Orange County Register

Photos: The first and second pairs of photos at right and below are actual “before” photos and digitally manipulated “after” photos from iSurgeon. The similar pair of photos at the bottom of this file are from BodyPlastika. (Photos courtesy of Dr. Michael Salzhauer and Think Basis Inc.)

ALTERED REALITY

Plastic surgery on the iPhone? It’s not a silly as it sounds, but does it wreak havoc with people’s minds?

Cosmetic procedures aren’t actually performed on the phone, of course. Instead, the hoped-for outcome of plastic surgery can be depicted there in pictures that potential patients can modify and discuss with their doctor.

That’s how the iPhone programs are supposed to be used. But several local cosmetic doctors worry that any such image manipulation can give patients unrealistic expectations.

Issues confronting users of iPhone apps include:

• Are the apps basically marketing tools?
• Can a bulging belly be turned into a slim one, as two iPhone apps suggest?
• Are disclaimers needed?

Three iPhone apps were the topic of this week’s online “In Your Face CHAT”:

The Shafer Plastic Surgery App, developed by plastic surgeon Dr. David Shafer of New York. This program provides answers to questions about plastic surgery. It’s is free for a “Lite” version that answers as many as 1,000 generic questions. The price is $2.99 for a version that allows users to ask specific questions. Shafer responds daily by email, he says.

On the iPhone App Store, the free version averages a two-star rating (out of a total of five stars) from a total of 52 users. The upgraded version gets a three-star rating from five users. “Thousands and thousands” have been downloaded, Shafer says.

iSurgeon, developed by plastic surgeon Dr. Michael Salzhauer of Florida. It allows users to take photos from the iPhone and change them to see what plastic surgery possibly could accomplish. It also includes a game mode. Salzhauer is the author of last year’s book “My Beautiful Mommy,” aimed at helping children understand why a mother undergoes plastic surgery.

His app “is currently in review at the Apple Store, and by some mysterious formula, they will determine the release date. Based on past application approval times, it should be any day now,” Salzhauer said during the chat. The price will be 99 cents for a “Lite” version that stamps a virtual watermark on patients’ photos, or $1.99 for a version with no watermark.

BodyPlastika, developed by Think Basis Inc. of Toronto and Seattle. Like iSurgeon, the program allows users to modify photos so they can be presented to a plastic surgeon or emailed to friends as a joke.

“The goal is to allow people the opportunity to state their desire and then allow the surgeon the opportunity to speak to them about what is realistic and what is not,” Nick Dumitru, the company’s president and founder, told chat visitors. “It’s a way for surgeons and patients to better engage in the conversation to come to a mutually acceptable goal.”

BodyPlastika costs $3.99 from the iPhone apps store. It has a rating of 2.5 stars out of 5 stars, with only eight raters. About 100 apps have been sold so far, Dumitru said.

Shafer was absent during the chat because he had an unanticipated operation during the scheduled time. He later submitted comments about some of the issues discussed in the chat.

“With a low number of raters, the ratings are not statistically significant,” Shafer said of App Store ratings. “Also, if you erase an app off of your iPhone, you are asked if you would like to rate it. Therefore, the ratings are skewed towards those people who did not like the app and erase it off of their phone. For those who are using the apps, they have not been prompted to rate the app since they have not erased it.”

These issues were discussed in the chat:

UNREALISTIC EXPECTATIONS

Plastic surgeon Dr. John Di Saia of San Clemente and Huntington Beach told me before the chat: “Although I am comfortable with computing, I have never felt comfortable with showing patients [manipulated images]. I felt they would set people up for disappointment.”

App developers disagreed.

“Personally, I couldn’t imagine practicing without imaging software,” Salzhauer said. “They are incredibly useful. In fact we use very similar digital imaging in the office all the time as a way of communicating to patients about their goals with surgery.”

Shafer added, “Simulated images are great for giving the patient an idea of how they may look after surgery. I have to caution patients that what is achievable in a computer rendering is not representative of what can actually be produced in the operating room,” Shafer said.

Dumitru said, “Any tool a patient can use to communicate with the doctor is useful. Of course there will be a lot of passing it around to the friends as well beforehand. It’s all part of a person’s decision-making process. Whether they choose to use it for fun or a medical discussion is up to them.”

DISCLAIMER NEEDED?

Since iSurgeon and BodyPlastika can create unrealistic photos, I asked whether either app has built-in disclaimers. Neither one does.

The question originated with a comment from plastic surgeon Dr. Val Lambros of Newport Beach: “Some plastic surgeons use imaging like this. I don’t. I think it is kind of gimmicky and the doctors’ insurance companies require that docs who use this software to have patients sign a release saying that the results shown on screen are not the results that will be seen in life. It is much easier to manipulate electrons than it is to move skin and bones and healing.”

Shafer, whose app has no such photos, stated, “There should be a disclaimer that the ‘afters’ produced on the app are for entertainment purposes only and do not substitute the qualified opinion of a plastic surgeon.”

In his face-to-face consultations, Salzhauer said, “I always say, explicitly and in writing that the images are NOT a guarantee.”

“Dr. Guyuron in Ohio (one of my plastic surgery heroes) actually prints the words “NOT A GUARANTEE” right on the photo.

Dumitru said, “Colin, you do make a great point. We’ll be adding a disclaimer to the Web site later today to cover that point. I hadn’t thought that people would take the software so literally.”

TURNING A BULGING BELLY INTO A SLIM ONE

Dr. Christopher Zachary, chairman of the UCI Department of Dermatology, objected to a pair of iSurgeon photos (at top of this post) showing a dramatic reduction in a man’s protruding belly.

Lambros joked that he wishes that change were possible. “I would kind of like the belly shot myself,” he said before the chat.

“This is unobtainable,” Zachary said in advance comments. “Much of this abdominal girth in this image is probably [fat deep in the abdomen]. I would say that it would be impossible to deliver on this pre vs. post image.”

Shafer and Dumitru agreed.

“These are not realistic results that could be achieved through surgery,” Shafer said.

Salzhauer defended the photos, which came from him: “Regarding the intra-abdominal fat… It’s true, with liposuction you can’t get that degree of improvement, but you can get closer to the results you showed with a tummy-tuck. That allows one to tighten abdominal muscles and the like.”

Dumitru said the similar photos on his Web site (at right) “are designed to show what the app can do and not so much what can be achieved with surgery.”

MARKETING TOOL?

“Are patients more likely to go to a plastic surgeon if they have fiddled with their photo and created an image that they’d prefer?” I asked.

Salzhauer replied, “Yes. Most people — once they see what they could look like — they will be excited and motivated about doing something about it.”

Di Saia commented in advance, “These programs set up sales. They tend to improve revenue probably due to the ‘wow factor.’ ”

Because of the apps’ value as a marketing tool, Salzhauer said he should contact the American Society of Plastic Surgeons to see if it would support the two products.

For more discussion of these issues, see a gently edited transcript of the online “In Your Face CHAT.”

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