Long before Madge the manicurist plunged women's hands into Palmolive dishwashing liquid in the '60s, the vain among us were keenly aware of the effect hands have on our appearance.

We've found that we can tighten our faces, lift our rear ends and augment our breasts, but when we walk out in public-or into a bar-our hands are often the ultimate arbiters of age. This is especially true in Florida, where a lifetime of sun can stain delicate skin like an invading oil slick.

And time is no help, sucking our flesh between our knuckles until our veins bulge through transparent skin.

For years, we've acquiesced to our fate. "The hands have been ignored because people thought there just wasn't any way of reversing the signs," says Dr. David Mobley of Sarasota Plastic Surgery.

The Wall Street Journal even described the hands as "the final frontier" in plastic surgery. Mobley won't go that far (he says we still have elbows and knees to worry about), but he acknowledges, "It's certainly the next frontier." And like any new territory, the terrain is changing fast.

Take injectable fillers. They've been used for years on the face, but are coming into vogue for restoring thickness in the hands as well. The process, sometimes called lipostructure, entails taking fat from the stomach or hips, and then injecting it back into the hands.

Costs range from $500 to $1,000 per hand for the one-hour procedure, which requires the equivalent of five or 10 small syringes of fat. Recovery takes a week to 10 days, then several weeks for all the swelling to subside.

"For some patients this is desirable," says Dr. Stephan Baker, a board-certified plastic surgeon in Miami and spokesperson for the American Society of Plastic Surgeons. "They're sometimes disappointed when the swelling goes down because that's the effect they were after in the first place."

Baker says he has mixed enthusiasm for the procedure: "Like everything else, you have to pick your patients carefully." He says it's hard to predict how much fat will be absorbed back into the body, and success depends on the technique used and blood circulation in the hands being treated.

"The trick is not to inject a large blob," he says, "but to insert tiny trickles that allow the fat to re-vascularize [take on a blood supply]." Inexperience with the procedure can lead to damaged tendons and nerves, even-on rare occasion-an embolism if fat is injected into a blood vein.

"Fat cells are very delicate things," he adds. "They don't like to be handled too roughly." And because only 30 percent of the fat cells will survive transplantation, the process has to be repeated. "The main drawback is that it's a limited result," he says.

Sarasota dermatologist Dr. Bradley Abrams agrees, which is why he stopped using fillers in his practice. He plans to make an exception for a new product called Restylane that (unlike collagen and human fat) claims permanent results. Already approved in parts of Europe, it is in clinical trials for use in this country.

The fastest-growing non-surgical procedure for hands is intense pulse light therapy (IPL), where a hand-held device emits a pulse of light that fades brown spots. Its major attraction for patients is that it causes no scarring or sloughing, although some redness may be present for a few days.

Since it doesn't break the skin's surface, recovery time is not an issue with IPL. "[Patients] can go out to dinner the same night," says Abrams, who claims IPL also plumps up natural collagen to give hands a smoother appearance.

Complete treatment can require up to three visits, with each lasting about 10 minutes. The average cost is $175-$300 per session, depending on the market (IPL is more expensive in metropolitan areas), and, according to Mobley, it causes less pain than being snapped by a rubber band. Because of its shorter healing and treatment times, IPL is starting to outpace procedures like microdermabrasion and chemical peels.

Microdermabrasion is a superficial abrasive process that strips the upper layer of skin to reveal new skin underneath. Peels use chemicals and fruit acids to remove the skin. Both are performed by an aesthetician and cost an average of $75-$100 a session. That's cheaper than IPL, but they require between six and 12 visits to achieve optimum results.

And while microdermabrasion causes minor redness, depending on the extent of the chemicals used, peels can cause extensive swelling and peeling of the skin. Plus, not everyone is a good candidate. According to Baker, the darker your skin, the higher risk you run of scarring and uneven skin pigmentation. The best candidates, he says, have light skin.

For deep wrinkles, you may want to consider laser treatments. Michael Jasin, a facial plastic surgeon with Jasin Facial Rejuvenation on Longboat Key, uses an erebium laser to treat deep lines, although he acknowledges that it can create wounds that an IPL doesn't.

Mobley is not as comfortable with lasers. He says the hands don't have the same healing capacity as facial skin, so they face a higher risk of scarring. "In my mind, the hands are off limits to them."

