While COVID-19 ran amok throughout the world, the field of aesthetic medicine did not stop charging forward. Rather than resting on their laurels during the mandated quarantines, many physicians put their newfound extra time to good use – studying, researching, investigating, reporting, explaining and challenging various aspects of aesthetic medicine. In this edition of Clinical Journaling we are reviewing three articles from the pages of the Journal of Cosmetic Dermatology, Aesthetic Surgery Journal and Facial Plastic Surgery & Aesthetic Medicine.
Kerry Heitmiller, MD
AI in Cosmetic Dermatology
In the Journal of Cosmetic Dermatology one study examines the evolving role of artificial intelligence (AI) in cosmetic dermatology,1 which is surprising in that much of it currently resides firmly in the mundane. Nevertheless, it is impactful and powerful, if not always meeting our science fiction expectations.
AI is, at heart, a term describing programming that examines information, ‘learns’ from it, and applies this learning as it moves forward. Artificial Neural Networks (ANN) mimic the
signaling and pathways of the brain with multiple nodes, and were designed to manage data simi- larly and adapt to the data over time.
According to Kerry Heitmiller, MD, chief resident in the Department of Dermatology at Sidney Kimmel Medical College, Thomas Jefferson University (Philadelphia, Penn.), who is a co- author of the paper, “AI allows for a personalized approach to each patient seeking treatment, while providing patients with an opportunity to help determine their own cosmetic regimens or treatment plans. It isn’t replacing the role of cosmetic dermatologists or specific procedures, but will augment and enhance the cosmetic experience.”
The paper delves into current and future applications of AI such as customizable skin and hair care; analysis of visual imagery to discern things the human eye cannot; the use of AI models to guide patient selection, objectively classify skin conditions, or present a relatively accurate pre- diction of treatment outcomes; and AI-guided laser hair removal.
Home-based applications that harness AI to analyze and learn from patient data are frontline right now, using machine learning, algorithms and growing databases to guide choices for skincare with individual patient input via questionnaires or quizzes; sometimes with visual references to help patients give the best answers, or analysis of selfies by the AI to provide data. These apps are accessed via home computer or on your phone. Some, with more patient input, may suggest lifestyle changes to influence improved skin health.
“Many of the home-based, consumer applications for customizable skincare and haircare products are having a real impact on the medical aesthetic industry,” Dr. Heitmiller said. “Not only are these applications convenient and accessible, but they provide consumers with a seemingly individualized treatment regimen.”
Several existing and emerging office-based technologies use AI to cap- ture, analyze and present information based on graphic imaging in normal light conditions, as well as novel lighting using spectra that may provide further information. After analysis, the devices may provide objective and quantifiable information to educate the physician and the patient about their skin and hair. Automated application of lasers during hair removal to maximize precise and safe energy delivery has been tried and continues to be developed; similar technology may arise for other energy-based therapies and microneedling. “Overall, AI is enhancing the precision and individualization of aesthetic medicine and providing a means for the patients and consumers to become more active participants in their cos- metic treatments,” said Dr. Heitmiller. “Personalization and customizability are things the newer generations value and are specifically seeking out.”
1. Elder A, Ring C, Heitmiller K, Gabriel Z, Saedi N. The role of artificial intelligence in cosmetic derma- tology—current, upcoming, and future trends. J Cosmet Dermatol 2021;20:48-52.
The original article The role of artificial intelligence in cosmetic dermatology—Current, upcoming, and future trends, is open access and available online at https:// onlinelibrary.wiley.com/doi/epdf/10.1111/jocd.13797
Mark J. Glasgold, MD Facial Plastic Surgeon
TXA During Surgical Facelift
An investigation of intravenous use of the antifibrinolytic agent tranexamic acid (TXA) in Aesthetic Surgery Journal took a compound commonly used in orthopedic surgery and other specialties to decrease intraoperative bleeding and improve results, and applied it to cosmetic surgery, specifically during rhytidectomy – the surgical facelift.
While significant bleeding isn’t generally associated with most aesthetic surgeries, the authors made the argument that reducing blood loss could reduce operative time and risk, and pos- sibly improve recovery and healing.
According to co-author Mark J. Glasgold, MD (South Brunswick Township, N.J.), there have been increasing anecdotal reports of suc- cess among plastic and facial plastic surgeons using TXA. “This is almost standard of care in orthopedic surgery. We tried it and didn’t really notice much difference, so we decided it deserved more rigorous study.”
The prospective, randomized, double-blind case series looked at patients undergoing extended deep-plane rhytidectomy (n=44, 27 treated, 17 control) under intravenous (IV) sedation. Subjects were administered 1 g of TXA by IV over a 15-minute period prior to surgery and again four hours later, versus a saline control.
Patients were grouped by coin flip, the results of which were known only to the nurse anesthetist who worked within all procedures. “We chose intravenous use because again, this is almost standard of care in orthopedic surgery, and was an intuitive way to integrate this into these procedures to start with,” Dr. Glasgold said. Intraoperative bleeding was rated on a one to three scale (converted from mild, moderate, or severe as rated by the primary author). Patients rated bruising and swelling on days one, six, and nine at post-procedure follow-up using a similar scale, the results of which were averaged. The surgeon rated these similarly, and each was documented via photography.
