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AlterImage - a New Price/Performance Standard for Digital Image Manipulation

By Andrew Barnett, M.D.

Chief, Plastic Surgery, St. Francis Memorial Hospital, San Francisco, CA

AlterImage Version 2.0 – Original release

The first time a plastic surgeon sat a patient in front of a mirror and pulled gently on her cheeks, image manipulation as an educational and marketing tool was born. Over the years, surgeons have used mirrors, screens, photographs, external implants, and most recently, computers, for this purpose. Digital image manipulation with computers has become the standard, but from its introduction in the early 1980’s, it has been an expensive tool. Recent price drops in computers and digital cameras have substantially reduced the hardware side of the equation, but software specifically designed for Plastic Surgery image manipulation has not followed suit. With the release of a new software program, AlterImage 2.0 by Seattle Software Design, that has changed.

While industry specific software remains expensive, the price of consumer software for photo manipulation has come way down in price over the past three years, following the proliferation of relatively inexpensive digital cameras. Many of us have played with programs such as Photoshop or SuperGoo and have thought that much of the functionality necessary for image manipulation was there. Unfortunately, these programs are either too simple or too complicated. The tools provided are simply not designed for the fairly specific needs of a plastic surgeon.

Image manipulation software designed for our specialty has traditionally cost between $10,000 and $25,000. Over the years, these prices have increased as the software designers introduced additional “modules” allowing for image storage, surgical planning, and the like. Prior to its recent bankruptcy, a fully configured Mirror system was selling for $40,000. With the increase in capability, these systems have become both slower and more challenging to use.

Seattle Software Design saw a niche. Over the past three years they analyzed the state of imaging for plastic surgeons and they wrote a program which is limited in focus and simple to use. It does not do everything, but it does almost everything you need it to do. It does it quickly and easily, with a very short learning curve.

The program, AlterImage 2.0, comes on a single CD-ROM. The manual is online (a printed User's Manual is now included). It installs on any Pentium grade computer running Microsoft Windows 95/98/NT (Windows 7, Vista and Windows XP are now supported) and accepts images from files, digital cameras, and any TWAIN devices, such as scanners or imaging boards. You can use a mouse or graphics pad. Within half an hour, you can be up and running, performing sophisticated image manipulation.

Three main tools are present: Warp, Stretch, and Smooth. All tools are present around the periphery of the screen. There is no need to work through layers of pull down menus to get to the correct level and perform the manipulation. To view the results you have two choices. The manipulated image and its original can be viewed split screen and you can use the “toggle” control to momentarily replace the modified image with its original image.

The warping tool lets you “Push” tissue to alter shape. Neck lifts, jowl correction, cheek implants, and most of what you need to do with rhinoplasty are performed with this tool. Warping is the workhorse of any image manipulation software for plastic surgery and AlterImage does it well.

AlterImage 2.0 sells for $995 (the latest version is much improved and is now $1295). For that you get the software and manual on a disk with an online tutorial. Training is not provided, nor would one expect it at that price. Customer support is limited but the program is so easy to use that it really is not necessary.

So what is AlterImage 2.0? It is a new standard in price performance. It lacks a few of the features of the higher end programs such as United Imaging and Mirror, and it does not do archiving or analysis. It has a few problems in its initial release, most notably the lack of cut and paste between images (cut & paste between images has been added). What it does do it does exceedingly well, quickly, efficiently, and accurately. After using this program for a while, I find it solves 90% of my imaging needs at 10% of the price of the other programs.


AlterImage Version 3.3 – Update, April, 2007

What makes AlterImage an essential part of my practice is its unique combination of power and ease-of-use. Within five minutes, I can take a photograph, manipulate the image, and show the patient a very accurate visual representation of their anticipated result. It educates and creates excitement, the goal of any consultation. And it’s fast! With the release of version 3.3, Seattle Software Design has brought it up a notch, providing additional power and actually making the program easier to use. All the same basic tools are present, but they work better. They are smoother, faster, have a few more features, and seem to require even less touch-up to provide a seamless result. On top of those tools, they have added a bunch of elegant utilities, and two really helpful new features. Finally, AlterImage continues its commitment to using industry-standard formats for all its files, so you can easily copy & paste to Microsoft Word, Nextech, image archiving programs like ACDSee™, and to virtually all EMR programs. This is absolutely essential, and I wouldn’t even consider an imaging program that uses a proprietary format.

The utilities are designed to enhance the quality of the image. Color correction, aspect ratio control, saturation, etc. For those who publish or put together presentations, these utilities eliminate the need for exporting the images to other programs to tweak them. I rarely use them, but it’s nice to have them available (and they never get in your way.)

The new features are really exciting – Eyelid fold creation and Ghosting. The Double Eyelid tool makes the creation of an upper eyelid fold simple. In the patient with a visible fold, I use the warping tool, but in the patient without a fold, (the Asian single eyelid, or the non-Asian with a large amount of excess skin), the Double Eyelid tool allows you to rapidly create a very accurate, realistic fold. Subtle manipulations of the fold can be done, showing the patient the difference between a high or low fold, and varying degrees of fat removal. The Ghosting feature allows you to overlay images, so you can place an x-ray over a soft tissue image. It also allows you to overlay the before and after, and using the slider control, gradually morph from the before-image to the after-image. Symmetry comparisons are made easier with the ghosting tool, and are really helpful with patients who may not be (and usually are not) aware of just how asymmetric they are. You can rapidly copy half the face, flip the side you’ve copied, and overlay it on the opposite side. Rotation and sizing tools allow for precise positioning, and the slider allows you to go from a barely visible ghost overlay to complete replacement of the copied image. This can also be used for showing before-and-after images in a single image (like you see in the presentations at meetings). Very cool.

The help features and tutorial are improved. I have to stress that this is an extremely easy program to use, and most physicians will be up and running within 30 minutes (really!) but the help and tutorial are there to guide you as you tap the features of AlterImage.

Version 3.30 of AlterImage has done an excellent job of increasing the sophistication of a very powerful and very affordable software tool, without sacrificing speed and simplicity. This essential part of my practice has become even more indispensable.


Andrew Barnett, M.D. is a board certified plastic surgeon practicing in San Francisco. He has been interested in computer software and design since the early 1980’s. He has no financial interest in Seattle Software Design. Dr. Barnett may be contacted at