If bulging blood vessels are getting under your skin, Abrams suggests injecting a sclerosing agent that collapses the vein so the body can destroy it. "It's the same procedure we do to reduce spider veins in the leg," he says. But be warned, the veins in your hands are the ones hospitals use to inject intravenous fluids. Once they're gone, should you ever require hospitalization, doctors will have to look elsewhere for a suitable IV vein.

But Baker notes that plumping up the underlying tissues and minimizing the appearance of veins only goes so far in disguising aging hands. Filler injections and IPL therapy are so new that no one knows for sure how permanent they will be, so he and other doctors all recommend complementing their use with sunscreens.

"I've seen people in their 40s who have the hands of a 60- or 70-year-old," says Jasin. "People think about their face all the time, but no one thinks about sun damage to their hands or arms." He tells patients to use sunscreens of at least SPF 15 that protect against both UVA and UVB rays, and encourages them to use products made for the face on their hands as well. Baker goes a step further; he recommends wearing gloves while driving.

Now, if they can just find a way to fix those sagging elbows and knees.

SOMETHING FOR EVERYBODY

Plastic surgery's new audience isn't rich or old.

Donna Rayner of Webster, Florida is so slim that her doctor couldn't find enough fat in her stomach to harvest for injections to her hands. Unfazed, she directed him toward her thighs. The single, sixth-grade school teacher is only 52, but she's already undergone an eye lift, facial implants and a facelift.

When Sarasota realtor Shelley King was 45, she says, "I looked fabulous. Everything was still in place. Then at 50, my body started going places I never dreamed." By 60, she was waiting in her doctor's office for her first shot of Botox. "I was delighted," she says. "The results were spectacular."

Rayner and King are part of cosmetic surgery's growing patient pool that is decidedly not the jet-set crowd. There's no way to know how many people like them are having plastic surgery, because the industry's certifying boards do not keeps tabs on occupation or socio-economic status.

"I've not felt in a long time that cosmetic surgery was something only available to the rich," says Dr. Robert Hillstrom of Sarasota's Hillstrom Facial Plastic Surgery. "Today it's more available, it's more affordable and it's safer."

And thanks to widespread marketing and diminishing stigmas, Hillstrom says, "Patients are definitely more educated. I am asked questions like, 'How long have you been doing this? What are the possible complications?' This reflects quite a bit of research."

King wanted to reverse decades of sun worship accrued during her childhood in Santa Fe, N.M. Divorced with no children of her own, Rayner felt a youthful appearance would help her connect with her students.

Another consideration: "People are very concerned about looking natural. They're doing little things earlier to keep the results subtle," says Dr. Michael Jasin of Jasin Facial Rejuvenation on Longboat Key. By taking smaller steps before age 40, you may avoid radical procedures down the road.

The most popular procedures are minimally invasive techniques like Botox and small-incision neck lifts, eyelid surgery and liposuction. Jasin says people can fit these into their budgets and busy lifestyles. "The average mother doesn't want to drop her child off at school, go get a face lift and then show up to pick the kid up in heavy bandages," he says.

And for plastic surgery's new clientele, money is no option. Says Hillstrom, "I constantly have patients tell me, 'When I turn such and such age, I'm going to get a facelift.' They plan for it." Some will scrimp for a decade to pay for a nose job.

Rayner didn't blink at the $2,000 it cost to lipostructure her hands. For her, it was the natural next step after laser resurfacing. "I'm very thin, and I have a lot of little bones and veins to cover up," she says.

King compares the cost to splurging on designer apparel, and she embraces undergoing more surgery if it becomes necessary. "We age daily," says King, "which is a good thing, but if you can do it gracefully, why would you want to do it any other way?"

TOE-ING THE LINE

Fashion, the bane of female existence, strikes again this season with pointy-toed shoes. Forget that they cost a fortune (a pair of Manola Blahniks surpasses $400) and can put an eye out if you reach for them in the dark; they're also downright painful to wear.

The Wall Street Journal reported that some women are resorting to surgery to squeeze into these impossibly shaped shoes. According to the Journal, the most popular procedures are toe shortening and nail narrowing. Too much? Then how about collagen injections to pad the soles of your feet?

Toe shortening entails removing a bone in the second (and sometimes third) toe to bring it below the first one. Nail narrowing (a solution to ingrown nails) involves permanent removal of the nail bed along the edge of the toe. These procedures are often paired with bunion surgery.

All this to fit into a shoe that looks like a pickax. And you thought high heels hurt.