Central to any aesthetic procedure, patient satisfaction is influenced not only by morphological changes but also by the degree of alignment between the outcome and patient expectations, which may not be realistically attainable.^1,2 Effective patient-focused care with shared decision-making and informed consent is critical to decrease the preoperative risk of insufficient clarification of patient preferences, decisional conflicts, and patient anxiety.^3,4 Discrepancies between patient- and surgeon-perceived goals seriously harm the surgeon–patient relationship. Patient dissatisfaction may generate disputes and serious litigation.¹

Many patients cannot visualize the expected outcome. Verbal communication, not infrequently, fails to reach a surgical design agreed upon by both patient and surgeon.^5,6 Better than verbal descriptions and confusing diagrams, preoperative “morphed” images help bridge the communication gap and display complex ideas simply, thus significantly enhancing patient empowerment for better decision-making and potentially higher satisfaction. In emotionally charged situations, visual empowerment provides better emotional support as well.^7–10

Traditionally performed by hand or 2D computer image alterations,^11–14 3D simulation brought a new dimension into surgical planning by improving doctor–patient communication, providing the opportunity for greater patient input during preoperative consultation, and allowing topographical measurements essential for aesthetic prediction. Its value for measuring outcomes and critical self-assessment by surgeons has been well demonstrated. The technology is also a powerful tool for teaching relationships and the resultant effects of various surgical maneuvers.^6,10,15–27

During the past 2 decades, there has been increasing awareness of 3D simulation in aesthetic surgery, driven by word-of-mouth, the internet, and social media, with patients seeking practices specifically offering this technology.^28,29 It reportedly provides a personalized, realistic visual prediction of the outcome and allows for measurements and volume calculations in the office setting.^1,3,8,20,30 It also helps identify patients with unrealistic expectations and underlying body dysmorphic disorder, who are prone to persistent postoperative dissatisfaction.^11,16,31 It can furthermore increase consultation-to-surgery conversion.^{2,5,15,28,30,32,33} At present, it is used mostly for planning breast augmentation and, to a lesser extent, rhinoplasty. It is rarely used for augmentation-mastopexy, mastopexy, and reduction mammoplasty, and for soft tissue filler augmentation, gender-affirming surgery, and body contouring.^{12,26,34–36}

Objective assessment of the factors that affect simulation accuracy is still lacking.^37–39 There is also no real discussion about the ethical and legal implications of an eventual mismatch between simulation and the actual outcome.³ The present review aimed to summarize the current status of 3D simulation in aesthetic surgery.

A comprehensive literature search of the PubMed, Embase, and Web of Science databases was conducted for English-language reports published from 2000 through January 2026 in accordance with PRISMA guidelines. The search strategy was developed using the PICO framework: population—patients undergoing aesthetic surgical procedures; intervention—3D preoperative simulation; comparison—the actual postoperative outcome; and Outcome—the accuracy of the preoperative simulation in predicting the achieved postoperative result. A nonstructured search was also conducted in addition to screening of the reference lists of retrieved studies and previously published reviews. Studies describing various 3D simulation software programs and their development, experimental studies, reviews, comments, and letters to the editor were excluded. The search algorithm is illustrated in Figure 1. Two investigators screened titles and abstracts and analyzed the full texts of selected papers for eligibility. Disagreements were resolved by consensus or discussions with the senior investigator.

