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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Posts Tagged ‘hand rejuvenation’

Hand Rejuvenation by Fat Injections

Sunday, December 13th, 2015


Aging affects every structure of the body and the hands are no exception. Age-related changes to the hands have been well described and includes thinning of the skin, brown spots and wrinkles and visible skeletonization with prominent veins, tendon and bone structures. Loss of fat volume is one of the key features in hand aging just as it is in the face.

Fat Injections to Hands Dr Barry Eppley IndianapolisIt is no surprise then re-voluminization of the dorsal side of the hand has become an established ant-aging strategy in hand rejuvenation. Fat is preferred over the use of injectable fillers due to its better volume retention and ultimately lower cost in the long run. It also has the potential benefits of providing improved skin tone and texture through dermal regeneration induced by blood vessel ingrowth and stem cell effects.

In the December 2015 issue of the journal Plastic and Reconstructive Surgery, an article entitled ‘Technical Refinements in Autologous Hand Rejuvenation’ appeared. In this paper the authors describe their technique for fat injections into the dorsum or back of the hand. Fat is harvested from the inner thighs. Approximately 20 to 25mls of aspirated fat is required for each hand. A central injection point is used located between the 3rd and 4th metacarpal joints. Fat is injected in a radiating fashion in the subcutaneous plane using about 10 to 15mls in the distal two-thirds of the hand to augment the region dorsal to the hypothenar eminence. A second injection site is done from between the first and second metacarpals where an additional 10mls of fat is injected into the proximal one-third of the hand  to augment the region dorsal to the thenar eminence. They have experienced no complications such as infection or any problens with hand function or sensation.

Fat injections into the hands places the grafts into the dorsal superficial lamina, the upper fascial  where the fat normally resides. The fascia that contains the veins and nerves lies deep to this layer. The deepest fascial layer is where the tendons and bones reside. Placing fat into the hands is easy as placing it right under the skin keeps it in the upper fascial layer and avoids the visible veins which seems like they would be unavoidable. The use of blunt cannulas avoids any risk of vein puncture. The injected fat must be massaged around to avoid lumps and irregularities. Aggressive and persistent massage is the key to a smooth fat distribution.

Fat Injections to the Hands Dr Barry Eppley IndianapolisWhile the authors inject from the distal part of the hand (metacarpal joint areas), I prefer to inject from the proximal area at the wrist. Three injection site are used  and the fat is placed in a retrograde fashion. The ability to distribute the fat by massage throughout the upper fascia layer of the hand makes the location of injection irrelevant.

Total hand rejuvenation requires both an internal and an external approach. Fat grafting treats the intrinsic problem of aging by restoring/adding volume. But the external appearance of the hand should not be forgotten and treatments such as laser resurfacing and pulsed light therapy (BBL) should not be overlooked for optimal improvement in the appearance of the back of the hands.

Dr. Barry Eppley

Indianapolis, Indiana

Total Hand Rejuvenation by Fat Injections

Monday, August 31st, 2015


One of the classic giveaways for the women who has had a facelift is how her hands look. While the face can be very successfully rejuvenated by many different techniques, the hands historically have been ignored until more recent times. It is now acknowledged that restoring volume through injectable fillers and fat injections can create hand rejuvenation. If combined with other skin resurfacing/remodeling techniques (laser skin resurfacing, brown spot removal by pulsed light therapies), a more complete hand rejuvenation approach can be done.

In the September 2015 issue of Aesthetic Surgery Journal, an article appeared on hand rejuvenation entitled ‘Lipomodeling: An Innovative Approach to Global Volumetric Rejuvenation of the Hand’. In this paper, the authors describe their approach with fat injections to total hand rejuvenation including adding fat volume to the radial and ulnar sides of the fingers. They term this ‘global hand rejuvenation’. In a review of 22 women who had  global hand rejuvenation by fat injections, no postoperative complications occurred.. Aesthetic outcomes were deemed satisfied to very satisfied in almost all patients (21 of 22 patients) to both patients and plastic surgeons alike. The authors advocate that since the fingers represent almost 50% of the length of the hand, volumizing efforts of the hand should extend into the fingers as well.

