PEER-REVIEW | INJECTABLE TREATMENTS | Figure 1 Identifying atrophic areas of the hands
Thin, sagging skin and wrinkles as well as prominent
tortuous veins are characteristic of ageing hands. The
most atrophic areas are identified between the
extensor tendons, especially in the second and third inter-digital space
Metacarpophalangeal (MCP) joints
Second matacarpal
Figure 2 Small bolus injections technique
Fifth metacarpal
Anatomy Before beginning the injection an accurate knowledge of the dorsal hand anatomy is required. The first anatomical study published by Bidic et al10
revealed three distinct
fatty laminae separated by thin fascia (three fascial layer system). The large dorsal veins and sensory nerves were shown to be located within the intermediate and the extensor tendons within the deep lamina. No structures traversed the superficial fatty lamina except eight to ten perforating vessels perpendicularly crossing the three laminae. As injuring the vessels or placing the material between the tendons may cause very serious and disfiguring complications, such as compression or in the worst case, compartment syndrome, the dorsal superficial lamina was considered to be the only area safe for volumetric rejuvenation. Further investigations revealed a more complex
anatomy of the dorsum of the hand with a 3D-net shaped fascial framework with the dorsal superficial fascia being partly attached to the dermis. Therefore, to avoid running the risk of disrupting the dermal fascia attachments, injuring the vessels, or penetrating into the deeper layers, the optimal and safest layer to deposit the filling material is the underface of the dermis, and the blunt cannula scratching on the bottom of the dermis is the safest tool. It is very important to use a thicker (stiffer and not flexible) cannula (at least 25 G), as a thinner cannula may be too flexible and would almost act as a sharp needle, increasing the risk of injuring the vessels and penetrating into a deeper layer. The tip of the cannula should always be directed slightly to the top with the body of the cannula almost being visible through the skin.
(A) Tenting of the skin, (B) bolus technique, and (C) scheme for small bolus injections
Some authors suggest injecting in the Trendelenburg
position to reduce vein pressure as well as any possible bleeding5
. Some authors also recommend using a topical
anaesthetic cream for 45–60 minutes immediately prior to injection6,7
. Second, it is important to identify the area of
treatment, for example, by asking a patient to extend and flex their digits8
. The target area is usually bound
laterally by the fifth metacarpal (MC), medially by the second MC, proximally by the dorsal wrist crease, and distally by the metacarpophalangeal (MCP) joints9 (Figure 1). At the beginning it may be helpful to define and draw the areas of volume loss and locate the ideal site(s) of puncture(s). The ideal space for filling is the subdermal interfascial lamina — the layer between skin and tendons that is made of two fascias5
. However, this interfascial lamina is
virtual or partitioned, and fixed to the skin by some interfascia septae, so the only ‘safe’ space for injection is the underface of the dermis.
38 ❚ October 2013 |
prime-journal.com ‘Tenting’ is
achieved by taking the thumb and forefinger of the non-injecting hand and lifting the skin of the dorsal aspect of the hand being treated.
Figure 3 Inflammation and
swelling of the left hand after single bolus injection with a
sharp needle (right hand blunt cannula)
Injection techniques Tenting technique ‘Tenting’ is achieved by taking the thumb and forefinger of the non-injecting hand and lifting the skin of the dorsal aspect of the hand being treated. The dorsal aspect is lifted, thereby separating the skin from vascular and tendinous structures9
(Figure 2a). The filling material is then injected into the tented area
below the skin with a syringe parallel to the dorsum of the hand using a sharp needle. This should be injected as a single bolus (0.5–1.5 ml) (Figure 2b) in the areolar plane between the subcutaneous layer and superficial fascia. Care should be taken to avoid injecting into a vein or a tendon9
.
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