Hands

Hand rejuvenation, three separate problems

After the face, the hands are the part of the body that gives away age fastest, and they are the part most people forget to protect. They are also the part where a single treatment almost never solves the whole picture, because what looks like one problem is usually three: lost volume, sun damage, and thin crepey skin. Each of those responds to something different. Dr. Paul Kuzel assesses which of the three you actually have before recommending anything.

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The three problems

One area, three different treatments

The back of the hand ages differently from the face. There is almost no fat there to begin with, the skin is thin, there are far fewer oil glands, and it takes as much cumulative ultraviolet exposure as the face while receiving a fraction of the sunscreen. The result is three processes running at once, and they are not interchangeable. Filler will not fix a brown spot. A laser will not fix a hollow. Working out which of the three is driving how your hands look is most of the consultation.

ThreeSeparate problems, separate treatments
1 to 2 weeksTypical swelling after hand filler
Under the skinWhere the dorsal veins sit, and why care is needed
Problem one

Volume loss, showing tendons and veins

The thin fat layer over the back of the hand thins further with age. As it goes, the structures underneath stop being padded and start being visible: the extensor tendons as cords when you move your fingers, the metacarpal bones as ridges, and the dorsal veins standing proud. The veins are usually not new. They have simply lost their cover.

  • Radiesse, a calcium hydroxylapatite filler, which restores volume immediately and stimulates collagen afterwards. It carries a specific approved indication for the back of the hand, which few fillers do.
  • Sculptra, a poly-L-lactic acid collagen stimulator, which builds thickness gradually over a series and suits diffuse, evenly thinned skin rather than one hollow.
Problem two

Pigmentation and sun damage

Solar lentigines, the flat brown patches usually called age spots or liver spots, together with freckling and rough scaly patches. These are cumulative ultraviolet damage, and the back of the hand is one of the highest exposure sites on the body. Some of what appears here is not cosmetic at all.

  • PicoWay, a picosecond laser, for clearing discrete brown spots with little heat and short recovery.
  • Light and laser treatment for diffuse mottling, covered on the vascular and pigmented lesions page.
  • Cryotherapy for individual lesions, which freezes a single spot rather than treating the whole hand.
  • Assessment for actinic keratosis, which is precancerous and needs medical treatment, not a cosmetic one.
Problem three

Skin quality and crepiness

Even with volume restored and pigment cleared, hands can still read as old because the skin itself is thin, finely wrinkled and loose, with the crepe paper texture that shows most when you pinch the skin and it is slow to flatten. That is collagen and elastin loss in a dermis that was thin to start with.

  • Fractional resurfacing, at conservative settings, because hands heal more slowly than faces.
  • Microneedling to stimulate collagen with minimal downtime.
  • RF microneedling, which adds controlled heat in the dermis and can tighten as well as thicken.
  • Daily sunscreen on the hands, which is unglamorous and does more for the ten year outcome than anything else on this list.
Order matters. When more than one of the three is present, they are usually staged rather than stacked. Pigment and resurfacing work is generally done before or well after injecting, not on the same day, because heat and swelling in the same tissue at the same time makes both harder to judge. A typical plan runs across a few months, not a single appointment.

Who it suits

Good candidates, and honest limits

This tends to be worth doing if

  • Your face has been treated and your hands now look older than it does. This is the single most common reason people come in for hands.
  • Tendons and veins have become visible where they were not five or ten years ago.
  • You have flat brown spots that have been checked and are benign, on skin that is otherwise reasonable.
  • You have realistic expectations about a body part that gets used, washed and sun exposed all day.
  • You are willing to wear sunscreen on your hands afterwards, because untreated ultraviolet exposure undoes pigment work quickly.

Reasons to wait, or to do something else first

  • Any brown or changing lesion that has not been examined. The back of the hand is a common site for actinic keratosis and for squamous cell carcinoma, and a laser removes the appearance of a lesion without removing the lesion.
  • Genuinely varicose or ropey dorsal hand veins. That is a vein problem, not a volume problem, and it needs a vascular assessment.
  • Active eczema, dermatitis or infection on the hands, which is treated first.
  • Blood thinning medication or a bleeding disorder, which raises bruising risk substantially and changes how and whether we inject.
  • An occupation or event in the next two weeks where visibly swollen, bruised hands would be a problem.
  • Expectations set by before and after photographs of someone whose hands were less affected than yours are.
Results vary more here than almost anywhere else. A person in their fifties with mild volume loss, a handful of spots and decent skin can look substantially different after one filler session and one laser session. A person in their seventies with advanced fat atrophy, prominent veins, heavy sun damage and thin fragile skin will improve, sometimes a great deal, but will not end up with the hands of a thirty year old, and no honest plan will claim otherwise. Where you start determines most of where you finish.