Seventeen studies (12 on breast augmentation and 5 on rhinoplasty) were identified and included for review. High accuracy of 3D simulation in predicting breast augmentation outcome has been reported.^9,32,40 Roostaeian and Adams⁹ observed 90.8% volume and 98.4% shape accuracy with Vectra (Canfield Scientific, Inc., Fairfield, NJ) simulation. Confirming that it is exceptionally accurate in predicting volume, Assaaeed et al⁴⁰ did not comment on breast shape. However, compared with the control, Hutchinson et al²⁶ did not demonstrate significantly improved patient satisfaction and predicted outcome scores; nevertheless, most patients would choose preoperative 3D simulation, indicating improved confidence regarding both surgeon and implant selection. In contradistinction, Vorstenbosch and Islur³⁰ reported moderate similarity between Crisalix (Virtual Aesthetics, Lausanne, Switzerland) simulations and surgical outcomes with respect to overall appearance, width, height, projection, volume, and nipple correction. Nevertheless, more similarity was observed for symmetrical than for tuberous or ptotic breasts. Although 90% of patients agreed that the outcome was similar to the simulation, and 93% were helped in choosing the implant, de Runz et al³² reported that 50% still preferred different-sized implants fitted in a bra for implant selection. Evaluating the extent to which Arbrea Breast Software (Arbrea Labs, Zurich, Switzerland) simulation generates accurate outcome images, La Padula et al³⁷ reported only patient satisfaction as an indication of good similarity. However, one of their illustrations revealed a significant difference between simulation and the final outcome, indicating that patient satisfaction is not a good measure of high simulation−outcome similarity. Donfrancesco et al⁵ documented a good 3D simulation of overall breast shape, height and width, and nipple ascent; however, cleavage can be poorly simulated due to poor accuracy in predicting implant position on the coronal axis. Uncertainties related to the patient’s chest circumference and the illusory “implant−breast complex” lateralization are also noted with apparent convexity of the central chest wall. The most accurate measurement reported by others is the sternal−nipple distance, and the least accurate is nipple−inframammary fold distance. Accuracy decreases in larger breasts.³⁸ A significant difference in mean upper and lower breast volume distribution between the simulated and actual outcomes has also been observed.³⁹ A significantly larger nipple–inframammary fold distance with 3D simulation was observed to be consistent with a tendency to choose larger implants.²⁸ Dissatisfaction with the accuracy of simulated preoperative information occurs in 25% of patients.⁴¹ Relying solely on simulation may lead to inaccuracies. Therefore, clinical judgment remains superior.⁴² Nevertheless, simulation is a valuable adjunct. It improves patients’ confidence regarding both surgeon and implant selection; however, it does not significantly impact satisfaction.^5,26,28 (See table, Supplemental Digital Content 1, which displays the reported similarity between 3D simulated images and actual surgical outcome of breast augmentation clinical studies and patient satisfaction, https://links.lww.com/PRSGO/F137.) (See table, Supplemental Digital Content 2, which displays the summary of breast augmentation clinical studies retrieved for review with measured similarities between 3D simulated images and actual surgical outcome, https://links.lww.com/PRSGO/F138.)

Simulation accuracy is variable for rhinoplasty. Although consistency with the outcome is reported,⁶ a similarity of no more than 72% was reported by Yamamichi et al,¹ with significant overestimation of tip projection and increased nasal length. Significant underestimation of the columella tip angle and no significant differences in other aesthetic features were described by Adelson et al.¹⁶ Choi et al⁴³ reported a correlation score of 0.672 between simulation and outcome for dorsum height, 0.842 for nasal tip projection, and 0.832 for the nasolabial angle. A surgeon panel preferred the actual outcome in 77.5% of cases compared with 22.5% of 3D simulated images.¹¹ Although simulation is reported to increase satisfaction with doctor–patient communication and not to impact satisfaction with the outcome,⁶ higher predictive accuracy is nevertheless associated with higher patient satisfaction (Table 1).¹ (See table, Supplemental Digital Content 3, which displays the summary of the clinical rhinoplasty studies retrieved for review with measured similarities between 3D simulated images and actual surgical outcomes, https://links.lww.com/PRSGO/F139.)

Given the wide range of opinions regarding ideal nasal aesthetics, many surgeons currently use computerized 3D simulation as a strategic tool for planning and refining the intervention. By visualizing the intended profile, simulation provides a framework for discussion of desirable and feasible alterations with patients, who thus become more reassured to proceed with the surgery.^{1,6–8,11,13,16,22,44} Its value has now extended to the development of 3D-printed intraoperative surgical contour guides that directly translate the desired dorsal height and tip position, increase the efficiency of alloplastic implant carving, and facilitate the prefabrication of implants for augmentation rhinoplasty.^{6,20,43,45–47}

Although accuracy was reportedly high with Mirror (Canfield Scientific, Inc., Fairfield, NJ),¹⁶ the accuracy of rhinoplasty 3D simulation remains moderate in both primary and revision surgery.^22,48 Achieving maximum benefit is hindered by surgeons’ ability to translate simulation into an achievable plan.^11,17 Outcome also depends on soft tissue factors that cannot be fully predicted,⁴⁶ with tip projection being a major challenge. Although it is easy to simulate with the software, the ideal tip is practically unattainable in patients with thick skin.⁴⁸ Compared with actual photographs, Vectra simulation is reported to be inferior to the actual aesthetic outcome, with nasal tip images appearing less smooth, projected, natural, or aesthetic.¹¹ On the other hand, tip projection is overestimated by Crisalix.¹ Even with great similarity, no significant difference in patient satisfaction has been reported between those who had simulation and those who did not.^6,16 The technology nevertheless remains useful for patient communication and surgical planning.²²

As surgeons and patients may have drastically different images of breast shape and volume,^49,50 and because outcome is dominated by the patient’s subjective visual assessment,⁴ preoperative 3D simulation, particularly of breast augmentation,² is becoming increasingly common. It is also being increasingly used to guide patients undergoing breast reconstruction in managing their expectations.^5,17,51 Although there is no generalizable gold-standard protocol for volumetric measurement,¹² simulation is claimed to be a highly useful, reproducible tool for implant selection and for measuring anticipated volume change, similar to determining implant position on the chest wall.^{5,8,11,15,30,33,39,40,52–55}

