Over the past 10 years, new concepts and technologies

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1 oth skin and subcutaneous tissues are targeted in this multistage hand rejuvenation protocol. Topical therapies and intense pulsed light are used for skin thickening, rejuvenation, and improvement of age spots and leathery texture. utologous fat is injected into multiple tissue layers to fill out underlying tissue. Excess skin is excised with a small, well-hidden incision on the ulnar surface (esthetic Surg J 2004;42: ) Over the past 10 years, new concepts and technologies have changed aesthetic surgery dramatically. There has been a paradigm shift from horizontal and diagonal pulling of underlying tissues to more vertical vector pulling and subcutaneous underlifting. There have also been innovations in dermal filling and in skin rejuvenation using topical treatments. In my practice, we are able to rejuvenate the face and neck and to restore soft, feminine curves and shape to the body. fter undergoing facial and body rejuvenation, many patients focus on their aging hands as an area of significant concern. Recent articles have discussed various approaches to rejuvenating the aging hand. 1-4 I have found that the same concepts underlying facial rejuvenation apply to hand rejuvenation. t birth and throughout childhood, the dorsum of the hand consists of a thickened, fibrous fatty layer of tissue underlying the skin. The dermis of the skin is thick and has minimal hair follicles. The epidermis has a visually smooth contour and uniform pigmentation. With aging, there is loss of the fibrofatty tissue and thinning of the dermis and epidermis with breakdown of the collagen matrix. The skin loses resilience as a result of trauma and sun exposure. Skin pigmentation abnormalities develop after ultraviolet sun rays damage the basal layer of the epidermis. The veins of the hand lose elasticity, becoming dilated and prominent. With this damage comes thinning of the skin, resulting in a bony appearance as well as unsightly age spots that can potentially lead to premalignant and malignant lesions. In a combined effort, the esthetic Skin Care Center and Plastic Surgery Center of Eastern Virginia Medical School designed a protocol for hand rejuvenation. The initial protocol involved the use of topical vitamin C, vitamin, endothelial growth factor, transforming growth factor beta, hydroquinone cream, fat grafting, and intense pulsed light (IPL) therapies. fter 6 weeks of Denton D. Weiss, MD, Virginia each, V, is a boardcertified plastic surgeon and otolaryngologist. Co-author: James H. Carraway, MD, Virginia each, V. this regimen, the modalities that yielded the best results were included in the final algorithm and those that were evaluated as excessive were eliminated. We currently use the following basic algorithm for hand rejuvenation: 1. During week 1, we start the patient on tretinoin.01%, used nightly; TNS Recovery Complex (SkinMedica, Inc, Carlsbad, C), used every morning; and hydroquinone cream applied directly to the aging spots. This therapy is continued for 6 weeks. 2. fter this treatment period, the patient undergoes fat grafting to the dorsum of the hand and digits. (We ask patients to avoid all but minimal pinch and observe light [5 lb] weightlifting maximums for 4 days after the fat grafting.) 3. t 8 weeks, we reevaluate the patient. If age spots are not sufficiently improved by the hydroquinone cream, we treat the patient s pigmented lesions with IPL therapy. We repeat IPL every 3 months until the pigmented sites have faded completely. 4. Three months after fat grafting, we formally reevaluate the patient and schedule minimal touchup fat grafting. Usually, from 1 to 2 cc of fat is required for each hand. t this time, we also evaluate for excess skin laxity and skin turgor. If the patient has excessive skin turgor, we make an incision along the later- ESTHETIC S URGERY J OURNL ~ NOVEMER/DECEMER

2 Figure 1. Core cells of fat are harvested from the flank using a 14-gauge needle technique. Figure 2. Fat is placed in a sterile container with cottonoids. al aspect of the palm along the glabrous skin junction. This zone, which is not a site that is usually exposed in everyday hand gesture and movement, hides the scars beautifully. Using this approach, we have been able to rejuvenate the hands, extending up into the lower and upper arm zones. Surgical Technique Place the patient in the supine position with arms Figure 3. Fat is drawn up into a 1-mL or 3-mL Luer Lok syringe. abducted outward on hand tables at 45 degrees. Place the hand with the palmar surface down. Prep and drape the hands and flanks. Harvest fat from the lateral thigh or flank. Inject 8 ml of local anesthetic into 4 separate sites. ttach a 14- gauge needle to a 10-mL syringe and proceed, with a standard lipoplasty-type motion, to harvest the fat, placing it in a sterile container (Figure 1). Once the sterile container is filled with about 30 ml of fluid, place neuro cottonoids along the periphery of the container. The neuro cottonoids wick away the local anesthetic as well as excess serous fluid (Figure 2). Using a mosquito clamp, gently remove the fat from the cottonoids. Collect the fat in either a 1-mL or 3-mL Luer Lok syringe (Franklin Lakes, NJ) (Figure 3). ttach a 1.2-mm cannula with a single port to the syringe (Figure 4, ). Cannulas that are about 1 to 2 mm wide can deliver the fat into the subcutaneous space without difficulty. For minimal fat grafting touchup, we frequently use a 20- gauge needle to place the fat (Figure 4, ). dminister a nerve block, starting with a wrist block involving the superficial branch of the radial nerve and the dorsal branch of the ulnar nerve. Once these injections are completed, inject in the web spaces of each of the digits. The web space injections not only anesthetize the specific cutaneous port areas, but also constitute digital blocks (Figure 5). Once the hand is appropriately anesthetized, use an 11 blade to make small, 2-mm stab 568 esthetic Surgery Journal ~ November/December 2004 Volume 24, Number 6

3 Figure 4., 1.2-mm single port cannula is used for hand fat grafting., 20-gauge needle is used for touchup grafting. incisions at each web space. lso place small stab incisions at the level of the metacarpal joint on the ulnar surface of the fifth digit and the metacarpophalangeal joint region of the radial surface of the thumb. Make a small 2-mm incision at the wrist crease over the radial and ulnar heads (Figure 6). Inject the fat through the web sites and the dorsal incisions into the subcutaneous plane. Gently bring up the blunt cannulas through the web spaces and place them over the dorsum of the hand. Inject streams of fat into this area. Massage the fat gently, using manual palpation to smooth the contour. Inject patients who have significant subcutaneous wasting of the digits with fat, preferably using the 1-mm cannula to inject along the dorsum of the digits. Take care to stay in the superficial plane over the joint spaces (Figure 7). Close the incision lines with 6-0 nylon sutures. We ask patients to move their hands minimally over the next 72 hours to encourage vascularization of the fatty cells. We also request that patients lift no more than 5 pounds for 5 days after surgery and use a pinch technique for lifting and movement involving the index finger and thumb. Immediately after surgery, on postoperative day 1, we instruct the patient to begin reapplying tretinoin.01% at night and TNS Recovery Complex in the morning as well as hydroquinone cream directly on to age spots. Three months after the fat grafting therapy, we formally evaluate the patient and perform minimal fat graft touchup. During this period, excess fat that was frozen is thawed and injected into the dorsum of the hand. If the areas are extremely small (as they are in about 99% of patients), use a 20-gauge needle to transcutaneously inject into the specific zone. t this time, if the subcutaneous tissue appears to be well filled, demonstrating decreased exposure of the underlying structures but an excess of skin, remove an ellipse of skin along the ulnar border of the palm. Place this incision along the glabrous cutaneous skin junction. 5 Typically, a deep 4-0 PDS suture (Ethicon Inc, Somerville, NJ) is placed for strength and a running subcuticular 4-0 Monocryl (Ethicon Inc.) is placed for final skin closure. I would like to emphasize a few key technical points. The procedure can be performed with the patient under local anesthesia or under deeper anesthesia in conjunction with other cosmetic procedures. We instruct patients to take 100 mg of Demerol (Sanofi-Synthelabo Inc, New York, NY) and 10 mg of Valium (Roche Pharmaceuticals, Nutley, NJ) preoperatively to relax them in preparation for the local injections. It is important not to leave the fat exposed to air in the sterile container for more than 5 to 10 minutes before injecting. Our experience has shown that when the fat is left sitting until other procedures have been completed and then injected, results are less favorable. Fat grafting should be performed using small cannulas in multiple passes. This allows for better revascularization of the transplanted fat. The local anesthetic we use is.25% bupivacaine, which provides an ideal block. Our single complication with the fat grafting was cellulitis that developed in 1 patient. The patient was treated with antibiotic therapy and the cellulitis resolved completely. ESTHETIC S URGERY J OURNL ~ November/December