What happens

Why injecting the back of the hand is not trivial

The dorsal hand is often described as an easy area to treat. Anatomically it is not. Everything of consequence is packed into a few millimetres of tissue, there is no fat to hide an error in, and the plane you want to be in is the same plane the veins are in.

  • SkinThin, mobile and easily tented away from what lies beneath, which is the property the technique depends on.
  • Subcutaneous layerThe target. It also contains the dorsal venous network, which sits superficially rather than deep, and the sensory branches of the radial and ulnar nerves, which run across the dorsum close to the surface.
  • Extensor tendonsJust underneath, gliding as the fingers move. Product placed onto or between the tendons can feel lumpy, migrate with movement and interfere with how the hand feels in use.
  • Deep arterial archThe dorsal metacarpal arteries run in the spaces between the metacarpal bones, deeper than the injection plane, and are the reason depth control matters rather than being optional.

  1. Assessment and mapping

    Which of the three problems you have, and in what proportion, is decided before any product is chosen. Hands are examined for lesions at the same visit, since this is a dermatology practice and skin cancer surgery is part of the work here. Anything suspicious is dealt with as a medical matter, separately.

  2. Choosing the product

    Radiesse suits a hand that needs visible volume now, placed as a thin diffuse layer rather than a discrete pillow. Sculptra suits a hand where the skin is diffusely thin and the goal is gradual thickening across a series of sessions spaced roughly a month apart. Some patients receive one, some the other, and some receive Sculptra for texture after Radiesse has restored contour.

  3. Numbing

    Topical anaesthetic is applied, and Radiesse is commonly mixed with lidocaine before injection, which makes the treatment itself and the massage afterwards much more tolerable. Ice is used before and after. Rings are removed at the start, because they will not come off easily later.

  4. Injection technique

    The skin is pinched or tented upward to lift it away from the tendons and vessels. Product is placed in the subdermal plane through a small number of entry points, either as a central deposit or with a blunt cannula threaded under the skin, and the injector aspirates and stays superficial to the tendons throughout. A cannula does not eliminate risk but it pushes vessels aside rather than through, which is why it is often preferred here.

  5. Moulding

    The product is then massaged and spread deliberately across the back of the hand so that it sits as an even sheet rather than a lump. This step takes several minutes per hand and is not optional. Uneven distribution is the most common cause of a hand that looks or feels wrong afterwards, and it is far easier to prevent at the time than to fix later.

  6. What it feels like

    Pressure and a spreading, full sensation more than sharp pain, with a brief sting at each entry point. The massage phase feels firm. Sessions run about twenty to forty minutes including numbing. You will be able to drive home, but your hands will feel swollen and slightly stiff for the rest of the day.

Afterwards and risks

Swelling is the part people are not warned about

Hands hang at your sides all day, so gravity works against you in a way it does not after a facial treatment. Swelling after hand filler is normal, it is often more than patients expect, and it is the single most common complaint in the first week.

Expected, and settles

  • Swelling that peaks in the first 48 hours and generally settles over one to two weeks. Rings frequently do not fit during that time.
  • Bruising at the entry points, which is common given how superficial the veins are, and typically lasts five to ten days.
  • Stiffness and a full, tight feeling when gripping or making a fist for the first few days.
  • Mild tenderness to pressure for about a week.
  • Elevating the hands, avoiding heavy gripping and heat, and keeping to light activity for a few days all shorten this.
  • With Sculptra, the initial fullness settles within days and the real change appears gradually over the following weeks as collagen builds, which is why the sessions are spaced out.

Real risks, stated plainly

  • Lumps and irregularity. Product that was not spread evenly, or that settled between tendons, can be felt or seen. Radiesse cannot be dissolved the way a hyaluronic acid filler can, which is precisely why the technique and the moulding matter so much.
  • Nodules. Less common, more associated with collagen stimulators, and generally the result of product placed too superficially or too concentrated in one spot.
  • Vascular occlusion. Rare in the hand but reported. Product entering a vessel can obstruct blood supply and cause skin damage or, in the worst cases, tissue loss. It is the reason for aspiration, cannulas, correct plane and slow low pressure injection, and the reason for calling immediately if a hand becomes unusually painful, pale, blotchy or dusky.
  • Nerve irritation. Temporary numbness, tingling or altered sensation over part of the hand, from a superficial sensory branch being bruised.
  • Infection. Uncommon, and reported as increasing rather than decreasing pain, warmth and redness after the first few days.
  • Prolonged swelling. A small number of people swell for closer to three weeks than one.
How long it lasts. Radiesse in the hands is often quoted at around a year, sometimes longer because of the collagen response it triggers. Sculptra is built over a series and the result is commonly reported as lasting up to two years. Laser and light treatment of brown spots can clear them for years, but new ones will appear if the hands keep getting sun, so sunscreen is not an upsell here, it is the maintenance plan. Individual results vary with age, skin thickness, sun exposure, weight change and how much the hands are used.