Fat Injections to the Hands Dr Barry Eppley IndianapolisFat injections into the dorsum (back) of the hands is relatively easy to do as there is a natural tissue plane between the skin and the fascia overlying the finger bones and the spaces between them. One can introduce a long blunt cannula near the wrist and deliver the fat in long linear rows as the cannula is pulled back. Once in place the fat can be digitally manipulated and massaged into a smooth distribution all along the back of the hand. This minimizes the risk of lumps and irregularities forming.

Extending the fat injections out further into the web spaces is a logical extension of this hand rejuvenation technique. There is no anatomic reason why this can not be done short of a lack of adequate fat to inject. Entering the sides of the fingers for fat injections poses a slightly different risk than the rest of the hand due to the neurovascular bundles blood vessels and nerves) that are located in the web space and course along both sides of the fingers. One does have to be careful to not place too much fat volume in this area to avoid neurovascular compression. Fortunately fat is soft and as a natural body component has a very low risk of this potential problem.

Global hand rejuvenation offers an aesthetic improvement over isolated dorsal hand injections and requires minimal extra fat to do so

Dr. Barry Eppley

Indianapolis, Indiana

Product Review – Radiesse for Hand Rejuvenation

Saturday, June 6th, 2015


One important aspect of hand rejuvenation is volume restoration of the back (dorsum) of the hand. Skeletonization of the hand occurs through loss of subcutaneous fat allowing the tendons and bones to be easily seen which is associated with aging.  (bony hands) This has been shown to be effectively treated using a variety of filler materials. The most commonly used are many of the off-the-shelf synthetic fillers since they can be done in the office under local anesthesia for a quick plumping of the back of the hands.

Radiesse Plus Injections Dr Barry Eppley IndianapolisRadiesse Injectable Filler Dr Barry Eppley IndianapolisOne of the potential synthetic injectabl efillers to use in the hand is Radiesse. This is an opaque injectable filler that contains calcium hydroxyapatite microspheres in a water-based gel carrier. It has been used for facial augmentation since it was introduced in 2001 and has a longevity of around one year after injection.

The US Food and Drug Administration (FDA) just announced that they have approved Radiesse for hand augmentation to correct volume loss in the dorsum of the hands. FDA approval essentially means that it is both safe and effective for this use and that its benefits outweigh the potential risks. The clinical study data to support its use was done in the hands of over 100 middle-aged women using grading scales of aesthetic improvement. Compared to a placebo (control) filler, Radiesse treated hands had at least a one-point improvement at three months after treatment compared to just 3% for the controls and 98% of the patient reported visible improvement by their assessment. Any adverse effects that occurred from the treatments were common to what is known for any injectable filler such as temporary redness, swelling and bruising which all resolved within one week after injection.

Fat Injections to Hands Dr Barry Eppley IndianapolisRadiesse provides an effective method of hand rejuvenation that has some of teh better persistence of any filler on the market today. Despite its white opaque color it is not seen through the skin as such and is not visible through the skin.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Hand Rolling of Fat Injections

Sunday, January 18th, 2015


One of the well known changes that happens in woman’s hands is a thinning or skeletonization look that can develop to them with aging. This is due to the loss of the subcutaneous fat on the back of the hands, creating greater exposure of the extensor tendons and the space between the bones of the hand. Rejuvenation of the aging hand, therefore, requires the addition of volume through some form of injectable filler.

Hand Rejuvenation by Fat Injections Dr Barry Eppley IndianapolisWhile a variety of synthetic injectable fillers are available to be used for hand rejuvenation, the use of one’s own fat offers the only long-term solution. It is also the most natural filler product given that it is the patient’s own tissue that is being injected. Fat injections to the hand are simple to place and are done with small blunt cannulas to prevent injury to the many veins that exist on the back of the hand.

While hand injections are fairly easy to perform, their greatest aesthetic issue is their potential for clumping. Unlike synthetic fillers, fat does not come out of an injection cannula in a perfectly uniform manner. This makes it very prone in thin tissues to be somewhat lumpy. If the fat is not perfectly smooth after injection, lumps or even fat cysts can form afterwards on the very visible back of the hands which can be difficult to treat.

