By Dr Adrian Lim, Phlebologist and Dermatoligist
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by Dr Adrian Lim, phlebologist and Hand dermatoligist rejuvenation he face and hands are prominent aesthetic features that VEIN INJECTIONS (SCLEROTHERAPY) command significant attention. Age related changes in these The dilated hand veins are treated first with sclerosant injections that areas result in volume loss – through bone and soft tissue collapse the veins. The most effective sclerosants are either fibrovein Tresorption – as well as skin laxity resulting in sagging and (sodium tetradecyl sulfate) or polidocanol (aethoxysklerol). The veins wrinkling. The face and hands are also more exposed to the premature can usually be injected by direct vision or in more difficult cases and for photoageing effects of ultraviolet radiation resulting in additional increased safety, under ultrasound guidance. The treated veins undergo pigmentary, vascular and textural degeneration. Much has been said sclerosis (shrinkage and hardening) and either disappear with time (up to about the face but the hands are starting to gain attention as an important three months) or become smaller in diameter and less prominent. Usually focus for rejuvenation. Undoubtedly, demand for hand rejuvenation will one to three treatment sessions are required for permanent results. soar when the procedure becomes more accessible as more practitioners Scientifically and clinically established sclerotherapy techniques exist become skilled in hand rejuvenating techniques. for effective treatment of varicose veins, especially on the lower limbs. When considering hands, volume depletion through subcutaneous fat In hand rejuvenation, sclerotherapy of dorsal hand veins are desirable to loss results in wrinkled skin, sinewy appearance and dilated veins typical correct dilated veins that are often not satisfactorily improved with filler of “old-looking” hands. Ageing hands are further characterised by dilated injections alone. The veins are injected with sclerosants either in either veins that become even more prominent through loss of skin thickness. solution or foam preparation. Novice injectors should start with solution aesthetics Hand volume restoration typically includes injectable synthetic fillers rather than foam sclerosants and formal sclerotherapy training and prior or transfer of the patient’s own fat - typically harvested from the abdomen. clinical experience in leg vein sclerotherapy is recommended. Current methods of hand rejuvenation often ignore the associated dilated Arguably, sclerotherapy of dilated and ageing veins is at least as veins. For optimum results, injection sclerotherapy to dilated hand veins is important as skin-plumping filler injections. Ideally both filler and vein ADVANCED essential to correct bulging veins that are often not satisfactorily improved injections are combined for optimum cosmetic improvement of ageing with filler injections alone. Traditional hand rejuvenation typically involves hands. Sclerotherapy complications include lumpy trapped blood within laser/light treatment of blotchy skin discolouration alone. Modern hand the treated vein, temporary discolorations – red matting (neo-angiogenesis) rejuvenation goes further and this article will focus on combination filler and brown blood-iron staining – and possible ulcers. Rare but potentially and vein injections as the state-of-the art treatment of ageing hands. serious complications include thrombophlebitis and deep vein thrombosis. australian 44 AAADA_vol2_09.inddADA_vol2_09.indd 4444 222/4/092/4/09 22:15:29:15:29 PPMM FEATURE six months. There have been early concerns about granuloma formation with Sculptra but this is unlikely to be an issue if the correct protocol is followed. Earlier reports of granuloma are most likely due to inadequate dilution, incorrect plane of injection (intradermal) and inadequate time for product reconstitution. It is desirable to reconstitute Sculptra 24 hours prior to minimise the risk of product clumping (pseudo-granuloma) and granuloma formation. The dilution is higher than for the face (7 to 8cc instead of 5cc, sterile water) as the dorsum hand skin is more atrophic with very little subcutaneous tissue. Another 1cc of 2 per cent plain xylocaine may be added to the reconstituted product just before the procedure to increase post-operative comfort. More recently, another biostimulating filler, calcium hydroxylapatite (Radiesse) has been successfully used for hand filling in Australia. Radiesse has the advantage of instant volume correction with a similar duration of effect. This comes in a ready-to-go syringe with 1.3cc of product and it is desirable that practitioners are adequately trained in sclerotherapy of leg veins before attempting hand veins. should be sufficient to fill the back of both hands. For increased patient comfort, 0.1 to 0.2 cc of xylocaine can be added to the filler via a two or three-way tap. Although a bolus method of injection has been described, a more even spread may be achieved with subdermal multi-depot (three to four) injections along the inter-metacarpal spaces. Alternatively, hyaluronic acid fillers can be used with the advantage of instant volume correction and established safety record, although the duration of effect is shorter when compared to the biostimulating fillers such as Scluptra and Radiesse. There are several proprietary products for the hyaluronic acid class of fillers. Commonly used hyaluronic acid hand fillers are Juvederm Ultra (0.8cc) and Restylane Vital (1cc). In general, the less viscous varieties of hyaluronic acids are preferred and up to one syringe may be required per hand. Injections are performed subdermally 1cm apart (0.05cc per injection). A similar bandaging and massaging protocol as described above is recommended. In expert hands, these complications are rare. Post treatment compression Ultimately, filler selection will depend on practitioner experience and and regular self-massage will further reduce these complications. For preference. Autologous fat transfer is technically more challenging and less these reasons, it is desirable that practitioners are adequately trained in predictable, both in duration and long-term behaviour, thereby limiting sclerotherapy of leg veins before attempting hand veins. its appeal. There have been reports of bizarre adipose hypertrophy at the recipient site presumably due to the transplanted fat – typically harvested FILLER INJECTIONS from the abdomen – assuming donor site characteristics. The combined Skin filler injections can immediately follow sclerotherapy. Commonly procedure of vein sclerothearpy and filler injections is well tolerated, with used fillers for the dorsal hands include poly-L-Lactic acid (Sculptra), or without topical anaesthetic (EMLA), and can be completed within 30- calcium hyroxylapatite (Radiesse) and hyaluronic acid (Juvederm, 40 minutes for both hands. Restylane, Esthelis). Fat transfer injections can also be used to plump up the back of hands. After the vein and filler injections, a compression LASER/IPL bandage is applied overnight. After 24 hours, no further bandaging is Like the face, the back of hands accumulates sun damage in the form of necessary and the patient is instructed to massage the back of the hands pigmentary changes commonly termed ‘sun-freckles’ or ‘liver-spots’. Red- with a moisturiser for five minutes, five times a day, over the next five days. blotchy areas may also occur from UV-induced microvascular damage. The technique and results of hand filler injections are similar to facial These are amenable to routine IPL or laser treatment procedures that most filler injections and should be familiar to most cosmetic practitioners. cosmetic practitioners will be familiar with and not discussed further here. aesthetics Unlike hand vein sclerotherapy that can result in long term to permanent In summary, optimum hand rejuvenation requires addressing all the reduction in vein size, filler injections will be resorbed with time and key aspects of the visible signs of ageing: (1) surface photodamage, (2) require re-filling at regular intervals. volume depletion and (3) dilated veins. Surface pigmentary and micro- Synthetic biodegradable fillers are preferred as they have low vascular changes can be effectively treated with appropriate light/ laser ADVANCED complication rates and very predictable characteristics. Poly-L-Lactic devices. The novel combination of vein sclerotherapy and filler injections acid fillers (Sculptra) injected into hands typically result in immediate should routinely be considered for ageing hands with dilated veins as this post-treatment swelling that will settle over the next three to four days. leads to excellent cosmetic results and is set to become the benchmark for The dorsal skin thickness will gradually increase over the next three to optimum hand rejuvenation. australian 45 AAADA_vol2_09.inddADA_vol2_09.indd 4545 222/4/092/4/09 22:15:30:15:30 PPMM.