume, Duration of Correction Its benefits include a long duration of correction (approximately 6 to 9 months) and a large volume. Each syringe of material contains about 1.3 mL of product. Opacity Whereas the hyalurons are translucent, CAHA is an opaque white matrix. Thus, it presents both opportunities and challenges when injected into the hands. One advantage of its opaque nature is that it can camouflage some of the underlying structures such as veins and tendons. However, it may also present visible white nodules if the skin overlying it is transparent and atrophic. Since there is no significant subcutaneous tissue in the dorsal hands, there is not a deep space into which to inject this product and it is frequently very close to the overlying epidermis. Thus, consideration of the thickness of the skin must be taken into account prior to using this as a filler for the dorsal hands. Poly L lactic Acid (Sculptra) Sculptra is composed of poly L lactic acid (PLLA). When mixed with water, it is used to stimulate collagen and replenish aging skin. Concentration For dorsal hands, it has been used in varying concentrations. To date, no well-designed trial has demonstrated optimal technique but many injectors utilize concentrations of between 7 mL and 9 mL of diluent. As with other areas, formation of subcutaneous papules is one potential pitfall associated with the use of this product. When injecting PLLA into the dorsal hands, it is best to err on the side of greater dilution and less frequent injections (e.g., at least 4 to 6 weeks apart). Collagen (Evolence) Until the approval of Evolence, collagen was not a realistic material to consider for injection into the hands. Prior collagen products were too expensive and too short lived to be practical products for this indication. However, Evolence, which is a ribose cross-linked porcine collagen, has the potential to provide long-term stable correction for this location. Evolence is available in 1 mL syringes, which are typically overfilled. As with other syringes of this size, approximately 1 to 1.5 syringes are needed for the average hand. Injection Recommendations Start with Hyalurons Injections into the dorsal hands require a fair amount of experience and caution. When beginning, it is recommended that one use hyalurons (which are reversible for lumps and bumps). Matzoh Ball Technique Serial fanning, linear threading and depot (what Mary Lupo, MD, calls “the matzoh ball technique”) may be used when injecting the hands. Safety Caveats One significant caveat is to be certain that the needle is not intravascular when injecting the filler. Thus, aspiration prior to injection or injection while withdrawing the syringe are two techniques that are crucial for safe injections. Potential embolization of product is possible, and the large veins of the dorsal hands must be avoided. In addition to the veins, it is best to avoid injection directly over the extensor tendons of the fingers. Step by Step Procedure • Whatever the product selected, my technique begins in the middle of the dorsal hand with the needle pointed towards the distal fingers. • A small amount of material — say about 0.1 mL — is injected to gauge the patient’s tolerance for the procedure and to lift the skin away from underlying structures. • A small amount of anesthetic — 1 mL of lidocaine with 1:1000 — epinephrine may also be utilized to accomplish these goals. • Injections of material are made in a serial puncture technique in an effort to lift up the epidermis and “re-inflate” the hands. • After completing one interdigital space, I treat the next one until the entire hand has been treated. Conclusion Treatment of the dorsal hands has been a goal for cosmetic dermatologists and plastic surgeons for decades. Recent advances in materials and methods now offer physicians and patients new opportunities for hand rejuvenation. Future discussions will more fully cover the actual techniques for performing the procedure as well as utilizing fillers in conjunction with lasers, lights, peels, prescription products and cosmeceuticals to put your best hand forward.n Dr. Beer is in private practice in West Palm Beach, FL. He’s also Volunteer Clinical Instructor in Dermatology at the University of Miami, a Consulting Associate in the Department of Medicine at Duke University, and Director of The Cosmetic Boot Camp meeting.
