October 14, 2021

New study addresses concerns about delegating the procedures to nurse practitioners and physician assistants.

FACE VALUE Increasing numbers of patients are interested in injectable dermal fillers, which non-physicians are administering to help practices keep up with demand.

Plastic surgeons and board-certified dermatologists continue to administer injectables used to fill wrinkles and add fullness to the face despite high demand for the treatments, according to a study published in the journal of the American Society for Dermatologic Surgery (ASDSA).

The study’s authors surveyed 492 dermatology and plastic surgery practices in major metropolitan areas to determine who performs injectables in those office-based settings. Only 18.35% of the dermatology and 25.4% of the plastic surgery practices had nurse practitioners or physician assistants administering the treatments — both with and without the supervision of an onsite physician, notes the study, which appears in Dermatologic Surgery.

Administration of injectables by nurse practitioners and physician assistants in dermatology and plastic surgery practices is viewed by some as a cost-effective way to meet the increasing demand for the procedures, which are regulated by the ASDSA. The organization promotes patient safety by calling for onsite physicians — preferably board-certified dermatologists — to supervise injections performed by non-physician providers.

"The role of non-physician practitioners in dermatology and plastic surgery practices is controversial and highly debated," says study coauthor Naomi Lawrence, MD, a dermatologic surgery specialist at Cooper University Health Care in Camden, N.J. “However, studies have shown that non-physician providers are being increasingly used in the delivery of dermatological care. We were surprised to see that a significant number of practices that use non-physician injectors could not verify onsite supervision at all times.”

ASDSA has introduced model legislation called the Medical Spa Safety Act, which calls for onsite physicians, preferably board-certified dermatologists, to supervise procedures performed by non-physician providers.

"There are risks of temporary and permanent side effects from improper techniques, and different injectables have a wide range of properties and associated adverse events," says study coauthor Ashley Decker, MD, a dermatologic surgery specialist at Cooper University Health Care. "The injector needs to be sufficiently experienced with the products being used, maintain a detailed understanding of facial anatomy and be prepared to provide appropriate treatment in the case of adverse events. The ultimate responsibility for each patient’s outcome rests on solely on the supervising physician."

Artificial intelligence shows patients how young they'll look after surgery.

SEEING IS BELIEVING Patients who schedule facelifts often want surgeons to provide accurate predictions of post-op results.

Patients often ask cosmetic surgeons for exact predictions of how much younger they will look after a facelift, but individual results are subjective and therefore difficult to quantify. New research suggests artificial intelligence (AI) algorithms can provide a more objective way to calculate the reduction of perceived years after surgery. The algorithms are designed to estimate age based on datasets of millions of facial photos, which allow AI to discern facial features and predict age.

The authors of a recent study published in Plastic and Reconstructive Surgery used AI to predict the facial age for 50 women before and after they underwent facelifts. The algorithms accurately predicted the age of each patient based on their before-surgery pictures. Interestingly, the algorithms recognized about a four-year reduction in age based on the after-surgery photos, significantly less than the nearly seven-year reduction rated by the patients — perhaps because patients overestimate the results of surgery due to their emotional and financial investment in the procedure.

"Our study shows that currently available AI algorithms can recognize the success of facelifting, and even put a number on the reduction in years of perceived age," comments senior author James P. Bradley, MD, vice chairman of surgery at Zucker School of Medicine at Hofstra/Northwell in Hempstead, N.Y.

Surgeons might not only benefit by being able to provide patients with objective data, but also from a more concrete way of tracking their own outcomes data. The findings could play a useful role in counseling patients and demonstrating successful results of facial rejuvenation procedures.

"We think that AI algorithms could also play a useful role for plastic surgeons in assessing their own results and comparing the outcomes of different techniques," says Dr. Bradley.

Soft tissue injury management improves surgical outcomes for overall patient satisfaction.

In the world of plastic surgery, the surgeons deal with a variety of challenging wounds and soft tissue injuries. Some injuries that appear include massive soft tissue defects that may be further complicated by varying degrees of accompanying orthopedic and peripheral nerve damage. To address the severe soft tissue defect, various combinations of advanced reconstructive methods are typically required to achieve definitive wound coverage.

Soft tissue management with a continuous external expander has been used successfully to provide wound closure in plastic surgery, according to a report in the Annals of Plastic Surgery. The authors note, "Continuous external tissue expansion has been used by our institution to significantly reduce wound burden and provide for definitive wound closure in certain blast-injured patients."¹

The authors present an early series of 14 patients who suffered massive extremity soft tissue injuries and were treated with an external tissue expansion system (DERMACLOSE RC). Outcome measurements included time to definitive closure and the method of definitive wound closure. A 5-patient subset of this group was prospectively analyzed to determine measurements including initial wound surface area (WSA), percentage reduction in WSA and related complications.

