CLINICAL ANATOMY/REGIONAL APPROACHES

Hand: Clinical Anatomy and Regional

Approaches with Injectable Fillers
Marc Lefebvre-Vilardebo, MD
Background: Cosmetic physicians are more and more frequently asked for hand
Patrick Trevidic, MD
rejuvenation. They commonly propose the same techniques as for the face. The
Amir Moradi, MD
authors undertook an anatomical study of the hand dorsum to understand the op-
Mariano Busso, MD timal location for an injected filler and to design the safest technique of placement.
Allison B. Sutton, MD, Methods: The first part of the study included dissections of 19 fresh cadaveric
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FRCPC, FAAD
Vivian W. Bucay, MD, FAAD
Carnac and Paris, France; Vista, Calif.;
Coconut Grove, Fla.; and San Antonio,
Tex.
hands and duplex ultrasounds investigation of 28 healthy hands. A technique
of injection specifically designed from anatomical findings was then tested on
8 fresh cadaveric hands using magnetic resonance imaging and dissection in
comparison with 3 other commonly used techniques of rejuvenating injections.
Results: Between the dermis and the tendons, the thickness of the fascial plane
was measured from 0.3 to 2.2 mm. Because of numerous fibrous septa, the en-
tire plane was found as a 3-dimensional sponge-like framework. Veins could be
located in all levels of this framework. There was no predefined free space. The
optimal place for the deposition of a filler was found to be the undersurface of
the dermis. The specific technique named Scrape Skin Threading Technique
and using a cannula scraping the deep side of the dermis was checked as the
only technique which could give a perfect placement of product restricted to
the fascial layer.
Conclusion: The Scrape Skin Threading Technique was designed to inject
safely and accurately any kind of injectable in contact with the undersurface
of the dermis, which appeared anatomically as the optimal location of a
filler for enhancing the outer appearance of the dorsum of hands.  (Plast.
Reconstr. Surg. 136: 258S, 2015.)

