Hand Rejuvenation

What is hand rejuvenation?

Hand rejuvenation is the use of filler to restore volume lost under the skin on the backs of the hands. Studies have looked at fillers containing hyaluronic acid (HA), calcium hydroxylapatite (CaHA) and poly-L-lactic acid (PLLA) for this purpose. The aim is to increase the soft tissue that covers the tendons and veins.

With age, the skin on the backs of the hands loses elasticity and becomes more translucent; veins, joints and tendons look more prominent, and bony prominences become noticeable. Two main methods have been described for these changes: filler injections and transfer of the person’s own fat. This page covers the first of these, filler.

According to a recent review that brings together studies on the back of the hand, these three classes of substance are used for volume loss, contour irregularity and tissue changes. HA replaces lost volume immediately, while CaHA and PLLA stand out for their effects on tissue quality.

To find out why the hand changes in this way with age – that is, how volume, skin quality and colour each change – see the hand rejuvenation article in our Aesthetics Guide.

RELATEDHand rejuvenation: what changes on the back of the hand?

SOURCEPMID 37007409PMID 41365422

What does ‘hand rejuvenation’ mean, and what does it cover?

‘Hand rejuvenation’ is not the name of a single procedure; it is an umbrella term for several different methods aimed at the appearance of the hands. If you search for the term, you will see filler, laser, peels and fat transfer listed together. However, these methods address different problems in the hand and are not substitutes for one another.

A systematic review of publications on rejuvenation of the back of the hand grouped the methods into four categories: fat transfer, injected fillers, laser and light-based treatments, and other methods. Some of these target volume loss and others target fine wrinkles on the skin surface. The great majority of patients in these studies were women.

Another review, which looked at combining different methods, keeps the same distinction: chemical peels, lasers and light sources, sclerotherapy of the veins (closing a vein by injecting a medicine into it), fat transfer and volumising fillers are covered under separate headings. On this page, ‘hand rejuvenation’ means only adding volume with filler; pigmentation, veins and the skin surface are covered separately in the limits section.

SOURCEPMID 33420511PMID 36728067

Prominent tendons and veins

Prominent tendons and veins on the backs of the hands are one of the findings that filler directly targets. This appearance is caused by thinning of the subcutaneous fat (the fat layer under the skin) that covers these structures. So the target of filler is not the structures themselves but the layer that covers them.

An ultrasound study of 105 people aged 20 and over found that the thickness of the three fat layers on the back of the hand decreased with age; the most marked and progressive loss was reported in the middle layer and after the age of 30. Of the factors examined, age was the only one found to determine layer thickness. A cadaver study also found that the large veins run in this middle layer.

Studies of the changes after filler point in the same direction. In 20 patients treated with hyaluronic acid (HA), ultrasound measurements were reported to show increased soft-tissue thickness, with veins and tendons becoming less prominent. In a study comparing HA and calcium hydroxylapatite (CaHA) in the two hands of the same person, the visibility of veins and tendons decreased in both hands.

However, these studies were carried out in small groups of patients; they do not allow any conclusion about how long the effect will last or whether everyone will get the same result. A visible vein that is enlarged is a separate matter: filler does not make the vein smaller; it only covers it.

SOURCEPMID 35170732PMID 20220561PMID 36877607PMID 30192908

Thin, wrinkled skin on the backs of the hands

Fine wrinkles and thinning skin on the backs of the hands are a separate problem from volume loss. Filler studies in this area measure skin quality rather than volume. The results are positive; however, what is measured is change in the skin surface, not volume, and the evidence is more limited than for volume.

In a randomised, multicentre study of 100 people, the two hands were compared: one hand received hyaluronic acid gel three times, and the person assessing the results did not know which hand had been treated. On a scale grading the appearance of the hands, a difference was found in favour of the treated hands, and improvement was also reported in objective measures including skin elasticity, roughness and hydration. At 15 months, 87% of treated hands (according to the assessor) and 96% (according to the participants) were reported as still improved.

In a study of 30 women in which one hand received hyaluronic acid gel and the other received normal saline (salt water), improved hydration and elasticity and reduced roughness were also reported. In a study of 15 women in which diluted calcium hydroxylapatite was injected using two different techniques, improved skin elasticity and an increase in total collagen density were measured.

