The face ages with a classic set of findings including the development of wrinkles, loose skin, fat atrophy and age or brown spots. The rest of the body ages as well but most of it does not have the amount of sun exposure to which the face is exposed. Therein lies the differences in appearance that occurs in skin that has a long history of being covered than the skin that hasn’t. The one place on the body that ages similarly to that of the face due to sun exposure is…the hands.

It is a well known observation that you can look at many female facelift patients in their mid-50s and beyond whose hands do not match their face. The hands look a lot older than the face who has had rejuvenative treatments such as surgery and  numerous topical skin care products. The hands undergo an identical aging process which includes the loss of skin elasticity, the development of wrinkly skin, near complete fat volume loss and the development of numerous brown spots and patches. What is unique about the hands is that as the thin fat layer absorbs with thin skin over the back of the hands, the veins and tendons become very apparent. This is known as the skeletonization of the hands. While one is not looking at the bones, the hands become so thin that it looks like it.

There are now a variety of hand rejuvenation procedures that are available. Sometimes called ‘hand lifts’, this term lends an erroneous impression that skin is removed like in a facelift. This is never done as the scars would be visible and would not look very good as widening of them is inevitable. The hand lift concept is really about plumping them up which lifts and fills them out to create a less skeletal look. Various synthetic filler materials are used of which the most common are Juvederm or Radiesse. Just like injectable fillers in the face, they are placed in a simple office injection session lasting about 15 minutes. They will last about as long as that of the face until they are naturally resorbed and depends on the filler material used. (about one year for Juvederm and Radiesse)

The other filling option, and my preferred approach, is the use of fat. Like the buttock procedure, the Brazilian Butt Lift, fat is taken from elsewhere on the body and injected into the back of the hands. Placed right under the skin at the wrist level, fat injections are massaged into the subcutaneous space between the fingers. This technique avoids injuring the large prominent veins which would cause a lot of bruising. Fat is a natural material so rejection or inflammation to it does not occur. Like when it is injected elsewhere in the body, how much fat is retained and is permanent is variable. Between the fat harvest and injecting into the hands, I prefer to perform this procedure in the operation room under either local anesthesia or with a little IV sedation.

Besides the introduction of volume into the aged hands, the skin can also be treated. The brown spots can be very effectively treated with high intensity pulsed light therapies such as IPL or BBL. As a quickly done office procedure, brown spots can be remarkedly reduced or completely eliminated. Many hand rejuvenation patients choose to do this brown spot reduction alone. The skin can also be smoothed and some wrinkles reduced through fractional laser resurfacing. Just like on the face, fractional laser us much better at skin tightening and wrinkle reduction than traditional full surface laser resurfacing. Sun protection, using a combined UVA/UVB product should be generously used after these light and laser treatments to prevent brown spot recurrence with ongoing sun exposure.

There are also treatments for hand veins such as sclerotherapy and stripping out some of the prominent veins. But there are risks in so doing including prolonged swelling, bruising and thrombophlebitis. As a result, they are less popular and often unnecessary with good dorsal hand filling.

Complete hand rejuvenation includes a combined approach of an injectable filler, BBL for brown spots and fractional skin resurfacing. All of these can be done in a single procedure. Expect the hands to take up to two weeks to recover and show the full benefits.

Dr. Barry Eppley

Indianapolis, Indiana

Like the face, the hands are a visible reminder of a lifetime of environmental exposure and the constant stress of repetitive movements. On the back of the hand, aging becomes apparent as thinning or loss of volume between the flexor tendons, very evident and prominent veins, wrinkled skin, and numerous age spots and brown discoloration. Most of the skin rejuvenation methods, such as peeling and exfoliation and light therapies, can improve the texture of the skin but can not replace the ‘gaunt look’ of the aging hand.

Injectable fillers are the only option for adding volume to the dorsum or back of the hands. While all filling materials will work, those with the longest known volume retention are best. While fat can be used, it is not a practical in-office treatment method. Of the synthetic fillers, I prefer Radiesse in my Indianapolis plastic surgery practice.

Radiesse consists of 30% spheres of calcium hydroxyapatite in an aqueous carrier gel. Based on its experience in the face, it has proven to be durable and long lasting out to about a year. It is eventually absorbed as its ceramic spheres are gradually degraded. It can be easily injected into the thin tissue on the back of the hand. Because it can be now mixed with a local anesthetic, hand rejuvenation can be a near pain-free experience. Even though Radiesse is white in color, it does not appear that color when under the skin.

