Content uploaded by Jeffrey Marc Adelglass
Author content
All content in this area was uploaded by Jeffrey Marc Adelglass on Mar 30, 2022
Content may be subject to copyright.
Calcium Hydroxylapatite Dermal Filler for Treatment of
Dorsal Hand Volume Loss: Results From a 12-Month,
Multicenter, Randomized, Blinded Trial
Mitchel P. Goldman, MD,* Amir Moradi, MD,
†
Michael H. Gold, MD,
‡
Daniel P. Friedmann, MD,* Kaveh Alizadeh, MD,
x
Jeffrey M. Adelglass, MD,
k
and Bruce E. Katz, MD
¶
BACKGROUND Calcium hydroxylapatite (CaHA) microspheres suspended in a carrier gel is an opaque der-
mal filler that has been used to provide immediate volume correction in the dorsal hands.
OBJECTIVE To assess the safety and effectiveness of CaHA for the correction of volume loss in the hands up
to 12 months.
MATERIALS AND METHODS This multicenter, controlled, single-blind study (NCT01832090) included 114 sub-
jects randomized 3:1 to CaHA treatment and untreated control groups. Effectiveness was assessed by blinded
investigators using the validated Merz Hand Grading Scale (MHGS). Subject-reported improvement was assessed
using the Global Aesthetic Improvement Scale. Effects of treatment on hand function were also assessed.
RESULTS A total of 75% of subjects achieved $1-point improvement on the MHGS (p<.0001)at3months
(primary end point); this response was generally maintained through 12 months. Proportions of subjects reporting
improvement ranged from 98% (3 months) to 86% (12 months). There were no clinically significant differences
between control and CaHA-treated subjects in any hand function measure. Adverse events were generally
expected, minor, short-lived, injection-related, and similar to those observed in previous CaHA clinical studies.
CONCLUSION Treatment with CaHA results in significant improvement in the appearance of the dorsal hand
and is well tolerated.
Sponsored by Merz North America, Inc. All authors have been investigators and/or consultants for Merz North
America, Inc.
The appearance of the hands is considered
a leading indicator of age.
1,2
Over time, the hands
experience a loss of dermal elasticity and atrophy of
subcutaneous tissue, resulting in an overall volume
loss and increased visibility of veins and tendons.
3
Successful treatment strategies have included the
injection of dermal fillers and adipose tissue to correct
the resulting volume loss in the dorsum of the hands, as
well as removal of hand veins through sclerotherapy or
phlebectomy.
4,5
Calcium hydroxylapatite (CaHA)
microspheres suspended in a carrier gel has been used
to effectively restore volume in the dorsal hands.
6–8
Calcium hydroxylapatite was first approved by the
United States Food and Drug Administration (FDA) in
2006, for the correction of moderate to severe facial
wrinkles and folds such as nasolabial folds and for the
restoration and/or correction of the signs of facial fat loss
*Dermatology Cosmetic Laser Medical Associates of La Jolla, Inc., San Diego, California;
†
Private Practice, Vista,
California;
‡
Tennessee Clincal Research Center, Nashville, Tennessee;
x
Cosmo Plastic Surgery, Great Neck, New
York;
k
Texas Pharmaceutical Research LP/Research Across America, Plano, Texas;
¶
Juva Skin and Laser Center, New
York, New York
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided
in the full text and PDF versions of this article on the journal’s Web site (www.dermatologicsurgery.org).
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 1076-0512 ·Dermatol Surg 2017;0:1–9·DOI: 10.1097/DSS.0000000000001203
1
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
(lipoatrophy) in people with human immunodeficiency
virus. Calcium hydroxylapatite has been approved for
hand augmentation in the European Union since 2003
and in Canada since 2010, and CaHA received a similar
approval for use in the hands from the FDA in 2015.
9
It is
the first and currently only dermal filler approved by the
FDA to correct volume loss in the hands.
Calcium hydroxylapatite is an opaque, white-colored
dermal filler that provides an immediate volume cor-
rection, and its opacity may also help to mask the
bluish tint associated with visible veins in the hands.
8
Studies on the physical properties of CaHA have
reported high-complex viscosity and a high and elastic
modulus (G9),
2
resulting in predictable performance as
afiller. Overall, the properties of CaHA make it well-
suited for volume correction in the hands.
