Dr Carolyn Berry considers rejuvenation techniques for the ageing hand
Hands are exposed, both to the elements and to public scrutiny, and their appearance often reflects how well they have been cared for, as well as the general lifestyle of their owner. Nowadays, it seems that we are entering an era of hand rejuvenation and, in my experience, patient demand for treatment is increasing. This could be because we are dealing with a more informed population, as patients are now able to research potential treatments online and read about their results in the media. Facial rejuvenation is considered by aesthetic practitioners to be very successful, however this is difficult to evaluate.1 Patients realise that they no longer have to endure hands that look older than their face. As aesthetic practitioners, for a holistic approach, it is important to take the ageing hand into consideration and assess how best to achieve patients’ desired results.
The skin on hands, like skin elsewhere on the body, undergoes both intrinsic and extrinsic ageing. Extrinsic ageing is caused by environmental factors such as sun exposure, chemicals and smoking. This will affect the epidermis and dermal layers leading to uneven pigmentation, solar lentigines, actinic keratosis, punctate hypopigmentation and solar purpura. Intrinsic ageing is affected by genetics and nutrition, also by disease processes such as diabetes, peripheral arterial occlusive disease, autoimmune disorders and medication, including chemotherapy. The capillary microcirculation of the dorsal hand differs between healthy individuals and those of the same age with diabetes or PAOD,2 hence why taking a full medical history is of paramount importance.
Intrinsic changes alter the deeper soft tissue planes, decreasing skin elasticity, loss of the subcutaneous tissue (dermal and fat atrophy) and dermal vascularity. The skin becomes paper-like and thin, whilst veins become more prominent. Distal pip joints swell and tendons become more apparent. Hand ageing can be graded in a five point system. Carruthers et al published a validated grading scale for assessment of the ageing hands,3 whilst others use the Busso hand volume severity scale.4
It is important to take the ageing hand into consideration and assess how best to achieve patients’ desired results
If we address the patient’s concerns, we will get the best patient satisfaction rates. According to one study,5 it seems that patients are most concerned by prominent veins and view these as the most ageing feature of hands. Therefore, I would suggest that reducing the appearance of veins should form part of the treatment plan. Treating the veins directly, or altering the soft tissue volume around them, can alter their appearance and make them less prominent.
Treating the veins of the hand with sclerotherapy (the injection of an irritant liquid which causes vein walls to inflame and stick together) requires a higher concentration of sclerosing agents than is used for leg veins and often results in a tender phlebitis cord. Another option to consider is phlebectomy (the surgical removal of veins). Studies have investigated an endovenous laser technique (introduction of a laser probe into the vein) to abolish unwanted hand veins.6 All patients were satisfied with the outcome but there were adverse events including the swelling of hands for two weeks and one case of skin burn.
Rejuvenation of hands should be considered as a successful reversing of the three-dimensional process of ageing.7 Hand ageing is a three dimensional process that involves osseous and subcutaneous structures as well as the skin. Often only one modality of treatment is considered and this will seriously limit the outcome. Hand anatomy is of paramount importance when considering treatment. Bidic et al studied 10 fresh cadaveric hands.8 Specimens were evaluated microscopically after histologic staining. They also used Doppler ultrasound on eight living hands to explore lamination of the dorsal hand fat. They showed three distinct fatty laminae separated by thin fascia. The large dorsal veins and dorsal sensory nerves resided within the intermediate lamina. The extensor tendons were found in the deep lamina. Eight to 10 perforating vessels travel within fascial septae traversing the laminae. In my opinion, consideration of this may improve results of treatment.
In my experience, patients have previously been concerned with extrinsic ageing, complaining of pigment changes and age spots in particular and have often requested laser treatments to remove pigment spots. A common theme is that they know that they don’t like the look of their hands but they don’t know how to correct it. As practitioners, we have responded by treating hands with chemical peels, microdermabrasion, tretinoin, IPL and 5- fluorouracil.
Intense pulsed light (IPL) has also been used very successfully to treat extrinsic ageing, showing excellent results in treating solar lentigines and improving skin quality.9 In Goldman et al’s study, patients were treated with four IPL sessions at three to four week intervals. There was a very high patient satisfaction with no significant side effects. Various lasers have been used to improve skin quality, including CO2 fractional laser and 1320-nm Nd:Yag. Sadick et al showed an improvement with Nd:Yag,10 but they were only able to show mild to moderate improvement and one could argue that this is insufficient to make it a treatment of choice.