The investigation found that mean[SD] intraoperative bleeding score for the TXA group was 1.74[0.71] versus 1.88[0.78] in the control group. Post-operatively, patient-rated mean ecchymosis and edema scores, respectively, were 1.56[0.43] and 1.63[0.55] among the TXA group and 1.73[0.56] and 1.88[0.55] in the control group. As rated by the physicians these numbers were 1.33[0.32] and 1.42[0.39] among the TXA group and 1.63[0.55] and 1.65[0.57] in the control group. Statistical significance was noted among the surgeon-rated bruising results only.
Although the overall results weren’t statistically significant, they did point to palpable potential benefits and direction for further research. “Retrospectively, we didn’t see much reduc- tion in need for diligent hemostasis, for example,” Dr. Glasgold explained. “We’ve heard that it has transformed practices but I didn’t see anything transformative, at least not with intrave- nous use. What we did see was statistically significant reduc- tion in post-operative sequelae such as bruising and the small collections of hematomas and seromas during recovery and healing. It definitely warrants more investigation. I am particu- larly interested to see rigorous study of locally-introduced TXA during surgery. That may provide a more directed, concentrated use of TXA, especially for problem areas we are aware of, and reveal a statistically significant impact on the recovery, during what remains a commonly performed and powerful aesthetic procedure.”
1. Cohen JC, Glasgold RA, Alloju LM, Glasgold MJ. Effects of intravenous transexamic acid during rhytidectomy: a random- ized, controlled, double-blind pilot study. Aesthetic Surg J 2021;41(2):155-160.
The original article Effects of Intravenous Tranexamic Acid During Rhytidectomy: A Randomized, Controlled, Double- Blind Pilot Study, is open access and available online at https://academic.oup.com/asj/article/41/2/155/5805501?log in=true
Alexander Rivkin, MD Director
Nonsurgical Rhinoplasty Safety and Technique
Nonsurgical rhinoplasty (NSR), or the use of fillers to reshape the nose, is examined in a safety review and procedural refinement paper by Alexander Rivkin, MD, director of Westside Aesthetics in Los Angeles, Calif. and assis- tant clinical professor at the David Geffen/ UCLA School of Medicine in Los Angeles, Calif. Appearing in Facial Plastic Surgery & Aesthetic Medicine, the study1 consisted of a retrospec- tive chart review of 2,488 NSR procedures among 2,275 patients over a ten-year period at Dr. Rivkin’s practice with specific examination of adverse event data.
The overall adverse event rate was 7.6%, the majority of which were common injection-site reactions with only five serious cases among them (ischemia and necrosis). Previous rhino- plasty showed statistically significant increase in the rate of adverse events (10.8% versus 7.4% among those without previous rhinoplasty). Injection of the tip and sidewall of the nose, known to be difficult areas, showed the highest rate of adverse events. NSR was thus shown to be reasonably safe with an expected adverse events profile.
More importantly, the study highlights four key aspects of the procedure: the relative safety of the procedure when performed by an experienced injector, the increased incidence of adverse events in post-surgical rhinoplasty patients, the use of needles to implant filler material, and the lack of aspiration during the procedure. “This procedure is blowing up, and like anything in this industry, it has the potential to be employed by underqualified personnel,” Dr. Rivkin stated. “We want to avoid that because anatomical understanding and proper technique are, as always, the keys to best results. Practitioners should be skilled at the avoidance, diagnosis and treatment of, adverse events.”
Because the nasal vessels are small, the reflux of blood during filler implantation is not recommended, which may go against conventional wisdom to some readers. “Whether we admit it or not, you cannot keep your hand perfectly still in a small area like this when you reflux,” Dr. Rivkin pointed out. “A negative test is rendered meaningless by minute hand motion. This may provide a false sense of security to injectors where maximum care should be exercised. Always moving the needle when injecting, limiting injection amounts to less than 0.05 cc at a time and low pressure are considerably more reliable safety precautions.”
Invited commentary by Sulyman and Dayan2 mostly lauded Dr. Rivkin’s thorough work, but suggested that the use of a cannula for filler implementation may improve safety, and that the low incidence of side effects may be partially explained by the superior technique seen with a world class injector such as Dr. Rivkin.
“I see their point and in the hands of expert cannula users, the results are great,” Dr. Rivkin said. “The cannula versus needle debate is ongoing for a reason. I like tiny needles because of precision, comfort and safety. Others like cannula and get great results. No matter which method is used, we must ensure that injectors are using the most effective safety precautions, espe- cially in post-rhinoplasty patients.”
1. Rivkin A. Nonsurgical rhinoplasty using injectable fillers: a safety review of 2488 procedures. Facial Plast Surg Aesthetic Med 2021;23(1):6-11.
2. Sulyman O, Dayan S. Commentary on “Nonsurgical rhinoplasty using injectable fillers: a safety review of 2488 procedures” by Rivkin: cannula use during dermal filler injection. Facial Plast Surg Aesthetic Med 2021;23(1):11-12.
The original article Nonsurgical Rhinoplasty Using Injectable Fillers: A Safety Review of 2488 Procedures, is available online at https://www.liebertpub.com/doi/full/10.1089/fpsam.2020.0291