The objective of this study was to assess the safety and
effectiveness of CaHA for the correction of volume loss
in the hands up to 12 months after treatment. An
additional component of this study (and a requirement
for FDA approval of CaHA for use in the hands) was to
assess the effects of CaHA treatment on hand function
using a comprehensive battery of validated tests.
Materials and Methods
Study Design
This was a prospective, randomized, masked, con-
trolled study (ClinicalTrials.gov identification number:
NCT01832090) including 114 subjects at 6 investiga-
tional sites in the United States (Figure 1). Eighty-five
subjects were randomized to a treatment group
(immediate treatment), and 29 subjects were random-
ized to a control group (delayed treatment) that was
untreated through 3 months after enrolment. After
collection of the required data for the analysis between
these 2 groups at Month 3, the control group was
crossed over and received an initial injection of CaHA
treatment. All subjects were eligible for an optional
retreatment 6 months after their initial treatment,
which enabled assessment of safety after retreatment.
Subjects were followed through 12 months from study
enrolment, with follow-up visits occurring at 1 week
and 2 weeks, and then monthly thereafter.
The clinical study was conducted in accordance with
21CFR812: Investigational Device Exemptions. The
study was approved by an accredited, central institu-
tional review board (IRB) before initiation (New
England Institutional Review Board, Newton, MA).
Each study site was individually approved for partic-
ipation in the study by the IRB. All subjects provided
written informed consent before enrolment.
Subjects and Treatments Administered
Male and female subjects $18 years of age were
required to have a rating of 2 or 3 for both hands on the
validated Merz Hand Grading Scale (MHGS)
10–12
to
be eligible for enrolment. Subjects were excluded if
they had any previous surgery or treatment with
Figure 1. Study design.
CALCIUM HYDROXYLAPATITE FOR HANDS
DERMATOLOGIC SURGERY2
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
injected dermal fillers or adipose tissue in the dorsum
of the hands, or had recent dermal resurfacing or
noninvasive skin tightening procedures (past 6 months
before treatment), or used topical treatments in the
hands (e.g., wrinkle creams, corticosteroids, pig-
menting agents) within the 2 weeks before treatment.
Before injection, each 1.5-mL syringe of CaHA was
manually mixed with 0.26 mL of 2% lidocaine HCl.
Subjects received injections of CaHA in the dorsum of
both hands (defined as the space bound laterally
between the first and fifth metacarpals, proximally by
the dorsal wrist crease, and distally by the meta-
carpophalangeal joints) using a 27-gauge needle.
Before injection, the skin was “tented”at the injection
site by grasping the skin between the thumb and
forefinger of the noninjecting hand and lifting to sep-
arate it from the vascular and tendinous structures of
the dorsum of the hand. The needle was then advanced
between the subcutaneous layer and the superficial
fascia. Injections started between the second and
fourth metacarpals (Figure 2), and the number of
injection points and were left to the discretion of the
treating investigator. The injector also determined
total injection volume (up to a maximum of 3.0 mL of
CaHA injected per hand), which was administered
using small individual boluses (0.1–0.5 mL). Gentle
distribution of product was used after the injections.
Assessments and End Points
The primary effectiveness end point was the proportion
of subjects with an improvement of $1 point on the
MHGS in both hands at 3 months in the immediate
treatment group compared with the control group.
Merz Hand Grading Scale assessments were performed
by a live, masked evaluator who was blinded to subject
randomization. Secondary effectiveness end points
included change from baseline in MGHS score and
subject-reported changes on the 5-point Global Aes-
thetic Improvement Scale (GAIS)
13
compared with
baseline. Global Aesthetic Improvement Scale ratings
included “Very Much Improved,”“Much Improved,”
“Improved,”“No Change,”and “Worse.”
Safety and adverse events (AEs) were at each visit by
the investigators; between follow-up visits, AEs were
recorded by subjects using a 30-day diary. A series of
validated, real-time hand function tests were also
completed at baseline and at 3 months to evaluate any
clinically significant changes in function in the
immediate treatment group compared with untreated
controls. At 12 months, hand function data were
collected in all subjects to evaluate possible longer-
term effects of CaHA treatment. Finger and thumb
flexion and extension were assessed using a Jamar
finger goniometer,
14,15
and dexterity was evaluated
using the Functional Dexterity Test (See Supple-
mental Digital Content, Figure 1, http://links.lww.
com/DSS/A73).
