OCT 2018

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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40 OCTOBER 2018 | MedEsthetics tips to improve safety and outcomes. "I like to use the Ac- cuVein viewer to help identify the vascular network on the backs of hands, especially if the patient has particular social concerns over bruising," he says. "I have the patient hold a squeeze ball, or similar object in the hand being injected with slight (~ 30 degrees from horizontal) fl exion. This allows the long cannula to glide easily in the loose aerolar space and is ergonomic for the injector. I like the patient to be sitting upright with her hands on a pillow over an absor- bent disposable pad for the injection. Immediately after the injections we use ultrasound gel (or something similar) and manual massage to evenly distribute the product. We then place a gauze pad followed by a cold pack over the dorsum and ask the patient to place her hand under her buttock." SAFETY NOTES "Swelling and bruising are the most common side effects of delivering fi llers to improve volume loss in hands, as well as discomfort," says Dr. Cohen. "Bruising is usually gone in fi ve days or so, but swelling can persist eight to 10 days in some cases. The accompanying soreness can be an issue for those with professions that focus on the hands, such as pianists or surgeons. "We are always looking at how we can make these procedures even safer," he continues. "One way is to be diligent about aseptic techniques. We go beyond just a rubbing alcohol skin prep and use a chlorhexidine scrub to minimize infection risk." Contraindications include any active infection or skin disease, a history of keloids or irregular wound healing, allergies to any of the products used, Raynaud's and bleed- ing disorders. "Relative contraindications include recent use of aspirin, nonsteroidal anti-infl ammatory drugs (NSAIDs) or herbal supplements known to affect coagulation and hemostasis," says Dr. Torres. "Patients with autoimmune diseases are treated on a case-to-case basis, taking into consideration prior treatments. Finally, I do not recommend volume cor- rection in patients with a history of carpal tunnel syndrome or other conditions affecting the radiocarpal joint, because of the risk of post-procedural pain that can later be attrib- uted to the procedure." Make sure patients remove rings and agree to leave them off for at least 24 hours, says Dr. Lupo. Failing to do so could result in an emergency room trip and the need to cut the rings off—an embarrassing outcome for the doctor and one the patient won't easily forgive. "Because of the functional nature of hands, it's important to take a careful history of any range-of-motion limitations, work type, unusual swelling, neuropathies or other medical or occupational conditions that could be affected," notes Dr. Werschler. "Post-injection swelling, edema, bruising, tight- ness and stiffness are common in patients with a history of arthritis, those who are on anti-platelet or anti-thrombotic therapies, and those with vocations that require excessive use of hands or practice martial arts. You can still treat most of these patients after a discussion of the risks and benefi ts, but they need to be aware that dermal fi ller treatments of hands are not without potential complications." COMING ATTRACTIONS Dr. Werschler and Dr. Torres are monitoring devel- opments in regenerative medicine that could lead to breakthroughs in hand rejuvenation. "Stem cells, PRP, PRF (platelet-rich fi brin), SVF (stromal vascular fraction)—these are where the future lies, not just for hands but for aesthetic medicine in general," says Dr. Werschler. "While we are getting close, we haven't yet arrived from a technology and technique perspective." Dr. Torres is looking forward to a new protocol created in Spain using an autologous gel composed of platelet-rich fi brin plus growth factors. "This gel provides an acceptable lifting capacity and has an important collagen stimulatory effect even though its volume correction lasts up to four months," he says. "This product will not replace tradition- al fi llers but is another valuable tool in the aesthetic medicine/cosmetic dermatology armamentarium." Linda W. Lewis is the contributing editor of MedEsthetics. ALL HANDS

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