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HAND ANATOMY AND

HISTOLOGY
(APPLICABLE FOR ESTHETIC TREATMENTS)
Christian Dumontier, Pierre Dumas
Plastic Surgery, Nice

WHAT ARE WE TALKING ABOUT ?

Only the dorsal part of the hand is involved in ageing and


cosmetic consequences (thin, fragile, close to important anatomical structures,
extensible, mobile without adhesion to the underlying structures - close to the superior
eyelid)

Not the palmar skin

(thicker, more resistant, less mobile, less extensible, without


cutaneous excess, more sensible and fixed to the underlying structures)

ANATOMY ?

Nothing new: Bones, joints, tendons,


muscles, nerves, arteries,....

However they do not participate at the


same level to hand ageing

Modification of the volume and


properties of the bones/muscles/
tendons...and skin

Modification of the appearance of the


skin

THE DORSUM OF THE HAND

From bones to skin

What are the layers ?


How many layers ?
Where to inject safely ?

How do they modify with


ageing ?

DEEP STRUCTURES (LAYERS)

Bone and muscles

Arteries

Tendons

OSTEO-ARTICULAR AGEING

Bone osteoporosis has no influence on the


morphology of the hand

bone mineral density of 0,72% per year after 50


years of age explain bone fragility (osteoporosis)

Joint arthritis however does participate to


finger modifications

67% F, 55% M present with an arthrosis (KL> 2)


after 55 years, with aggravation with time - cosmetic
consequences on the fingers

van Saase Ann Rheum Dis 1989

RATIO P1/PIP

Pearson: M:-0.22, F: 0.46

Jakubietz, JPRSA 2008

NEURO-MUSCULAR AGEING

> 60 years of age: of Motor unit in ulnar


innervated muscles (interosseous) and more
severe in median innervated (thenar atrophy)

> 60 years

muscular mass (25-45%)

Grip strength (20-25%)

Amyotrophy participates slightly to


cosmetic hand modifications

TENDON AGEING
Does not participate

tendon vascularisation grip strength, appearance of finger


flexum, tensile strength (30-50%)

frequency of tendon rupture (mallet finger)

Ageing of tendon sheath (trigger finger,...)

SUPERFICIAL LAYERS
Nerve ageing
has no
influence

Nerves

Veins

Skin

VEINS

Become more visible with


age (50% of patients > 60 yrs venous

Pearson: M: 0.67, F: 0.79

dilatation, microthrombosis,...)

Jakubietz, JPRAS 2008

Phlebectomy (no more than 1) has been proposed for large


veins (6-7 mm diameter)

Dr LEFEBVRE-VILARDEBO

HOWEVER

Old anatomical papers have studied


the veins of the dorsum of the hand

Many anastomoses in different


planes

There is not a single layer for


veins: Based on this investigation, we think

that the arrangement of the subcutaneous veins


in the dorsum of the hand is a three
dimensional network. It is appropriate to
divide the veins into superficial and deep layers.
Zhang S-X, Schmidt H-M. Clinical anatomy of the subcutaneous
veins in the dorsum of the hand. Ann. Anat 1993; 175: 381-384.

THE SKIN

The visible part

Modification of both
volume and aspect

Glanz S et al. Aesthetic surgery of the arm. Part I. Aest Plast Surg 1981;5:1-17.

SKIN AGEING

Extrinsic ageing affects the epidermal and dermal layers (following


exposure to the sun, chemicals and smoking), and can manifest as actinic
keratosis (premalignant), solar lentigines, punctate hypopigmentation
and solar purpura.

Most hand rejuvenation treatments focus on extrinsic ageing


by unifying pigmentation and skin resurfacing (topical acids, topical 5fluorouracil, bleaching agents, microdermabrasion, chemical peeling, laser or intense pulse
light treatments)

(Sclerotherapy and phlebectomy to minimize the appearance of veins)

Kuhne U, Imhof M. Treatment of the Ageing Hand with Dermal Fillers. J Cutan Aesthet Surg. 2012 Jul-Sep; 5(3): 163169

SKIN AGEING

Intrinsic ageing include wrinkles, translucent, lax


and thinner skin with prominent veins, joints
and tendons

After 40 years old, thickness of the dorsal


hand skin decreases of 3% each year

Hand volume restoration or contouring can


address most intrinsic signs of ageing.

