Attention to the appearance of hands has increased tremendously in recent years. The million-dollar manicure and nail industry are a testimony to this rising trend
Women talk with their eyes and hands, so not giving appropriate attention to the rejuvenation of hands belies the concept of anti-aging. Rejuvenated hands can complete the appearance of youth.
 From my point of view, incorporating hand treatments is a great addition for any aesthetic practitioner as it is satisfying for both the doctor and patient.
In addition, most aesthetic practitioners will not need to invest in any new lasers, equipment, or products to achieve satisfactory results. You can use what is already available in your clinic in the right chronology.
Grading Hand Age
How do you grade the aging of ‘hands? There are several ways to grade the aging process, but one of the most practical ways, which I follow, is the Hoy’s Grading Scale (HGS). This scale helps patients understand the stages of aging and the need to combine various methods of treatment. The HGS is the most practical method for a physician to plan his or her treatment protocol. I have interpreted these grades as follows:
Grade 1: Loss of moisture
Grade 2: Loss of collagen and moisture
Grade 3: Beginning stages of volume loss
Grade 4: Loss of volume and collagen leading to crepey skin, and pigmentation due to solar damage
Grade 5: Severe loss of volume, collagen, crepey skin and actinic damage
Often, we need to show these gradations to the patients to educate them. Also, hand treatments require a consult before starting the treatments to show the patients what they need prior to beginning.
Understanding the Impact of Key Characteristics
Now, before I get into the treatment approach, it is important to understand that anatomy wise, the hands are extremely forgiving unlike the face. The key changes can be classified into:
Epidermal changes:
a. Lentigines
b. Dullness of skin
c. Textural changes (fine lines)
d. Skin laxity (loss of collagen)
Deeper changes:
 a. Volume loss (fat atrophy)
 b. Appearance of wrinkles
c. Visible bone and tendons
Further, thickness of skin on the dorsum of the hand is just (0.2 – 0.9 mm) as compared to cheeks (2.56 mm). Vasculature wise, it is extremely safe too. Important landmarks are the radial artery, which curves around the lateral side of the wrist into the hand, and the ulnar artery which forms the palmar arteries. The venous network comprises deep and superficial veins that follow the arteries.
Though the hand is generally safe to treat, it is rich in vasculature. Bruising is commonly observed, so honing your skills will prevent downtime.
Treatment Options
A main point of this article is to demonstrate how you can use the products and devices you already have available in your practice to incorporate and deliver effective hand rejuvenation treatments for maximum patient satisfaction. But of course, as with other therapies, all treatments must be combined with at-home care to achieve a complete result.
Here are my in-office combination procedures. In addition, every patient is prescribed adjunctive homecare.
In office I incorporate a combination of peels, lasers, radiofrequency (RF), fillers, PDO threads and PRP with microneedling. I generally have three to four treatment plans:
Plan 1: For Grade 2 aging, I combine: • Monopolar RF (four to six sessions) with an interval of two weeks between every two sessions.
 • Every RF treatment session is combined with an alpha hydroxy peel (glycolic acid is most common).
Plan 2: For Grade 3 aging, I combine:
• Monopolar RF, around six sessions over the course of three months.
• This is followed by use of non-crosslinked hyaluronic acid (HA) fillers – around 1 mL in each hand using a multiple puncture technique. • The patient returns for a follow-up after three months wherein simple rejuvenation procedures are performed via a Q-switched laser or an epidermal peel (alpha hydroxy or polyhydroxy acid peels).
 Plan 3: For Grade 3 and 4 aging, when there is associated volume loss and visible tendons. These will be your most commonly seen patients and will require added volume initiation of neocollagenesis and treatment of actinic damage.
 • I begin by adding PDO non-cogged threads – 38 mm mono-threads in the dorsum of the hands and 25 mm non-cogged mono threads in the digits. One can use 10 to 20 threads on each hand.
• Three weeks after the treatment with threads I have the patient return for treatment with fillers. Preferably, one should use only HA fillers, keeping the safety profile in mind. In addition, HA is a hygroscopic molecule that makes the skin texture appear hydrated, smoother and youthful. One could use a low or medium ‘G’ prime filler – 1 mL each hand (I use the Juvéderm range of fillers from Allergan Aesthetics, with my preferred choice being Juvéderm Ultraplus or Volift). This can be done using a needle or cannula.
• I have the patient return for a follow-up after three months and then we start peels or Q-switched laser treatment. If the degree of damage is severe one could also do PRP with microneedling, three months after the filler treatments.
 Plan 4: If the patient is unable to come often for their follow-ups and the aging is at a Grade 4 or 5, then I take the following actions:
• I inject a high ‘G’ prime filler (Juvéderm Voluma) with a cannula, 1 mL in each hand.
• I have the patient return after six months, at which point I insert mono non-cogged PDO threads (around ten in each hand).
• Then I have them return again after six months for more filler. With this protocol, the patient only has to see you twice a year.
Again, the above-mentioned plans are incomplete without homecare.
 At-Home Care Protocols
 Generally, I always tell my patients to use whatever they use on their face on their hands too. In addition, I recommend the following protocol:
• Regular use of sunscreen (Broad-spectrum, SPF > 30)
• Use of retinols
• Topical creams containing AHAs, peptides, growth factors, etc.
• Oral antioxidants
 Final Thoughts
 Evidence continues to show that results achieved with a combination of therapies and techniques are not only superior to most standalone treatments, but they are also more satisfying to both practitioners and patients.
In addition to my recommended guidelines above, you can customize treatment plans per individual concerns.
It has been observed that after the face, women are most conscious about their neck and hands, in that order, so including hand rejuvenation is a must!
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