Morphing Images to Demonstrate Potential Surgical Outcomes

Morphing patient images to offer some demonstration of the intended surgical outcome can support shared expectations between patient and facial plastic surgeon. As part of the preoperative consultation, showing a patient an image that compares their face before surgery with what is planned after surgery can greatly enhance the surgical experience. This article refers to use of Photoshop CS3 for tutorial descriptions but any recent version of Photoshop is sufficiently similar. Among the topics covered are creating a before-and-after, rhinoplasty imaging, face- and brow-lift imaging, and removing wrinkles. Each section presents a step-by-step tutorial with graphic images demonstrating the computer screen and Photoshop tools.

Much of the success in facial plastic surgery comes from having a set of shared expectations with the patient. Offering some demonstration of the intended surgical outcome has long been a part of the preoperative consultation. Morphing patient images is a huge improvement over drawing on a Polaroid with a Sharpie. Many companies have developed software to make patient image manipulation simpler. Typically these programs cost several thousands of dollars and some of them store their images in proprietary data formats. They are attractive to many surgeons because they offer a prepackaged solution for what seems like a daunting task. Many facial plastic surgeons already have Adobe Photoshop (Adobe Systems Inc, San Jose, CA, USA) for image editing and are unaware that it can do everything that the proprietary systems can. With some scripting, Photoshop can effectively mimic the more task-specific alternatives at a lower price. This article refers to use of Photoshop CS3 for descriptions but any recent version of Photoshop is sufficiently similar. Video tutorials and Photoshop actions for morphing can be found at http://www.granthamilton.com/UIFPS/Morph.html .

Ethical considerations in patient imaging

Ideally, preoperative photographs should be manipulated to enhance communication with the patient and not to sell surgery. Showing a change that is surgically unlikely is not only misleading but will do nothing to create a happy patient. With that in mind, it is reasonable to leave some imperfections in the manipulated image to reinforce the expectation that the surgical goal is improvement and not perfection. It is also a good idea to do your own imaging. Some surgeons may have their fellow or a patient-care coordinator manipulate the images. Having the experience of previous surgical cases creates a more realistic and accurate prediction of the surgical result. A well-defined tip in a thick-skinned patient is easy to show with the computer but, in reality, would be an unlikely surgical outcome. There is also some controversy about whether or not the images should be printed and given to the patient. Proponents believe that providing the patient with a copy may make the psychological adjustment to the postoperative result smoother and may stimulate informed questions. Others think that giving the images to the patient may expose them to litigation if the images are misconstrued as a guarantee.

Creating a before-and-after image

Before manipulating patient images, it is helpful to create a side-by-side before-and-after image so that the patient can easily compare the two. In practice, this involves duplicating the preoperative image and applying the changes to only one of them.

Creating a before-and-after image

In the dialog box that opens, set the canvas width to 200% and place the current image to the left. Select OK to accept the changes.

The canvas should now have the original image on the left and a white space on the right. Paste the contents of the clipboard into the image by choosing Paste from the Edit menu (Mac: V Windows: Ctrl-V). The pasted image is on a separate layer and is centered.

To move the new image over to the right, select the Move tool and click and drag the image to the right side of the canvas.

The image on the right should be labeled so that the patient is aware that it is the manipulated image. Select the Text tool and click it once, above the photograph on the right. Next, type something to identify the image. Some surgeons simply label it “After”, whereas others type a short disclaimer explaining that the manipulated image is only a simulation and not a guaranteed result ². The size and color of the type may be changed in the Type toolbar.

Rhinoplasty imaging

Using Photoshop to simulate a rhinoplasty result primarily uses two techniques: the T ransform tool and the Liquify tool. Typically a frontal view and a profile view are demonstrated for the patient. When manipulating the profile view, a right-handed surgeon should choose the right profile. That way, it can be mounted horizontally in the operating room, making comparisons with the patient’s face simple. The following are the steps for simulating a profile. The process for creating a frontal view is even simpler: steps 2, 3, and 5 may be skipped.

First, create a before-and-after image as described above. When imaging the profile, it is important to duplicate the After layer before manipulating the image. This is to prevent any gaps from becoming visible. If you are using the actions that accompany this article, this is already the first part of the action named Morphing.

Next, set the tip position by selecting it with the rectangular marquee tool and choosing the Free Transform command (Mac: T Windows: Ctrl-T). By clicking and dragging inside the selection, you can adjust nasal length and projection. Grabbing 1 of the corner handles permits changes in rotation. Make sure that the cursor changes to the curved arrow before grabbing the corner. Once the tip is satisfactory, double-click inside the selection or press the Enter key.

Frequently, it is necessary to erase areas of significant discontinuity. If this is needed, clean up the tip with the eraser tool. The brush size can be adjusted in the Options bar or by using the bracket keys on the keyboard. The hardness may be changed in the Options bar.

Next, flatten the image by compressing all the layers into 1. This process is performed by choosing Flatten Image from the menu in the Layers palette.

To manipulate the dorsum, change the shape of the tip or augment the chin, and select Liquify from the Filter menu. If you are using the action, just press P lay again in the Actions palette. In the Liquify window, you can adjust the brush size using the slider. It is not necessary to change any of the other settings in this window.

To use the L iquify tool, place it near an area you want to push or pull, like a dorsal hump. Click and drag to mold the area like you would to manipulate clay. Once the dorsum, tip, nasolabial angle, and chin are set, click ok to save the changes. Sometimes there is still an area of discontinuity in the supratip. This technique is addressed in the next step.