PEER-REVIEW | INJECTABLE TREATMENTS | Figure 4 Linear threading distal technique
(A) Scheme for the linear threading distal (LTD) technique; (B) creation of the insertion point at the fourth metacarpophalangeal (MCP) space with a sharp needle; (C) insertion of the 25 G blunt cannula at the fourth MCP space; (D) insertion of the 25 G blunt cannula and filling at the third MCP space; (E) insertion of the 25 G blunt cannula and filling at the second MCP space
Alternatively, the total filler amount can be injected
in a number of smaller boluses (0.2–0.5 ml) (Figure 2c), starting slightly medial to the second MC space followed by the next injection at the next MC space until the entire syringe is emptied6
. Sometimes it may be useful to save
0.1–0.2 ml for the ulnar compartment if needed, especially if this is a subsequent hand augmentation. This is done only for aesthetic purposes as this area may not be atrophic at the beginning (i.e. at the time of the first session), but may become atrophic over time. Special care should be taken not to inject any material into the so-called ‘snuff box’ — a triangular deepening on the radial aspect of the hand at the level of the carpal bones, specifically the scaphoid and trapezium bones forming the floor — owing to the higher risk of disrupting a vascular supply and causing necrosis. Some physicians use a mixture of dermal filler and anaesthetic agent9
. Others firstly create a single bulla with
a 2 ml bolus of 1% lidocaine or two to three bullae with approximately 0.5 ml each using a 30 G needle8,12
large volume of lidocaine is injected, a bulla (bleb) immediately rises from the hydrodissection of fluid. The filler is now injected directly into the bulla. It is important to position the tip of the needle well into the lidocaine bulla but above the tendons, arteries and veins12
. The bolus is then gently massaged with the fingers in
complete flexion (to form a fist) staying distal to the wrist crease, proximal to the MCP joints, and medial and lateral to the sides of the hand5,12
. Some authors also advise their
patients to sit on the dorsum of their hands for 10 minutes after the implantation of the bolus5,13
. The pressure and
warmth should flatten out the boluses considerably. This is a quick, easy-to-administer technique that
provides consistent results and positive patient feedback. Furthermore, limiting the procedure to one or two injections decreases the chance of subcutaneous nerve irritation8
. It is important to remember that the superficial dorsal
fascia adheres to the underside of the skin at some points. When tenting the skin, important underlying structures may be drawn up with the skin, thereby placing the injected material into the deeper layers that contain essential functional structures like vessels and tendons,
40 ❚ October 2013 |
prime-journal.com . As the
Figure 5 Single proximal insertion point (SPIP) technique; (A) marking of the insertion point; (B) creating entry point with a sharp needle; (C) and (D) insertion of the blunt cannula and filling of a number of metacarpal spaces from a single injection point in a fanning technique
It is
important to remember that the superficial dorsal fascia adheres to the underside of the skin at some points.
and increasing the risk of complications. This may even be more dangerous when using a sharp needle. The author does not recommend the tenting or bolus
technique, as the injection is, in most cases, performed too deep when using a needle (Figure 3). Also, the risk of a compression is much higher with a single bolus injection. Therefore, the author never recommends using more
than half of the 1.5 ml syringe of calcium hydroxylapatite (CaHA) per dorsum of the hand, even when using a cannula. If necessary, the author would perform a second injection session after 6 to 8 weeks. The author has never experienced any problems with this method, not even severe swelling.
Tunnelling or linear retrograde threading Depending on the patient’s pain sensitivity, it may be useful to inject a small amount of lidocaine intradermally at the puncture points. Some authors suggest administration of a filling material in a single injection into the dorsum of the hand, distal to
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