3D imaging and procedure planning

A conventional photograph is a flat record of one moment and one angle. To understand a nose, a jawline or a neck we already take a set of views. That set is still a collection of flats. The 3D capture builds a surface that can be turned, so the three-quarter view with the head leaning forward, the nostril shape from below, the way the bridge meets each cheek, and the contour under the chin can be read from the same model.

Because the model is sized, measurements can be taken from it. That is the difference between an impression of “a little less projection” and a figure that can be checked against the plan in theatre. For cheek implants it is how target projection is measured. For the chin it is how width and the semi-profile are read against the rest of the face. For the nose it is how de-projection, rotation, shortening and bridge width are written into a dimensional plan.

The model does not replace looking at you. It organises what is already there so that the conversation is about specific changes rather than a general wish to look better.

The camera we use for this work is the VECTRA H2 from Canfield Scientific. It is a hand-held 3D camera that works by stereophotogrammetry: the same surface is recorded from two slightly different angles at the same instant, and the software turns the pair into a measured three-dimensional surface. Each capture takes about two milliseconds, so it is as quick as an ordinary photograph.

You sit or stand comfortably while the camera is moved around you. Two ranging lights on the camera guide it to the correct distance, and captures from the front and from each side are stitched together into one model. The same camera captures the breast and the torso, which is why it is used for breast planning as well as for the face.

The model is high in detail — on the face the surface is described in steps of little more than a millimetre — and it is sized, so the measurements taken from it are real measurements. The analysis software measures distances, contours and changes in volume, can show the difference between two captures as a colour map, and has a grey mode that shows shape without the distraction of skin colour. Simulation tools make it possible to try changes to the nose, chin, cheeks and jawline, or the effect of different breast implants, on your own model.

Once the model is processed, the in-depth analysis can begin. That is the part of the consultation that takes time — not the capture itself.

Preparing for the 3D capture helps the model to be accurate:

• Heavy make-up can make it difficult for the capture to take place accurately, and is best avoided on the day of the consultation.

• Earrings and piercings can create problems, as does a beard.

• A high collar is a potential problem for imaging the neck, and is best avoided.

• Oiliness of the skin is an occasional problem. Wiping the skin or washing the face just before the capture improves quality and accuracy.

• With current technologies it is virtually impossible to capture hair adequately, so a headband that pulls the hair back is often useful.

• The more comfortable and relaxed you appear, the better the model. Relax the lips in a natural way and avoid smiling while the photographs are being taken.

This is the limit that matters most, and it is the same sentence we keep on the procedure pages. A simulation is a planning tool. It is not a photograph of the result.

The model shows a proposed change in shape, volume or proportion. Healing, the way skin sits on the new support, the behaviour of a fat graft, the set of an implant, and the way each side of an already asymmetric face settles, are not identical to the picture on the screen. We use the simulation to agree the direction and the scale of change, and to decide which operation or combination is capable of that change. We do not treat the image as a contract for a face.

2D imaging is sometimes used in the same spirit. Whether the working picture is 2D or 3D, the principle is identical: the simulation organises the plan; the operation and the healing produce the result.

One of the traditional concepts that has been shaken by the availability of 3D imaging is the idea that beauty is fundamentally linked to symmetry.

All faces are asymmetric, most often along a pattern that can be described for the upper, middle and lower thirds of the face. Even the most beautiful faces that we see also have significant asymmetries, but there are other aspects that we feel drawn towards and impressed by.

Severe asymmetries often come with unaesthetic features, and putting those right can be better understood in 3D. At the same time, it is possible to understand that pleasing facial shapes can be achieved even without perfect symmetry.

From image capture, to procedure planning, to the surgery itself and enjoying the results, there is a journey of discovery that can be fascinating and rewarding. It takes more time and effort, but it gives you the knowledge and the standing to be the most important part of that transformation.

Will a new nose make me a different person? Difficult questions receive a clearer answer when rhinoplasty is planned in 3D. The work is about the proportions between the nose and the rest of the face, not about the nose in isolation.

Questions that are difficult to answer in standard photography — the ideal width of the tip and the bridge, projection in the quarter view — become clearer in 3D. The important parts of assessment include the height and width of the bridge and tip, the projection of the chin, and the facial asymmetries that make it impossible for the nose to follow a true midline.

In 3D, difficulties about understanding the appearance of the nose from the three-quarter view, with the head leaning forward and so on, become a thing of the past. Understanding the shape of the nostrils from the front and three-quarter view is also significantly easier.

One of the difficult things to understand on standard photography is how changes in the shape of the tip would balance and integrate with the shape of the nostrils and the bridge. Gradual reshaping and the view from a variety of angles in 3D can clarify this.

It is also a lot easier to understand how much de-projection and how much rotation is required to achieve the desired shape, which can then be integrated in a dimensional rhinoplasty plan.

The contours of the bridge of the nose are always asymmetric. What is very difficult to see on standard photographs is how the bridge meets the cheeks, because they are different on the right and left sides.

It becomes a lot easier in 3D to turn the image around and understand how much narrowing or widening of the bridge is necessary, and how much projection needs to be achieved for a balanced appearance of the nose.

Changes in the width of the base of the nose and the rim of the nostrils can be more difficult to evaluate on standard photographs, but become easier in 3D. Comparison across a variety of views is made easier by turning the image around.

When it comes to planning the projection of the nose, and transposing it into a surgical blueprint, 3D imaging can give accurate measurement of the changes, because the 3D image is sized, unlike standard photographs. Those measurements are then used during surgery to verify that the degree of adjustment to the shape and size of the nose corresponds to the plan.