16
Grip strength and pinch strength
were assessed using a Jamar hydraulic hand dyna-
mometer and Jamar hydraulic pinch gauge, respec-
tively (See Supplemental Digital Content,Figure1,
http://links.lww.com/DSS/A73).
17
Statistical Analyses
Descriptive summaries of continuous data are pre-
sented as number of observations, mean, SD,
median, minimum, and maximum values. Categorical
data were summarized using frequency counts and
percentages. Statistical hypothesis testing for the pri-
mary end point was conducted using Fisher Exact
Test. For secondary effectiveness variables, statistical
significance was assessed using Fisher Exact Test or
Figure 2. Areas of the hands treated during the procedure.
GOLDMAN ET AL
0:0:MONTH 2017 3
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Wilcoxon Rank–Sum Test. Statistical significance was
declared if the one-sided p-value of a Fisher Exact Test
or Wilcoxon Test was #.025.
Results
Subjects and Treatments Administered
A total of 114 subjects were enrolled the study and were
randomized 3:1 to an immediate treatment group (n=
85) or delayed-treatment group (n= 29); 113 subjects
(99%) remained in the study through the 3-month visit.
One subject (control group) withdrew during this period
because of an injury unrelated to the study. Two addi-
tional subjects were withdrawn between Months 3 and
12 because of inability to comply with the study visit
schedule. The mean age of the subjects was 53.3 years,
and most were women (95.6%) and Caucasian (76.3%).
Subject demographics are summarized in Table 1.
For the initial injection (N= 113 subjects; 226 hands),
a mean volume of 2.6 mL CaHA was used in each
hand. Among the 78 subjects (156 hands) who
requested the optional retreatment at 6 months,
a mean volume of 1.6 mL CaHA was injected in each
hand.
Improvement on the Merz Hand Grading Scale
The primary effectiveness end point of the study was
met with 75.3% of treated subjects demonstrating an
improvement of $1 point on the MHGS at 3 months,
compared with 3.4% of subjects in the control group
(p< .0001) (Figure 3). The proportion of hands
achieving a $1-point improvement on the MHGS at 3
months was also significantly higher for the treatment
group compared with the control group (77.1% vs
5.2%; p< .0001). The mean MHGS improvement for
the treatment group was significantly greater than the
control group (1.1 points vs 0.1 points; p< .0001) at 3
months. Representative before-and-after photographs
of subjects with a 1-point improvement on the MHGS
can be found in both Figures 4 and 5, the latter of
which illustrates the improvement observed in a 79-
year-old African American woman (the oldest subject
TABLE 1. Subject Demographics
CaHA
(N = 85)
Control
(N = 29)
Mean age, yr (range) 52.8 (26–75) 54.8 (34–79)
Female, % 95.3 96.6
Race, %
Caucasian 77.6 72.4
African American 3.5 10.3
Hispanic 14.1 10.3
Other 4.7 6.8
Fitzpatrick score, %
I 3.5 0
II 52.9 37.9
III 22.4 37.9
IV 15.3 13.8
V 4.7 6.9
VI 1.2 3.4
MHGS score
Mean 2.6 2.6
2 44% 40%
3 56% 60%
CaHA, calcium hydroxylapatite; MHGS, Merz Hand Grading
scale.
Figure 3. Subjects achieving $1-point improvement on the Merz Hand Grading Scale (MHGS) in both hands at 3 months.
CALCIUM HYDROXYLAPATITE FOR HANDS
DERMATOLOGIC SURGERY4
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
enrolled in the study). A 2-point improvement on the
MHGS is illustrated for reference by the before-and-
after photographs in Figure 6.
Durability of improvement on the MHGS was
demonstrated over the 12 month duration of the
study. Among the immediate treatment group sub-
jects who received a single treatment, the pro-
portions of hands maintaining a $1-point
improvement on the MHGS ranged from 73.9% at 6
months posttreatment to 71.7% at 12 months
posttreatment (Figure 7). When including
delayed-treatment group subjects who crossed over
at Month 3 postenrolment, the proportions of
hands demonstrating durable improvement after a
single treatment were similar (Figure 7). As expec-
ted, a somewhat higher proportion of subjects who
received retreatment at Month 6 postenrolment
achieved a $1-point improvement on the
MHGS: 82.1% of subjects at 3 months and
88.5% of subjects at 6 months after the second
injection.