Hand Rolling of Fat Injections Dr Barry Eppley IndianapolisHand Rolling for Fat Injections Dr Barry Eppley IndianapolisThe use of a small pastry roller can be very effective at helping smooth out the back of the hands after fat injections. Once the fat is injected, the hand is rolled back and forth until the smoothest dorsal contour is obtained. Fat is very easy to move around on the back of the hands after injection since it is placed in the subcutaneous space above the fascia. It becomes spread out like a very thin layer of rolled out pasta across all the back of the hands from thumb to the little finger.

While massaging the fat around is one method of smoothing it out once placed under the skin, I have found the use of a roller creates a more even distribution of fat and has eliminated postoperative problems of visible fatty lumps.

Dr. Barry Eppley

Indianapolis, Indiana

Total Hand Rejuvenation

Wednesday, July 11th, 2012

While the aging of the face seems the most visible and subsequently the most treated by plastic surgery, it is not the only visible and unclothed body part that ages. I have seen many older women whose face is quite smooth because of numerous facial rejuvenation procedures but whose hands give their age away. The hands simply don’t go with their face, age or lifestyle. The hands are as much exposed to the elements as the face but are far less pampered and protected.

Like the face, the hands age in a similar way. They lose volume through fat atrophy, the skin loses elasticity and becomes wrinkled and age spots appear. As the fat layer in the hands disappears, which is already thin to begin with, the skin becomes partially translucent and thinner. This creates the classic skeletonized hand appearance where the veins and tendons are clearly visible. The rows between the hand bones become sunken in. The skin when you pinch it on the back of the hands doesn’t bounce back due to loss of elasticity.

The aging of the hands can clearly be seen in many tabloids and magazines. Famous aging women with youthful faces and great bodies have old-looking hands. Their veins can clearly be seen bulging out on their emaciated hands. This may be why some performers wear fingerless gloves in an effort to hide the back of their hands.

Treatment of the aging hands can be done through various rejuvenation methods. The most common treatment by far is for the brown age spots or sunspots. Intense pulsed light (IPL) or broad band light (BBL) can quickly remove brown spots, many of which can be eliminated in a single treatment session of about 15 minutes. It turns them dark and speckled and they then fleck off over the next week or so. A touch-up treatment may be needed a month later to clear what remains. It is important to wear sunscreen on the back of the hands afterward to prevent reflaring of some of the brown spots. A minimum of SPF50 sunscreen should be used.

These light therapies can be supplemented with laser resurfacing to help tighten the loose skin and reduce the wrinkling. Fractional is the best laser method because it has enhanced collagen stimulation effects. Laser resurfacing can be combined with light therapies to get a better overall effect than either one alone. Laser treatments take the same amount of time to do, about 15 minutes per hand.

Most so-called ‘hand lifts’ employ the use of injectable fillers to plump out the atrophic subcutaneous tissues and ‘deskeletonize’ the back of the hand. Fillers like Juvederm, Restylane and Radiesse can be quickly injected in the office for an instant filling effect. Placed right under the skin near the wrist level, they can be pushed into the indented rows once injected right under the skin. While they are not permanent the filling effect will last anywhere from six months to a year.  Fat injections are another option and generally create a better result because the volume injected is greater. It is a minor surgical procedure where fat is harvested from inside the belly button, concentrated, and then injected just like synthetic fillers. Unlike off-the-shelf fillers, fat has the potential to be longer lasting.

Other hand treatment options included the use of skin tightening devices like Exilis and the sclerosing of hand veins by injection or their actual extraction like varicose veins of the legs. One treatment option that is not used is a formal hand lift where skin is excised and the skin tightened. While it can be done by making an incision at the wrist level, the scarring is not acceptable.

A complete hand rejuvenation approach is the combination of injectable filling, light therapy for brown spots and fractional laser for wrinkling and skin tightening. Both hands can be treated in one hour in the office with complete healing in just one week.

Dr. Barry Eppley

Indianapolis, Indiana

Options in Hand Rejuvenation

Saturday, March 17th, 2012


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

Hand Rejuvenation with Radiesse Injectable Filler

Thursday, September 10th, 2009

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
Indianapolis, Indiana


Hand Rejuvenation with Injectable Fillers

Wednesday, August 27th, 2008

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

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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