All of these options are useful reasons for photography before and after treatment in plastic surgery. The most useful function from a patient’s perspective is probably to help measure outcomes and improve communication. For example, patients can be shown photographs of other patients to help them better understand likely outcomes, including scarring and cosmesis. They can also review their own preoperative and postoperative photographs with their surgeon to see positive and negative aspects of their outcome. Clinical photography in plastic surgery is very important for education and research among clinicians. This should help to improve clinical care. Medicolegal protection may apply to both surgeon and patient. The use of patient photographs in marketing carries a high risk and is not advisable. Courts have imposed liability in cases in which the provider has exploited the patient for commercial benefit.1–3
Standardized approaches must be used when performing clinical photography to ensure accuracy, reproducibility, and consistency across all images taken for any given individual, such that they show a fair representation of the person at any given stage of his or her treatment. This facilitates a comparison of pre- and postoperative images to help assess progress and outcomes. Such an approach also means that images from different patients can be compared or contrasted when required, and that when images are used for education and research purposes, the audience are able to view them in the context of a standardized setting. Often, when patients take their own photos such as “selfies” or have their family members/friends do so, there is significant distortion, and this means reliable analysis and interpretation of the images is difficult. The standardization process not only considers the precise views which typically include frontal, lateral, and oblique or quarter views for most body areas (as well as more specific views for any given procedure series), it also includes the method for obtaining the images. For example, the type of camera used, its placement in relation to the patient, the lighting, background, and specific camera factors such as lens type, magnification, and focal length and depth. Patient factors should also be standardized including clothing worn, makeup, and jewelry removal. The use of a flash or standard lighting setup should be standardized across any given series, but the type of flash will depend on the camera type and setting. For example, a separate bounce flash with a swivel head is recommended for photographs of the face and body so as to allow the consistent lighting without harsh flattened effect of a straight on flash. Clinical photographs can be taken well with either traditional or digital cameras and there are pros and cons to each. Camera lenses are categorized as normal, wide angle, and telephoto. Lens selection will need to be adjusted to suit the series being undertaken and will most often be a normal lens.1–3
3. DiBernardo BE, Adams RL, Krause J, Fiorillo MA, Gheradini G. Photographic standards in plastic surgery. Plast Reconstr Surg 1998;102(2):559–568
Depth of field refers to the distance between the closest and farthest in-focus area of a photograph. It is also known as the focal range. The depth of field is affected by some of the other options described including aperture size and focal length. The aperture refers to the size of the adjustable opening (iris) of a camera lens. This determines the amount of light falling onto the film or sensor. The smaller the aperture, the greater the depth of field. Shutter speed determines how long the iris of the camera is open to expose the film or sensor to light. In essence, it represents how long the camera spends taking a photo and therefore can affect both the brightness and crispness of a photo with shorter shutter speeds potentially freezing movement within an image and longer shutter speeds tending to emphasize or create an appearance of motion within an image. The focal length is the distance in millimeters from the optical center of the lens to the focal point, which is located on the sensor or film. The longer the length, the narrower the field of view. Lens types can be categorized as normal, wide angle, or telephoto according to focal length and film size. Normal lenses are most frequently used for clinical images.1
Resolution is a measurement of the pixel count of an image and is given either as pixels per square inch (PPI) or total number of pixels. The choice of resolution should be matched to the planned output type. It is, therefore, not consistent across all planned image uses. In general, a higher resolution is required for print uses compared with digital uses. Increasing resolution does not always improve image quality and can become excessively large with negative effects on software applications and file transfer times. Lower resolution, however, can lead to pixilation if the image is overly enlarged. High-resolution retina display devices require higher, not lower, resolution images than regular display devices.1,2
images? Resolution is a measurement of the pixel count of an image. When considering the resolution required for any given photograph, the planned output use for the image must be considered. There will be a balance to be met regarding resolution of the image in terms of quality and clarity versus image size and usability. Increased resolution is not always better and as resolution increases, so too does the image file size which can impact on file transfer times and storage. In general, it is recommended that lower resolution is used for digital images compared with those to be printed. The recommended resolution for a PowerPoint image is 150 PPI compared with 72–96 PPI for internet and email, and 300 PPI for print publications.1,2
commissures. A true lateral image can be ensured by viewing across the oral commissures (Fig. 14.2). This can be achieved by asking the patients to open their mouth to check alignment. It is important as under-rotation and over-rotation may markedly distort the appearance. Avoiding head tilt in the anterior view is also important and comparing the position of the earlobes can help with this. A face-lift series should include anterior, lateral, and oblique views. Images should be taken from both a distance and close-up to aid with scale, perspective, and proportion. The oblique view can either show the nasal tip touching the far cheek, or the nasal dorsum touching the medial canthus according to surgeon’s preference. The Frankfort plane tends to exaggerate submental fullness compared to the natural horizontal facial plane. Therefore, this natural plane is generally preferred for face and neck images. To exaggerate the submental tissues, a reading view is used, which flexes the neck. Having the head held in extension will improve the appearance of the neck contour and must be avoided. Additional views with the teeth gritted will demonstrate platysmal banding (see Fig. 14.9, A and B, Essentials of Plastic Surgery, third edition). Bird’s-eye and worm’s-eye views are more typical of a rhinoplasty or midface/facial fracture series (see Fig. 14.13, Essentials of Plastic Surgery, third edition).1–3 Fig. 14.2 A true lateral image may be obtained by viewing straight across the two oral commissures to verify correct rotation.