Only limited conclusions can be drawn from this: all of these studies were carried out in small or medium-sized groups and with specific products. According to one review, calcium hydroxylapatite and poly-L-lactic acid stand out for tissue quality; which of them might be considered for your hands is decided at a consultation. Injections that do not add volume and target only skin quality are a separate topic; their use on the backs of the hands is explained on the Skin Boosters page.

RELATEDMesotherapy

SOURCEPMID 31769596PMID 25738851PMID 32976172PMID 41365422

Which types of filler are used, and how do they work?

Fillers used on the backs of the hands work in two different ways. Hyaluronic acid (HA) creates volume in the layer where it is placed; calcium hydroxylapatite (CaHA) and poly-L-lactic acid (PLLA) add volume and also stimulate the tissue’s own collagen production. Which one is discussed depends on what your doctor finds in your hands, your expectations, and whether the filler can be reversed if needed.

HA fillers differ from one another in their HA content, their degree of cross-linking (how much the molecules are linked to one another) and their flow properties. According to a review of how fillers break down, these fillers are broken down over time by the body’s own hyaluronidase enzyme and by free radicals; they can also be dissolved with hyaluronidase given as a treatment. One of the main factors affecting how long a filler stays in the tissue is its degree of cross-linking.

CaHA is a synthetic substance made of minerals found naturally in bone and teeth. According to a review of the evidence, this filler first replaces volume immediately and then stimulates collagen production (biostimulation); it has also been found suitable for adding volume in areas other than the face, such as the back of the hand. Unlike HA, which can be completely reversed with hyaluronidase, it is considered an ‘adjustable’ filler.

PLLA is also one of the fillers that stimulate the tissue. In the early years of its use, a marked rate of bumps and nodules (small firm lumps that can be felt under the skin) was reported in patients with HIV-associated facial fat loss; with later experience, the preparation and injection technique were redefined to reduce this risk. Published experience of its use on the back of the hand is limited. CaHA and PLLA are broken down by hydrolysis (breakdown by water) and by enzymes; they are classed as semi-permanent fillers.

RELATEDCollagen Stimulator Treatments

SOURCEPMID 41365422PMID 24301235PMID 22926148PMID 39649762

What do the studies show, and what do they not show?

There are randomised controlled trials of filler for the backs of the hands – trials in which participants are randomly assigned to treatment and comparison groups. These trials have shown that the appearance of treated hands improved more than that of untreated hands. What they do not show is how long the result will last for each individual; there is no definite information on this that we can give you.

In a multicentre study of calcium hydroxylapatite (CaHA), 114 people were divided in a 3:1 ratio into a treatment group and an untreated control group. At 3 months, 75% of participants had improved by at least one grade on a hand grading scale, according to assessors who did not know who was in which group; this response was generally maintained for up to 12 months. In measures of hand function, no clinically meaningful difference was found between the treated group and the control group.

In a multicentre study of hyaluronic acid (HA) in 90 people, one hand was treated and the other was left untreated for comparison. At 12 weeks, the responder rate was 85.9% for the treated hand and 21.2% for the untreated hand. In an 18-month uncontrolled study (a study with no comparison group) in which 75 people had HA injected into both hands, 60% of hands received an additional treatment on day 30; more than 65% of participants were still responding at 18 months.

However, there are also studies showing that the effect decreases over time. In a CaHA study of 10 women, 80% of hands were rated as improved at 9 months, but at 12 months this fell to 40% for the right hand and 30% for the left hand. A series of 38 patients treated with HA also reported that results did not stay at the same level after 6 months and that longer follow-up is needed to understand how long they last.

A systematic review of controlled CaHA studies reported improvement on the backs of the hands but noted that there was a high level of variation between studies and that new controlled studies are needed. These figures come from studies carried out with specific products in other countries; they are not data from this clinic and should not be read as a promise of how long results will last.

SOURCEPMID 28562435PMID 31568288PMID 41693212PMID 21197523PMID 23052378PMID 38541911

The layers of the back of the hand and the plane where filler is placed

On the back of the hand, there is a thin layer of soft tissue between the skin and the tendons, and the safety of filler depends largely on which layer it is placed in. However, researchers do not fully agree on how this tissue should be described or exactly where filler should be placed.

