AESTHETICS IN HAND SURGERY:

FROM RECONSTRUCTION TO REJUVENATION

Matthieu BEUSTES-STEFANELLI, MD
Plastic Surgery & Hand Surgery
Paris, France

AESTHETICS IN HAND SURGERY:

FROM RECONSTRUCTION TO REJUVENATION

I) Aesthetic considerations in hand surgery

II) Hand aesthetic reconstruction

III) Hand rejuvenation

AESTHETICS IN HAND SURGERY:

FROM RECONSTRUCTION TO REJUVENATION

I) Aesthetic considerations in hand surgery

II) Hand aesthetic reconstruction

III) Hand rejuvenation

AESTHETIC CONSIDERATIONS
IN HAND SURGERY
Aesthetic units of Michon
Adaptated Skin incisions
Mini-invasive surgery (endoscopy, arthroscopy)
Conservation of the dorsal aspect of the hand and the forearm
No skin grafts on the palmar aspect of hand and pulp
Skin graft and flap donor sites
etc

 Aesthetic units of the hand (Michon)

Non-meshed skin graft respecting aesthetic units

of the dorsum of the hand and the fingers

 Adaptated Skin incisions

Palmaires +++

Latrales +++

Dorsales +

Respect the skin tension lines of Langer

 Mini-invasive Surgery

reduces scars

ex : Wrist therapeutic arthroscopy

ex: Knife light for CTS

 Conservation of the dorsal aspect

of the hand and the forearm
. Avoid dorsal scars
. No meshed skin grafts
. Thin flaps
. Avoid IOP flap in children or young women

Unaesthetic aspect
of a meshed skin graft

Groin flap too thick

 Avoid skin grafts in palm and pulp

ex : Pigmented and heary Full Thickness Skin Graft

Mac Cash procedure

(open palm) +++
in Dupuytrens disease

Day 21

2 month

 Be careful with the choice and the quality of harvesting of donor

sites

Skin graft too thick

Full thickness skin graft harvested in the groin of a black patient for the palm

Medial aspect of the arm to harvest a

large full thickness skin graft

AESTHETICS IN HAND SURGERY:

FROM RECONSTRUCTION TO REJUVENATION

I) Aesthetic considerations in hand surgery

II) Hand aesthetic reconstruction

III) Hand rejuvenation

HAND AESTHETIC RECONSTRUCTION

A) Hand reconstructive surgery for aesthetic indications
B) Adjuvant treatments (aesthetic prostheses, dermatological
treatments)
1 Rhumatismal Deformations without pain
+++ DIPJ arthritis
+ Rhumatoid Arthritis
+ 1st CMC Arthritis

2 Dorsal Dupuytrens disease

3 Congenital malformations
4 Sequelae of traumas of the fingertip
5 Amputations (aesthetic amputations, aesthetic prostheses)
6 Cutaneous defects
7 Subcutaneous defects
8 Skin surface disorders
etc

1 DIPJ Arthritis
(most common aesthetic indication in hands)

3 conservative techniques +++

corticoid injections
Romanos DIPJ arthroplasty
DIPJ Swanson Prosthesis (size 0)

If Arthrodesis :
at 0 of extension
bone graft if middle finger

Mucoid cyst

Heberdens nodul

Romanos DIPJ Arthroplasty

Microlift of the skin : Butterfly design

 Defatting of the 4 flaps

Resection of the lateral osteophytis

Resection of soft tissue

Resection of the dorsal osteophytis

under the extensor tendon very
precautiously

 Skin closure in VY

VY

4 months
compression

DIPD Swanson Prosthesis

(size 0)

DIPJ Arthrodesis of middle finger:

- at 0 of extension
- with bone graft to keep the length

1 Rhumatoid arthritis

1 1st CMC arthritis

2 Dorsal Dupuytrens disease

Knuckle pads

3 Congenital malformations

aesthetic indication in 95% of cases

4 Sequelae of fingertip traumas

ex : Nail complex
vascularized transfer

Curved nail
ex : nail striation and fixation + island flap +/bone graft

5 Amputations
Aesthetic surgical amputations

ex : middle finger aesthetic amputation

by intra-carpal osteotomy of Le Viet

 Aesthetic hand prostheses

Pillet Hand Prosthesis (PHP), Paris - France

Thumb

trauma

Long fingers

congenital

trauma

Partial Hands

congenital

trauma

Total hand

congenital

Forearm

Arm

Prosthesis after reconstructive surgery

Non aesthetic phalangisation of 4

metacarpals

Partial hand prosthesis

Toe transfer for the function

Long thumb prosthesis to improve

aesthetic aspect

6 Cutaneous defects

Groin flap: too bulky

Skin substitutes or fascial flaps more adapted

7 Subcutaneous defects
fat grafting +++

ex: ulnar palsy with amyotrophy of interosseous muscles

. Maladie de Dupuytren un stade prcoce (I ou II)

ex: Dupuytrens disease (early stages)