Disclosure: Dr. Moradi is a board-certified facial plastic

From E2e; private practice; Aesthetic Dermatology, Division
of Dermatology and Cutaneous Surgery, University of Texas
Health Sciences Center at San Antonio; and Bucay Center
for Dermatology and Aesthetics.
Received for publication May 12, 2015; accepted August
5, 2015.
Presented, in part, as “Scrape Skin Threading Technique,
the Optimal Technique for Hand Dorsal Filling” at the
FACE 2 f@ce 2014, in Cannes, France, September 12–
13, 2014; Aesthetics 2014, Preconference Workshop, in
New Delhi, India, August 22–24, 2014; 11th Anti-Ag-
ing Medicine World Congress, in Monte Carlo, Monaco,
April 4–6, 2013; FACE 2 f@ce 2012, in Cannes, France,
November 2–3, 2012; 5th European Multidisciplinary
Hand Aesthetic Congress, in Paris, France, October 12–
13, 2012; 2nd International Course on Aesthetic Plastic
Surgery and Minimally Invasive Techniques, in St. Pe-
tersburg, Russia, June 1–3, 2012; and 10th Anti-Aging
Medicine World Congress, in Monte Carlo, Monaco,
March 29–31, 2012.
Copyright © 2015 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000001828
surgeon in private practice in Vista (San Diego County,
Calif.) and serves as consultant and researcher for Al-
lergan, Galderma, and Merz North America. He did not
receive compensation for this article. Dr. Busso has been a
paid consultant for Merz North America and Galderma.
Dr. Bucay is a consultant and speaker for Allergan, Gal-
derma, and Merz. Dr. Sutton has no relevant financial
disclosures. Dr. Lefebvre-Vilardebo and Dr. Trevidic have
no commercial associations or financial disclosures that
might pose or create a conflict of interest with information
presented in the article. This study was supported by E2e.
Scrape Skin Threading Technique and SSTT are regis-
tered trademarks of Marc Lefebvre-Vilardebo.
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 Volume 136, Number 5S • Hand: Clinical Anatomy and Injectable Fillers
SCRAPE SKIN THREADING
TECHNIQUE, THE OPTIMAL
TECHNIQUE FOR HAND DORSAL
FILLING
Anatomy and Technique
Mainly because of the media, which have high-
lighted that hands are giving away age as reliably
as the face, hand rejuvenation has been becoming
an increasing demand from patients for around
10 years. Through a review of the literature up
until March 2013, Gout1 listed 157 significant clin-
ical peer-reviewed publications on hand rejuvena-
tion, primarily within the nonsurgical aesthetic
field. Fifteen of publications focused on hand
aging, and the rest of the publications related to
hand rejuvenating treatments, mainly external
treatments since 2000 and using injectables since
2005.2–8 Quite all of publications proposed tech-
niques and products already commonly used in
other parts of the body, especially the face. They
did not take into account that the dorsum of the
hand is obviously a very particular area due to its
major thinness at the time of rejuvenation and the
extreme mobility of its underlying tissues. We have
found only one anatomical study specific for hand
rejuvenation, which came late (2010) in the his-
tory of this new field.9 The authors suggested the
“dorsal superficial lamina” as the most convenient
place for injections, but they did not propose a
technique to reach it safely. Conversely, Coleman10
described precisely his technique of structural fat
grafting for hand rejuvenation. But the technique
was based on his large clinical experience of fat
grafting and not on a dedicated anatomical study.
And his technical guidelines are commonly not
followed for injecting synthetic fillers.
We believe that still nowadays successful hand
rejuvenation remains a major underestimated
challenge. Here, a perfect treatment is the addi-
tion of a good product and of a good technique of
injection. The recent Food and Drug Administra-
tion (FDA) approval of Radiesse for hand rejuve-
nation should open the door of a good product.
The aim of our global research was to propose an
effective and safe technique based on more accu-
rate anatomical investigations and scientifically
validated. The main guideline was always to place
the product in the right location to give an opti-
mal correction of the volume loss and a natural
clinical endpoint without any risk of side effect.
We agree with Wiest11 that “because of the thin-
ness of the hand dorsal layers, the technique for
placing a material is certainly more valuable than
the material itself.”
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Anatomical Research Relevant
to an Injection Technique
The overall anatomical study has been
designed to be not only analytic but mainly
focused on the ideal place for the safe deposition
of an injectable. It took place from mid-2009 to
mid-2012.
Anatomical Dissections of the Dorsal Side of
Hands
Nineteen fresh cadaveric hands were obtained
from the Body Donation Centre of Paris Descartes
University, Paris. All hands had their arteries pre-
viously washed and injected with colored latex
through the brachial artery. Age, gender, and
body mass index of the cadavers were unknown.
All dissections were performed within 5 days after
death. They were done layer by layer from the
skin to the bone plane. The incision was made
as a straight line on both edges of the dorsum
and extended by a crescent-shaped line over the
metacarpophalangeal joints. Much attention was
given to understand the links between layers and
to try to find several planes inside the fascial layer
itself. All dissections were recorded in video and
pictures.
Duplex Ultrasound Investigations
Ultrasound imaging (still images and video)
was performed over the entire dorsum of the
hands in 14 healthy volunteers aged 25–72 years
(28 hands). All of them had previously given a
verbal informed consent in relation with the prin-
ciples outlined in the Declaration of Helsinki. We
used 2 different ultrasound machines (Toshiba
Aplio XG Precision Imaging [Japan] and Hitachi
Hi-Vision Preirus [Japan]) with high-definition
18-MHz probes. The ultrasonic reference was
the tendons, which can be located through their
fibers sliding when the fingers are moved.
Dissection allows analysis of the anatomy but
often provides little information about the rela-
tionship between the various layers. Ultrasonogra-
phy with the latest technology and high-definition
probes are an ideal complement because they
accurately show the thickness of the layers and
their interconnections.
Results
Between the epidermis and the deep fascia
covering the metacarpals and the interosseous
muscles, both techniques reveal 3 layers, the der-
mis, a fascial plane, and the tendons.
On ultrasonographic images, the thickness of
the dermis was measured from 0.2 to 0.9 mm, the
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 Plastic and Reconstructive Surgery • November Supplement 2015
Fig. 1. Tight adhesions between dermis and fascial plane.
fascial plane from 0.3 to 2.2 mm, and the tendon
layer from 0.7 to 1.7 mm, for a total thickness of
all layers between 2.2 and 4.6 mm.
Because most of our dissected hands were
from elderly subjects, the skin was so thin and
transparent that it was possible to read printed
text through it.
Even if there were tiny adhesions between its
deep side and the tendons layer, the fascial plane
was always very mobile over the tendons. On the
contrary, the outer side of the fascias was tightly
stuck onto the undersurface of the dermis. These
adhesions between the dermis and the fascial
plane were so tight (Fig.  1) that they had to be
released using a scalpel; no natural plane of cleav-
age seemed to exist. They stuck the veins to the
dermis and could support arterioles.
Except in 2 cases, even very careful dissections
have always failed to separate the fascial layer
in several sheets. Here too, no natural plane of
cleavage seemed to exist. In ultrasonography, the
fascial plane sometimes seemed to be divided in
places, forming 2 perfectly distinct layers sepa-
rated by less echogenic tissues. But more often,
it looked like a single layer. Only video-recorded
ultrasound dynamic analysis of the thickest fascias
showed the key components of the fascial frame-
work. A lot of tiny multidirectional fibrous septa
partition the total thickness of the fascial layer,
giving a 3-dimensional (3D) framework similar to
the “walls” of a sponge around its tunnels (Fig. 2).
This feature of multipartitioned superficial fascia
is equal to the one already known, at least by many
sonographers, in many parts of the body.
The outer global picture of the venous net-
works seemed to be single layered and covering
the entire surface of the dorsum. In fact, although
they were interconnected, the veins were located
in different levels within the fascial layer (Fig. 3).
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Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
They could cross over in space and switch from
one plane to another “using the tunnels of the
sponge-like fascial framework.” The fascias and
septa diverged or split to surround the veins and
provide them with support. Veins and fascias were
closely linked. These superficial venous networks
were also connected to the veins of muscles via
perforating veins which enter the deep fascia.
Several procedures of skin tenting were per-
formed on both cadaveric hands during dissection
and volunteer hands during ultrasounds imaging.
All gave the same results. Because of the tight der-
mofascial adhesions, pulling on the skin pulled
the entire fascial plane along with it. As a conse-
quence, during tenting, the skin and the fascial
plane were lifted together. And because of their
interconnections with the multiple multidirec-
tional fascial partitions and septa, the veins were
dragged into the resultant dermofascial triangle.
The tendons layer was always a complete and
well-organized lamina attached to the deep fascia
covering the bones and muscles. Tendons were
not isolated from each other but interconnected
by a thin fibrous sheet, at least over the proximal
two thirds of the dorsum. Some arteries and veins
perforate the deep fascia and then this tendinous
sheet to enter the fascia layer, mainly at the proxi-
mal end of the first and fourth intermetacarpal
spaces.
Conclusions of the Anatomical Study: Scrape
Skin Threading Technique
All these anatomical findings led us to a series
of conclusions. The tendons layer and the space
between tendons and deep fascia are certainly not
a correct place for a volumizing filler:
• because too deep for changing reliably the
outer dorsal appearance of the hand,
• because of the unknown longevity within
such constantly mobile tissues,
• and because of the potentially harmful
effects of products in current use in the
tendon space.12
The ideal space should be the fascial layer. But
at the time of a rejuvenation requiring volumiz-
ing fillers, the thickness of this plane is no more
than 1 mm, due to the loss of fat tissue. The blind
insertion of a needle or cannula in such a thin
place leads to an unpredictable positioning of the
injected product. And lifting the skin between 2
fingers (skin tenting) does not help, as it raises
the entire fascial layer simultaneously without cre-
ating space for the product. To insert a needle is
 Volume 136, Number 5S • Hand: Clinical Anatomy and Injectable Fillers

