Extreme Hand Repair

Between Botox injections to her face, Pilates workouts, a brilliant colourist, and an almost macrobiotic diet, 64-year-old Caroline didn’t look her age. The self-described “ball of energy” looked at least 20 years younger — but her hands gave away the truth. Ropy with large blue veins, and discoloured by sun damage and age spots, they could’ve been badges of a long, active life. But to Caroline, they were a problem.

Although she invested in gel nails and regular fills to keep her fingers attractive and well- groomed, Caroline wanted more from her hands — and eventually, she got it. While undergoing a routine Botox injection to her forehead, Caroline learned she had options. Mere weeks later, her hands matched her youthful body and outlook — and her family is still sworn to secrecy.

While we understand Caroline’s need for privacy, cosmetic medical and surgical proce­dures for the hands are no longer being kept secret. As women (and men) like her rush to restore their youthful appearance, they’ll find a number of choices to set the clock back on those all-telling hands.

Out, Out Damn Spot!

Those smooth, brown marks that appear on skin that’s been exposed to the sun throughout the years are known as age spots, or lentigines. While alpha- or beta-hydroxy acid gels, chemical peels, or prescription medications like Retin-A can sometimes be effective in reducing the appearance of age spots, more drastic methods are often required. Trained estheticians can spray liquid nitrogen (chilled to -321 degrees Fahrenheit) onto the skin, causing the spots to whiten and essentially disappear within a month.

But there’s a better option. Stephen Greenberg, M.D., a board-certified plastic surgeon who specializes in cosmetic surgery, removes age spots by using an intense pulsed light treatment in his Long Island and New York City offices. “It’s very popular,” Dr. Greenberg explains, “and one of the easiest procedures.”

According to Dr. Greenberg, just three to five treatments of 10 minutes each are required to eliminate or greatly reduce age spots. “We do both hands at once,” he says, “and there’s no pain, so no anesthesia is required.” Dr. Greenberg’s patients can drive themselves home from the office, and experience no downtime as a result of the procedure.

Intense Pulsed Light, or IPL, is just one of the products offered by Lumenis Aesthetic, which also markets laser therapy devices to physicians. But IPL has a number of advantages. It’s non-invasive, and patients experience no redness or scarring. During IPL photorejuvenation treatment, physicians place a small, flat, glass handheld device over the skin. The device then emits broad-spectrum light in the visible, near-infrared range, from 515- 1200 nm (nanometers). These quick bursts of light target the melanin (or excess pigment) in the skin, heating it to the point where it is damaged or destroyed. And, because it’s so gentle, it can be used on the face, neck, and chest, as well.

Manufacturers and physicians caution that IPL isn’t for everyone. Patients prone to keloids, hyper or hypopigmentation, or those who are dark-skinned, deeply tanned, or especially sensitive to burns, may not be good candidates. Insulin-dependent diabetics are also advised to avoid the procedure, due to difficulty in healing.

Just as with any medical procedure, patients should undergo a thorough examination and consultation before undergoing IPL treatment. “You may need a spot or patch test to make sine there are no negative reactions,” advises Penn Plastic Surgery, a division of the University of Pennsylvania Health Care System.

It’s Time to Plump It Up

It’s a rare woman who wouldn’t remove a bit of the fat from her hips or derriere. But now, that fat can actually be recycled. When patients complain that their hands are too thin, plastic surgeons now have a fast, safe solution: fat injections, also known as autologous fat implants, or soft tissue augmentation. As skin ages, it thins, and natural fat is lost below the surface, giving hands a much older look than the rest of a woman’s body.

“Fat is removed from the hip or butt,” says Dr. Greenberg, “then injected into the hands. It plumps them out, giving them a fuller, more youthful appearance.”

Because the patient’s own fat is used, adverse reactions or rejection are extremely rare. After the fat is liposuctioned, it’s cleaned and has its fluid removed. It’s then inserted into the hands with a small needle. The procedure takes about 30 to 45 minutes, and can be performed on an outpatient basis. Only a mild, local anesthetic is necessary, and mild pain medication may be prescribed for a short period following the surgery. Most patients sail through the procedure with minimal side effects, although some experience mild swelling for about a week. Results are immediate — and lasting, with the American Society for Aesthetic Surgery reporting that patients won’t need a second treatment until seven to 10 years after the procedure.

When fat injections aren’t appropriate, there are non-autologous (not derived from one’s own body) and synthetic options, including Restylane, an injectable treatment that contains hyaluronic acid, a naturally occurring substance that is especially attractive to vegetarian and vegan patients as it contains no animal products. Restylane is considered non-allergenic and can often be administered in a physician’s office during a patient’s initial consultation. For those who are willing to wait for test results, collagen implants Zyderm and Zyplast can also be used to fill out aging hands. Manufactured by INAMED Aesthetics since 1985, the implants are made of bovine dermal tissue from a carefully monitored herd of cows in California. Treatments generally last three to six months.