+++ in association with percutaneous aponevrotomy by needle (S. Hovius)

8 Skin surface disorders

Hyperpigmented skin graft

Q switched Laser

Toe transfer with hair

Epilatory Laser

Tattoo on the hand dorsum

Laser Yag Q switched

AESTHETICS IN HAND SURGERY:

FROM RECONSTRUCTION TO REJUVENATION

I) Aesthetic considerations in hand surgery

II) Hand aesthetic reconstruction

III) Hand rejuvenation

With the development

of facial rejuvenation,
appear some paradoxal
situations where face
aging and hands aging
do not correspond
Madonna syndrom

HAND REJUVENATION

WE CAN CHANGE EVERYTHING IN A WOMAN,

HER HANDS WILL ALWAYS SHOW HER AGE?

Hand aesthetics in medical meetings

Before 2007: only few isolated free papers
1st MEGA HAND Symposium (February 2008, Paris, 1 day)
AMWC Congress (April 2008, Paris, a session of 2 hours)
FESSH Congress (June 2008, Lausanne, a session of 2 hours)

IMCAS Congress (January 2009, Paris, a session of 1 hour)

2nd MEGA HAND Symposium (February 2009, Paris, 2 days)
AMWC Congress (March 2009, Monaco, a session of 2 hours)
SOFCEP Congress (April 2009, Cannes, a session of 45 minutes)

3rd MEGA HAND Symposium (March 2010, Paris)

4th MEGA HAND Symposium (October 2011, Paris)
5th MEGA HAND Symposium (October 2012, Paris)
6th MEGA HAND Symposium (Sept 2013, Nice): 1st iClass Hand

Hand rejuvenation
Why so late?
. we dont look our hands in the mirror
. we dont take pictures of our hands
. hand aging is later than face aging
. and also because of the specific anatomy of the hand which
induces fear in many physicians and slowed down the
development of hand rejuvenation techniques

Semiology of hand aging

(+++ dorsal, ++ lateral, + palmar)

INTRINSIC AGING (age)

Skin = dermatoporosis

dryness

- epidermal atrophy

skeletonization (veins, tendons and skeleton too much visible)

- dermal atrophy

general aspect thinner and longer

Fat atrophy

skin transparence and fragility (cigarette paper skin)

Muscles = amyotrophy

skin sagging (deep wrinkles)

Vessels fragility

spontaneous hematomas

Nails (aging nails)

Joints = deformation (DIPJ and 1st CMC arthrosis +++)

EXTRINSIC SKIN AGING (sun +++, smoking +)

= dermatoheliosis: dark spots +++ / fine wrinkles +

Hand rejuvenation treatments

SURGICAL TREATMENTS:
Liftings
Fat grafting

Dermal grafts: autologous (sheet or crushed+injected) or allogenic (ex: Alloderm)

Dermal-fat grafting (en bloc or injected separately)
Fascial grafts (temporalis fascia, fascia lata, lumbar fascia)
Dermal Substitutes with 1 step procedure (Integra DRT Single Layer, Matriderm 1mm)
Pliable biomaterial sheets (Silicone, Gore-tex)

Plasma injections (PRP, PRGF)

Phlebectomies
Correction of joint arthrosic deformations (DIPJ, 1st CMC, )

MEDICAL TREATMENTS:
Synthetic Fillers (HA, OHapatite, PLA, Collagene, Silicone) / Mesotherapy
Radiations: Lasers, Lights (IPL, LED), Phototherapy (PDT), Radiofrequency
Chemical peels

Dermabrasion and microdermabrasion / Skin needling

Carboxytherapy
Vein sclerotherapies
Nail rejuvenation

ADJUVANT TREATMENTS:
Cosmeceutics (moisturizing, anti-oxydants, cooling, solar screen, depigmentants, )
Anti-Aging Medicine (dietary advices, food supplements, vitamins, hormones, smoking stop)