Fig. 2. Illustration of the 3D sponge-like fascial framework on the dorsal side of hands.

injection without massage is selected to avoid

Fig. 3. Ultrasonography of the dorsum of hands: power-Doppler
imaging of the multileveled superficial dorsal venous network.
certainly unsafe because of the vicinity of tendons
and intrafascial veins. The best instrument for
injecting safely a filler product into the back of
the hand is therefore a soft-tipped blunt cannula.
Although it seemed to be virtual in anatomi-
cal dissections, the optimal place for injection is
the interface between the dermis and the fascial
layer. A round-tipped cannula can easily create a
subdermal space for injection. The technique of
very gentle and progressive retrograde threading
a too far away and deep diffusion of product
through the “tunnels” of the 3D sponge-like fas-
cial framework. To find and follow the subder-
mal plane, the undersurface of the dermis has
to be scraped with the cannula. We named this
procedure “Scrape Skin Threading Technique”
(SSTT) to emphasize the importance of scraping
the undersurface of the skin when the cannula is
being advanced.
Three major steps characterize the SSTT13:
Marking out areas to be filled: Subdermal
injection changes the appearance of the hand
quickly. It is therefore wise to mark out the areas
in most need of filling before the procedure, that
is, the triangles corresponding to all interosseous
spaces. The spaces in contact with the bone on the
medial edge of the fifth metacarpal and along the
first metacarpal should not be forgotten. Position-
ing the cannula entry points at the tops of the tri-
angles makes it easy to inject them in a fan-shaped
configuration.

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 Plastic and Reconstructive Surgery • November Supplement 2015
Cannula insertion: To avoid friction in the
to-and-fro movements, the entry points are made
with a needle slightly larger than the cannula. The
needle’s bevel should be facing down to guide the
cannula in the right plane. The incision is cres-
cent shaped. When the cannula is later inserted, it
engages in the weakest part of the incision, that is,
at the top of the convexity, in direct contact with
the undersurface of the dermis.
Injection: The tip of the cannula is introduced
through the entry point with the lateral hole pointed
up, that is, toward the dermis. This orientation of the
side hole further helps to keep injection of the prod-
uct subdermal. The cannula is then pushed in with
a small angle of its tip toward the dermis to scrap
easily the undersurface of the dermis. The product
is slowly injected as the cannula is retracted.
In this way, tracing injections are progressively
carried out in a fan-shaped configuration from a
single entry point, gradually covering the marked
out space. The aim is to deposit enough product
on each passage. A touch-up is always possible.
However, it is important to avoid depositing too
much product, which would necessitate correc-
tive massaging. Product can always be added, but
it can never be taken out. All the marked spaces
can be filled in this way. This technique allows
remodeling, “real sculpting,” of the hand by add-
ing filler. Gentle massaging can be used to smooth
over small local defects, but broad massaging to
redistribute the product is contraindicated.
Validation Study of the Scrape
Skin Threading Technique
Once this new specific technique for hand fill-
ing was tested and accurately designed on 3 cadav-
eric hands, we decided to check and validate its
reliability in positioning the injected product, com-
pared with others already published techniques.
Materials and Methods
Eight fresh cadaveric hands were obtained
from the Body Donation Centre of Paris Des-
cartes University. They were injected using dif-
ferent methods and then examined by magnetic
resonance imaging (MRI) to locate the injected
product prior to dissection.
Four different injection methods were studied:
(1) one single bolus (1  mL injected using a 21-G
needle) with no massage; (2) one single bolus (1 mL
injected using a 21-G needle) followed by massag-
ing to spread the product out; (3) blind retrograde
threading injection of 0.8 mL into the subcutaneous
plane, using a 27-G cannula (blind in the sense that
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Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
the cannula was pushed into the subcutaneous layers
without any particular wish to follow a well-defined
plane, notably subdermal); and (4) strictly subdermal
fine threading retrograde injection (SSTT) of 0.7-mL
product using a 21-G cannula. In all boluses proce-
dures, the tip of the needle was inserted in the cen-
ter of the dermofascial triangle created by lifting the
skin (skin tenting), taking care to remain as parallel
as possible to the bone plane to minimize the risk of
injecting into the tendon layer. The second and third
methods are commonly used throughout the world
for rejuvenation of the back of the hand. The only
real difference between the third and fourth methods
is the emphasis on scraping the underside of the skin
in the to-and-fro cannula movements to ensure sub-
dermal injection (SSTT). In both methods, cannulas
were inserted through slightly larger holes made with
a needle. The same fan configuration of injections
was used starting at 2 different entry points.
Two hands were injected using each method
with the same MRI data acquisition and analysis
protocols used for each hand before and after the
procedure to make an objective comparison pos-
sible. All the hands were then dissected plane by
plane. The same product was injected in all cases,
that is, calcium hydroxylapatite (CaHA) diluted
2-fold in colored normal saline. The purpose of
diluting it was to make the product easy to inject
gently and accurately, and the purpose of coloring
it was to make it easy to follow in its spread through
the tissues and its location in different layers dur-
ing dissections. Injection methods were allocated
as the hands came available, that is, randomly.
Results
One Single Bolus with No Massage.
The first injection was made on an unusually
fat hand, due to both the fatness of the cadaver
and probably localized premortem edema. The
analysis of MRI images after injection showed that
the entire product was above the tendon layer,
inside the fascial plane as confirmed by the dissec-
tion. But such a hand would never be a candidate
for augmentation. Nevertheless, this experiment
confirmed that injection confined to the fas-
cial plane is possible as long as the layer is thick
enough to “accommodate” the product injected.
The second hand injected with a single bolus
alone was more compatible with the demand for
rejuvenation. MRI and dissection showed that
the product was in contact with the deep fascia,
between and below the tendons (Fig. 4).
One Single Bolus Followed by a Massage.
Examination of colored tissue through the
skin showed that vigorous massage had not been
 Volume 136, Number 5S • Hand: Clinical Anatomy and Injectable Fillers
Fig. 4. Dissection of the fascial layer after a bolus without mas-
sage: the colored injected product is found in and below the
tendon layer.
Fig. 5. Dissection of the fascial layer after SSTT: the colored
injected product “humidifies” the undersurface of the dermis
and infiltrates the fascial layer. There is no product in the tendon
plane.
successful in spreading the product out evenly.
Injecting boluses into each intermetacarpal space
would almost certainly be more effective than a
single bolus. However, again in both hands, the
product was found in contact with the deep fascia,
between and below the tendons.
Blind Retrograde Threading Injection.
In both treated areas in both hands, the prod-
uct was still found in and under the tendons layer.
Strictly Subdermal Linear Retrograde Injection.
On all the MRI images (both transverse and
axial) of the 2 such injected hands, the product
was only found above the tendon layer. Dissec-
tion showed that all the injected product stayed
in contact with the dermis or in the fascial plane,
without any leakage in the underlying space
(Fig. 5).
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Conclusions of the Validation Study
MRI and anatomical dissection of the super-
ficial layers on the back of the hand before and
after filler injection using different techniques
confirmed the conclusions of the anatomical
study. If one considers that the fascial plane is the
only place that can accommodate a filler without
risks of side effects for the tendons, then the SSTT
is the only technique that allows to place the prod-
uct in the right location.
DISCUSSION
Our anatomical findings and conclusions
diverge from the ones by Bidic et al.9 We did
not find a milfoil cake-like fascial system as they
described, but a 3D sponge-like fascial framework
as in many other parts of the body. The much
higher quality of our imaging due to our high-
definition ultrasounds probes is certainly a major
explanation of such a divergence.
As already described,2–4 the main features of
dorsal hand aging are a progressive loss of volume
linked to fat atrophy; a skin laxity and dermal
atrophy giving too much visible bones, tendons,
and veins; and a superficial aspect of crumpled
skin. The immediate idea is to use already known
injection techniques, intradermal to improve the
skin and/or deeper to correct the volume loss.
Ultrasound investigations with high-definition
probes were the most exciting and fruitful part of
our research, as they gave us many key findings as
the thickness of the layers and the multipartitions
system inside the fascial plane. The 0.2- to 0.9-mm
thickness of the dorsal skin must be compared
with the 2.56 mm on the check or 2.25 mm on the
alar of the nose.14 It seems impossible to reliably
inject any filler intradermally.15 A better approach
could be to voluntarily use the immediate sub-
dermal space with SSTT or change for alternative
methods such as percutaneous collagen induction
or all “lights” devices.
It is surprising that in our time when all the
techniques for the face tend to become more and
more meticulous and scientifically controlled,
the injection techniques in the hands remain as
rough and blind.16 We have not found published
investigations of the position of the injected prod-
uct after bolus and massage or after blind thread-
ing. Physicians who insert a needle in the center
of a skin tenting believe that they inject in the fas-
cial layer. We showed they are wrong. The product
is deeper around the tendons and during a blind