Hand rejuvenation therapy is simple to perform and a fairly quick procedure. I do like to apply a topical anesthetic cream first to the back of the hands for about 15 or 20 minutes. By first using  a micro-roller and then applying the cream, the onset of skin anesthesia is more rapid and profound. The skin is then lifted on the back of an outstretched hand between the second and the fifth ray which leaves the veins behind and out of the way. About .65 ccs of Radiesse (1/2 syringe)  is then injected as a bolus into the back of each hand.  With the patient now making  a closed fist, the material is then massaged to spread it evenly throughout the subcutaneous space over the entire back of the hand. Another technique is to inject it in smaller volumes in three areas between 2-3, 3-4, 4-5 rays. Either way, keep massaging until the dorsum looks even.

The results of hand rejuvenation are immediate. It will typically last a year or so. There is no recovery and bruising is either absent or very minimal. I don’t give any particular restrictions afterwards other than not to do any strenuous or excessively repetitive hand movements for the rest of the day. With a simple 30 minute total treatment time and less than one day of recovery, one can have rejuvenated hands that last for the rest of the year. 

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Do your hands give away your age? In many people, the hands are just as revealing as our faces about our age. But our faces understandably get much more attention and the hands are often forgotten. (but not unseen by others) As we age, our hands (particularly women) loose that once plump fullness and youthful look. Aging hands become thinner with vein and joint exposure, loose creapy skin, and brown spots over the back of them. These changes occur from chronic sun exposure and extensive use. While hand creams are a good first line of defense, they are not enough to produce a dramatic rejuvenating effect.

 
Adding volume back into the hands through injectable fillers is a good way to lessen the prominence of the veins and give a more plump appearance. The question is….which injectable filler? In my experience, you have 4 options…three off-the-shelf and one operative (which is only done if you are in the oprating room anyway for other procedures)

 
While all of the hyaluron-based injectable fillers (e.g., Restylane, Juvaderm) are extremely well tolerated, their effects are too short-term and do nothing to stimulate actual collagen tissue ingrowth so I prefer not to use them in the hands. The particulated fillers, such as Radiesse and Artefill, are better options as they last longer and may actually help stimulate favorable tissue ingrowth for longer-term results. Radiesse uses resorbable ceramic beads in its mixture so the effects are immediate but the beads are eventually resorbed over a year or so. It is also white in color although much of this is masked by the color of the skin. Artefill uses non-resorbable plastic beads in a collagen base which is much more likely to last longer and produce a better tissue-thickening result. Because both particulated fillers have a tendency for ‘clumpiness’ and irregularities, injection technique is critical and it is best to not inject too much at once. A
few staged treatments (spaced 6 to 8 weeks apart) slowly adding volume, and doing daily massage over the injected areas is the best way to ensure a smooth-looking result. Sculptra is another off-the-shelf filler option that is really like injecting ‘liquid plastic’ rather than a bead or particulated approach. Its material is resorbable over time and you have to be really careful about adding too much volume at once as it can cause local tissue reactions. Which one of these off-the-shelf injection materials is better for the hands is not yet known….and none of them are FDA-approved as of yet for use in the hands.

 
Another injectable option, which has been around for a long time with a track history of use in the hands…is your own fat. This is certainly the injectable filler option with the least potential for any downside with the exception that it has not historically lasted. In the past, I have done some beautiful results with it as it fills the depressed areas between the rays (fingers) quite well creating a nice plump hand. Five to seven ccs of fat per hand (which is much more volume than one could afford with an off-the-shelf- filler) is about what each hand needs. But the long-term outcome was disappointing. Now with improved purification and concentration methods, and with the addition of PRP concentrate (extracted platelets from the patient), fat is more likely to have a better long-term result. For this reason, this is my preferred method when the patient is in the operating room anyway…particularly if they are already having a liposuction procedure.

 
Hand rejuvenation, sometimes referred to as a ‘hand lift’ (erroneous term but catchy nonetheless), is based on the concept of restoring volume. Whether it is from a synthetic injectable filler or your own fat, short-term results appear to be quite good. Whether they will stand the test of time and what complications may yet emerge is not yet known. But at this point in time, I will give it at least a temporary thumbs up with the other four fingers still in neutral position.

Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis