This is a quick, easy-to-administer technique that provides consistent results and positive patient feedback. Furthermore, limiting the procedure to one or two injections decreases the chance of subcutaneous nerve irritation8.

It is important to remember that the superficial dorsal fascia adheres to the underside of the skin at some points. When tenting the skin, important underlying structures may be drawn up with the skin, thereby placing the injected material into the deeper layers that contain essential functional structures like vessels and tendons, and increasing the risk of complications. This may even be more dangerous when using a sharp needle.

The author does not recommend the tenting or bolus technique, as the injection is, in most cases, performed too deep when using a needle (Figure 3). Also, the risk of a compression is much higher with a single bolus injection.

Therefore, the author never recommends using more than half of the 1.5 ml syringe of calcium hydroxylapatite (CaHA) per dorsum of the hand, even when using a cannula. If necessary, the author would perform a second injection session after 6 to 8 weeks. The author has never experienced any problems with this method, not even severe swelling.

Tunnelling or linear retrograde threading

Depending on the patient’s pain sensitivity, it may be useful to inject a small amount of lidocaine intradermally at the puncture points.

Some authors suggest administration of a filling material in a single injection into the dorsum of the hand, distal to the wrist, using a threading technique with a sharp needle and avoiding vessels and tendons, followed by the massage towards the direction of the fingers7.

When using multiple punctures (approximately three) a needle or a blunt cannula is introduced from the most proximal or distal point (Figure 4) of the atrophic MC space at the appropriate depth—scraping against the skin, injecting the filler along a line in a retrograde fashion.

With the fanning technique the material is injected without withdrawing the needle or the blunt cannula, and a number of threads are injected radially (Figure 5). This may be done using most commonly one, if necessary two, single proximal insertion points (SPIP) or single distal insertion points (SDIP) located either proximally or distally at the dorsum of the hands (Figure 6). Often no or minimal massage is needed when using this injection technique as the filling material is distributed evenly already during the injection procedure (Figures 7 and 8).

Single distal insertion point (SDIP) with cannula

Figure 6: Single distal insertion point (SDIP) with cannula

Multiple small injections14 or micro-droplets (minute amounts of filler at a large number of points) are predominantly recommended for use with non-crosslinked native hyaluronic acid (HA) and intradermal injections when treating dermal elastosis13 (Figure 9). The author’s preferred product is Restylane Vital™ Light (Q-Med, a Galderma division, Uppsala, Sweden) because it is stabilised HA and with lidocaine, although most products used for this purpose are not stabilised. The use of very small, thin needles (30 G to 32 G x 1/2”), also known as mesoneedles, is recommended. This leads to the smoothening and thickening of the skin without affecting the subdermal volume very much13.

Cannula versus needle

On first sight it may appear easier, faster, and more comfortable to use a needle. However, as the only correct injection space is the underface of the skin and an injury to deeper structures must strictly be avoided, it is important to stay immediately below the skin during the whole injection procedure.

(A) Before and (B) after augmentation in proximal single injection point with a blunt cannula

Figure 7: (A) Before and (B) after augmentation in proximal single injection point with a blunt cannula

For this purpose, when compared to a sharp needle, a blunt cannula appears to be the most appropriate tool to ensure staying in the correct injection layer, thereby minimising the risk of damage to nerves and blood vessels, or even worse complications such as compartment syndrome. It is important that the blunt cannula is stiff and not too flexible (21 G to 25 G), and the length will depend on the severity of the atrophic area to be treated.

After injection

Some authors recommend the application of ice packs after an injection to reduce the possibility of swelling7,12, and/or use of an anti-bruising cream7, or to keep the hands in rest position for 2 hours and apply topical antibiotics daily for approximately 5 days5.

(A) Before and (B) after augmentation in distal single injection point with a blunt cannula

Figure 8: (A) Before and (B) after augmentation in distal single injection point with a blunt cannula

After hand augmentation procedures patients may return to normal activities of daily living as soon as they feel comfortable. In some cases there may be mild swelling and bruising over 1–2 weeks, especially when using a sharp needle or when injecting large amounts of filling material11. If necessary, an additional touch-up treatment is recommended after 4–6 weeks. Fat transfers often require multiple treatments, as they are of an uncertain duration11. Patients should be advised to avoid visiting a sauna, excessive sun exposure, heavy manual work, and other cosmetic procedures for around 2 weeks after hand augmentation. They should also be reminded to consult the treating physician immediately if they experience any problems, including swelling, pain, dysfuncion, or dysaesthesia.

(A) Multiple puncture points after native hyaluronic acid injection; (B) intradermal three-point injection with Restylane Vital Pen (Q-Med, Sweden); (C) shining trough of the needle during the intradermal injection

Figure 9: (A) Multiple puncture points after native hyaluronic acid injection; (B) intradermal three-point injection with Restylane Vital Pen (Q-Med, Sweden); (C) shining trough of the needle during the intradermal injection

Conclusions

Rejuvenation of the ageing hands is experiencing a growing popularity owing to the recognition that the hands are the ‘new’ face. One of the most popular methods is volumisation with filling materials, which addresses the volume and contour loss, ‘bony’ appearance, prominence of the veins and tendons, and the loss of skin elasticity and thickness. Yet, there are only a few controlled studies regarding the anatomy and the use of different filling materials in the ageing hands. Fortunately, as our interest in rejuvenation of the hands is increasing, so too does our knowledge.

As the primary concern should always be the correct functioning of the hands, followed by their aesthetic appearance, it is essential to avoid any kind of complications owing to cosmetic treatments that may interfere with their function. Therefore, it is essential that a practitioner should have an exact knowledge on the anatomy, characteristics of the range of products, advantages, disadvantages, and risks of different injection techniques, as well as the correct treatment in case of complications.

The author’s preferred technique for hand volumisation is the single proximal insertion point (SPIP) technique with a 25 G or 23 G 2-inch (50 mm) blunt cannula (Figure 5). From the single insertion located at the most proximal atrophic point at the dorsum of the hand, all atrophic areas can be reached. This technique is less traumatic and less painful for the patient than other techniques that use multiple insertion points. Also, the risk of injuring the vessel and causing haematoma is lower when performing the single insertion point than with multiple insertion points. Furthermore, from this point it is easier to introduce the blunt cannula than from a distal position, as well as to place the material in the correct layer (immediately below the dermis). As the filler is already distributed during the injection, no massage after the treatment is necessary. The author’s preferred material for hand augmentation is CaHA (Radiesse®; Merz Aesthetics, Frankfurt, Germany) because of its good volumising properties as well as induction of a new collagen deposition. The author recommends diluting a 1.5 ml syringe with 0.5 ml 2% lidocaine with adrenaline, and then injecting half of the material in each hand. In cases with more severe atrophy a second injection session after 6–8 weeks is recommended.