threading as well. Because of the multilayered
venous network (with 2 main levels17) inside the
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 Plastic and Reconstructive Surgery • November Supplement 2015
Fig. 6. A 51-year-old woman. Result at day 21 after injection of
1 mL of diluted CaHA, using the SSTT.
Fig. 7. A 51-year-old woman. Result at day 21 after injection of
1 mL of diluted CaHA, using the SSTT.
fascial plane, this area itself is not the safest one
for a needle. A soft-tipped cannula is certainly a
better tool in hands. Compared with a small cali-
ber cannula, 23-G or 21-G cannula has thicker
heads that readily slide against the dermis with-
out snagging inside it. Experience of teaching the
technique has consistently shown that the stiffer
the cannula, the easier it is to advance it in con-
tact with the skin. However, such a large lumen
means learning how to control injection pressure
for regular product deposition, particularly since
a relatively fluid filler product seems the best as
it precludes the need for strong pressure. The
underface of the dermis appears to be the optimal
location whatever the filler (Figs. 6 and 7).
Already in 2004, Coleman18 stated in his tech-
nical book on surgical fat grafting that “the key
to structural fat grafting of the dorsum of the
hand is purposeful placement of a smooth layer
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Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
of tissue against the undersurface of the dermis.”
The majority of physicians treating aging hands
certainly failed to take this guideline into account.
We are glad that our purely anatomical approach
comes to the same conclusive statement for inject-
ing a synthetic filler.
Conclusions
The SSTT, a strictly subdermal linear retro-
grade injection, became our preferred treatment
approach. It is simple and reliable because it is
always easy to follow the undersurface of the der-
mis with a soft-tipped cannula. It is safe because
the cannula is kept far away from the veins and
the injected product remains distant from the ten-
dons. Because of the extreme thinness of the der-
mis and the fascial layer at the time of a request for
hand rejuvenation, it appears as the optimal tech-
nique for correcting both skin textural changes
and subdermal volume depletion.
Nevertheless even if the technique refer to
a solid anatomical basis, it must be confirmed by
studies of clinical outcomes on patients using sys-
tematic high-definition ultrasounds controls, easier
to manage, and probably more reliable than MRI.
REGIONAL APPROACHES
Amir Moradi, MD; Vista, Calif.
Radiesse is made of CaHA particles suspended
in a gel. Approved for facial injections since 2006,
physicians have been using Radiesse off-label to
correct volume loss in the hands. In February 2015,
an FDA Advisory Panel voted favorably to expand
the indication to include hand augmentation.
Radiesse is a safe and effective product when
injected in the subcutaneous layer of the dorsum
of the hand.
The technique demonstrated in this video
slightly differs from the protocol used in the FDA
Clinical Radiesse Hand Studies and illustrates the
author’s technique in his practice.
Thorough knowledge of the anatomy and
function of the hand is essential with this proce-
dure. One needs to be aware of the neurovascular
location, but also different layers and compart-
ments that exist within the hand (Fig. 8).
Evaluation of the hand includes the visibil-
ity of the veins, tendons, and loss of fatty tissue.
Although the process of aging includes changes
in all structures of the hand, including muscles,
tendons, and bone, the injection mainly corrects
the loss of tissue and fat in the subcutaneous layer
(Fig. 9).
 Volume 136, Number 5S • Hand: Clinical Anatomy and Injectable Fillers
Fig. 8. Hand cross-section: area of procedure. Illustration depict-
ing a cross-section of the hand.
The patient is informed about the common
risks and common adverse events associated with
this procedure.
Prior to the injection, 0.26 cc of 2% lidocaine
HCI will be added to 1.5 cc of Radiesse with 10
mixing strokes using the Radiesse accessory kit.
The patient is instructed to wash both hands
with soapy water, and just prior to the injection,
both hands are prepped with antiseptic solution
such as chlorhexidine. Each hand needs to be
evaluated prior to injection to plan the sites of
volumization that would give the best aesthetic out-
come. The area that can safely be treated is defined
proximally by the wrist-hand junction, distally the
metacarpal-phalangeal joint, between the 1st and
5th metacarpals (Fig. 10). Using skin tenting, small
boluses of 0.2–0.5 cc should be injected in the dor-
sum of the hand between the subcutaneous and
Fig. 9. A 47-year-old white woman; Fitzpatrick type IV (before and after).
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
superficial fascia (Fig.  11). In the accompanying
video, the author at times uses even smaller vol-
umes to fine tune the effect, which is smaller than
the range of volumes used in the FDA clinical tri-
als. After each individual injection, the site should
be massaged thoroughly, and ice can be dispensed
as necessary. The author recommends focusing the
injections in areas that would give the best overall
improvement by softening the transitions around
the veins and the tendons of the hand. The use
of small volumes (0.1–0.2 cc) may improve the
aesthetic results through strategic injections and
decrease the chance of irregularities based on small
volumes. This is based on the author’s hypothesis
that large boluses may lead to graduated radial dis-
tribution with the larger molecules of CaHA near
the center of injection point and the smaller par-
ticles including the carrier gel distributed farther
radially when massaged. Although during the mas-
saging process we see the filler easily spread radi-
ally, this could be a false indication of correction
as much of that result could be the glycerin and
sodium carboxymethylcellulose. The aesthetic end-
point is to correct the volume deficit and minimize
the appearance of veins and tendons. Generally, a
1- to 2-point improvement on the Merz Hand Scale
is desired. Although the video demonstrates 3 cc
of Radiesse used per hand, smaller volumes can be
used as necessary (see Video, Supplemental Digital
Content 1, which demonstrates Dr. Moradi’s per-
sonal technique using Radiesse for hand volumiza-
tion, available in the “Related Videos” section of
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 Plastic and Reconstructive Surgery • November Supplement 2015
Fig. 10. Illustration of hand.
the full-text article on PRSJournal.com or, for Ovid
users, at http://links.lww.com/PRS/B436).
In our experience, there is a significant
improvement in the appearance of the hands.
Fig. 11. Illustration depicting the tenting of hand for injecting.
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Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Video 1. Supplemental Digital Content 1. Dr. Amir Moradi’s per-
sonal technique using Radiesse for hand volumization, available
in the “Related Videos” section of the full-text article on PRSJour-
nal.com or, for Ovid users, available at http://links.lww.com/
PRS/B436.
The accompanying photographs demonstrate
the results at different time frames post injection
in different subjects, and some of the subjects
retained visible results that lasted beyond 1 year
(Figs. 12 through 16).
In our experience, the most common adverse
events include edema, erythema, tenderness,
and bruising. The patients need to be informed
about the possibility of delayed onset swelling
and reassured that it will also resolve without
intervention.
Mariano Busso, MD; Coconut Grove, Fla.
There has been an increased interest in hand
augmentation over the past years.19–28 After the
face and neck, hands are the most visible area
of skin, with a surface area similar to that of the
face. In fact, a person’s age can be estimated by
looking at the hands alone.29 Potential patients
become interested in hand rejuvenation when
there is a discrepancy between the appearance
of facial age and hand age. In general, volume
replacement of the hands occurs in an older
population.30
Youthful hands have fullness and a lack of
visible veins and wrinkles. Volume disguises
underlying structures (eg, veins, extensor ten-
dons, and bones) and makes the skin tighter.
Veins in older hands often appear or are, in fact,
dilated because the emptying of dorsal veins dur-
ing finger flexion decreases with aging. Like in
the face, chronological hand aging is a 3D pro-
cess, but in contrast with the face, gravity does
not play an important role in hand aging. Hand
wrinkles are a tissue reservoir of motion and not
the consequence of gesturing. Other factors that
influence volumetric changes of the hands are
 Volume 136, Number 5S • Hand: Clinical Anatomy and Injectable Fillers