Subject-Reported Improvement on the Global
Aesthetic Improvement Scale
Nearly all treated hands (97.6%) were rated at least
“Improved”by subjects at 3 months (Figure 8).
Improvement on the GAIS was generally maintained
over the course of the study: 93.4% and 86.4% of all
treated hands were considered at least “Improved”
at 6 months and 12 months posttreatment, respec-
tively (Figure 8). Among subjects who opted to
receive retreatment, 98.7% and 95.1% of hands
Figure 4. Representative before (top) and after (bottom) photographs showing a 51-year-old Caucasian woman with
a 1-point improvement in the Merz Hand Grading Scale (MHGS) at 3 months. Injection volume, MHGS scores, and subject-
assessed Global Aesthetic Improvement Scale (GAIS) rating noted in the accompanying tables.
Figure 5. Representative before (top) and after (bottom) photographs showing a 79-year-old African American woman with
a 1-point improvement in the Merz Hand Grading Scale (MHGS) at 3 months. Injection volume, MHGS scores, and subject-
assessed Global Aesthetic Improvement Scale (GAIS) rating noted in the accompanying tables.
GOLDMAN ET AL
0:0:MONTH 2017 5
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
were improved at 3 and 6 months after retreatment,
respectively. No hands were rated as being worse
compared with baseline at any point during the
study.
Safety and Hand Function
Adverse events reported were generally expected and
typical of other CaHA studies,
6–8
and most events
were mild or moderate in severity. The most common
AEs were swelling, pain, redness, and bruising
(Table 2), and nearly all events (96.4%) occurred
within the first 2 weeks of treatment. A significantly
higher proportion of subjects who received injection
volumes greater than the mean injection volume (2.6
mL) reported bruising, compared with those who
received injection volumes less than the mean (84.6%
vs 65.6%; p= .03).
No new or unexpected AEs were observed among
those opting for retreatment. Subjects who received
retreatment reported a lower incidence of bruising,
swelling, redness, pain, and itching when compared
with initial treatment. Interventions were not needed
for >98% of AEs, and all resolved without sequelae.
The mean duration of observed AEs was 8.19 days,
and 89% resolved within 14 days. There were no
treatment-related serious AEs. Seven subjects (6.2%)
experienced nodules, including 2 after initial treat-
ment and 5 after retreatment. All cases of nodules were
rated “mild”in severity and were isolated to 1 study
site. No more than 1 nodule was present on the dorsum
of each hand, and hand function was not affected. A
representative photograph of one of the nodules is
shown in Figure 9.
Results of the validated real-time hand function tests
demonstrated that hand function was not clinically
affected by CaHA treatment. At 3 months, changes in
flexion and extension angles for the fingers and thumb,
functional dexterity measurements, and grip strength
were all similar between the treatment group and
untreated control group. No clinically significant
changes in any hand function assessment were
observed between 3 months (when all control subjects
received initial treatment) and 12 months. Complete
Figure 6. Representative before (top) and after (bottom) photographs showing a 50-year-old Caucasian woman with
a 2-point improvement in the Merz Hand Grading Scale (MHGS) at 3 months. Injection volume, MHGS scores, and subject-
assessed Global Aesthetic Improvement Scale (GAIS) rating noted in the accompanying tables.
TABLE 2. Summary of Adverse Events Through
12 Months
Adverse Event
Subjects With Event at 12
Months, n (%)* (N = 113)
Bruising 82 (72.6)
Swelling 112 (99.1)
Redness 92 (81.4)
Itching 52 (46.0)
Pain 104 (92.0)
Hematoma 1 (0.9)
Nodule 7 (6.2)
Difficulty
performing
activities
54 (47.8)
Loss of sensation 17 (15.0)
*Counts and percentages include subjects who received
optional retreatment at 6 months (N= 78).
CALCIUM HYDROXYLAPATITE FOR HANDS
DERMATOLOGIC SURGERY6
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
hand function test results are summarized in the Sup-
plemental Digital Content, Figures 1–6, http://links.
lww.com/DSS/A73.
Discussion
Results of this study showed that a single treatment with
CaHA is associated with statistically significant
improvement in the appearance of hands as assessed
using the MHGS by masked, live evaluators. This result
was concordant with subject-reported improvement
using the GAIS. A key finding of the study was the
observed durability of CaHA treatment effectiveness;
similar MHGS results were maintained through 12
months postenrolment after a single treatment. In
addition, the proportion of all treated hands rated as
improved remained >85% through the end of the study.
