Why do I feel digital imaging is important? Imagine trying to discuss exactly what it is you hope to achieve with your surgery by pointing to your nose while your surgeon looks on. The surgeon then tries to do the same thing with you looking in a mirror. The problem is you both see different things, and you both are viewing your nose from different angles. You both use different words to describe what you want. In some cases, I may use a word like “Projection” and you may think I am referring to one thing, when in fact I am referring to another. I think it is obvious, sometimes us surgeons are not the best verbal communicators! The only way around this, is to make the changes and see if the resulting effect is the one you both had in mind. There are two ways to do this. The first, is make a plan and then do surgery. Obviously, this is not ideal if things don’t turn out as planned. The second, you can to sit together and make changes on a high quality digital photograph.
At JB Cosmetics and Facial Surgery in Ottawa, I use a computerized program to do both digital imaging and virtual rhinoplasty surgery. I feel as though using digital imaging allows for ideal communication between the patient and me. To me, there is nothing worse than misunderstanding, particularly when it comes to surgery. In addition to this, a computer image allows us to assess to perform virtual surgery and see how your appearance changes after we actually make changes to the nose. We can adjust the height, the bump, the rotation, the width in real time and immediately see the changes. Talk about communication!
However the question arises, how close is the approximation we made with the computer image to the outcome we get with nose surgery? Well, let me start off by saying there are limitations of Digital Imaging for Rhinoplasty. Some photographic views and positions are better than others.
For example, the side view of your face is probably the best with respect to digital imaging and virtual surgery. You can adjust the bump of the nose, the tip of your nose as well as your chin and get an adequate representation (at least I think so, but we’ll get to the research soon).
This is the side view, it is much easier to change these features on digital imaging
The frontal view (looking at the person from the front) is a bit more complicated. You can adjust the width of the nose and tip, but much of the view from the front relies on shadowing, which is difficult to mimic with computerized imaging. Sometimes when adjusting the frontal view on digital imaging, the lines tend to look too “straight.” Nobody has perfectly straight facial features. We all have subtle curves and irregularities; this makes us who we are and prevents us from looking “fake.” I always tell people that lines are never as straight as they may look on these images.
Even with all this, some people still ask, how close is the result of surgery to what you see on the digital image. Before I talk about research, the most important thing is, the results are NOT meant to be exactly what you will see after surgery. Remember, digital imaging only allows me to see the outside of your nose, not what is under the skin. Once surgery starts, 100’s of other factors come into play. It is my job to do everything I can to get the result you desire with the anatomy you have. In addition to this, no one can predict how you heal. Our genetics as well as how patients take care of themselves after the surgery all have a roll in dictating this. With respect to digital imaging, these are factors that cannot be predicted nor controlled.
Ok, lets talk about what the research says. Muhlbauer and Charlotte (2005, Plastic and Reconstructive Surgery; 115(7)) published an article discussing the reality of digital imaging in aesthetic Rhinoplasty Surgery (“Nose Jobs”). This was an interesting article where the surgeons, who were very experienced (36 years of experience), followed 120 patients who had digital imaging followed by a Rhinoplasty (Nose Job).
All patients had digital imaging and virtual surgery performed before their Rhinoplasty. The patients were then seen in follow-up anytime between 1-5 years after surgery. A side note, this is a weakness of the paper as there was no standardized time in which the patients returned to the surgeon for an assessment for the research paper.
At the time of follow-up, the patients and the physicians rated the quality of the match between the original virtual surgery/digital images and the final surgery results. Ratings could be 1=identical, 2=similar, 3=approximate and 4=poor. Another side note, when we do research, any time we use a rating scale like this we need to make sure it is measuring what we expect it to measure. We often have to do research and assess the scale in terms of its “validity” which basically means, is the rating scale actually measuring what we want it to measure. This study did not do this so there is a limitation in the scale they used.
29.1% of patients rated the result of their surgery as identical to the original digital imaging. 54.2% of patients rated the results as similar. 14.2% of patients rated the results as approximate while only 2.5% rated them as poor matches. Of those 2.5% who had poor matches, the majority of these people needed a touch-up second surgery.
So in summary, 83% of patients had a very close match between the virtual surgery/digital imaging and the results of the surgery.
As the authors noted in their study, in today’s technologically advanced world patients who want a Rhinoplasty or any cosmetic facial plastic surgery procedure are very educated and often ask for digital imaging. As a surgeon, I believe it is my job to offer it. Some plastic surgeons do not offer this service as they feel as though it can be misleading as well as result in longer consult times. Well, I ask you, would you rather spend extra 10-minutes with your surgeon ensuring that your wishes are understood and communication is maximized? I am sure you would and I personally do not understand why a surgeon would not want the same. Perhaps, it comes down to a medico-legal point of view. Some surgeons are worried that digital imaging can lead to legal trouble if the desired result is not achieved. At my clinic, I always tell people that results may vary and that digital imaging is meant for communication with the goal of getting the best result as possible. The digital image is the target, our goal is to get as close to the target as possible, it is not meant to be perfect.
James P. Bonaparte, MD, MSc, FRCSC
Assistant Professor, Department of Otolaryngology – Head and Neck Surgery
Otolaryngology – Head and Neck Surgery
Facial Plastic and Reconstructive Surgery
Ottawa, Ontario, Canada