3D Photography in the Objective Analysis of Volume Augmentation Including Fat Augmentation and Dermal Fillers

The authors present quantitative and objective 3D data from their studies showing long-term results with facial volume augmentation. The first study analyzes fat grafting of the midface and the second study presents augmentation of the tear trough with hyaluronic filler. Surgeons using 3D quantitative analysis can learn the duration of results and the optimal amount to inject, as well as showing patients results that are not demonstrable with standard, 2D photography.

Three-dimensional photography

Three-dimensional (3D) photography provides a means for objective evaluation of both pretreatment facial volume loss and the results of volume replacement therapy in treatment of the aging face. In recent years there has been an increasing appreciation of the role of facial volume changes in the aging process and the benefits of implementing volume augmentation as part of the facial rejuvenation armamentarium. One of the challenges leading to this change was making patients and physicians aware of the volume changes that occur with aging and providing a means of showing the results of addressing these. Standard two-dimensional (2D) photography has limitations in providing this information, providing limited information on volume changes and thus being inadequate in evaluating the success of facial augmentation techniques. Before the development of 3D photography, there was no reliable or in-office method to quantitatively measure and assess volume replacement treatment using either injectable fillers or autologous fat grafting. Analysis of standard 2D photographs with subjective rating systems of improvement was the only methods used in measuring outcomes of facial augmentation. The subjectivity of these techniques was an inherent weakness that led to debates regarding the adequacy of study results.

Canfield Vectra-CR 3D camera system

Our experience with 3D photography technology has been limited to the Canfield Vectra-CR 3D camera system (Canfield Imaging Systems, Fairfield, New Jersey). It provides excellent 3D detail as well as the ability to quantitatively measure volume changes and provide a colorimetric graphic analysis of such volume changes. These colorimetric photographs can be easily shown in both research papers and to patients. The Canfield Vectra 3D photographic system has been an excellent objective tool for evaluating volume changes because it has been shown to have an accuracy of 5 to 20 μm in testing by the National Institute of Standards and Technology.

This camera is compact and can fit in a corner of a small photographic studio that may have already been set up in the office for 2D photography. Lighting does not have an effect on the results because highlights on the skin from various sources of light can be removed by the software during the analysis. The level of computer expertise required to use the system and efficiently obtain 3D photographs is minimal. However, obtaining quantitative data for evaluation requires some expertise in software use but can be easily acquired after a few hours of training and use. Overall, the software is intuitive and user-friendly. The retail cost of the Canfield Vectra M3 Face and Neck 3D photography system is $27,500. The Vectra X3 Face and Body system retails for $39,500. In either case, it is a turnkey system that includes camera system and computer, Mirror 3D Image Management and Analysis tools, Sculptor 3D simulation tools, on-site installation and training, and 1-year upgrades and warranty.

Canfield Vectra-CR 3D camera system

Our experience with 3D photography technology has been limited to the Canfield Vectra-CR 3D camera system (Canfield Imaging Systems, Fairfield, New Jersey). It provides excellent 3D detail as well as the ability to quantitatively measure volume changes and provide a colorimetric graphic analysis of such volume changes. These colorimetric photographs can be easily shown in both research papers and to patients. The Canfield Vectra 3D photographic system has been an excellent objective tool for evaluating volume changes because it has been shown to have an accuracy of 5 to 20 μm in testing by the National Institute of Standards and Technology.

This camera is compact and can fit in a corner of a small photographic studio that may have already been set up in the office for 2D photography. Lighting does not have an effect on the results because highlights on the skin from various sources of light can be removed by the software during the analysis. The level of computer expertise required to use the system and efficiently obtain 3D photographs is minimal. However, obtaining quantitative data for evaluation requires some expertise in software use but can be easily acquired after a few hours of training and use. Overall, the software is intuitive and user-friendly. The retail cost of the Canfield Vectra M3 Face and Neck 3D photography system is $27,500. The Vectra X3 Face and Body system retails for $39,500. In either case, it is a turnkey system that includes camera system and computer, Mirror 3D Image Management and Analysis tools, Sculptor 3D simulation tools, on-site installation and training, and 1-year upgrades and warranty.

Studies in the literature quantifying fat transfer: augmentation outcomes

2009 Initial Study: Midface Fat Graft Survivability

The first study in the literature to clinically quantify autologous fat transfer and volume replacement or augmentation was performed using the Canfield Vectra 3D camera in 2009. This study was undertaken because of the lack of clinical objective data in the literature regarding longevity, predictability, and survivability of the fat grafts. There were conflicting results from numerous studies each recommending various techniques to improve the survivability of transplanted autologous fat. Autologous fat grafting has been incorporated more recently in treatment of the aging face because of a better understanding of the aging process and facial volume loss as well as to achieve a natural rejuvenated appearance.

Before this study, there was great disparity in the literature regarding the results of fat grafting in terms of survivability and long-term outcomes. Studies that evaluated the durability of transplanted fat have reported volume retention between 20% and 90%. However, most of these data are based on subjective analysis of 2D photographs or anecdotal assessment based on the physician’s experience. Most studies claimed to use objective analysis but, in reviewing their methodology, their data came from evaluation based on subjective interpretation of results from 2D photographs. In the few truly objective studies attempted, magnetic resonance imaging (MRI) or ultrasonography was used to measure fat survivability and longevity. Both of these showed quantified volume retention at 1 year. However, using measurements with MRI or ultrasound requires significant cost and inconvenience to the patient compared with the 3D photography system that can be performed in an office.

After obtaining institutional review board approval, analysis of all patients who underwent autologous fat transfer to the midface region at our private practice during a 12-month period was completed. Written informed consent was obtained before any procedures and patients were followed prospectively for at least 1 year. Patients who did not complete preoperative or postoperative 3D imaging were excluded.

Standard atraumatic harvesting and injecting techniques with blunt cannulas were used. Autologous fat grafting was frequently combined with other facial procedures, such as rhytidectomy and blepharoplasty ( Table 1 ). Care was taken to inject fat into a plane that was not surgically interrupted during the combined procedures.

Table 1

Ancillary procedures

Ancillary Procedures	Number
Upper lid blepharoplasty	14
Lower lid (transconjunctival) blepharoplasty	11
Deep plane rhytidectomy	10
Touch-up fat grafting	8
Browlift	3
Septorhinoplasty	2
Submental liposuction	2
Mentoplasty	1
Canthopexy	1

Data from Meier JD, Glasgold RA, Glasgold MJ. Autologous fat grafting: long-term evidence of its efficacy in midfacial rejuvenation. Arch Facial Plast Surg 2009;11(1):24–8.

Thirty-three patients (accounting for 66 hemifacial regions) were included in the autologous fat transfer study and were prospectively followed for at least 1 year and analyzed with the Canfield scientific Vectra camera and software. Care was taken to ensure similar nonsmiling facial tone in both preoperative and postoperative photographs. 3D color schematic representation of volume changes between preoperative and postoperative photographs was first obtained ( Fig. 1 A). The midface region that was defined and measured included the inferior orbital rim, the nasojugal groove, the anterior cheek, and the lateral cheek. The midface region as defined was selected and highlighted as the area of volume measurement (see Fig. 1 B). Quantitative volume measurements were then made using the Canfield Vectra imaging software, which compares the volume differences between preoperative and postoperative images in this midface region. All volume measurements were recorded in milliliters (mL).

The mean amount injected into each midface region was 10.1 mL. All but 3 patients had equal amounts injected into each side in the midface. At a mean follow-up of 16 months, the amount of augmentation was recorded in milliliters and compared as a percentage with the total amount injected into the midface region at the initial procedure. There was some variability between patients in the absolute amount and percentage of volume retention ( Table 2 ). Overall, the mean absolute volume augmentation that was present at the last follow-up examination was 3.3 mL. The mean percentage of volume that was present at the last follow-up examination was 31.8%, which was statistically significant ( P <.05).

Table 2

Patient data

Patient	Side	Follow-up (mo)	Amount Injected (mL)	Final Volume (mL)	% Volume Retained	Age (y)
1	Right	17	6	0.7496	12.5	50
	Left		6	0.7829	13
2	Right	20	6.8	0.8029	11.8	51
	Left		6.8	0.9432	13.9
3	Right	15	14.5	8.256	56.9	53
	Left		14.5	7.749	53.4
4	Right	14	13	2.108	16.2	63
	Left		13	2.436	18.7
5	Right	18	13.5	2.218	16.4	60
	Left		13.5	1.615	12
6	Right	17	11.5	2.014	17.5	43
	Left		11.5	3.789	32.9
7	Right	17	7	1.258	17.9	39
	Left		7	1.308	18.7
8	Right	16	13	5.57	42.8	53
	Left		13	2.174	16.7
9	Right	14	12	6.549	54.6	61
	Left		12	8.186	68.2
10	Right	18	20	7.329	36.6	46
	Left		20	5.637	28.2
11	Right	20	9.5	1.433	15.1	53
	Left		9.5	3.412	35.9
12	Right	19	10.5	3.073	29.3	56
	Left		10.5	6.092	58
13	Right	16	8	3.384	42.3	52
	Left		8	3.175	39.7
14	Right	21	11.5	1.308	11.4	70
	Left		8.5	3.524	41.5
15	Right	17	10.5	2.494	23.8	58
	Left		11	5.949	54.1
16	Right	17	10.5	2.661	25.3	45
	Left		10.5	3.22	30.7
17	Right	19	10	4.099	41	39
	Left		10	4.125	41.3
18	Right	17	5.5	0.4935	9	55
	Left		5.5	1.396	25.4
19	Right	18	10.5	3.611	34.4	50
	Left		10.5	4.234	40.3
20	Right	17	3.5	3.109	88.8	54
	Left		3.5	2.624	75
21	Right	14	22.5	8.492	37.7	56
	Left		22.5	12.91	57.4
22	Right	17	6.5	0.6243	9.6	64
	Left		6.5	0.0622	1
23	Right	15	13	1.697	13.1	43
	Left		13	3.527	27.1
24	Right	16	3	0.117	3.9	63
	Left		3	0.554	18.5
25	Right	13	13	2.495	19.2	54
	Left		13	2.551	19.6
26	Right	12	11	1.145	10.4	64
	Left		11	2.622	23.8
27	Right	15	16	3.606	22.5	59
	Left		16	6.501	40.6
28	Right	15	4	0.6819	17	44
	Left		3	0.5722	19.1
29	Right	12	6	2.581	43	66
	Left		6	3.583	59.7
30	Right	15	8.5	6.377	75	50
	Left		8.5	7.153	84.2
31	Right	16	8	2.343	29.3	51
	Left		8	3.746	46.8
32	Right	13	11	4.169	37.9	69
	Left		11	5.183	47.1
33	Right	14	8	0.257	3.2	58
	Left		8	0.832	10.4