Fig. 12. A 67-year-old African-American woman; Fitzpatrick type VI (before and after).

Fig. 13. A 51-year-old white woman; Fitzpatrick type IV (before and after).

rheumatologic diseases, hand injuries, weight
changes, and hand dominance.
Although the benefits of fat transfer for hand
revolumization have been documented,31 pre-
packaged, ready-to-use fillers provide a cost-effec-
tive alternative, particularly for those patients
who do not tolerate significant down time. By
contrast, fat grafting requires about 10  mL to
produce a slight improvement, whereas 20 mL is
necessary for significant improvement, and the
latter can be associated with edema that lasts 4
months.31 This article describes a technique to
use dermal fillers for hand voluminization.
Quantification of Volume Loss
A visual grading scale was developed by Busso
to measure volume loss on the dorsum of the
hands. This validated scale is based on the extent
to which the 3 central tendons are visible, which is
proportional to the degree of dorsal hand volume
loss. This is a 5-point scale, where 0 denotes no
tendon seen and 4 indicates that all 3 central ten-
dons are seen in their full length (Table 1).

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 Plastic and Reconstructive Surgery • November Supplement 2015

Fig. 14. A 57-year-old white woman; Fitzpatrick type III (before and after).

Fig. 15. A 50-year-old white woman; Fitzpatrick type II (before and after).

Anatomical Basis of Technique 3 fascial layers (dorsal superficial, intermediate,

Bidic et al32 reexamined fat compartmental-
ization as well as intracompartment and traversing
structures of the dorsum of the hand. Using his-
tologic analysis, duplex ultrasound imaging, and
lead oxide evaluation of adhesions, they found
that there are 3 fatty layers (dorsal superficial,
intermediate, and deep laminae) separated by
and deep fasciae) (Fig. 17).
The dorsal superficial lamina is found between
the dermis and dorsal superficial fascia; this is the
target plane for filler injections. Perpendicular to
this lamina, there are 8–12 vessel-containing septa
that insert into the dermis. It seems that these ves-
sels traverse through septa from volar deep arch

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 Volume 136, Number 5S • Hand: Clinical Anatomy and Injectable Fillers

The dorsal intermediate lamina is situated

Fig. 16. Illustrates the needle in the subcutaneous plain where
CaHA is injected.
Table 1.  Busso Hand Volume Severity Scale*
Score Description
0 None of the 3 central tendons is exposed
1 1 or 2 of the 3 central tendons are partially exposed
2 All of the 3 central tendons are partially exposed
3 1 or 2 of the 3 central tendons are fully exposed
4 All 3 central tendons are fully exposed
*All ratings are made with hand at rest.
to dorsal to supply the subdermal plexus. Using
blunt cannulae or bolus injections followed by
massage decreases the chance of dissecting these
septa and of bruising. These septa can also influ-
ence the direction of filler spreading.
between the dorsal superficial and intermediate
fascial layers. This compartment contains visible
veins.
The dorsal deep lamina contains the extensor
tendons. The fascial floor of this lamina, the dor-
sal deep fascia, also covers the dorsal interosseous
muscles and metacarpal bones.
Injection Technique
Video, Supplemental Digital Content 2, dem-
onstrates Dr. Busso’s personal technique using
dermal filler for hand volumization. This video
is available in the “Related Videos” section of the
full-text article on PRSJournal.com or, for Ovid
users, at http://links.lww.com/PRS/B437.
Filler Selection
Although CaHA (Radiesse; Merz North Amer-
ica, Raleigh, N.C.) has proven to be an effective
volumizing stimulatory filler, limiting factors have
included swelling and lack of reversibility.33 Hyal-
uronic acid (HA) derivatives, especially small-gel-
particle (SGP)-HA (eg, Restylane; Galderma S.A.,
Lausanne, Switzerland), provide an effective and
safe alternative.34,35 A range of 1–4  mL of CaHA
or HA per hand is required to decrease tendon
visibility in the area bound proximally by the wrist

Fig. 17. Anatomy of the hand. Adapted from Bidic et al. Reproduced with permission from Bidic
SM, Hatef AD, Rohrich RJ. Dorsal hand anatomy relevant to volumetric rejuvenation. Plast Reconstr
Surg. 2010;126:163–168. Figure 7 from this article. Illustration demonstrating the different fascial
layers and fatty laminae, with injection cannula placed within the dorsal superficial lamina.

