John Pallanch, MD, MS, Guest Editor

3D media using stereo vision has been around almost as long as photography. Those of us who had “View-Masters” as children enjoyed seeing storybook characters in 3D. We’ve all seen antique 3D viewers (including for temporal bone sections) and the posters of a bespectacled 1950’s audience viewing a 3D movie. Twenty-five years ago we (some of us) played 3D video games with our children using shuttered glasses with a much slower frame rate and lower resolution that didn’t quite catch on. To have 3D cinema and media move to the mainstream took a critical point in technology and skill by the motion picture industry and a higher quality of artistic material and execution for widespread audience appeal. Dr Richard Robb in his “Biomedical Imaging, Visualization, and Analysis” quotes Albert Einstein, “After a certain high level of technical skill is achieved, science and art tend to coalesce in esthetics, plasticity, and form.”

3D has arrived as never before. As consumers we can take pictures or videos with 3D cameras and view them on the large screen in 3D using 3D glasses. We can watch movies in 3D at home and play video games in 3D. Cameras and accelerometers in our video games and cell phones detect our movements in 3D and allow games to tell us that we are superb at a video game or exercising with incorrect form. We can take pictures with our handheld video game and view the result in 3D on the game’s screen without 3D glasses. We now have ads for “3D” products throughout stores, eg, “3D whitening” in tooth care products, etc. With the inertia of large commercial success of 3D, “3D” is now mainstream. This means widespread, increasingly sophisticated 3D tools (if anything, to support the entertainment industry), better quality 3D imaging, and ultimately less expensive 3D tools with optimized user interfaces. No longer will 3D tools only be the domain of an engineer designing a car or fabricating a machine or part. Now homebuyers will be designing and decorating homes in 3D; families will have 3D home movies, and surgeons will employ a world of useful 3D tools for understanding the 3D intricacies of the anatomy of patients before or during surgery.

It follows that, as developments in 3D became more mainstream, there has been expansion of the application of 3D tools in medicine, and facial plastic surgery.

The public is becoming increasingly aware of this burgeoning technology. Facial plastic surgeons, who once advertized the ability to discuss surgical options using digital images on a computer screen, now advertise the ability to discuss proposed surgical changes in 3D. It takes little imagination to conclude that, in the near future, it will be common place to be able to utilize 3D tools in our surgical practices. (See the Dream Machine description in the Introduction.)

As described below, this collection of articles shows a wide range of applications in which 3D tools have been shown to be advantageous over previous methods of utilizing and analyzing images for facial plastic surgery. In the table of contents, the synopses for each article provide summaries for the reader, but I will mention here the thought behind the selection and sequencing of the articles. The review starts with a broad description of the technology of the 3D tools available. The articles then discuss the use of 3D tools for planning surgery including aesthetic considerations and creation of the virtual patient. The next group of articles delineates the use of 3D tools in surgery. Last, articles describe the use of 3D to assess the changes resulting from surgery.

The descriptions of the technology include a broad overview of many of the capabilities of various 3D imaging modalities (Schendel, Duncan, Lane) and then additional useful background information about the development of 3D technology including guidelines for shopping for a 3D system (Tzou and Frey). For 3D esthetic considerations, the article by Cingi and Oghan brings a different perspective as the authors describe how their course provides facial plastic surgeons with a real and tactile 3D experience, and also cerebral practice, that very much overlaps the 3D appreciation of how a surgeon will interact with anatomy obtained from 3D image analysis. It touches also on communication with the patient.

Further surgical preparation uses the virtual patient described in Kau’s article, with integration of different imaging technologies. A system of landmarks for comparison with other populations, growth, or surgical change is described. Mazza and Barbarino, in their article, show the state of the art as far as including the biomechanical behavior of the underlying tissues in the virtual 3D rendering. This is one of the facets of the 3D image analysis that will present the greatest challenges as progress continues. The further dimension in analysis using 3D is the novel method for study of facial motion in the article by Frey and coworkers.

The applications of 3D in surgery start with the description of a 3D template for complex nasal reconstruction (Sultan and Byrne). Markiewicz and Bell’s article then reveals the myriad of ways that CAD/CAM technology can be used in facial plastic surgery including not just stents, but implants, templates, jigs, and models, to assess surgical progress toward a planned result. The article by Patel and colleagues recounts case examples in different facial surgery subdisciplines, integrating the 3D tools described in the preceding articles for planning and executing surgery.

Last, measuring the 3D results of surgery includes assessment of changes with different rhinoplasty techniques (Toriumi and Dixon); volume change from autologous fat or filler injections in the midface (Meier, Glasgold, Glasgold); and changes to photo-damaged skin from IPL or laser (Clementoni et al). The latter objectively quantitates changes in vascularity, melanin distribution, and degree of individual deep wrinkles. These are exciting applications of 3D. The article by McCarn and Hilger shows the value and potential of 3D quantification in tissue expansion and the final article, by Amin and colleagues, looks at changes in midface soft tissue of the upper lip after LeFort I osteotomy.

Many of the articles include information about the technology available for 3D imaging, so it is possible for the reader to review the material without strict adherence to sequence, but either of the first two articles would be a good place to start.

Often the authors, while giving examples of the advantages of these various applications of 3D tools, also mention the numerous, not yet attained, applications to be realized in the future. An example is the 3D analysis of the results of different rhinoplasty techniques—Drs Dixon and Toriumi note that they do 3D imaging on all their patients. The article gives an excellent description of the 3D assessments that can be done, using two patients. One can imagine the wealth of information yet to come from applying these analyses to their large patient data base, eg, what are the 3D changes that occur from three different methods of tip refinement done for patients having similar presurgical tip anatomy? Clearly 3D tools are enhancing the excitement of future horizons in facial plastic surgery.

I want to thank all of the authors, the pioneers in 3D applications in facial plastic surgery, who contributed to this information source on the current use of 3D in our specialty. They have done a superb job describing the many ways that 3D tools and various methods of imaging can help us, with novel and ingenious ways to provide optimal care for our patients. These teams and individuals have spent many hours discovering which applications can shorten procedure and anesthetic time, increase the chances of success, and expand the possibilities in precise reconstruction. They are collecting data that is already helping to increase the predictability of our surgical results.

Although I used a wide network, my research may not have led to contact with some of the active pioneers in this field, and for that I am sorry and wish they were included. There are also some imaging modalities not included that have relevance in facial plastic surgery and that may soon enhance 3D information for our patients. Two examples are determination of potential flap viability and localization of surface blood vessels.

I also would like to acknowledge and thank Dr Richard Robb—ultimate guru and pioneer in 3D Biomedical Imaging—and his talented team at the Mayo Biomedical Imaging Resource, including Jon Camp and Phil Edwards, who patiently taught me various applications of 3D image analysis tools over the past 6 years. Starting 30 years ago, they developed software from scratch that could do 3D analysis of CT data from multiple cone beam scanners. (See the Introduction in this issue.)

Dr Regan Thomas had the idea for this subject but deserves the greatest credit for inspired timing on when to suggest that I take this on. Many thanks to Joanne Husovski, superwoman editor, who produces dozens of different books on different subjects each year. Clearly, this volume would not be possible without her experience and expert guidance. Finally, I want to thank Kitty Pallanch for her understanding and support of so many projects including the time and effort needed for this volume.