Realistic Expectations: To Morph or Not to Morph?

D Agarwal and his coauthors try to determine whether computer-morphed images convey realistic expectations of rhinoplasty. They ask four questions, the most of important of which are the last two, which are very similar to one another: “Did the computer-morphed image predict the postoperative result? ” and “In your opinion, how does the actual postoperative result compare to the morphed image? ” To the authors’ credit, they conducted this study in a very scientific manner and eliminated any potential bias by using blinded raters. The authors combined the impression of surgeons and patients in their analysis. Sixty-eight percent of blinded rater/patient combinations said that, for the most part, the morphed image does predict correctly. It would have been interesting to know whether there was a difference between the blinded surgical raters and the patients. My impression is that patients are more easily satisfied with the similarity between morphed images and postoperative results than surgeons are. Muhlbauer and Holm’s data1 would seem to agree. They found that 83 percent of patients (not surgeons) felt that the imaged results were identical or similar to the postoperative results. Only 17 percent of patients felt there was at best an approximate or poor match. In general, the data of Agarwal and his coauthors are confirmatory. Realistic expectations depend greatly on proper communication between patient and surgeon, and not just on the similarity between the morphed image and the postoperative result. Therefore, there are a couple of other questions that I might have included in their study. For example, in what percentage of cases is imaging essential for communication between patient and surgeon and perhaps indispensable? I suspect the answer would be close to 100 percent. I can recall numerous cases where I thought the patient was a good candidate based on the interview. After morphing what I thought was a reasonable result, the patient did not like the result and did not like any morphed images that I thought were obtainable. Consequently, surgery was not offered as an option. Without imaging, surgery might have been performed and her expectations would definitely not have been met. Another question I might have posed is, what percentage of anatomic deformities is picked up by imaging that is not picked up by routine examination? I have occasionally been surprised when the two-dimensional image of the patient on the monitor made the patient’s radix deficiency apparent. I actually would have missed it without the imaging and morphing procedure. Another example is the way imaging and morphing emphasize lip length. Whether it is long or short, the length of the lip seems to be emphasized by a still two-dimensional image of the patient on the monitor in contrast to what is seen in a dynamic, talking, moving patient. The authors correctly implied that the morphed image is potentially an implied warranty, the effect of which can largely be mitigated by attaching some type of notice on the printed version of the morphed image, saying that it is not a guarantee of the postoperative result. That is sound advice. Muhlbauer and Holm1 reported no such medicolegal difficulties as a result of giving their patients a copy of the morphed image. My personal experience with giving patients a copy of their morphed result concurs with that of Agarwal et al. and Muhlbauer and Holm. Clearly, the potential for legal issues is there if the surgeon morphs a totally unrealistic image in an attempt to convince the patient that the surgeon should perform the operation. However, in nonmedical situations, visual aids are commonly given to consumers before the purchase of a service or commodity. Would anyone sign on with an architect who did not provide them with a proposed drawing of what the house is likely to look like? The focus of the authors’ study was on patients’ realistic expectations. Another way to view From Stanford University and the University of California, San Francisco. Received for publication January 31, 2006. Copyright ©2007 by the American Society of Plastic Surgeons