4 C Figure 5., Dorsal branch of the ulnar nerve block., Superficial branch of the radial nerve block. C, Digital blocks. Figure 6. Injection sites for local anesthetics and future fat grafting ports. Discussion Illustrations by William M. Winn, tlanta, G Hand rejuvenation is a multistage procedure that requires treatment of both the skin and subcutaneous tissues. Similar to treatment of the face, topical therapies are extremely successful for thickening the skin and bringing a more youthful appearance to the tissues. ge spots and leathery texture can be greatly improved with these topical therapies as well as IPL treatment. Subcutaneous tissues are addressed with placement of transplanted fat into multiple subcutaneous tissue layers. y using thin streams of fat, we have rejuvenated and camouflaged the exposed extensor tendons and hand veins (Figures 8, 9). Patients who continue to have excessive amounts of skin can be effectively treated with a small incision on the ulnar surface of the hand. The incision can be broken up with a very small, intermittent W- plasty that is well hidden. Sclerotherapy has been described in the past for dorsal veins, 4,6,7 but at this point, in my practice, it has not been necessary for overall hand rejuvenation. 570 esthetic Surgery Journal ~ November/December 2004 Volume 24, Number 6

5 C Figure 7., Subcutaneous fat injection using a 1.2-mm single port cannula., Primary layer fat grafting to the hand dorsum. C, Secondary layer fat grafting to the hand dorsum and digits. ESTHETIC S URGERY J OURNL ~ November/December

6 Figure 8., Preoperative view of the hand of a 55-year-old woman., Postoperative view 6 months after fat grafting protocol. Figure 9., Preoperative view of the hand of a 58-year-old woman., Postoperative view 6 months after 3-month touchup fat grafting. Patient underwent fat grafting protocol. 572 esthetic Surgery Journal ~ November/December 2004 Volume 24, Number 6

7 References 1. Coleman SR. Hand rejuvenation with structural fat grafting. Plast Reconstr Surg 2002;110: bergel RP, David LM. ging hands: a technique of hand rejuvenation by laser resurfacing and autologous fat transfer. J Dermatol Surg Oncol 1989;15: boudib JH Jr, de Castro C, Gradel J. Hand rejuvenescence by fat filling. nn Plast Surg 1992;28: owes LE, Goldman MP. Sclerotherapy of reticular and telangiectatic veins of the face, hands, and chest. Dermatol Surg 2002;28: Saffar P. What s new in cosmetic surgery of the hand? nn Chir Plast Esthet 1998;43: Duffy DM, Garcia C, Clark RE. The role of sclerotherapy in abnormal varicose hand veins. Plast Reconstr Surg 1999;104: Lee J. The role of sclerotherapy in abnormal varicose hand veins. Plast Reconstr Surg 2000;106: Reprint requests: Denton D. Weiss, MD, Division of Plastic Surgery, Eastern Virginia Medical School, 5589 Greenwich, Road, Suite 100, Virginia each, V Copyright 2004 by The merican Society for esthetic Plastic Surgery, Inc X/$30.00 doi: /j.asj ESTHETIC S URGERY J OURNL ~ November/December