The hand is the most visible unclothed body part, besides the face and neck, and is, therefore, of major aesthetic importance. Because of its form and function, the hand has become a symbol of beauty and is widely accepted as an indicator of character.1 However, it is also a visual marker of age that is difficult to conceal. Like every part of the body, the hands are subject to the intrinsic aging process.2 In addition, they are constantly exposed to extrinsic environmental factors such as UV radiation; climatic influences; and the stress of intense, continuous use. These factors together can accelerate the aging process, resulting in premature aging of the hands. Together with the face, the hands are often the part of the body where aging is most visible.
Hand aging has to be understood as a three-dimensional (3D) process that involves bones, vessels, and skin. With aging, the wrinkling pattern of the skin increases and gives hands a wrinkly, often leather-like appearance. Dermal changes, muscle atrophy and loss of subcutaneous fat together result in pronounced dorsal veins that present as a bluish color through the skin. Age spots emerge on the back of the hand, due to the lifetime accumulation of UV radiation, and give the hands a mottled and uneven appearance. Dermal atrophy and volume loss result in a more visible skeleton, commonly mistaken as significant joint thickening of the proximal interphalangeal joints.3
Considering the different factors of hand aging, a multidimensional approach that addresses all issues is necessary for successful treatment. This 3D rejuvenation approach must include the treatment of skin laxity and prominent veins, augmentation of volume loss, and removal of discolorations. A combination approach utilizing multiple modalities is often beneficial and yields optimal treatment results.
Large veins with diameters from 1 to 6 mm on the dorsal aspect of the hands often become more prominent with aging and are a common source of patient dissatisfaction. This phenomenon is only partially due to intrinsic changes in the veins themselves. With age, they may become enlarged and tortuous, but of equal importance is volume loss within the surrounding tissue. Volume loss is a result of muscle atrophy, bone demineralization, and loss of adipose tissue.3 Consequently, vessels protrude to an increasing extent on the backs of the hands, and their bluish color is visible through the skin, giving the hands a fragile and unsightly appearance.
Dorsal hand veins represent the equivalent of varicose veins of the lower extremities.3 Thus, the same treatment options are available as for leg veins, including sclerotherapy with or without foam, endovenous laser therapy for hands (EVLH), and ambulatory phlebectomy. However, the treatment of hand veins for cosmetic reasons remains controversial as the vessels are necessary to provide intravenous access should medical emergencies occur.4 Furthermore, complications can result in motor ...