Key issues with fillers for the hands include avoiding overfilling and informing patients about the likelihood of post-injection swelling.
David M. Ozog, M.D.As treatments for the hands gain popularity, the use of fillers and other resurfacing techniques requires caution, according to David M. Ozog, M.D., director of cosmetic dermatology, Division of Mohs and Dermatologic Surgery, and Vice Chair, Department of Dermatology at Henry Ford Hospital.
"Most complications that have occurred with facial filler injections can and will occur on the hands. And because the skin is so thin, nodules and granulomas will be much more visible," he says.
As in the face, he adds, "We must use caution not to overfill the hands. Even in a youthful hand, some tendons and veins are visible."
Female patient in her late 50s, before 1 cc of CaHa,Photos: David Ozog, M.D. Overall, Dr. Ozog says, "Severe complications in the hands are quite rare, and most patients are very satisfied with their treatments. However, minor complications including transient post-treatment swelling are quite common and should be discussed prior to treatment."
In fact, he says, all injections of the hands cause some degree of temporary swelling.
"The hand is very sensitive to minor trauma," he says. Minimizing swelling requires using "common sense" measures including wearing compression gloves or elevating the hands post-procedure, Dr. Ozog advises. Additionally, "Some injectors will give anti-inflammatories such as prednisone," and a few suggest nonsteroidal anti-inflammatory drugs, though these can exacerbate bruising.
Female patient in her late 50s,after 1 cc of CaHa, with improvement in visible veins, including some effects from epinephrine. Photos: David Ozog, M.D.With autologous fat transplantation, the most common "complication" is less impressive
results than expected, which has hindered wide acceptance of this treatment.1 This is due to resorption and failure of grafts to take, Dr. Ozog says. "Fat is a bit unpredictable, so patients and injectors need a plan for re-evaluation and potentially additional injections."
Some experts recommend waiting six to eight months for the edema to resolve before retreating, he says. This timetable and the technical challenges of harvesting and preparing autologous fat also have stymied the technique's popularity, Dr. Ozog adds. Nevertheless, "Fat transplantation can provide outstanding results that can last much longer than those of other fillers."
The only synthetic filler with FDA approval for use in the hands is calcium hydroxylapatite (CaHa). Its pivotal trial for this indication included 85 treated patients and 29 controls. "Results were fairly impressive," Dr. Ozog said. One year after undergoing injections of up to two syringes per hand (performed with a 27-gauge needle), 75% of patients achieved greater than 1-point improvements on a validated grading scale.2
"However," he says, "the mean injected volume was 2.6 cc per hand, which is quite a bit." Swelling was almost universal, he adds, "which is in keeping with our clinical experience and what we've seen with all the filler products. The other post-treatment complication that we see is mild pruritus," which occurred in almost 46% of phase 3 study patients. Due to severe swelling, adds Dr. Ozog, three study patients who had undergone higher-volume injections experienced transient difficulty using their hands. Additionally, some patients experienced temporary anesthesia, which also resolved.
Bruising occurred in 75% of the FDA study patients. "And these were experienced injectors. The rate may be higher for inexperienced injectors." Cannulas will reduce but not eliminate the risk of bruising, he says.
In his practice, Dr. Ozog says, "I use both cannulas and traditional needles. Cannulas are quite easy to use for the hands, and I slightly prefer them for fillers. I would like to see a hand-versus-hand study with needles used on one side and cannulas on the other to investigate whether there is a favorability to bruising for one and swelling with the other."
Among synthetically produced fillers, Dr. Ozog says, "Poly-L lactic acid initially was thought to be possibly the best candidate" for hand treatments. However, he says, it's fallen from favor primarily due to delayed (up to one year postinjection) nodule formation. Techniques used to reduce nodule formation include reconstituting the material with higher dilution volumes such as 7 cc of bacteriostatic saline and lidocaine, Dr. Ozog says. "Also, try to ensure that the product is adequately mixed at least 24 hours before use, and that it's properly agitated in the syringes so it spreads evenly."
Treating PLLA nodules often proves challenging, he adds. Options that have been used range from Kenalog (triamcinolone acetonide, Bristol-Myers Squibb) injections to surgical excision. "There have even been attempts to add additional filler, with HA, around the nodules to soften their appearance," he says. Injecting HA as a primary filler into the hands with a needle or cannula can provide a very natural look, Dr. Ozog says. One issue with HA gaining wide acceptance is that it provides less tissue longevity versus the newly approved CaHa, he says.
Female patient in her mid 50s, mild pruritus 2 days after CaHa injection. Photo: David Ozog, M.D.Treatment options for resurfacing hand skin include lasers and light sources. "For superficial lentigines and flat seborrheic keratoses," Dr. Ozog says, "A Q-switched laser is outstanding for patients with skin type 1 through 4." Alternatively, Dr. Ozog sometimes uses mild electrodesiccation on individual lesions, until a light frost appears.
For overall hand skin texture, "Multiple treatments with nonablative lasers, including the 1,550 nm and the 1,927 nm thulium, can be effective," he suggests. Both provide fractional nonablative treatments, leaving minute columns of thermal damage (including denatured epidermis and collagen) without vaporizing or charring tissue, he explains.
Among ablative lasers, "Both the fractional 2,940 nm erbium:YAG and the 10,600 nm fractional have been used." Due to the lack of pilosebaceous units and the increased risk of scarring and long-term erythema or hypopigmentation on the dorsal hand, said Dr. Ozog, reducing the total amount of energy used and planning on multiple treatment sessions are imperative.
"My rule of thumb is to go slowly on the hand, and use test spots on almost all individuals – particularly with ablative devices," he says.
Above all, counseling regarding side effects is crucial for patients to understand that the common complications, most notably swelling with filling agents, will occur but they're manageable and transient.
"We discuss elevation, and we will add steroids, either topically or orally, if patients are concerned," he says. Other techniques he addresses in his counseling and consent procedures include post-treatment compression and ice.
Finally, "I would not perform hand injections or other hand treatments within two weeks of any major upcoming events such as weddings, where the hands will be on display."
Disclosures: Dr. Ozog reports no relevant financial interests.