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 Plastic and Reconstructive Surgery • November Supplement 2015
Video 2. Supplemental Digital Content 2. Dr. Mariano Busso’s
personal technique using dermal filler for hand volumization,
available in the “Related Videos” section of the full-text article on
PRSJournal.com or, for Ovid users, available at http://links.lww.
com/PRS/B437.
crease, distally by the metacarpophalangeal joints,
and laterally by the second and fifth metacarpal.
Patient Positioning
Place the patient in the supine position
because there is more control of the venous return
from the hand. The hand to be injected should be
below the level of the heart to increase vein vis-
ibility. Although the dorsal vein vasculature is the
prominent marker, identify and mark entry points
and plan needle depths. Next, elevate the hand
above the level of the heart to collapse veins and
decrease chances for bruising.
Accentuating Target Space through Skin
Tenting
The combined thickness of the dorsum, epi-
dermis, dermis, and subcutaneous is 1–2  mm in
most patients. Instead of aiming at the dermal/
subdermal space, it is easier to inject into the dor-
sal superficial lamina. This plane allows better filler
distribution and decreases papule formation. Skin
tenting magnifies this distensible injection space,
which is the areolar fatty plane between the der-
mis and the superficial dorsal fascia. Skin tenting
also provides more separation between the sharp
tip of the needle and the veins and tendons that
are located at the base of the tent. Avoid intracom-
partmental injections, below the deep dorsal fas-
cia, as doing so can cause vascular or nerve injury.
Filler Injection and Massage
Two main techniques have been used to distrib-
ute fillers in the dorsum of the hand: tunneling and
bolus injection. In tunneling, the filler is distributed
in a weaving pattern, using a blunt cannula. Tunnel-
ing is more traumatic to the injection area than bolus
injection, but tunneling increases surface exposure
to the surrounding tissue. Bolus injections are less
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Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
traumatic and appropriate for prepackaged fillers.
If a single bolus is desired, deliver the full content
of the syringe perpendicular to the 3 dorsal tendons
using a blunt cannula. Otherwise, split the content
of 1 syringe into 4 boluses not too far apart so that
a continuous implant can still be achieved, making
the filler easier to massage. Figure  18 depicts the
techniques described in this section for hand place-
ment, filler injection, and massage.
Although there is abundant literature sup-
porting the use of blunt microcannulas for hand
augmentation, the author favors this bolus/mas-
sage technique using sharp needles. Microcan-
nulas still require entry points obtained with a
higher gauge needle; therefore, the number of
entry points can be the same as those requires
with regular sharp needles, and advancing a blunt
cannula can still dissect septa found in the dorsal
superficial lamina.36,37
If fingers require augmentation, inject only
in between metacarpophalangeal and proximal
interphalangeal joints. Injecting over joints will
result in making them more prominent. After
injection, perform a blending massage with the
hand in hyperflexion until the filler is evenly
distributed.
Postprocedure Instructions
A few strategies seem to decrease swelling:
advise patients to keep hands above the level of
the heart and make a fist 5–10 times per hour and
maintain a low-salt diet for 2 days. If CaHA mixed
with lidocaine is used, further measures such as a
compression garment or tape can be added.
Aesthetic Endpoint
When a single bolus of CaHA (1.60 mL; range,
0.40–3.30 mL) was injected in the dorsum of the
hand, 76% of patients were satisfied with their
results at 6 months. Similar results were observed
with a SGP-HA derivative with 50% of patients
being satisfied at 12 months. Figure  19 shows
before and after results with injection of SGP-HA
derivative filler.
Adverse Events
Adverse reactions are transient and limited to
bruising, swelling, pain, redness, and itching. Swell-
ing has been reported to be more prominent when
using CaHA mixed with lidocaine.33 Swelling can
start immediately postinjection or within 30 days
post injection and can last up to 30 days. Limiting
the volume of filler injected per session to 1 mL per
hand of SGP-HA or 1.5 mL of CaHA for both hands
significantly decreases the incidence of postproce-
dure swelling. Management of swelling includes
 Volume 136, Number 5S • Hand: Clinical Anatomy and Injectable Fillers

Fig. 18. Step-by-step illustration of the technique. Top left, mark entry points placing hand below level of heart; top right, elevate
hand above level of the heart; bottom left, tent skin of the dorsum of the hand; bottom center, inject bolus; and bottom right,
massage.

hand elevation above the level of the heart, com-
pression, and diuretics (eg, triamterene 37.5 mg/
hydrochlorothiazide 25 mg [Dyazide; GlaxoSmith-
Kline, Research Triangle Park, N.C.).
Allison B. Sutton, MD, and Vivian W. Bucay, MD;
San Antonio, Tex.
An aged appearance to the hands is a result of
both intrinsic aging and extrinsic forces, especially
ultraviolet light exposure. Age-related changes in
the dorsal hands are characterized by lentigines,
actinic keratosis, rhytids, skin laxity, atrophy of
the dermis and subcutaneous fat, prominence of
bones and tendons, large intermetacarpal spaces,
and bulging veins.
After the face, the hands are the most con-
spicuous part of the human body.38 With facial
rejuvenation procedures so commonplace, peo-
ple have begun to notice the discrepancy between
the hands and the face thus driving requests for

Fig. 19. Before and after injecting 2 mL of SGP-HA derivative in the dorsum of the right hand.

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 Plastic and Reconstructive Surgery • November Supplement 2015