An anatomical study of 10 cadaver hands described three fat layers under the skin, separated from one another by thin sheets of connective tissue (fascia). No structures were found passing through the most superficial layer; the large veins and sensory nerves were found in the middle layer, and the extensor tendons in the deep layer. Eight to ten perforating vessels run within partitions that cross the layers at right angles. A more recent study found an additional membrane dividing the middle layer in two, and showed that the network of veins lies in the more superficial compartment and the sensory nerves in the deeper one.

There is also a different view. In a study of 19 cadaver hands and 28 healthy hands, the layer between the skin and the tendons measured between 0.3 and 2.2 mm. According to this study, the layer behaves like a three-dimensional sponge because of its many fibrous partitions; veins can be found at any level, and there is no predefined empty space. The same study stated that the appropriate place for filler is directly against the underside of the skin. However, another cadaver and ultrasound study on calcium hydroxylapatite identified the middle layer, where the veins are, as the appropriate layer.

In a retrospective series reviewing 440 hand treatments with calcium hydroxylapatite over 11 years of experience, using a needle was significantly associated with side effects compared with using a cannula (a fine, flexible tube with a blunt tip). The same series described placing the filler in a fan pattern in the superficial layer, less than 1 mm below the skin, as the safer technique. A recent review also describes the superficial layer as the plane with the fewest blood vessels and nerves, and therefore the safest.

This information is not a technique guide; it explains why this area needs care. At the clinic, the doctor chooses a needle or cannula for each person individually, according to the treatment area and the anatomy; no fixed template is used. Which plane is chosen depends on the doctor’s own assessment.

SOURCEPMID 20220561PMID 33303411PMID 26441105PMID 33214113PMID 29697606PMID 41365422

Regulatory status: why the back of the hand is a separate topic

Among the areas of the body treated with filler, the back of the hand has a distinct regulatory position: in the US, there are filler products that have been separately approved for this area. These approvals are specific to a particular product and country; they are not a general assurance for a whole class of substance.

The US Food and Drug Administration (FDA) lists adding volume to the back of the hand among the approved uses of fillers, alongside the lips, cheeks and chin, and states that different products are reviewed and approved separately for specific areas of the face and hands. The FDA also recommends that you discuss the approved product information (instructions for use) for the product to be used on you with the doctor carrying out the treatment.

These approvals are recent. According to a randomised trial published in 2018, calcium hydroxylapatite was at that time the only soft-tissue filler approved in the US for the back of the hand. According to a 2019 publication, the number of products approved for the hand was limited, and the first hyaluronic acid product had received this approval that year.

When the clinic assesses a product, FDA approval is not used as a criterion on its own; the decision is based on the product’s CE marking, its registration and conformity status in Türkiye and the manufacturer’s intended purpose. The FDA is the US regulator; this information is given not as an indicator of quality or safety but to explain why the back of the hand is treated as a separate topic. Before treatment, you can ask how the product to be used on you is registered for use on the back of the hand.

RELATEDBody Fillers

SOURCEFDAPMID 29406482PMID 30859035

Limits of this treatment

Filler for the backs of the hands addresses volume loss only. On its own, it does not treat pigmentation, enlarged veins themselves or sun damage to the skin surface; there are different methods for these. Because the name ‘hand rejuvenation’ often suggests all three, it is important to understand this distinction.

• Sun spots and uneven skin tone: In research, laser and light-based treatments are considered a separate group from filler; pigmentation and skin-tone problems are outside the scope of this treatment.

• Enlarged veins: Filler covers the vein; it does not make the vein smaller. For enlarged veins on the back of the hand, and for thinning skin that does not respond fully to filler alone, an approach that adds sclerotherapy to filler has been described.

• Skin surface: In research, chemical peels, and lasers and light sources, are studied under separate headings from filler.

• Longevity: The body breaks down hyaluronic acid and calcium hydroxylapatite over time. In a calcium hydroxylapatite study of 10 women, the proportion of hands rated as improved was clearly lower at 12 months than at 9 months.