Breast characteristics and volumetric changes are a complex, dynamic process involving mechanical and biological factors.^56,57 Simulation may be suitable for small breasts with no ptosis or asymmetries.^{5,9,15,30,33,40,52} With Arbrea Breast Software, only volume simulation is extremely accurate.³⁷ Crisalix can accurately estimate volume in breasts with volumes less than 600 cm³,⁵¹ and greater resemblance to outcomes is observed in symmetrical breasts.³⁰ Nevertheless, simulated images are often harsh and unflattering compared with actual clinical results.⁵⁸ Whether an accurate simulation is possible with various implant shapes or different insertion planes is also questionable.³⁰ Landmark positioning is more accurate with Vectra for thinner breast tissue and an exposed inframammary fold.⁴² Simulated volume precision decreases with larger breasts and previous pregnancy.^12,38 The least accurate simulations occur when an implant of size 50 cc greater than the optimal volume is chosen based on measurements and inserted.⁹ With Mirror software, it is difficult, and occasionally not possible, to perform simulation in women with large breasts, high body mass index, or high-grade ptosis.⁸ Patients with almost any degree of ptosis are not well imaged, nor are postpartum patients with significant atrophy.^29,58 Simulation of ptotic breasts results in overly optimistic images, whereas simulated images are much worse than actual outcomes for tuberous breasts, breasts with a wide intermammary space, or with a deflated upper pole.^30,33

In general, simulation accuracy for breast augmentation is, at best, moderate. Very often, the simulated shape is quite different from the achieved outcome,^15,30,59 with poor correlation between chosen implant volume and the visual effect generated.⁵⁸ Large implants may be applied with simulation programs while still producing reasonably appealing results, making patients pleased with implant sizes not suitable for them and giving them the wrong impression that they can have implants as large as they desire.^33,60 In a comparative study, implant volumes selected with simulation underestimated the outcome, leading to erroneous implant size selection exceeding patient-specific anatomical limitations.⁵⁸ Reportedly, only 66% of women admit that simulation represents their actual outcome.³¹

Uncertainties with simulation related to the patient’s chest circumference are also common, as it is not possible to evaluate the thoracic wall with surface imaging.^{29,39,49,56,61} Moreover, most 3D systems are set to show optimally filled breasts and tend to adjust breast shape to the chest regardless of actual implant width.³³ Lateral breast protrusion may also be overestimated, and medial implant borders may be less defined than in the real outcome.⁵ Simulation limitations in showing upper pole improvements are also notable.⁶⁰ Moreover, as software adjusts images primarily through volume changes and does not reflect the implant areola stretching effect, nor does it illustrate changes in nipple–areola complex position, the nipple–areola complex is the area for which 3D simulation is least reliable.^30,33,60 It must also be noted that certain inherent variables, such as variations in posture, affect quantifications from one image to another. Volumetric breast assessment in the supine position does not correlate with volume in the standing position.^9,29,61

Current software ignores individual beauty characteristics, using predefined algorithms of linear finite elements that may not be based on databases of true, attainable outcomes.^2,7,8,13,62 These tools not account for breast dynamic changes due to variability in tissue mechanics and the surgeon’s approach, which interfere with actual long-term outcomes.³⁹ A new Vectra scanner with a numeric soft tissue mechanics extension model may enable realistic soft tissue deformation prediction, provided simulation is applied only to patients with minimal volume, significant inframammary crease definition, and no pregnancy history.⁵²

Incorporating real data is a new frontier to inform simulation. Artificial intelligence machine learning algorithms can guide 3D models to more intelligent and realistic designs.^{2,13,17,63,64} Using data sets of experienced surgeons, artificial intelligence algorithms can be optimized to generate more harmonious individualized preoperative designs.¹³ Furthermore, intraoperative augmented reality, applicable mainly to rhinoplasty, can be used to visualize differences between the planned model and the achieved outcome, allowing adjustments if necessary.⁴⁶

Until recently, available software was prohibitively expensive, requiring significant equipment, training, and office space. However, at present, new, simple, user-friendly programs and devices are available.^2,4,29,37 The technology has also evolved, offering major advances in quality and accuracy of image capture, postproduction processing, and simulation of potential outcomes,⁶⁵ even allowing preoperative online 3D simulation consultations.⁶⁶ Despite multiple innovative features, it must be acknowledged that young surgeons mostly lack enough experience to reproduce in practice a difficult 3D aesthetic design, whereas experienced senior surgeons lack enough time to deal with complex, time-consuming simulation tasks;¹³ their reputation may be sufficient to build trust and confidence.