The use of lip filler with hyaluronic acid has become very popular during the past decade both in the aging lip to restore volume and also in the youthful lip to augment the natural lip fullness. In this setting it is very important to have consistent images before and after treatment. The standardized lip series includes seven images, six of which will be taken with the lips slightly parted and relaxed. A seventh image is taken in the frontal view when smiling. The series includes close-ups in frontal, lateral, and oblique views. It is important to remove lipstick and liners for the images and treatment, and when photographing the oblique view, the inferior philtral column should intersect the cheek on the opposite side (Fig. 14.3).1–3
When taking images for the purpose of skin resurfacing, additional views are required to try and capture the close-up appearance of the skin quality and texture. In a standard facial series, the camera is placed at 1 m with a 105-mm lens. In contrast, when performing a resurfacing series, a close-up at 0.6 m is required of the oblique cheek and also lateral photographs taken further back at 0.8 m. These are intended to show tonal changes in the skin if any from cheek to jaw (Fig. 14.4). The other elements are consistent across both series such as makeup and jewelry removal, image orientation (vertical) and the absence of facial animation.1,2
The rhinoplasty series is difficult and often needs minor adjustment. Keeping the patient’s face relaxed throughout may misrepresent preoperative problems when release of depressor septi is required. To demonstrate this, additional anterior and lateral views are required with the patient smiling. Fig. 14.3 Close-ups of the lips are photographed at 0.6 m with a 105 mm lens, whereas the full face is photographed at 1 m. Fig. 14.4 Laser/chemical peel series. These photographs are taken in addition to the standard face/neck lift series. Close-ups are photographed at 0.6 and 0.8 m with a 105-mm lens. The oblique view may either have the nasal tip touching the cheek or the dorsum touching the medial canthus (see Fig. 14.5, Essentials of Plastic Surgery, third edition). Also see Figs. 14.13–14.15, Essentials of Plastic Surgery, third edition for additional rhinoplasty views and note that while the full-face views are portrait (see Fig. 14.8, Essentials of Plastic Surgery, third edition) close-up images are better taken as landscape (horizontal) views.1
The diver’s view is taken in the oblique plane and demonstrates abdominal skin laxity by asking the patient to lean forward with the abdomen relaxed (Fig. 14.5). The standard body series is described in Box 14.6 and Figs. 14.16 and 14.17, Essentials of Plastic Surgery, third edition, and should include the patient standing with the feet parallel at hip width. The patient should wear standardized undergarments, the camera should be at level with the umbilicus and the patient’s arms should be no higher than breast level.1–3 Fig. 14.5 The diver’s view is an oblique view with the patient folded over while relaxing the abdomen.
When performing the standard breast series, both shoulders and navel should be included in the views to achieve reference and proportion. The images should be taken horizontally (landscape) with a 50-mm lens at a distance of 1 m. The camera should be at level with the areolae rather than the clavicle. Patients should have their hands placed by their side with shoulders relaxed for the majority of the images. These will include frontal, oblique, and lateral views. In addition, a frontal image with hands on hips to show pectoralis major activation is also included. When performing reductions, mastopexies, and reconstructions, the arms may be positioned behind the body and when performing latissimus dorsi reconstruction, the back should also be imaged and a lateral view taken with arms above the head.1
When storing patient data in the form of clinical photographs, it is important to use both encryption software and password protection in order to prevent unauthorized access in the event of theft or loss. This includes desktop and laptop computers, external storage devices, and mobile devices. The images should not be saved on memory cards for any extended duration because they cannot be encrypted. It is advisable to transfer the images from a memory card, shortly after taking them, onto a computer with a backup system. It is also advisable to destroy or erase any memory cards used for patient photographs when no longer in use. It is advisable to avoid adding any patient information to the saved images when storing them and ideally an alternative method such as saving by date taken can be helpful to eliminate any patient information. Of course, facial images will remain identifiable even without name, hospital number, or date of birth being listed, but the patient details should still not be saved within the file. The use of a screen guard may be helpful to avoid unintended viewing of images. However, patient images should not be reviewed in public settings. Their review should be kept to private places such as the office or clinic. It is better to remove metadata from photographs in most cases as even the location taken for the image may not be desired, and beware as such metadata can often be seen, for example, by simply “mousing over” digital images on the computer or web if used for that purpose. When taking photographs for patients they should complete written consent to include the precise usage for and storage of their images.1–4
treatment purposes, this is not required by HIPAA. The U.S. Department of Health and Human Services has published standards to protect the privacy of patients’ identifiable health information. This comprises many elements, ranging from telephone number and IP address to credit card number and fingerprints or voiceprints. The standards are documented as the Health Insurance Portability and Accountability Act (HIPAA).1 According to these guidelines, patient’s authorization is not always required for photographs to be taken. However, best practice should be to always obtain written consent for images and have the agreement for use clearly documented. From a HIPAA perspective, the purpose of obtaining photographs is categorized into two groups, namely, treatment or nontreatment, and the need for consent differs between the two groups. Nontreatment purposes include education, research, or patient education. Treatment HIPAA, a situation in which all identifiable information is removed from the photograph is an exception. It is important to recognize that all identifiable information cannot be removed from a face, and merely blacking out the eyes is not acceptable. Facial views therefore will always require formal consent specific to the required use. A safe approach to patient images is to obtain written consent and then to store images safely without any patient identifying information and ideally offline on a secure device. Care should be taken when taking and processing images to ensure that identifying features such as named jewelry and tattoos are hidden if possible. Unfortunately, because it is not really possible to anonymize full facial images, patients must accept the risk that if viewed, then this will identify them.1–4