One of the common fears of people approaching rhinoplasty, in particular if the tip of the nose is dipping down, is the thought that they might end up with an upturned nose and very visible nostrils. Although these changes can also be explained on standard photographs, it becomes a lot easier to understand in 3D that the shape of the nose can be altered to look shorter without increased visibility of the nostrils.

To put a vision for enhancement into a logical plan of action, from a myriad of options, shape and surface come to the rescue. Ageing in the face and neck is a complex process, and most of the time what we want is not to run away from it, but to manage it so that the interesting changes are enhanced and the unsightly changes are reduced or eradicated.

Because the changes that affect us involve volume, elasticity of the tissues and, inevitably, sagging, it is often difficult to put together a full picture so that a suitable plan for change can be established. An accurate photograph in 3D brings the information together, and makes it possible to judge better what the priorities are and how much change makes things look right.

Facial rejuvenation is not all about tightening. Just tightening means an increased chance of the dreaded “wind-tunnel” effect. Volume brings softness to the facial features, but how much volume is fundamental information, to avoid excess.

Most people prefer the distinction that occurs in the facial features as we advance in age, but would like it enhanced by a subtle blend of fullness and tightness. That is why a facelift, fat transfer, or both, are planned against the same model rather than as competing slogans.

Although most of the time we see the shape changes, and become distressed about the lines of the face and the sagging, one of the fundamental changes is in the quality of the skin. The notion that beauty is skin deep is truly applicable here. The 3D imaging offers additional information regarding the degree of sun damage and the changes in the blood vessels of the skin — the camera’s skin analysis separates brown pigment from redness, and maps texture, pores and lines — so that properly directed action can be planned.

Shape is the surgical conversation. Texture is mixed — surgical tightening helps it to a degree, and the rest is looked after with skin treatments chosen against that analysis, not against a hope that the lift will also be a peel.

The neck contour is paramount to an elegant and youthful appearance of the face, like a beautiful pedestal brings beauty to the statue above it. It is easy to misrepresent how much change is necessary with regard to neck contouring. 3D assessment and planning make that significantly clearer.

On the procedure pages we separate the four elements that can detract from aesthetic balance in the neck — volume, hyperactive platysma bands, laxity, and skin texture. The first three are surgical; texture is mixed. The model helps to see which of those is actually present, so that an anterior neck lift, a deep contouring neck lift, or a facelift with neck work is chosen for the right reason.

Most of the time we see the changes in the face that occur along the jawline, because everybody dreads the jowls, but we rarely see the changes in the chin shape. That means the overall plan for improvement can end a little shortsighted.

The lines that run from the corner of the mouth downwards, giving a somewhat sad appearance, can be improved by tightening and lifting, but look better if the combination of tightening and volume restoration is used.

Restructuring the proportions of the face is one of the most fascinating challenges in aesthetic treatments. Beauty is in the eye of the beholder, and there is a great deal that imaging and procedure planning in 3D can do to pave the way for a successful outcome.

Faces and bodies are fundamentally asymmetric, in all aspects. Although the asymmetries are frequently small and easily overlooked, a good understanding of them before surgery makes it a lot easier to incorporate subtle differences between the treatment plan on the two sides of the face, for a better end result.

The relationship between the strength of the cheekbone, the fullness of the cheek, the strength of the jawline and chin, and the contours of the neck, all contribute to create a certain emotional response. Ultimately the surgery aims to strike that chord; the shape change is just the vehicle.

Chubby cheeks make some people feel very self-conscious, and the most common demand is for buccal fat reduction to correct this. In 3D it is easier to appreciate why the fullness occurs or is perceived, and whether liposuction, buccal fat reduction, or a combination is necessary to create the contours that patients seek.

The contours of the jawline, chin and neck are closely related when it comes to defining the strength, youthfulness or balance of the face. Although basic alterations can be visualised on standard photographs, 3D makes it possible to design shape changes in depth, evaluate the amount of change to plan for appropriate reductions or enhancements, and bring clarity to the appearance from a variety of angles.

The height and projection of the cheekbones is always different, and for this reason people tend to feel that they look better from one angle than the other. Building up cheek volume can bring definition to the face or a more youthful appearance.

In 3D it is also possible to measure the amount of change, plan the size of implants, direct volumes for enhancement, and establish how much of the asymmetry is worth correcting. Facial asymmetry is a natural part of our appearance and cannot be entirely eliminated. A degree of improvement is generally achievable.

Although facial asymmetry is universal, and most people are not in the least affected by its presence, when the asymmetry is more pronounced the face can appear twisted, and that can affect body image. Sometimes more extensive changes are necessary to achieve balance; sometimes subtle changes may be sufficient. In 3D it is possible to evaluate this and determine which changes are most relevant, so that you can choose a treatment plan that suits you.

The VECTRA H2 captures the breast and torso in the same way as the face. The same principle applies: the capture organises volume, base width, projection and asymmetry so that implant choice, the need for an uplift, or the extent of a reduction is discussed against a model rather than against a cup-size slogan.

The same caveat holds. The simulation is not the postoperative photograph.

The capture is short. The conversation around the model is the consultation. We look at the present shape from the angles that bother you, try the changes that would address those angles, and then ask whether surgery, a combination of procedures, or a non-surgical option is capable of that change without creating a new imbalance.

That is also when medical history and medicines are taken seriously. Blood thinners and raised blood pressure both increase bleeding risk in facial and breast operations and need a specific plan. The imaging does not replace that discussion.

Fees for the operations themselves remain consultation-led, once the plan — and not only the wish — is defined.

It does not perform the operation. It does not guarantee symmetry. It does not make texture into shape, or shape into texture. It does not show healing. It does not replace a clinical examination of the bite when the chin is being considered, or of the breast when implants, reduction or an uplift are being considered. It is a way of seeing, measuring and agreeing a plan.