12 minute read
Rejuvenating the Hands
Mr Dalvi Humzah outlines a five-point plan to enable a holistic approach for hand rejuvenation
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Age-related changes affect all body areas, but in aesthetics, while the most treated areas are the face and neck, the ageing hands are rarely addressed.1 Concomitant skin wrinkles, hollowing of the dorsal web spaces and prominence of veins and extensor tendons are all indicators of the ageing process in the hands, which can be visible to the observer. These are associated with atrophy of the intrinsic muscles of the hand and subcutaneous fat, accompanied by laxity of the skin, which allows the underlying tendons and veins to become more prominent.2
Concern for the ageing hands is growing, and from a patient perspective, 75% said they believe their age is betrayed by their hands, with 80% of women saying they would notice if another woman’s hands looked elderly. In addition, 42% stated that their hands had started looking old as early as age 34, and 33% of married women admitted they felt self-conscious on their wedding day as they felt their rings would draw attention to any changes in their hands.3
A strategy to address the ageing hands will be explored in this article, as a ‘five-point plan’ that practitioners can introduce into their clinical practice.
Anatomical changes to the hands
There are many anatomical-pathological changes in hand appearance and function, and many of these are clinically important in the more mature patient aged over 65, with a decrease in hand function in both sexes, mostly related to secondary degenerative changes in their musculoskeletal, vascular and nervous systems.2 From an aesthetic perspective, the most common patient concern is excess skin laxity and prominent veins.4
Aesthetic evaluation of the hand correlates to the structural proportion of the hand in relation to artistic ideals– a factor that is not easy to deal with – and the concept of hand attractiveness which has rarely been addressed.5 A distinct correlation between facial attractiveness and hand attractiveness has been drawn, with links to hand shape, femininity, ‘fattiness’, skin health and grooming.6 For the aesthetic practitioner, there are many validated photo-numeric rating scales that should be used during the consultation to have a discussion with the patient regarding their specific concerns and possible outcomes.7,8 These scales are also useful to communicate with the patient the possible outcomes that may be achieved through treatment of the dorsal hand.
The five-point plan
When planning possible treatment options, I believe the following five points should be considered: 1. Skin lesions 2. Skin quality/laxity 3. Volumetric changes 4. Veins 5. Nails
A helpful acronym for these points is ‘S2 V2 N’. These points should all be examined and evaluated prior to initiating a treatment programme. It is best to deal with any underlying medical issues and skin lesions before embarking on volumetric treatment and progressing to skin laxity and quality. Often the visible veins are hidden by the other treatments and can be disguised by volumetric changes. However, dorsal hand vein treatment can be complex and will need specialist opinion for adequate treatment. A detailed knowledge of the anatomy of the dorsal hand (Figure 1) is mandatory before starting any treatment programme, and the concept of the dorsal layers is useful in planning the depth of placement of products used in hand rejuvenation.1
Skin lesions Skin lesions are one of the most common issues with the ageing hand and need a dermatological assessment to distinguish normal age-related pigmentation from actinic damage, benign lesions, pre-cancerous lesions (such as actinic keratosis) or malignant lesions (such as basal cell carcinomas). The normal age-related lesions will need to be treated appropriately, with the options being:
• Topical skin lightening – practitioners can use tyrosinase inhibitors. The novel oxyresveratrol, for example, appears to be showing some benefits in this area9 • Chemical peels – a variety of superficial peels can address different aspects of skin pigmentation10 • Laser – vascular specific lasers and
fractional lasers may be used to deal with any specific vascular or structural abnormalities11 • Radiofrequency – surface treatment and resurfacing with radiofrequency on a low setting will work effectively in a similar way to ablative laser12 • Cryotherapy – an effective technique to treat early surface lesions causing apoptosis of the superficial tissues in the epidermis and dermis e.g. actinic keratosis13 • Plasma treatment – judicious use with caution, as the skin on the dorsum of the hand is sensitive to ablative treatments and may cause visible scarring14
Volume loss With ageing, the dorsal interossei exhibit a decrease in volume and develop weakness over time.2 This volumetric change can be treated by specific augmentation in the intermediate laminae with either autologous fat grafting or the use of biocompatible dermal filler/injectable implants. Currently there are only two specific compounds that have approval by the US Food and Drug Administration (FDA) to be used as dermal fillers for hands (product code ‘PKY’ under FDA coding). These are Radiesse, which obtained regulatory approval in 2015, and Restylane Lyft with lidocaine, which obtained approval in 2018.15 Other products have been proposed for the volumetric treatment of the hands, however, these are currently all off-label and the practitioner using these will need to be aware of the regulations regarding off-label use of injectables.16 The technique of injection into the intermediate laminae may be performed by either needles or a minimum 25 gauge cannula.17 The practitioner will need to be trained to use a cannula and know how to enter this space – a skin-tenting technique will often allow this space to be entered. A dorsal distal wrist crease insertion point is a useful entry site – a multiple web space entry technique, although relatively easier, may risk injury to the dorsal intermetacarpal arteries which are communicating vessels between the dorsal and palmar arterial vessels.18