Despite numerous advantages, if misused, 3D simulation technology can become counterproductive for both patient and surgeon.^10,33 Although there is mounting evidence that visualization of potential outcomes may increase patient reassurance and confidence,^7,8 some programs may provide unrealistic simulations and can be unpredictable.³⁰ They may even lead some patients susceptible to manipulative/suggestive photographic material to expect outcomes that are not attainable.^1,10 A high level of expectation may lead to dissatisfaction and disappointment in many patients.^8,10 “Once they see it, they cannot unsee it.”^33,60 The importance of patients having flexible expectations regarding the surgical outcome must not be overlooked, as this may be more valuable for satisfaction than a certain simulated preoperative image that narrows appreciation of the outcome to a predetermined, artificially generated reference picture.⁶

Unfortunately, at present, none of the existing tools for visual communication can provide a consistent platform for customized breast surgery planning. Reliable quantitative interlinkage between virtual simulation and real surgery is largely lacking.^43,52 When deciding on implant volume, simulation cannot be used as a “virtual try-on fitting room.”³³ It is interesting to note that a significant percentage of patients demanding breast implant size change has remained unchanged despite improved simulation planning methods that theoretically should decrease the number of patients dissatisfied with their breast size.⁶⁷ Tissue-based methods, together with preoperative sizing with implants, remain reliable; they are more likely to contribute to high patient satisfaction.⁵⁸

Regardless of clear promise and initial enthusiasm, simulation technologies are still relatively new. Validated instruments to evaluate their accuracy in a variety of clinical settings are still not available.^5,12 It is becoming evident that 3D simulation is less useful in some specific clinical settings, greatly limiting its practical utility to justify the cost and effort.^33,58,59 Although many large academic centers and clinics have acquired 3D imaging systems, until now, these systems do not seem to be cost-effective for peripheral centers or small-volume practices.⁶¹

At present, previous patient photographs are still the primary driver for patients to undergo surgery, seconded by communication with the surgeon. Third comes 3D simulation for decision-making.³⁴ It must not be viewed as a promise of exact outcome, but rather an approximation, and should not be relied on entirely to establish a reliable surgical plan; physical measurements and the surgeon’s experience remain most reliable, and clinical judgment is still superior to simulation programs.^33,40,42

Nevertheless, 3D simulation has undoubtedly been a significant step forward in aesthetic surgery. However, for its successful adoption without compromising ethical standards, enhancing patient care and satisfaction by careful consideration of associated challenges is essential. Regulatory oversight is definitely required to ensure that the technology is used responsibly.¹⁰ It should be acknowledged that one-third of simulated images do not accurately predict the outcome. Discussing eventual mismatches with patients is essential. Conservative imaging is also encouraged, and obtaining signed consent stating that no legal action may be taken if such a difference exists is recommended.^{5,19,20,30,32,48} With such recommendations, simulation becomes less attractive, specifically when used primarily by surgeons as a marketing tool during preoperative consultation to increase the volume of their practice.^21,58 Moreover, showing a simulation that routinely appears better than the outcome and intentionally withholding a poor simulation that may deter patients from undergoing surgery as suggested^27,30 cannot be ethically justifiable.

Concerns regarding the medicolegal implications of computer-simulated imaging in aesthetic surgery remain a topic for debate. It is important for surgeons not to simulate an outcome they cannot achieve.^11,13 Potential litigation whenever simulated visual expectation is not met can be a contentious issue.^16,32,40 Recently, a Brazilian judge ordered compensation for a patient because the rhinoplasty outcome did not match the 3D simulation. Although the court did not identify technical negligence, it ruled that promising a result through simulation and not delivering it constitutes a failure in the obligation. This type of ruling reinforces the jurisprudence that simulation, when presented as a “guarantee” or as something very close to reality, generates legal obligations.⁶⁸

This review is not without limitations due to the small number of identified studies and the limited number of patients involved. Study comparison was not feasible due to different simulation software, simulation protocols, image-capturing methods, and different time points at which similarity between simulation and actual outcome was measured, in addition to variable outcome measurement tools, carrying a nonnegligible risk of bias (Figs. 2, 3).

Originally introduced to enhance patient consultations, 3D simulation is now becoming a strategic tool in planning and refining some aesthetic surgical interventions. However, reports about similarity between simulation and actual outcome are conflicting. Mismatch with actual postoperative outcome is common, and unrealistic “morphed” images may be generated, leading some patients to expect unattainable outcomes. Litigation may potentially be a serious risk whenever simulated visual expectation is not met. Despite numerous advantages, if misused, the technology can be counterproductive for both patient and surgeon. As for informed consent, stating that simulated images do not accurately predict outcomes and that no legal action may be taken if a difference between simulation and final outcome exists is essential. Undoubtedly, there is a critical need for regulatory oversight to ensure that 3D simulation is used responsibly.

The authors have no financial interest to declare in relation to the content of this article.