Hand rejuvenation treatments

SURGICAL TREATMENTS:
Liftings
Fat grafting

Dermal grafts: autologous (sheet or crushed+injected) or allogenic (ex: Alloderm)

Dermal-fat grafting (en bloc or injected separately)
Fascial grafts (temporalis fascia, fascia lata, lumbar fascia)
Dermal Substitutes with 1 step procedure (Integra DRT Single Layer, Matriderm 1mm)
Pliable biomaterial sheets (Silicone, Gore-tex)

Plasma injections (PRP, PRGF)

Phlebectomies
Correction of joint arthrosic deformations (DIPJ, 1st CMC, )

MEDICAL TREATMENTS:
Synthetic Fillers (HA, OHapatite, PLA, Collagene, Silicone) / Mesotherapy
Radiations: Lasers, Lights (IPL, LED), Phototherapy (PDT), Radiofrequency
Chemical peels

Dermabrasion and microdermabrasion / Skin needling

Carboxytherapy
Vein sclerotherapies
Nail rejuvenation

ADJUVANT TREATMENTS:
Cosmeceutics (moisturizing, anti-oxydants, cooling, solar screen, depigmentants, )
Anti-Aging Medicine (dietary advices, food supplements, vitamins, hormones, smoking stop)

Handlifts
Dorsal scar
(Wendt)

Palmar + Commissural scar

(Saffar)

Ulnar scar

Invasive
Rejuvenation
Autologous
Dermal grafts

Alloderm
GANCHI P., USA

PHLEBECTOMIES
In cases of veins more than 6-7 mm of diameter
NO MORE THAN 1 or 2 VEINS +++

 Phlebectomy

DIPJ MICROLIFT butterfly (Romano)

FAT GRAFTING
2 procedures:
Fourniers procedure (old)
aggressive aspiration, no centrifugation, big canulas, big volumes
= more resorbtion (2 procedures), lumps in 15%

Colemans procedure (new)

soft aspiration, centrifugation, small canulas, small volumes
= less resorbtion (1 procedure)
increased rate of AdSC = trophic effect

We use the Colemans procedure

PF Fournier, Paris

20 cc in the dorsum of the wrist

by one incision

Closure of the fist

Homogeneous distribution

Mitz modification :
multiples incisions and Crisscross fat grafting

FAT IMMEDIATE AND DIRECT HARVESTING

4 mm canulas
aspiration
No centrifugation

20 cc syringes
2 mm canulas for injection

Advantages of Fourniers procedure

No need of specific material
Short

Disadvantages of Fourniers procedure

50 to 70% of resorbtion (need of 1 to 2 others injections)
lumps in 15%, to remove
non homogeneous distribution of the fat

Lumps in 15% (fatty cyst)

 Lipostructure of the dorsum of the hand

Sydney COLEMAN, NY

Advantages of Colemans procedure

only 30% of fat resorbtion (no need of 2nd procedure)
no lumps
trophic effect demonstrated

Disadvantages of Colemans procedure

specific material
long procedure

BYRON canulas

Aspiration (2 mm)

Injection (1 mm)

Harvesting of the fatty tissue

(aspiration under low depression)

10 cc syringe

2 mm canula

centrifugation

Colemans centrifugation protocol

:
3
minutes at 3000 r.p.m

3 components :
fat
blood

oil

Removal of the oil and the

blood

1 cc syringe

1 mm injection canulas

Technique of structural fat grafting

Creation of a tunnel with the 1 mm canula

Injection going backward in the tunnel just created

Multi-layer and multi-direction injection

revascularization

FAT GRAFTING (Colemans procedure)

Thenar
eminence

Hand dorsum
P1

Distal dorsal
forearm

Hypothenar
eminence

10 mini-incisions

30 cc

LEVEL OF GRAFTING:
above and around
the venous layer

INCISIONS

(after local
anesthesia and sedation)