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Filler Treatments for Hands
Treatment for the dorsal hands may involve a variety of fillers including hyaluronic acids, collagens, poly L lactic acid and calcium hydroxylapatite, each of which offers advantages and disadvantages, including variation in duration and cost of correction. Here, Dr. Beer offers recommendations on how to handle hand injections. The use of various fillers to treat the signs of facial aging is well-established in dermatology and plastic surgery. Its history dates back to the early part of the 20th century when paraffin was used to change the appearance of the face. More recently, a real plastic-type material, Artefill, was FDA-approved for cosmetic use. And now in 2009, despite challenging economic times, physicians and patients alike are interested in ways to treat signs of aging on nonfacial, as well as facial skin. One area garnering interest is the hands. Injections for Hands Unlike the soles of the feet, which may be treated with a variety of fillers for therapeutic indications, the dorsal hands are injected for primarily cosmetic reasons. Treatment for the dorsal hands may involve a variety of fillers including hyaluronic acids, collagens, poly L lactic acid and calcium hydroxylapatite. Each of these offers some advantages and some disadvantages and also varies in the duration and cost of correction. Here, we discuss some of the main issues and injection methods. Patient Selection Considerations It is true with most surgical procedures — but is especially the case with elective cosmetic procedures — that patient selection can make all the difference in both actual and perceived results. With that in mind, in our practice, we restrict the hand rejuvnenation approaches described below to patients with moderate, not severe, hand aging. Hyalurons One of the most common materials used for treating dorsal hand atrophy is hyaluronic acid. The hyalurons have various commercial products available, including Perlane, Restylane and Juvederm. They vary in their cross linkage, effective hyaluronic acid concentration — that is, total hyaluronic minus free hyaluronic — as well as their anesthetic content, the resistance of the gel to flow, duration and cost. Volume Since volume is a primary consideration for the correction of dorsal hand atrophy, one consideration for product selection is the volume of the products available. Perlane and Restylane, which are supplied in syringes that are filled to approximately 1.2 mL, provide adequate volume for treating an average hand with 1.5-mL syringes. Juvederm 24 has about 0.9 mL of product per syringe and may require more syringes per hand. Calcium Hydroxylapatite Radiesse is a calcium hydroxlyapatite (CAHA) filler approved for cosmetic indications. Although used primarily in the face, it has also been used in the hands. Volume, Duration of Correction Its benefits include a long duration of correction (approximately 6 to 9 months) and a large volume. Each syringe of material contains about 1.3 mL of product. Opacity Whereas the hyalurons are translucent, CAHA is an opaque white matrix. Thus, it presents both opportunities and challenges when injected into the hands. One advantage of its opaque nature is that it can camouflage some of the underlying structures such as veins and tendons. However, it may also present visible white nodules if the skin overlying it is transparent and atrophic. Since there is no significant subcutaneous tissue in the dorsal hands, there is not a deep space into which to inject this product and it is frequently very close to the overlying epidermis. Thus, consideration of the thickness of the skin must be taken into account prior to using this as a filler for the dorsal hands. Poly L lactic Acid (Sculptra) Sculptra is composed of poly L lactic acid (PLLA). When mixed with water, it is used to stimulate collagen and replenish aging skin. Concentration For dorsal hands, it has been used in varying concentrations. To date, no well-designed trial has demonstrated optimal technique but many injectors utilize concentrations of between 7 mL and 9 mL of diluent. As with other areas, formation of subcutaneous papules is one potential pitfall associated with the use of this product. When injecting PLLA into the dorsal hands, it is best to err on the side of greater dilution and less frequent injections (e.g., at least 4 to 6 weeks apart). Collagen (Evolence) Until the approval of Evolence, collagen was not a realistic material to consider for injection into the hands. Prior collagen products were too expensive and too short lived to be practical products for this indication. However, Evolence, which is a ribose cross-linked porcine collagen, has the potential to provide long-term stable correction for this