According to the study, "Overall time to wound coverage ranged from 1 to 6 days, with mean time to wound coverage being 4.4 days. Of the 14 patients included in the series, 12 (85.7%) were able to undergo delayed primary closure, whereas 2 required split thickness skin grafting."¹

The results provided a tool to achieve effective wound closure. As the authors note, "In the management of large complex wounds, external tissue expansion has proven to be a valuable adjunct in achieving definitive wound closure. It can often aid in successful delayed primary closure of certain soft tissue wounds, has low associated morbidities, and can reduce the need for more complex or morbid procedures when used properly."¹

Additionally, the authors propose an algorithm for the use of continuous external tissue expansion system to achieve successful wound closure, while potentially reducing the need for increased donor-site morbidities associated with more complex or larger reconstruction measures.

DERMACLOSE provides plastic surgeons with a tool to use their creativity when treating challenging wounds.

Applications include:

• Fasciotomy repair
• ALT donor site wound closure
• Trauma
• Wound dehiscence
• Oncologic excisions
• Complex, non-healing wounds
• Scar revisions

The clinical benefits of DERMACLOSE include the following:

• Reduces time to closure
• Proven in multiple surgical specialties and applications
• Helps avoid skin grafts donor sites, and associated risks and complications
• Quickly becoming a standard of care for fasciotomy wounds
• Reduces time to closure, surgical complexity, and risk of open wound complications
• Improves surgical outcomes, cosmesis and patient satisfaction

Note: For more information, go to www.synovismicro.com.

Study pegs analytic thinkers as more likely to undergo cosmetic surgery to fix perceived physical flaws.

Individuals who are hyper-focused on the details of problem-solving are inclined to notice the imperfections of their appearance and seek out surgery to fix them, say researchers at St. Edward’s University in Austin, Texas.

Their multi-part study, published in the journal Marketing Letters, reports women identified as analytical thinkers were less satisfied with the look of their noses and expressed more of an interest in undergoing a rhinoplasty. The women’s age, relationship status and body type did not impact their opinions.

The researchers also tracked the eye movements of female participants as they viewed pictures of themselves to determine how long their gaze lingered on their noses. According to the study, participants who spent more time looking at their nose were more likely to have negative feelings about its appearance and had more interest in rhinoplasty.

In the final part of the study, 300 participants were divided based on their thinking style — holistic or analytical — and asked if they had undergone cosmetic surgery in the past. More than half (52%) of analytic thinkers had undergone cosmetic surgery, compared with about one-third (35%) of holistic thinkers.

Study coauthor Sarah Mittal, a marketer and consumer behavior expert at St. Edward’s University, says plastic surgery practices could use marketing strategies aimed at having patients focus on specific physical flaws. She also says patients could take a more holistic view of their appearances when considering cosmetic surgery.

"If they have a procedure done, where do they see themselves in one, three, five, 10 years from now?" she asks. "Is it actually going to have a long-lasting, positive impact on their life? Is it worth the risk? What is recovery going to look like, even just over the next couple of months? Taking a forward focus is something that consumers can do before making a final decision."

The treatment is increasingly used to enhance cosmetic surgery outcomes.

The American Society of Plastic Surgeons says use of platelet-rich plasma (PRP) treatments, which involve injecting small amount of a patient’s own blood to improve natural tissue growth and repair, has increased by 25% over the past four years.

During PRP production, a small sample of blood is separated through centrifugation, a process that removes red blood cells and leaves behind plasma and a high concentration of platelets. A review published in Plastic and Reconstructive Surgery says applications of PRP are evolving in cosmetic procedures, partly because it’s inexpensive to produce and unlikely to cause adverse effects.

For example, according to the review, physicians inject platelets underneath the skin’s surface to improve its texture and reduce wrinkle depth. PRP is used to treat acne scars and skin pigmentation disorders, and is part of a "vampire facial," a microneedling of the skin to increase collagen production and tightening.

The review says PRP also helps to increase hair follicle growth, reduces the redness and inflammation caused by facial rejuvenation laser treatments and enhances the outcomes of fat grafting, which involves using a patient's fat cells to improve skin contouring and volume.

"PRP has emerged as one of the most desired non-surgical treatments for a range of different cosmetic procedures, although in some cases the claims may exceed the available evidence," says lead author Edward Chamata, MD, a plastic surgeon at Baylor College of Medicine in Houston. "Plastic surgeons are on the leading edge of identifying promising uses for PRP, including developing standardized procedures and building a body of evidence for good patient outcomes."