treatment of the hands to maintain harmony with

a youthful facial appearance.
There are several approaches to address
changes of the aging hands. Options to improve
textural and pigmentary changes include chemi-
cal peels, photodynamic therapy, intense pulsed
light, pigment-specific lasers, and fractional lasers.
Volume loss in the hands is manifested as an
increased visibility of underlying bones, tendons,
and veins. Volume restoration can be accomplished
with several injectable agents, including HA, CaHA,
poly-l-lactic acid, and autologous fat. The ideal
filler for the hands should be moldable, long-last-
ing, and durable to withstand repeated movements
and pressure associated with daily activities, all the
while maintaining normal function of the hands.
Volume Restoration
Whereas all of the previously mentioned fill-
ers are options for volume restoration of the dor-
sal hands, we have found that the use of injectable
HA in this area to be limited by longevity and the
Tyndall effect, which creates a bluish and unnatu-
ral appearance. Although poly-l-lactic acid has
a longer duration of action, there exists the not
insignificant risk of nodule formation with its use
in the dorsal hands. Autologous fat transfer is
complicated by the need to harvest the fat from
another site and the variability in the viability of
the transplanted fat.38
In our practices, we prefer to use CaHA
(Radiesse; Merz North America) as our agent of
choice in dorsal hand rejuvenation. It is long last-
ing, is easy to inject and mold, and does not pro-
duce a Tyndall effect. In addition, it has had FDA
approval in Canada for hand rejuvenation since
2010 and has gained US FDA approval for this
indication earlier this year.39 CaHA is in reality a
combination filler, possessing both biostimulatory
properties and immediate space filling effects. In
addition, because of its white color, CaHA acts
as a camouflage, helping to hide structures such
as prominent veins that contribute to the aged
appearance of the hands.
Anatomy
The relevant anatomy in the dorsal hands has
been beautifully elucidated by Rohrich and co-
workers.40 They have elegantly shown that 3 fatty
layers exist in the dorsal hand. Beneath the dermis
lies the dorsal superficial lamina, a layer devoid
of nerves and vessels. The dorsal superficial fas-
cia separates this layer from the dorsal interme-
diate lamina, where the dorsal veins and sensory
nerves exist. Beneath this layer is the dorsal deep
lamina, where the extensor tendons are found.
Video 3. Supplemental Digital Content 3. Dr. Vivian Bucay and
Dr. Allison Sutton’s personal technique to hand volumization,
available in the “Related Videos” section of the full-text article on
PRSJournal.com or, for Ovid users, available at http://links.lww.
com/PRS/B438.
These layers are separated by the dorsal interme-
diate fascia. The dorsal deep fascia is the inferior-
most structure and is contiguous with periosteum
(Fig. 17).
How We Do It
We use a maximum of one 1.5-mL syringe of
CaHA per hand. To each syringe, 0.5  mL of 1%
lidocaine without epinephrine and 1.0 mL of bac-
teriostatic 0.9% sodium chloride are added. This
is mixed at least 10 times via a female-to-female
Luerlock connector (Baxter, Englewood, Colo.)
until the product is homogeneous in consistency,
yielding a total of 3  mL of filler per hand (see
Video, Supplemental Digital Content 3, which
demonstrates Dr. Bucay and Dr. Sutton’s personal
technique to hand volumization, available in the
“Related Videos” section of the full-text article on
PRSJournal.com or, for Ovid users, at http://links.
lww.com/PRS/B438).
The dorsal hand is photographed in repose
(Fig. 20). If requested by the patient, the area is
covered in topical anesthetic for 20–30 minutes.
After this time, the topical anesthetic is removed
and the area cleansed with chlorhexidine and
alcohol. The area to be treated is bound by the
second metacarpal medially, the fifth metacarpal
laterally, the metacarpophalangeal joints distally,
and the wrist proximally.41 We prefer the use of
blunt-tipped cannulas on the hand. We create
the first insertion point in the webspace between
the second and third metacarpal. A small wheal
of 1% lidocaine is placed in an intradermal loca-
tion, and a 25-G needle is used to create a portal
of entry within the lidocaine bleb. A 25-G 50-mm
blunt-tipped DermaSculpt cannula (Cosmo-
France, Miami, Fla.) is then inserted through this
port while the skin is tented upward. This allows

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 Volume 136, Number 5S • Hand: Clinical Anatomy and Injectable Fillers

Fig. 20. Right dorsal hand of a 52-year-old woman prior to hand

rejuvenation.

Fig. 22. Dorsal hands of a 52-year-old woman. The right hand

is shown immediately after injection of CaHA. The left hand is
shown before injection. Top, At rest. Bottom, In fist formation.
Fig. 21. The skin is tented upward to allow the cannula to easily
enter the dorsal superficial lamina; a safe plane to inject filler.

easy entry of the cannula into the dorsal superfi-

cial lamina, a safe plane to inject fillers (Fig. 21).
A depot of CaHA is deposited in this location in
a retrograde fashion. It is then massaged for even
distribution. A second portal of entry is made in
a similar fashion at the fourth webspace, and the
procedure is repeated. If there are additional
sites of volume loss, additional entry points may
be used (Figs. 22 through 24).
After the product has been placed, the area is
Fig. 23. Right dorsal hand of a 52-year-old woman immediately
vigorously massaged to disperse the product uni-
post injection with CaHA.
formly over the entire dorsal hand and to ensure
no nodules are present. We have found that the
use of ultrasound gel is very helpful during the during the first 24 hours and are discouraged
massage. The area is cleansed once again with from doing strenuous tasks in the first week. We
chlorhexidine. Ice packs are applied to minimize also recommend that the hands be elevated using
edema. A simple trick to keeping the treated hand 1 or 2 pillows during sleep. We find correction in
iced is to place the hand in a glove and to slide in this area to last between 12 and 24 months.38
either frozen gauze or an iced gel pack between The most common adverse events with this
the glove and the hand (Fig.  24). Patients are procedure are erythema, pruritus, ecchymoses,
asked to elevate their hands as much as possible and edema. Postprocedure edema can be dramatic

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 Plastic and Reconstructive Surgery • November Supplement 2015
Fig. 24. Post procedure, a gel ice pack is placed within a glove
over the treated hand.
and last up to 2 weeks or longer.38,39,41 The use of
judicious ice, hand elevation, massage, carpal tun-
nel gloves, and avoiding strenuous tasks can all be
helpful adjuncts in decreasing swelling.
CONCLUSIONS
Addressing aging changes in the dorsal hands
is important in maintaining an overall youth-
ful appearance. We have had good success with
the use of CaHA and blunt-tipped cannulas for
addressing volume loss of the hands and have
found it to be a safe and effective procedure that
results in high patient satisfaction.
Marc Lefebvre-Vilardebo, MD
Private Office82 route du Moustoir
56340 Carnac, France
m.lefebvrevilardebo@orange.fr
or
Plastic and Reconstructive Surgery
8150 Brookriver Drive, Suite s-415
Dallas, TX 75247
PRS@plasticsurgery.org
ACKNOWLEDGMENTS
“Scrape Skin Threading Technique, the Optimal
Technique for Hand Dorsal Filling” section was written
by Marc Lefebvre-Vilardebo, MD, and Patrick Trevidic,
MD. “Regional Approaches: Hand” section was written
by Amir Moradi, MD, Mariano Busso, MD, Allison B.
Sutton, MD, FRCPC, FAAD, and Vivian W. Bucay,
MD, FAAD.
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