location. Evolence is available in 1 mL syringes, which are typically overfilled. As with other syringes of this size, approximately 1 to 1.5 syringes are needed for the average hand. Injection Recommendations Start with Hyalurons Injections into the dorsal hands require a fair amount of experience and caution. When beginning, it is recommended that one use hyalurons (which are reversible for lumps and bumps). Matzoh Ball Technique Serial fanning, linear threading and depot (what Mary Lupo, MD, calls “the matzoh ball technique”) may be used when injecting the hands. Safety Caveats One significant caveat is to be certain that the needle is not intravascular when injecting the filler. Thus, aspiration prior to injection or injection while withdrawing the syringe are two techniques that are crucial for safe injections. Potential embolization of product is possible, and the large veins of the dorsal hands must be avoided. In addition to the veins, it is best to avoid injection directly over the extensor tendons of the fingers. Step by Step Procedure • Whatever the product selected, my technique begins in the middle of the dorsal hand with the needle pointed towards the distal fingers. • A small amount of material — say about 0.1 mL — is injected to gauge the patient’s tolerance for the procedure and to lift the skin away from underlying structures. • A small amount of anesthetic — 1 mL of lidocaine with 1:1000 — epinephrine may also be utilized to accomplish these goals. • Injections of material are made in a serial puncture technique in an effort to lift up the epidermis and “re-inflate” the hands. • After completing one interdigital space, I treat the next one until the entire hand has been treated. Conclusion Treatment of the dorsal hands has been a goal for cosmetic dermatologists and plastic surgeons for decades. Recent advances in materials and methods now offer physicians and patients new opportunities for hand rejuvenation. Future discussions will more fully cover the actual techniques for performing the procedure as well as utilizing fillers in conjunction with lasers, lights, peels, prescription products and cosmeceuticals to put your best hand forward.n Dr. Beer is in private practice in West Palm Beach, FL. He’s also Volunteer Clinical Instructor in Dermatology at the University of Miami, a Consulting Associate in the Department of Medicine at Duke University, and Director of The Cosmetic Boot Camp meeting.
Treatment for the dorsal hands may involve a variety of fillers including hyaluronic acids, collagens, poly L lactic acid and calcium hydroxylapatite, each of which offers advantages and disadvantages, including variation in duration and cost of correction. Here, Dr. Beer offers recommendations on how to handle hand injections. The use of various fillers to treat the signs of facial aging is well-established in dermatology and plastic surgery. Its history dates back to the early part of the 20th century when paraffin was used to change the appearance of the face. More recently, a real plastic-type material, Artefill, was FDA-approved for cosmetic use. And now in 2009, despite challenging economic times, physicians and patients alike are interested in ways to treat signs of aging on nonfacial, as well as facial skin. One area garnering interest is the hands. Injections for Hands Unlike the soles of the feet, which may be treated with a variety of fillers for therapeutic indications, the dorsal hands are injected for primarily cosmetic reasons. Treatment for the dorsal hands may involve a variety of fillers including hyaluronic acids, collagens, poly L lactic acid and calcium hydroxylapatite. Each of these offers some advantages and some disadvantages and also varies in the duration and cost of correction. Here, we discuss some of the main issues and injection methods. Patient Selection Considerations It is true with most surgical procedures — but is especially the case with elective cosmetic procedures — that patient selection can make all the difference in both actual and perceived results. With that in mind, in our practice, we restrict the hand rejuvnenation approaches described below to patients with moderate, not severe, hand aging. Hyalurons One of the most common materials used for treating dorsal hand atrophy is hyaluronic acid. The hyalurons have various commercial products available, including Perlane, Restylane and Juvederm. They vary in their cross linkage, effective hyaluronic acid concentration — that is, total hyaluronic minus free hyaluronic — as well as their anesthetic content, the resistance of the gel to flow, duration and cost. Volume Since volume is a primary consideration for the correction of dorsal hand atrophy, one consideration for product selection is the volume of the products available. Perlane and