Although an optional second treatment was offered at 6
months, there was only a nominal corresponding
increase in MHGS improvement and subject-reported
improvement and among those who chose this option.
The optional second treatment was primarily included
to enable assessment of retreatment safety, which
revealed no new or unexpected AEs.
Calcium hydroxylapatite is the currently the only der-
mal filler approved by the FDA for use in the hands;
however, the use of other dermal fillers such as hyalur-
onic acid (HA) and poly-L-lactic acid (PLLA) for volume
correction in the hands has been reported over the last
Figure 7. Proportions of hands maintaining $1-point improvement on the Merz Hand Grading Scale (MHGS) after initial
treatment.
GOLDMAN ET AL
0:0:MONTH 2017 7
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
10 years.
4,5,18–22
Although treatment of the hands with
PLLA can provide aesthetic benefits with durability
lasting >1 year, multiple treatment sessions with high
dilutions of product may be required,
4
and some pro-
viders avoid use of PLLA in the hands because of the
potential for complications.
21,22
Studies on HA fillers in
the hands also show that subjects may achieve marked
aesthetic improvements after treatment.
18–20
However,
HA fillers may not exhibit the same durability as CaHA
in the hands; only one of the available studies on HA
fillers (an open-label study) showed that aesthetic out-
comes were maintained through 12 months,
20
whereas
a second HA study showed a marked decline in aesthetic
outcomes after 6 months.
18
Safety in this study was generally favorable through all
follow-up visits, with no serious AEs. Most AEs were
related to the injection procedure and were mild to
moderate in severity. Subjects who received retreatment
reported a lower incidence of injection-related AEs,
which may have been related to the lower injection vol-
ume used during the second treatment. Incidence of
bruising during the initial treatment was also shown to
be correlated with injection volume.Theoverallsafety
profile was complemented by hand function analyses
using a battery of validated, objective tests. Range of
motion of all fingers and the thumb, functional dexterity,
and grip strength, were all unaffected by CaHA treat-
ment over the 12 month duration of the study. Pre-
sentation of such a comprehensive set of objective
functional analyses in subjects receiving dermal filler
treatments in the hands is unprecedented in the literature.
As is the case for all injectable fillers, use of proper
injection technique and knowledge of anatomy are
also important for optimizing outcomes and satisfac-
tion, as well as avoiding AEs. To maximize subject
comfort and aesthetic outcomes in this study, small
boluses of material (0.2–0.5 mL) were applied slowly
with continuous even pressure followed by gentle
distribution of product after injection. Nodules were
observed at 1 site in the study, which used a more
vigorous postinjection massage technique. To
decrease the risk of AEs such as nodules, it is recom-
mended that the dorsum of the hand be massaged
gently as the patient makes a fist. To facilitate gentle
spread of the injected CaHA, the patient may sit on
their hands (while covered in sterile gauze) to warm
and soften the material; use of lubicricant (e.g., ultra-
sound gel) may also help the gentle spread of material.
Overall, the techniques used in this study were con-
sistent with both the CaHA instructions for use
9
and
another recent study that reported favorable aesthetic
outcomes and high levels of subject satisfaction after
CaHA treatment in the hands.
10
Figure 8. Subject-assessed ratings on the Global Aesthetic Improvement Scale.
Figure 9. Reported nodule with onset at Day 54 after retreat-
ment. A white box shows the area where the 2 mm nodule
was observed. All nodules observed in the study were mild,
resolved without sequelae, and did not require intervention.
CALCIUM HYDROXYLAPATITE FOR HANDS
DERMATOLOGIC SURGERY8
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
The findings from this multicenter, controlled, single-
blind pivotalstudy support and extend the observations
from previousclinical studies
6–8
on the effectiveness and
safety of CaHA use in the hands. A single treatment
with CaHA provided immediate volume correction in
the dorsum of the hands with durable results lasting up
to 12 months.
Acknowledgments The authors express their sincere
appreciation to Martin Wong (formerly of Merz
North America, Inc.) for his direction in the execution
of the study and to Steven L Moran, MD for critically
reviewing the data in this article. The authors also
thank David J Howell, PhD for early assistance with
the article outline and Michael Hast, PhD (Merz
North America, Inc.) for editorial assistance.
References
1. Shamban AT. Combination hand rejuvenation procedures. Aesthet
Surg J 2009;29:409–13.
2. Sundaram H, Voigts B, Beer K, Meland M. Comparison of the
rheological properties of viscosity and elasticity in two categories of soft
tissue fillers: calcium hydroxylapatite and hyaluronic acid. Dermatol
Surg 2010;36(Suppl 3):1859–65.
3. Jakubietz RG, Jakubietz MG, Kloss D, Gruenert JG. Defining the basic
aesthetics of the hand. Aesthetic Plast Surg 2005;29:546–51.
4. Fabi S, Goldman MP. Hand rejuvenation: a review and our experience.
Dermatol Surg 2012;38:1112–27.
5. Man J, Rao J, Goldman MP. A double-blind comparative study of
nonanimal-stabilized hyaluronic acid versus human collagen for tissue
augmentation of the dorsal hands. Dermatol Surg 2008;34:1026–31.
6. Sadick NS. A 52-week study of safety and efficacy of calcium
hydroxylapatite for rejuvenation of the aging hand. J Drugs Dermatol
2011;10:47–51.
7. Busso M, Applebaum D. Hand augmentation with Radiesse (Calcium
hydroxylapatite). Dermatol Ther 2007;20:385–7.
8. Edelson KL. Hand recontouring with calcium hydroxylapatite
(Radiesse). J Cosmet Dermatol 2009;8:44–51.
9. RADIESSE Hands [Instructions for Use]. Franksville, WI: Merz North
America Inc.; 2016.
10. Bertucci V, Solish N, Wong M, Howell M. Evaluation of the Merz hand
grading scale after calcium hydroxylapatite hand treatment. Dermatol
Surg 2015;41(Suppl 1):S389–96.
11. Carruthers A, Carruthers J, Hardas B, Kaur M, et al. A validated hand
grading scale. Dermatol Surg 2008;34(Suppl 2):S179–83.
12. Cohen JL, Carruthers A, Jones DH, Narurkar VA, et al. A randomized,
blinded study to validate the Merz hand grading scale for use in live
assessments. Dermatol Surg 2015;41(Suppl 1):S384–88.
13. Narins RS, Brandt F, Leyden J, Lorenc ZP, et al. A randomized, double-
blind, multicenter comparison of the efficacy and tolerability of
Restylane versus Zyplast for the correction of nasolabial folds.
Dermatol Surg 2003;29:588–95.
14. Cooper C. Fundamentals of Hand Therapy. St. Louis, MO: Elsevier
(Mosby); 2007.
15. Rondinelli RD. Guides to the Evaluation of Permanent Impairment.
Chicago, IL: American Medical Association; 2008.
16. Aaron DH, Jansen CW. Development of the Functional Dexterity Test
(FDT): construction, validity, reliability, and normative data. J Hand
Ther 2003;16:12–21.
17. Mathiowetz V, Weber K, Volland G, Kashman N. Reliability and
validity of grip and pinch strength evaluations. J Hand Surg Am 1984;
9:222–6.
18. Brandt FS, Cazzaniga A, Strangman N, Coleman J, et al. Long-term
effectiveness and safety of small gel particle hyaluronic acid for hand
rejuvenation. Dermatol Surg 2012;38:1128–35.
19. Dallara JM. A prospective, noninterventional study of the treatment of
the aging hand with Juvederm Ultra 3 and Juvederm Hydrate. Aesthetic
Plast Surg 2012;36:949–54.
20. Gubanova EI, Starovatova PA, Rodina MY. 12-month effects of
stabilized hyaluronic acid gel compared with saline for rejuvenation of
aging hands. J Drugs Dermatol 2015;14:288–98.
21. Fathi R, Cohen JL. Challenges, considerations, and strategies in hand
rejuvenation. J Drugs Dermatol 2016;15:809–15.
22. Riyaz FR, Ozog D. Hand rejuvenation. Semin Cutan Med Surg 2015;
34:147–52.
Address correspondence and reprint requests to: Mitchel P.
Goldman, MD, Dermatology Cosmetic Laser Medical
Associates of La Jolla, Inc., 9339 Genesee Avenue, Suite 300,
San Diego, CA 92121, or e-mail: mgoldman@clderm.com
GOLDMAN ET AL
0:0:MONTH 2017 9
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.