Injection techniques Once a patient has been adequately assessed and a treatment plan proposed, any intervention involving injection into the hand should observe strict aseptic techniques. Infections in the hand can cause severe long-term problems and should be avoided.19 I recommend these steps as a protocol for use in our clinical practice: 1. Patient uses a liquid soap to wash hands and wrists thoroughly and socially clean hands – rings should be removed 2. Antiseptic is applied to palmar and dorsum of hands using the ‘WHO Hand
Rub’ technique20 3. Aseptic technique should be maintained while the procedure is performed
(practitioner to ensure personal aseptic protocols are followed), and the patient’s skin kept clean with antiseptic prior to insertion of cannula/needle. This should be repeated prior to each pass into the skin 4. At the end of the procedure, the skin should be cleaned with antiseptic and injection points should be covered for further protection to prevent entry or contamination 5. Patients are recommended to maintain hand elevation when possible, and to not wear rings for 24-48 hours until any swelling subsides
Skin quality Skin quality is an important component of facial attractiveness, so in terms of hand attractiveness, it is also an important issue to consider.11 I find that products that may be used intradermally such as NCTF 135HA work well in stimulating the dermis and improving skin quality. Injecting products such as Profhilo Body or dilute/hyperdilute Radiesse can also be effective, in my clinical experience. For these, you should inject in the superficial laminae using a sub-dermal gliding technique and in the hypodermis with a cannula, which provides a longer-lasting effect through a multicellular activation of dermal elements. With appropriate training and careful placement, injecting normal dilute/hyperdilute Radiesse superficially appears to provide a longer-term rejuvenation of the dorsal hand.1 As above, injection into the hand should observe strict aseptic techniques.
Veins The dorsal veins appear more prominent with age as do the dorsal tendons, which is often due to dermal thinning with age and volume loss of the soft tissues in the
I S
D Skin
Dorsal Superficial Fascia
Dorsal Deep Fascia
Dorsal Intermediate Fascia
Extensor Tendon
S: Superficial lamina I: Intermediate lamina D: Deep Lamina
intermetacarpal space.4 Treatment of the volumetric changes and skin quality often results in camouflaging the veins and many patients are no longer concerned with the minimal venous protrusion. For the more recalcitrant venous appearance, sclerotherapy has been used as an option for the cosmetic treatment of dorsal hand varicose veins.12 This is a specialised procedure and should be performed by those with specialist knowledge and training in hand anatomy and treatments, as many complications including acute hand ischaemia have been described following this procedure.13
Endovenous laser treatments are being developed, although currently the larger truncal veins are more accessible, with a combined sclerotherapy approach for the dorsal veins providing a good option for this treatment. Disruption of the dorsal veins of the hand may also be problematic in limiting venous access for many surgical procedures requiring anaesthetic access to the veins.21
Nails In youth, the nails appear smooth with a consistent colour, but with age they develop longitudinal ridges and may become brittle. Often these longitudinal ridges may be polished by a manicure; but brittle nails may be due to a relative insufficiency of biotin – here, an oral supplementation such as Skinade may be beneficial.22
The nails are also an indicator of underlying disease processes, such as:22-29 • Onycholysis – fungal/psoriasis/ thyroid disease • Clubbing – cardiovascular disease/liver disease/inflammatory bowel disease • Koilonychia – iron deficiency/ hypothyroidism/Raynaud’s disease • Pitting – psoriasis • Leukonychia – minor trauma/infections/ systemic disease/drugs • Mees’ lines – arsenic poisoning • Beau’s lines – malnourishment/zinc deficiency/pneumonia • Terry’s nails – congestive cardiac failure/ diabetes/liver disease • Yellow nail syndrome – internal malignancy/respiratory disease This is not an exhaustive list, but an indication of some associations that the practitioner should be aware of, and they should ensure patients are referred appropriately to a specialist e.g. dermatologist for investigations before embarking on a treatment pathway.
Appropriate treatment of ageing nails will also require grooming with specific manicures. Good nail care to prevent infection and moisturising the nail and nail bed using urea creams or mineral oils should be recommended to patients.
Maintenance Following the five-point plan, the practitioner should also consider that the initial treatments may need further maintenance. Patients should consider a rigorous prevention programme, including the use of SPF creams to mitigate against sun damage and physical protection such as gloves when undertaking activities like washing or gardening. Regular use of hand moisturisers should also be recommended as an ongoing maintenance programme.
Create a treatment plan Following an evaluation and assessment of the patient’s concerns, a five-point plan will enable the practitioner to provide the patient with a possible treatment pathway. The S2 V2 N acronym will allow a full evaluation and plan to be made to treat the main areas of concern that patients have with regards to the appearance of their hands.
