Rejuvenation of the hand: fat injection combined with TCA peel

Often, the appearance of the hands is a telltale sign of a patient's true age. The skin on the dorsum of the hand is both mobile and delicate; with age, it becomes thin and transparent. The aging process also causes fine wrinkles and irregular pigmentation or dark spots, and actinic and seborrheic keratosis may also be noted.1–4 To obtain a more youthful appearance of the hand, we recommend the injection of autologous fat followed by the cutaneous application of trichloroacetic acid (TCA). Fat may easily be harvested from the abdomen, flank, or thigh. The donor site is selected according to the preference of the patient. Tumescent solution is injected until the skin becomes tense. A Tulip syringe with a 2-to 3-mm cannula is used to harvest 15 to 20 mL of fat. The fat is allowed to separate in the syringe and the fluid layer is expelled. A mesh strainer is used to further drain the liquid, and the fat is left unwashed. The injection site on each hand is anesthetized with lidocaine, and a 14-gauge angiocatheter is inserted. The needle and its catheter sheath are inserted under the skin—between the third and fourth metacarpal phalangeal joints—and are then advanced 6 to 7 cm toward the wrist. The needle is then removed, and the catheter is left in place. Fat is injected and the catheter is simultaneously pulled back. Approximately 15 to 20 mL of harvested fat is sufficient to give both hands a slightly “puffy” look. Care should be taken not to inject the veins. Once injected, the fat is vigorously massaged into place, and in a matter of minutes, the prominent vessels and tendons disappear. Bahman Teimourian, MD, Bethesda, MD, is a board-certified plastic surgeon and an ASAPS member. Bahman Teimourian, MD, Bethesda, MD, is a board-certified plastic surgeon and an ASAPS member. Mehdi N. Adham, MD, Oklahoma City, OK, is a board-certified plastic surgeon and an ASAPS member. Mehdi N. Adham, MD, Oklahoma City, OK, is a board-certified plastic surgeon and an ASAPS member. After the fat injection, 30% to 35% TCA is applied to the entire dorsum of the hand. This improves the quality of the skin and lightens the pigmentary changes. Thick seborrheic keratosis is difficult to treat but may be addressed with a carbon dioxide laser or argon beam coagulator. The patient is advised to massage the hands on a daily basis. For the first week, an antibiotic ointment should be applied to the treated areas. Thereafter, the usual moisturizer or hand lotion may be used (Figures 1 and 2). A, Preoperative view of the hands of a 68-year-old woman. B, Postoperative view 1 month after autologous fat injection with cutaneous TCA application. A, Preoperative view of the hands of a 68-year-old woman. B, Postoperative view 1 month after autologous fat injection with cutaneous TCA application. A, Preoperative view of the hands of a 67-year-old man. B, Postoperative view at 1 month and C, 2 years after autologous fat injection with cutaneous TCA application. A, Preoperative view of the hands of a 67-year-old man. B, Postoperative view at 1 month and C, 2 years after autologous fat injection with cutaneous TCA application. Although immediate effects of fat injection are evident, the long-term results are difficult to predict. Injected fat may be absorbed, remain as free fat cells, or become scar tissue and retain bulk, causing unpredictable results. More than 25 patients have undergone this procedure in our study. A follow-up period of 5 years has revealed no complications or scarring. Six patients have required repeat fat injection between 6 months and 2 years after the initial procedure due to the resorption of fat. In most cases, the benefits have lasted over 3 years. All patients have been pleased with the results, and those requiring reinjections have taken them with no objections. Fat injection combined with TCA peel is a simple and worthwhile procedure that can give the hands a younger and more beautiful appearance. The youthful restoration of the hand can present a real challenge for any surgeon. Fat injection combined with TCA peel is extremely effective for treating the aged hand. This simple and worthwhile combination of procedures gives the hand a younger and more beautiful appearance. Patients should be advised, however, that results from fat transfer may be unpredictable.