Questions

What patients actually ask

Which treatment do my hands actually need?
That depends on which of the three problems you have. If tendons and veins are showing through, that is volume loss and it needs filler. If the shape is fine but the hands are covered in brown spots, that is sun damage and it needs laser, light or cryotherapy. If the volume and the colour are both acceptable but the skin is thin and crepey, that is skin quality and it needs resurfacing or microneedling. Many people have two or three of these at once, in which case they are staged over a few months rather than done in one visit.
Will filler get rid of my veins?
Not exactly. Filler restores the padding that used to sit over the veins, so they look less prominent because they are less exposed, not because anything has been done to the veins themselves. That is usually enough for the appearance people are unhappy with. If the veins are genuinely enlarged and ropey rather than simply uncovered, that is a different problem, it is assessed as a vein problem, and filler is not the answer.
How long does hand filler last?
Radiesse in the hands is often quoted at around a year, and sometimes longer, because the calcium hydroxylapatite stimulates your own collagen as it breaks down. Sculptra is given as a series of sessions about a month apart and the result is commonly reported as lasting up to two years. Both are averages. How long yours lasts depends on your age, how thin the skin was to begin with, weight changes and how heavily you use your hands.
How much swelling should I expect?
More than most people are told. Your hands hang at your sides all day, so swelling collects there. It peaks in the first 48 hours and usually settles over one to two weeks, occasionally closer to three. Rings often do not fit for several days, so take them off before the appointment. Bruising at the entry points is common because the dorsal veins sit very close to the surface. Elevating your hands, avoiding heavy gripping and heat, and keeping activity light for a few days all help.
Does injecting the hands hurt?
It is more pressure than sharp pain. Numbing cream is applied first, Radiesse is usually mixed with lidocaine, and there is a brief sting at each entry point. The part people notice most is the massage afterwards, when the product is spread evenly across the back of the hand, which feels firm and takes several minutes per hand. Most people describe the whole thing as uncomfortable rather than painful, and it is over in about half an hour.
Can brown spots on the hands be anything serious?
Yes, which is why they are examined before they are treated. The back of the hand takes as much lifetime ultraviolet exposure as the face and is a common site for actinic keratosis, which is precancerous, and for squamous cell carcinoma. A laser will remove the visible colour from a lesion without removing the lesion, which destroys its appearance and can delay a diagnosis. Dr. Kuzel is a certified dermatologist who does skin cancer surgery, so anything that does not read as a straightforward benign spot is investigated rather than lasered.
What does hand rejuvenation cost?
It is quoted at consultation, because the price depends entirely on which of the three problems you are treating and how many of them. One session of filler across both hands, a course of Sculptra, a laser session for pigment and a resurfacing plan are four different costs, and most people need a combination. Cosmetic treatment is not covered by Alberta Health Care, although the medical assessment of a suspicious lesion is a separate matter. You will be given the full plan and its cost before anything is booked.
How soon can I go back to the gym or to normal work?
Light activity and desk work are fine the same day, though your hands will feel full and stiff. Avoid heavy gripping, weights, hot tubs, saunas and vigorous hand washing with very hot water for about three to five days after filler, because heat and pressure both worsen swelling. Manual work that involves gripping tools all day is best scheduled around the first week. After laser or resurfacing on the hands the restrictions are different, mainly sun avoidance and not picking at the treated spots while they flake.

Next step

Start with a consultation

Hands are assessed in person, in good light, with your fingers moving. That is the only way to tell how much of what you are seeing is volume, how much is pigment and how much is skin quality, and it is also when any lesion that needs looking at gets looked at. Tell us about blood thinners and about anything already planned in the next fortnight.

Dr. Paul Kuzel, MD FRCPC
Rejuvenation Dermatology Calgary South
10201 Southport Rd SW #102, Calgary AB T2W 4X9
(403) 286-6888

Book a consultation Call (403) 286-6888

Related pages: Radiesse, Sculptra, PicoWay, cryotherapy, RF microneedling, vascular and pigmented lesions.

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