THE SKIN

Fours layers of epidermis: basal


(1), spinous (2), granular (3),
cornified (4)

THE SKIN

Two layers of dermis separated


by the rete subpapillare

THE SKIN

Then the hypodermis with adipose


tissues

DORSAL SKIN
2 mm thick

Epidermis 0,3 mm;

Dermis 1 mm (no
meissner corpuscles),

Hypodermis 0,66 mm -no


fixation to deep
structures)
Palmar skin: 0,6 mm/1,5 mm/ 2 mm

DORSAL SKIN

150 cm2

Large surface

Different areas (esthetic units


of Michon have surgical
implication)

190 cm2

ANATOMICAL LAYERS ?

Kanavel (1939) found two layers: above muscles (deep) and above
tendon (superficial) where infection can spread

Anson (1945) found 2 layers divided each in superfical and deep


and separated by areolar tissues

THREE LAMINAE ?

lume 126, Number 1 Dorsal Hand Anatomy

Fig. 2. reported
Histologic slideof
demonstrating
dorsal superficial
(DSL), dorsal
superficial fascia (DSF),
Bidic
three distinct
fattylamina
laminae
(superficial,
and dorsal intermediate lamina (DIL).
intermediate and deep) divided by thin fascia on the dorsum of
the hand.

Tendons are located in the deep lamina.

Veins and sensory nerves are located within the intermediate


lamina
Bidic et al. Dorsal Hand Anatomy Relevant to Volumetric Rejuvenation. PRS 2010;126: 163-168

THREE LAMINAE ?

Fig. 2. Histologic slide demonstrating dorsal superficial lamina (DSL), dorsal superficial fascia (DSF),
and dorsal intermediate lamina (DIL).

Fig. 3. Intraoperative photograph demonstrating dorsal intermediate fascia overlying the dorsal deep lamina where the extensor tendons run.

The thickness of the superficial lamina seems to correlate with


body mass index, and there are no vascular or neuronal structures
in this lamina.

tinuous with the periosteum overlying the doraspect of the metacarpals.


Anecdotally, it appeared that the hands of

mediate fascia with the intervening fatty-are


laminae. The veins were clearly within the do
intermediate lamina, running deep to the do

WHERE TO INJECT ?

Above the veins ?

In the subcutaneous tissue (superficial lamina) as the dermis is to


thin in aged person ?

WHERE TO INJECT ?
Volume 126, Number 1 Dorsal Hand Anatomy

It is technically impossible to
inject into the superficial lamina
without puncturing the veins !.

Into the deep lamina, above the


metacarpal plane, is effective
using a 25- to 32-gauge needle
or a blunt cannula.
Fig. 7. Illustration demonstrating the different fascial layers and fatty laminae, with injection cannula placed within the dorsal superficial lamina.

THE IDEA OF INDEPENDANT LAYERS IS


NOT ACCURATE

Lefebvre-Vilardebo has demontrated a vertical network with


veins not passing from a layer to another but running from
superficial to deep part of the dorsum of the hand in a nonarranged fashion

Guimberteau had long ago shown a three dimensional network in


the subcutaneous tissues

Guimberteau: Promenades sous la peau, Elsevier

When you enter the skin

No order, fibrils branching out in everything direction !

Fibrils, made of collagen and elastin delimit microvacuoles


filled with proteoglycans.

This flexible architecture has great mechanical resistance which


increases the potential response to stress

So where to inject ?

THERE ARE NO REAL PLANES

Inject not too superficially to avoid the


Tyndall effect (light scattering by particles in fine
suspension- As the intensity of the scattered light depends
on the fourth power of the frequency, blue light is
scattered much more)

Avoid veins injury (blunt canulas)

HAND AGEING CONCLUSION

Cutaneous modifications are the most visible

But the hands are an expansion of the brain, a mean


of non-verbal communication, a sensory organ, a tool
for creativity,...

And ageing is responsible for the loss of dexterity and


strength

Do not forget that hand rejuvenation is only the cosmetic


treatment of a global decline