Potential patients should consult a qualified plastic surgeon or dermatologist m order to choose the best procedure. Those who want to be prepared before the initial visit can talk with Joanne Gladfelter, RN, CPSN (certified plastic surgery nurse) of INAMED, who is available at wwwJookmgyourbest.com. Gladfelter recommends due diligence, and suggests the sites of American Academy of Dermatology (www.aad.org), American Society of Plastic Surgeons (www.plasbcsurgery.org), and The Ameri­can Society for Aesthetic Plastic Surgery (www.surgery.oig) for more information.

Make It Go Away

While some patients benefit from filling in the hands, others face another problem: large, blue-green ropy veins that cover the backs of the hands and wrists. According to the Schulman Vein and Laser Center in New York City and Long Island, “Many women are self- conscious about the way their hands look. Some have unusually large bulging veins that are very masculine.” Physicians at the Schulman facility inject FDA-approved medications into the unsightly hand veins, and no anesthesia is necessary. After the proce­dure, patients may wear compression bandages for several hours, but are free to drive home and resume normal activities immediately. There may be mild swelling and tenderness, but both are generally insignificant.

The technique, known as sclerotherapy, has been available since the 1920s, and was first used to treat spider veins in the thigh or lower leg. The injected medication, or sclerosing solution, causes large reticular veins to turn white and gradually disappear. Each treatment takes about 30 minutes to an hour. Recent improvements to the technique include the use of transillumination, a device that passes light through the skin and allows doctors to visualize the hand’s surrounding veins more completely.

Most patients tolerate it well, although it should not be performed on those with circulatory system injuries or illnesses, as well as patients who will require future IV treatment. This is because by removing the obvious veins, you are reducing the number of easy access points to place an IV. For someone with diabetes, kidney disease, cancer requiring chemotherapy, or other diseases, this could pose a problem.

Despite its long and successful track record, sclerotherapy is rapidly being replaced by a new technique, known as laser ablation.

Laser ablation uses a laser placed on the tip of a wire, which plastic surgeons thread into the vein after administering topical anesthesia. However, since the procedure is considered to be painless, many patients forego anesthetic. Most describe the sensation as similar to having a rubber band snapped on the skin. As the wire is slowly removed, the energy from the laser (surgeons conducting the study used a 600- micron laser fiber) heats up the vein and blood cells, damaging the inner lining of the vessel wall. Once the wire is out, a tight dressing is put on the hand, clamping down the tissue and collapsing the vein. Over the next couple of weeks, the vein dies, gives way, and is reabsorbed by the body, leaving a smooth hand.

During the two-week recovery period, patients wear a compression glove or ace bandage to decrease swelling and help the veins lay flat, and are encouraged to use their hands.

In a recent study by Dr. Roxanne Guy, a Florida reconstructive and plastic surgeon, and Dr. Asad Shamma of Beirut, Lebanon, 60 veins were treated on eight women in an office surgery setting. Of those treated, only one vein did not respond to laser ablation and required sclerotherapy and eventual phlebectomy (the removal of veins by inserting a hook-shaped tool through several small holes punched in the skin).

Other Things to Know

All of the procedures can be performed on both men and women, although the vast majority of cosmetic hand patients are female. And the need to make the hands appear more youthful starts early: 35 and up, say a number of plastic surgeons.

Minimally invasive procedures, including laser, pulsed light, and injectable therapy, are on the rise, and the use of traditional surgical proce­dures is declining, according to the American Society of Plastic Surgeons.

The Society also reports another surprising statistic: Cosmetic surgery isn’t just for the rich and famous. According to their recent study, 71% of people considering cosmetic surgery had household incomes of less than $60,000.

That’s important to note that, since all of the procedures detailed above are considered to be cosmetic when performed on the hand, health insurance companies won’t cover them. At best, the initial consultation maybe partially covered, but patients should expect to absorb the significant cost of treatment themselves.

What’s the most important thing for patients to do when considering cosmetic surgery or invasive treatment? “See a board-certified plastic surgeon,” insists Dr. Greenberg, himself a member of the American Board of Plastic Surgery and the American Society of Plastic Surgeons. Board certification ensures that the physician has graduated from an accredited medical school, completed at least five post-graduate years of training as a resident surgeon, including a three-year surgical residency and a two-year plastic surgery residency, and completed a comprehensive series of oral and written examinations. For those who prefer even more intense training, members of the American Society of Plastic Surgeons are board certified also, but may practice only in accredited medical facilities, adhere to a strict code of ethics, and undergo a rigorous program of continuing education courses that keep them current on the latest surgical and patient safety techniques.

Physicians also advise patients to be honest, and realistic, about their medical history, habits, and goals for the surgery. During the initial consultation, patients should feel free to ask questions, including whether alternative treatments are available and appropriate. “I wanted to hear the risks as well as the benefits,” said one woman who successfully underwent laser therapy. “I felt good about making an informed decision.” Thanks to her surgeon, she now feels good about her hands, too.