Restylane, which are supplied in syringes that are filled to approximately 1.2 mL, provide adequate volume for treating an average hand with 1.5-mL syringes. Juvederm 24 has about 0.9 mL of product per syringe and may require more syringes per hand. Calcium Hydroxylapatite Radiesse is a calcium hydroxlyapatite (CAHA) filler approved for cosmetic indications. Although used primarily in the face, it has also been used in the hands. Volume, Duration of Correction Its benefits include a long duration of correction (approximately 6 to 9 months) and a large volume. Each syringe of material contains about 1.3 mL of product. Opacity Whereas the hyalurons are translucent, CAHA is an opaque white matrix. Thus, it presents both opportunities and challenges when injected into the hands. One advantage of its opaque nature is that it can camouflage some of the underlying structures such as veins and tendons. However, it may also present visible white nodules if the skin overlying it is transparent and atrophic. Since there is no significant subcutaneous tissue in the dorsal hands, there is not a deep space into which to inject this product and it is frequently very close to the overlying epidermis. Thus, consideration of the thickness of the skin must be taken into account prior to using this as a filler for the dorsal hands. Poly L lactic Acid (Sculptra) Sculptra is composed of poly L lactic acid (PLLA). When mixed with water, it is used to stimulate collagen and replenish aging skin. Concentration For dorsal hands, it has been used in varying concentrations. To date, no well-designed trial has demonstrated optimal technique but many injectors utilize concentrations of between 7 mL and 9 mL of diluent. As with other areas, formation of subcutaneous papules is one potential pitfall associated with the use of this product. When injecting PLLA into the dorsal hands, it is best to err on the side of greater dilution and less frequent injections (e.g., at least 4 to 6 weeks apart). Collagen (Evolence) Until the approval of Evolence, collagen was not a realistic material to consider for injection into the hands. Prior collagen products were too expensive and too short lived to be practical products for this indication. However, Evolence, which is a ribose cross-linked porcine collagen, has the potential to provide long-term stable correction for this location. Evolence is available in 1 mL syringes, which are typically overfilled. As with other syringes of this size, approximately 1 to 1.5 syringes are needed for the average hand. Injection Recommendations Start with Hyalurons Injections into the dorsal hands require a fair amount of experience and caution. When beginning, it is recommended that one use hyalurons (which are reversible for lumps and bumps). Matzoh Ball Technique Serial fanning, linear threading and depot (what Mary Lupo, MD, calls “the matzoh ball technique”) may be used when injecting the hands. Safety Caveats One significant caveat is to be certain that the needle is not intravascular when injecting the filler. Thus, aspiration prior to injection or injection while withdrawing the syringe are two techniques that are crucial for safe injections. Potential embolization of product is possible, and the large veins of the dorsal hands must be avoided. In addition to the veins, it is best to avoid injection directly over the extensor tendons of the fingers. Step by Step Procedure • Whatever the product selected, my technique begins in the middle of the dorsal hand with the needle pointed towards the distal fingers. • A small amount of material — say about 0.1 mL — is injected to gauge the patient’s tolerance for the procedure and to lift the skin away from underlying structures. • A small amount of anesthetic — 1 mL of lidocaine with 1:1000 — epinephrine may also be utilized to accomplish these goals. • Injections of material are made in a serial puncture technique in an effort to lift up the epidermis and “re-inflate” the hands. • After completing one interdigital space, I treat the next one until the entire hand has been treated. Conclusion Treatment of the dorsal hands has been a goal for cosmetic dermatologists and plastic surgeons for decades. Recent advances in materials and methods now offer physicians and patients new opportunities for hand rejuvenation. Future discussions will more fully cover the actual techniques for performing the procedure as well as utilizing fillers in conjunction with lasers, lights, peels, prescription products and cosmeceuticals to put your best hand forward.n Dr. Beer is in private practice in West Palm Beach, FL. He’s also Volunteer Clinical Instructor in Dermatology at the University of Miami, a Consulting Associate in the Department of Medicine at Duke University, and Director of The Cosmetic Boot Camp meeting.