RADIAL MCP THUMB INCISION P1 THUMB

ULNAR MCP THUMB INCISION P1 of THUMB

1st WEB THUMB and INDEX INCISIONS 1st WEB

1st WEB INDEX INCISION P1 of D2-D3-D4

MIDDLE MCP INCISION P1 of D2-D3-D4-D5

ULNAR MCP LITTLE FINGER INCISION P1 of D5

ULNAR MCP LITTLE FINGER INCISION P1 of D2-D3-D4-D5

MIDDLE MCP INCISION SPACES BETWEEN MCP

RADIAL MCP THUMB INCISION M1

RADIAL WRIST INCISION DORSUM of the HAND

and of the WRIST

ULNAR MCP THUMB INCISION DORSUM of the HAND

1st WEB INDEX INCISION DORSUM of the HAND

MIDDLE MCP INCISION DORSUM of the HAND

ULNAR MCP LITTLE FINGER INCISION

DORSUM of the HAND

RADIAL WRIST INCISION DORSUM of the HAND

and the WRIST

POST-OP

dressing with evaporate

cooling

Day 8

Fat Grafting + Skin needling (1 year po.)

30 cc

Aging Hand

Day 12

Day 60

5y

Day 60

3y

7y

8y

five
5 yyears

7y

Day 60

3y

8y

5y

7y
Day 60

3y

8y

2 effects with fat grafting according

to Colemans Procedure :
- Filler (adipocytes)
- Trophic (stem cells = ASC)

+++ numerous stem cells in the fatty tissue (1000

to 5000 cell. / cm3)

2 effects with fat grafting according

to Colemans Procedure :

- Filler (adipocytes)
- Trophic (stem cells = ASC)

ex : sequelas of chemical peeling and corticoid

injection

G : 32.5cc

D : 25cc

8m

Day 45

3y

8m

Day 45

3y

8m

Day 45

3y

Combination with PRP

injection
to bring growth factors
and to correct the
epidermal dystrophy

Same centrifugation device for Fat

and PRP

Fat grafting (30 cc)

PRP (10 cc)

Hand rejuvenation treatments

SURGICAL TREATMENTS:
Liftings
Fat grafting

Dermal grafts: autologous (sheet or crushed+injected) or allogenic (ex: Alloderm)

Dermal-fat grafting (en bloc or injected separately)
Fascial grafts (temporalis fascia, fascia lata, lumbar fascia)
Dermal Substitutes with 1 step procedure (Integra DRT Single Layer, Matriderm 1mm)
Pliable biomaterial sheets (Silicone, Gore-tex)

Plasma injections (PRP, PRGF)

Phlebectomies
Correction of joint arthrosic deformations (DIPJ, 1st CMC, )

MEDICAL TREATMENTS:
Synthetic Fillers (HA, OHapatite, PLA, Collagene, Silicone) / Mesotherapy
Radiations: Lasers, Lights (IPL, LED), Phototherapy (PDT), Radiofrequency
Chemical peels

Dermabrasion and microdermabrasion / Skin needling

Carboxytherapy
Vein sclerotherapies
Nail rejuvenation

ADJUVANT TREATMENTS:
Cosmeceutics (moisturizing, anti-oxydants, cooling, solar screen, depigmentants, )
Anti-Aging Medicine (dietary advices, food supplements, vitamins, hormones, smoking stop)

Filler injections
ex: Radiesse

Q switched Laser
. induces also a skin tightening
. But more social exclusion

IPL +++

Skin Needling

Skin rollers

Skin stamp

Fernandes D. Clin Derm. 2008;26:192-9.

Hand rejuvenation treatments

SURGICAL TREATMENTS:
Liftings
Fat grafting

Dermal grafts: autologous (sheet or crushed+injected) or allogenic (ex: Alloderm)

Dermal-fat grafting (en bloc or injected separately)
Fascial grafts (temporalis fascia, fascia lata, lumbar fascia)
Dermal Substitutes with 1 step procedure (Integra DRT Single Layer, Matriderm 1mm)
Pliable biomaterial sheets (Silicone, Gore-tex)

Plasma injections (PRP, PRGF)

Phlebectomies
Correction of joint arthrosic deformations (DIPJ, 1st CMC, )

MEDICAL TREATMENTS:
Synthetic Fillers (HA, OHapatite, PLA, Collagene, Silicone) / Mesotherapy
Radiations: Lasers, Lights (IPL, LED), Phototherapy (PDT), Radiofrequency
Chemical peels

Dermabrasion and microdermabrasion / Skin needling

Carboxytherapy
Vein sclerotherapies
Nail rejuvenation

ADJUVANT TREATMENTS:
Cosmeceutics (moisturizing, anti-oxydants, cooling, solar screen, depigmentants, )
Anti-Aging Medicine (dietary advices, food supplements, vitamins, hormones, smoking stop)