Plasma skin regeneration has shown promising results on the face and many patients favour this type of less invasive treatment. Alster et al evaluated face, chest and hands treated with PMR and discovered clinical improvements of 57%, 48% and 41% respectively. There was significant reduction in wrinkle severity and hyperpigmentation, with increased skin smoothness.11
Volume restoration dramatically improves the appearance of the ageing hand by minimising the appearance of veins. A method favoured by surgeons is autologous fat injections, where fat is harvested and then injected into the hands. The fat is generally taken from the abdomen or thighs. This is an invasive procedure but can be combined with liposuction at the patient’s request. If fat is centrifuged, this is associated with better results.12 Giunta et al studied fat grafting with 3D surface laser scanning, which permits evaluation of the permanent volume over time and were able to show 69% of initial fat volume was present at six months, and this seems to be the amount integrated as a graft.13
Another method of treatment involves using hyaluronic acid (HA). The ageing process results in depletion of endogenous HA, which has an important role in the dermal extracellular matrix for hydration, biomechanical integrity and oxidative stress protection.14,15 Crosslinked HA is not degraded as quickly as native HA and has been shown to enhance the production of collagen.16 Native HAs will increase the thickness of dermis but don’t last as long. Biphasic HA needs to be injected sub-dermally to prevent the Tyndall effect, a preferential scattering of blue light, giving a bluish appearance. One has to treat the very aged hand, with thin and papery skin, with great care, as it is less forgiving of a poor technique. Adverse events can include papule development, which are hard, circumscribed, elevated skin lesions. Hyaluronic acid fillers have been favourably compared to collagen.17
Calcium hydroxyapatite (CaHa) has become popular for the treatment of hands in recent years, with considerable success. The volume of CaHa injected, as well as the amount of lidocaine used for the mixture, varies according to the practitioner’s preference.18 It can also be injected with lidocaine as a bolus technique. In one study, at 12 months post-procedure, 60% of subjects rated their results as “satisfactory” or “better”.19 The opacity of CaHa blends well with the skin and conceals veins and tendons. Long-lasting results may be attributed to the neocollagenesis, which in laboratory studies continued up to 72 weeks.18
Another option for treatment is poly-l-lactic acid (PLA), which can be successfully used to rejuvenate hands. It requires careful patient selection as they will need multiple injections and several treatments. Results cannot be appreciated immediately but can last up to 24 months.21 In a study of three clinical practices using PLA, no papules or nodules were reported.19 Patients were very satisfied with the results and experienced only minor adverse events such as bruising, swelling and pain. One author,22 recommends it for patients requesting longer lasting results. The results by Redaelli et al were evaluated by a definitive graduated score (1 to 10) and ranged from 4 to 9 (av 6.55).23 There was one case of unnoticeable nodulations. Nodules can be minimised by using 7mls of diluent per PLA bottle and massaging daily for one month post-treatment.
Polycaprolactone (PCL) is a relatively new treatment emerging at the moment. This consists of microspheres suspended in an aqueous carboxymethylcellulose gel carrier. Due to the gel carrier, there is an immediate volume replacement and improved appearance. The gel carrier is gradually resorbed by macrophages over a period of several weeks. The smooth PCL microspheres stimulate neocollagenesis to replace the carrier. The PCL microspheres become coated with a monolayer of macrophages and a scaffold of new collagen. The PCL microspheres are bioresorbed into non-toxic degradation products and excreted into CO2 and H2O. Satisfaction among patients has been high in studies, 24 and rated as 82% at 24 weeks, with 88% of patients saying they would be likely to return for repeat treatments.
Some patients may opt for surgical intervention. This is particularly beneficial if a patient has a lot of excess skin on the dorsum of their hands. One option is a minimal-scar hand lift.25 This technique limits scar size and visibility by locating the incision in a unique position on the ulnar side of the dorsum of the hand. This involves skin flap advancement and rotation and can be performed under local anaesthesia and sedation. Satisfaction amongst patients was high in the study cited.
It would appear that the treatment selected would depend very much on the individual patient’s requirements. It is very advantageous and cost effective for the patient to select a treatment that will provide them with both volume restoration and neocollagenesis. Maintenance has to be part of the regime; very few patients will think of applying SPF to their hands. Patients who are treated for pigmentation need to be counselled that if they do not protect hands in the sun, their pigmentation will return. Some feel staying out of the sun and using high SPF is too high a price to pay and will opt for volume restoration and live with their pigment spots. So what does the future hold? We need studies to compare modes of volume restoration, for efficacy, and for length of action. The message to use high factor sun cream on the face is gradually getting through to patients, but they have, as yet, to care in the same way for the rest of their body. I find it amazing that patients would rather have solar lentigines than give up a tan, particularly when the bottled tans are so good. Neocollagenesis seems to be of key importance but I am extremely interested to follow the mixing of growth factors with platelet rich plasma and we need to see more research conducted in this area.