Dorsal hand anatomy relevant to volumetric rejuvenation

Background: In recent years, plastic surgeons have performed volumetric hand rejuvenation with either structural fat grafts or injectable fillers; however, the relevant anatomy has not been examined. The authors undertook a cadaveric investigation of the hand dorsum to elucidate anatomical guides that may eventually lead to improved hand rejuvenation techniques. Methods: Samples were obtained from 10 fresh cadaveric hands. Specimens were evaluated microscopically after histologic staining. Doppler ultrasound was used on eight living hands to further explore the lamination of the dorsal hand fat. A lead oxide injection of eight fresh cadaveric hands permitted examination of the vascularity of perforating septa. Results: Histologic examination revealed three distinct fatty laminae separated by thin fascia. No structures that traversed the subcutaneous, superficial fatty lamina were identified. The large dorsal veins and dorsal sensory nerves resided within the intermediate lamina. The extensor tendons were found within the deep lamina. Doppler ultrasonography confirmed the compartmentalized ultrastructure of the hand dorsum, clearly elucidating the distinct fascial layers, gliding tendons, and compressible veins. Eight to 10 perforating vessels travel within fascial septa that perpendicularly traverse the three laminae. Conclusions: The subcutaneous tissue of the dorsal hand is divided into three fatty laminae separated by fascia layers with multiple vessel-containing septal perforations. An injection technique that addresses the fatty laminae and the perforating septa may yield improved and consistent rejuvenation results.