Mr Dalvi Humzah is a consultant plastic surgeon and delivers his clinical practice through PD Surgery in the West Midlands, Gloucester, and The London Welbeck Hospital. He is also director of the award-winning Dalvi Humzah Aesthetic Training and clinical director of Derma-Seal Ltd. He has wide experience in teaching and training nationally and internationally. Qual: BSc(Hons), MBBS(Hons), AKC, FRCS(Glas), FRCS(Eng), FRCS(Plast)
REFERENCES
1. M. Humzah and A. Baker, “Hand Rejuvenation,” Aesthetics Journal, 2016 2. E. Carmeli, et al, “The Aging Hand,” Journal of Gerontology: Medical Sciences, 2003 3. K. Winter, “Forget wrinkles or crow’s feet:75% of women fret most about their HAND aging,” Mail Onine, 2014, https:// www.dailymail.co.uk/femail/article-2591694/Forget-wrinklescrows-feet-75-women-fret-HANDS-aging.html> 4. P. Saffar, “What’s new in cosmetic surgery of the hand? Technical notes,» Ann Chir Plast Esthet, 1998 5. R. Jakubietz, M. Jakubietz, D. Kloos and J. Gruenert, “Defining the Basic Aesthetics of the Hand,” Aesthetic Plastic Surgery, 2005 6. K. Koscinski, “Hand attractiveness - its detetminants and associations with facial attractiveness,” 2012. 7. A. Carruthers, et al, “A validated hand grading scale.,” Dermatol Surg, 2008. 8. M Suwanchinda et al, “Validated 5 - Point photonumeric scales for the assessment of hand atrophy”, 2022 9. Y. Kim et al , “Oxyresveratrol and Hydroxystilbene Compounds Inhibitory Effect on Tyrosinase and Mechanism of Action,” The Journal of Biological Chemistry, 2002 10. N. Zakopoulou and G. Kontochristopoulos, “Superficial chemical Peels,” Journal of cosmetic dermatology, vol. 5, 2006 11. G. J. Hruza, “Laser treatment of epidermal and dermal lesions,” Dermatologic clinics, 2002 12. S. Sachdeva and A. Dogra, “Radiofrequency ablation in dermatology,” Indian Journal of Dermatology, vol. 52, no. 3, 2007 13. D. M. Hexsel, et al, “Clinical comparative study between cryotherapy and local dermabrasion for the treatment of solar lentigo on the back of the hands,” Dermatological surgery, 2000 14. E. V. Di Brizzi et al, “Plasma rediofrequency ablation for treatment of benign skin lesions. Clinical and reflectance conofocal microscopy outcomes,” Skin Research and Technology, 2009 15. F. P. Database, 2002, <https://www.accessdata.fda.gov/ scripts/cdrh/cfdocs/cfPMA/pma.cfm> 16. C. S. Pavicic et al, “Plastic and reconstructive surgery,” 2019 17. Y. Maruyama, “The reverse dorsal metacarpal flap,” British Journal of Plastic Surgery, vol. 43, no. 1, pp. 24-27, 1990. 18. Y. S. Ong and L. S. Levin , “Hand Infections,” Plastic and Reconstructive Surgery, vol. 124, no. 4, pp. 225e-233e, 2009. 19. W. H. Organization, “WHO guidelines on hand hygiene in health care,” 2009. 20. G. Galanopoulos and C. Lambidis, “Minimally invasive treatmentof varicose veins: Endovenous laser ablation (EVLA),” Int J Surg Lond Engl, 2012 21. S. Rao, S. Banerjee, et al, “Study of nail changes nd disorders in the elderly,” Indian journal of dermatology, 2011 22. R. Scher, A. Takakkol, B. Sigurgeirsson et al, “Onychomycosis and definition of cure,” Journal of the American Acadamy of Dermatology, 2007 23. O. J. Stone, “Clubbing and koilonychia,” Dermatologic clinics, vol. 3, 1985 24. R. S. Fawcett, S. Linford and D. L. Stulberg, “Nail abnormalities clues to systemic disease,” American family physician, 2004 25. C. Robert, V. Sibaud, C. Mateus et al, “Nail toxicities induced by systemic anticancer treatments,” The Lancet Oncology, 2015 26. J. O. Podjasek and R. H. Cook-Norris, “Mees Lines,” Clinical Toxicology, 2010 27. H. J. Park et al, “A Clinical study of Beaus lines,” Korean Journal of Dermatology, 2013 28. F. Flores, et al, “Terry’s nails, tracking an underneath disease,” Postgraduate Medica; Journal, 2019 29. F. Maldonado, et al, “Yellow nail syndrome: analysis of 41 consecutive patients,” Chest, vol. 134, 2008
