CHAPTER 3 Virtual Surgery

10.1055/b-0040-178143

CHAPTER 3 Virtual Surgery

Philip J. Miller and Boris Paskhover

Summary

Using computer software to demonstrate the anticipated postoperative result has now become very common. Virtual surgery allows the creation of a unified vision between the surgeon and the patient, thus creating an ideal goal that can be achieved.

Introduction

Using computer software to demonstrate the anticipated postoperative result, once a rare instance in a plastic surgery office, has now become very common ( Fig. 3.1 , Fig. 3.2 ). Considered decades ago as a marketing gimmick, photo morphing or virtual surgery has become a crucial and indispensable component of the plastic surgery consultation. Its chief and primary role is eliminating the confusion and misunderstanding associated with vague terminology like “softer” or “more defined” or “bigger.” These types of qualitative descriptions are thoroughly subjective, leave too much room for interpretation and misunderstanding, and more often than not, lead to dissatisfied patients. It is incumbent upon the plastic surgeon to depict an end result that he or she honestly believes can be achieved. Virtual surgery allows the creation of a unified vision between the surgeon and the patient, thus creating an ideal goal that can be achieved.

**Fig. 3.1** Three-dimensional simulation of male face-lift. (a) Patient image. (b) Simulation image. (These images are provided courtesy of Canfield Scientific, Inc.)

**Fig. 3.2** Three-dimensional simulation of male rhinoplasty and chin augmentation. (a) Patient image. (b) Simulation image. (These images are provided courtesy of Canfield Scientific, Inc.)

Ideal Attractiveness

In the senior author’s (P.J.M.) experience, undergoing the virtual surgery session opens up an important discussion regarding ideal attractiveness. Some patients believe that attractiveness is a peak to climb to, a point of indisputable greatness. Rather, an aesthetic ideal is more of a plateau representing a range of ideal aesthetic results signifying the myriad of aesthetic ideals found in the general population. The question is often asked “what is the best result,” which typically warrants the aforementioned discussion. Virtual surgery allows the range of possible results to be shown to the patient, emphasizing that each one is, in and of itself, an ideal result.

Technological Advances in Virtual Surgery

Almost 30 years ago, Dr. Ira Papel ¹ wrote a paper discussing the benefits of computer imaging for the instruction of residents and fellows. Using an IBM XT 286 with a 20-MB hard drive, he made the argument that digital analysis and virtual augmentation help to teach residents and fellows. He also noted that it should project what the postoperative result strives to achieve. Widespread adoption of photo morphing was slow, secondary to cost, and there was also a concern that patients would too often compare their actual results to the virtual surgery results. Furthermore, this practice could result in a disappointed patient if the results were not perfect. However, in practice, this was not the case.

In the past few years, a rise in the general public use of “selfies” and the development of plastic surgical apps has fueled and allowed the prospective patients to consider changes in their appearance. ² Modern mobile devices have provided the prospective patients with the ability to perform virtual surgery of their own. A quick review of the Apple App Store or apps for Android devices shows multiple free applications, which allows an individual to augment his or her photographs easily.

It is important to note that the patient’s desires and what is realistically possible may not coincide, and it is the duty of the plastic surgeon to guide the patient responsibly. Virtual surgery can help educate the patient and improve the discussion with the surgeon. The surgeon can show the patient what his or her artistic eye would suggest while incorporating the requests of the patient. The surgeon could also recommend other changes that may not have been considered by the patient, such as a chin augmentation to help balance their appearance with rhinoplasty.

Three-Dimensional Digital Imaging

The past decade has seen advances in simulation, particularly with regard to three-dimensional (3D) imaging ( Fig. 3.3 , Fig. 3.4 ), and the advent of stereoscopic cameras with at least dual lenses and sensors separated by a fixed horizontal distance allows the capture of two simultaneous images. The two slightly different images of the same subject are converted using digital algorithms. These systems allow visualization on a two-dimensional screen of an image that can be seen at different angles, thus providing a 3D feel. This, in particular, is very beneficial when discussing body imaging, especially with regard to pectoral augmentation. The software involved in these systems allows rather fluid changes in appearance, creating realistic virtual augmentations ( Fig. 3.5 , Fig. 3.6 ).

**Fig. 3.3** Canfield Scientific’s VECTRA H1 handheld imaging system for clinical-quality 3D imaging to deliver precision optics for high-resolution 3D images is ideal for facial aesthetics and clinical documentation. (This image is provided courtesy of Canfield Scientific, Inc.)

**Fig. 3.4** Canfield Scientific’s VECTRA XT complete 3D imaging solution captures face, breast, and body images in ultra-high-resolution 3D, including 360-degree body imaging and circumferential measurements. (This image is provided courtesy of Canfield Scientific, Inc.)

**Fig. 3.5** Three-dimensional simulation of male stomach liposuction with circumference measurements. (a) Patient image. (b) Simulation image. (These images are provided courtesy of Canfield Scientific, Inc.)

Multiple studies have shown the benefits of this new imaging methodology and its ability to accurately predict postoperative volumes. ³ ^, ⁴ As with other types of virtual surgery, this is used by the skilled practitioner as a means of communication. By adjusting the virtual images, the patient can obtain a better sense of what is being surgically offered.

**Fig. 3.6** Three-dimensional simulation of male rhinoplasty using markerless tracking, a quantitative approach to soft tissue change assessment that characterizes the degree of stretch, compression, lift, and volumization. (This image is provided courtesy of Canfield Scientific, Inc.)

Multiple studies using dimensional imaging for rhinoplasty have shown that surgeons have relatively good comparisons between their preoperative morphed images and actual patient outcomes, although this heavily relies on three factors: the surgeon’s decision-making, skill in the morphing, and the intraoperative skill set. ⁵ ^, ⁶ ^, ⁷ Interestingly, one study that enlisted experienced, independent raters identified several virtually augmented images that they deemed would not be surgically possible, and as anticipated, these patients were noted as having perceived poorer than expected results postoperatively. 5 The importance of this single finding cannot be overstated. Digital imaging may show end-result augmentation that in actuality may not be attainable because of anatomical constraints. The surgeon’s role must be to identify this during the decision-making process in consultation with the patient.

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