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Structural fat grafting fills, rejuvenates hands

Article-Structural fat grafting fills, rejuvenates hands

Key iconKey Points

  • Veins, joints and tendons in hands stand out as skin ages and thins
  • Dorsal hand rejuvenation involves not just filling but also thickening the skin
  • Post-treatment fullness typically stabilizes at two to four months

Dr. Coleman
In hand rejuvenation, fat grafting performs long-term skin thickening and rejuvenating functions far beyond its initial filling effect, says Sydney R. Coleman, M.D., a New York plastic and reconstructive surgeon in private practice.

"People wonder why we're putting fat in the hand," Dr. Coleman says. Normally, after childhood, "There's little if any fat in the hand. But we're learning now that aging has a lot to do with atrophy," he says.

Dr. Coleman says that initially, "I approached the hands by restoring fullness to them, which undoubtedly is a component in reversing aging. However, hand rejuvenation isn't just filling, if it involves changing the quality of the skin."

In particular, he says that the hand of a person age 16 to 25 appears soft and has thicker skin than older hands do. Additionally, "Healthy, athletic hands have visible veins," with as much as 50 to 60 percent of the vein circumference protruding. "But as we age, the skin gets much thinner," which makes veins, joints and tendons much more obvious, he adds.

More than a decade ago, researchers discovered that fat contains a high quantity of mesenchymal stem cells whose functions include repairing tissues, improving blood supply and preventing or even reversing scarring, Dr. Coleman says. "These are almost exactly the same stem cells found in bone marrow."

Subsequent investigators showed in an animal model that injecting fat under normal skin thickened the skin as much as 100 percent, due most likely to neocollagenesis at the recipient site (Mojallal A, Lequeux C, Shipkov C, et al. Plast Reconstr Surg. 2009;124(3):765-774). "That's probably the more important aspect in dorsal hand rejuvenation — not just filling, but thickening the skin and rejuvenating it," he says.

HOW IT'S DONE One patient Dr. Coleman treated in this fashion was a 52-year-old female with arthritis and wasting between the fingers that made her hands look much older than she was. "I injected 26 cc over the back of each hand, up to the middle joint of each finger. There are veins going up that far. And if you don't go that far out on the fingers, the rest of the hand suddenly looks better, but the fingers don't," he says.

A typical patient receives 25 cc to 35 cc per hand. "It sounds like a lot, and on the face, it would be," he adds. "But to the back of the hand, it's just a very thin layer." Dr. Coleman says he usually starts injecting at the fingers then works his way down the back of the hand past the wrist.

Typically, Dr. Coleman injects through seven or eight puncture-like incisions per hand. "I used to use a knife, but now I use a large needle to make the incision sites," he says. "And I place the fat entirely against the skin. I don't inject anything deep, so I'm staying between the skin, and the veins and tendons."

Additionally, he says that to prevent entering and injecting arteries, which could cause not only bleeding and bruising but also a pulmonary or arterial embolus, he uses only blunt cannulas — typically 17 or 18 gauge, and 19 gauge in the fingers.

Along with preserving veins and arteries, Dr. Coleman says, blunt cannulas provide more stable results. "Cutting a swath in the tissue with a sharp needle destabilizes the tissue, whereas if you're pushing a blunt cannula through, the cannula goes through the natural tissue planes." That way, he says that when the cannula is withdrawn, the tissues fall back into their natural plane.

Because this approach creates minimal tissue disruption, it allows one to inject more fat, and it's less likely to move than it would if injected via sharp needle," Dr. Coleman says. It's also important, he says, to weave the fat into the subcutaneous layer with multiple passes, using the blunt cannula to place miniscule amounts of fatty tissue with each pass (Coleman SR. Plast Reconstr Surg. 2002;110(7):1731-1744; discussion 1745-1747).

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