COSMECEUTICS

+
PREVENT
with AOX pro-penetrating to stop
free radicals at the cellular level

CORRECT
With stain complex

+
PROTECT
with a potent UV filter

MOISTURIZING
CREAM

COSMECEUTICS
ANTI-AGING GLOVE

dressing with evaporate

cooling

MEGA HAND STRATEGY

SURGICAL TREATMENTS:
Liftings
Fat grafting

Dermal grafts: autologous (sheet or crushed+injected) or allogenic (ex: Alloderm)

Dermal-fat grafting (en bloc or injected separately)
Fascial grafts (temporalis fascia, fascia lata, lumbar fascia)
Dermal Substitutes with 1 step procedure (Integra DRT Single Layer, Matriderm 1mm)
Pliable biomaterial sheets (Silicone, Gore-tex)

Plasma injections (PRP, PRGF)

Phlebectomies
Correction of joint arthrosic deformations (DIPJ, 1st CMC, )

MEDICAL TREATMENTS:
Synthetic Fillers (HA, OHapatite, PLA, Collagne, Silicone) / Mesotherapy
Radiations: Lasers, Lights (IPL, LED), Phototherapy (PDT), Radiofrequency,
Chemical peels

Dermabrasion and microdermabrasion / Skin needling

Carboxytherapy
Vein sclerotherapies
Nail rejuvenation

ADJUVANT TREATMENTS:
Skin-care creams (moisturizing, anti-oxydants, solar screen, depigmentants, )
Anti-Aging Medicine (dietary advices, food supplements, vitamins, hormones, smoking stop)

MEGA HAND STRATEGY

SURGICAL TREATMENTS:

Fat grafting
PRP injection
+/- Phlebectomies
+/- Correction of joint deformations

(DIPJ, 1st CMC)

MEDICAL TREATMENTS:

IPL

Skin Needling

ADJUVANT TREATMENTS:
Cosmeceutics

(moisturizing, anti-oxydants, cooling, solar screen, depigmentants, )

For DIPJ arthrosis:

For dermatoporosis

Microlift Butterfly
+ Osteophytectomy

Needling (plastic surgeon)

Cosmeceutics

(hand surgeon)

DIPJ

MEGA HAND
Strategy
for Dorsal and
Lateral Hand
Rejuvenation
(2008)

P1

Hypothenar
eminence

Hand dorsum

For dark spots

Thenar
eminence

Distal dorsal
forearm

IPL

For volume loss

Fat grafting + PRP

(+/- 1 or 2 phlebectomies)
(plastic surgeon)

(dermatologist)

1st CMC

For 1st CMC arthrosis:

1st web release
+ trapezectomy
(hand surgeon)

 4 layers technique
for volume restoration and surface
treatment of aging hands

4-

3 - SKIN NEEDLING
2 - PRP
1 - FAT
GRAFTING

COSMECEUTICS

The dorsal hand is thin, fragile and therefore less

adapted than the face to classical rejuvenating
procedures, with a higher risk of inefficiency and
complications, thats why hand is a challenging area
for rejuvenation.
Hand rejuvenation requires a multidisciplinary
strategy performed by specialists knowing the
anatomy and the specifities of the hand.
Fat grafting together with PRP injection is our first
choice for volume restoration and skin trophicity
improvement.

AESTHETICS IN HAND SURGERY:

FROM RECONSTRUCTION TO REJUVENATION
I) Aesthetic considerations in hand surgery

II) Hand aesthetic reconstruction

III) Hand rejuvenation

CONCLUSION
Aesthetics, it is already function
R. Vilain, France

Thank you for your attention

Matthieu BEUSTES-STEFANELLI, MD
Plastic Surgery & Hand Surgery
Paris, France

www.megahand.eu
matthieubeustes@gmail.com

iClass Hand 2013

1st International master Class with Live demos
on Aesthetic Surgery & Skin rejuvenation of the Hand
Nice, France, Faculty of Medicine

September 25-26, 2013

Organisation:
MEGA HAND
www.megahand.eu

Registration:
MCO CONGRES
www.mcocongres.com

Pr Dumontier
Pr Casoli
Dr Beustes-Stefanelli
Dr Beilin
Dr Landau
Dr Zenker

Practical Workshop on Rejuvenation & Aesthetic Reconstruction of the Hand & Upper Limb