• Reversal: Calcium hydroxylapatite and poly-L-lactic acid are semi-permanent fillers; in this respect, they differ from hyaluronic acid, which can be dissolved with hyaluronidase. You can find details in the reversibility section.

The aim of this information is not to put you off but to help you set realistic expectations. Which problem is most prominent in your hands is identified at a consultation. When filler is expected to do something it cannot do, the result often does not match that expectation.

SOURCEPMID 33420511PMID 27343224PMID 36728067PMID 21197523PMID 39649762

Known risks

The most commonly reported effects of filler on the backs of the hands are swelling, bruising, pain and redness; most of these are mild and temporary. What is specific to the back of the hand is that swelling can sometimes last a long time and, because you use your hands all day, this can affect everyday tasks.

In a retrospective series of 440 hands treated with calcium hydroxylapatite (CaHA), side effects developed in 7.3% of hands within the first 15 days; swelling was the most common, followed by pain, redness and discolouration. In a 90-person study of hyaluronic acid (HA), treatment-related side effects were reported in seven participants; most were mild, and none was serious. In a series of 38 patients, nine patients had mild bruising, which cleared within a week.

Swelling is not always short-lived. A randomised trial of CaHA reported that swelling and oedema (fluid build-up in the tissue) were common after treatment of the back of the hand and could at times reach a level that limits what the person can do. In an 18-month HA study of 75 people, 29.3% of participants had treatment-related side effects; although most were mild or moderate, these effects lasted an average of 45.1 days. In a study comparing the two hands of the same person, bruising and swelling were significantly more common in the hand treated with CaHA.

Among the common risks of fillers, the US Food and Drug Administration (FDA) lists one that occurs only with treatment of the back of the hand: difficulty performing everyday activities. According to the FDA, if you have a joint, tendon or blood vessel condition affecting your hand, you need to tell your doctor before treatment of the back of the hand. Less common risks include lumps that can be felt under the skin (nodules or granulomas); according to a review of CaHA, nodules may be more frequent in areas that move a lot, such as the lips, or in areas where the anatomy leaves little room for error, such as around the eyes.

Before the procedure, you will be asked about blood thinners, antiplatelet medicines (medicines that stop platelets from clumping together) and supplements that can affect bleeding. Do not stop any prescribed medicine on your own. If needed, the procedure is planned or postponed after consulting the relevant doctor. The figures in this section come from studies carried out at other institutions; they are not data from this clinic.

SOURCEPMID 29697606PMID 31568288PMID 23052378PMID 29406482PMID 41693212PMID 30192908PMID 24301235PMID 36728067FDA

Reversibility: the difference between hyaluronic acid and calcium hydroxylapatite

Hyaluronic acid (HA) filler can be dissolved with the enzyme hyaluronidase; there is no equivalent option for calcium hydroxylapatite (CaHA). So the choice of filler for the back of the hand is a question not only of its effect but also of whether it can be reversed if needed, and it is one of the things you should ask about before treatment.

According to a review of how fillers break down, hyaluronidase breaks down HA filler and can be used to treat medical or cosmetic problems related to this filler. CaHA and poly-L-lactic acid (PLLA) are semi-permanent fillers. Sodium thiosulfate, which can stimulate the breakdown of CaHA, acts slowly and is of no use in an emergency. Permanent fillers, once placed, stay for life.

In an experimental study on facial arteries from cadavers, CaHA injected into the vessels could not be dissolved either with sodium thiosulfate or with a mixture of sodium thiosulfate and hyaluronidase. Although the filler was seen to break up on direct contact in the laboratory, the researchers concluded that there is no suitable antidote if this filler enters a blood vessel. A review of permanent complications also stated that HA fillers continue to be preferred because they can be reversed, whereas permanent fillers increase the risk of long-term complications.

Hyaluronidase is kept at the clinic. If you have previously had filler on the backs of your hands elsewhere, you will first be asked about the type of filler, when it was injected and which area was treated. Dissolving treatment is not given straight away for filler of unknown type or filler that cannot be confirmed to be HA. If you have a record of the previous treatment, it helps to bring it to your consultation.

RELATEDFiller Dissolving

SOURCEPMID 24301235PMID 39649762PMID 33544840PMID 42298154