Pitfalls of Nonstandardized Photography

Accurate, consistent, high-quality photographs of patients before, during, and after surgery are critical for planning and performing surgical procedures, analyzing and documenting surgical outcomes, and educating patients and surgeons. Attaining the necessary high standards of photography and avoiding common pitfalls associated with nonstandardized medical photography requires stringent uniformity in equipment, lighting, room setup, patient positioning, and camera settings.

The use of high-quality photography is a critical part of any facial plastic surgery practice. Preoperative photographs serve as a reference and adjunct to the clinical examination, helping the surgeon plan and carry out surgical procedures, and should be available in the operating room for reference. Intraoperative photographs should demonstrate a dynamic series of events to document the procedure and educate the operating surgeon, colleagues, and staff. Postoperative photographs document outcomes and may be used for research, educational purposes, or legal justification. These photos can also be used to educate and counsel patients, to ensure uniformity of evaluation and treatment from patient to patient, and for marketing and advertising purposes after appropriate patient consent has been obtained.

For photography in facial plastic surgery to be useful, however, it must be accurate, consistent, and of high quality. Photos should be free of distortion, with the greatest possible depth of field. Unlike a portrait studio, the goal is not to make the patient look as good as possible, even in the postoperative setting. Instead, the goal should be to represent the patient as accurately as possible.

Poor photography, due to factors such as improper lighting, poor patient positioning, and inconsistent room setup, can misrepresent the patient’s original chief complaint and distort the patient’s perception of the outcome. In some cases, poor lighting can even simulate postoperative results; for example, it can reduce wrinkles and scars, cause hemangiomas to change color, and inaccurately portray nasal tip anatomy in rhinoplasty patients. Slight changes in patient or camera position can lessen a nasal hump, vary nose size, and alter skin tension. Small changes in neck flexion or head protrusion/retrusion can lead to noticeable changes in perception of jaw line definition and submental soft tissue.

The best way to prevent these common errors is photographic standardization with high-quality equipment. Pre- and postoperative photos should be taken by the same photographer (preferably the surgeon or someone with medical knowledge) and be obtained under identical conditions. Equipment, room setup, and camera settings should also be consistent. Patients should be positioned using standard protocols specific to their chief complaint.

Although surgeons are not professional photographers, they should be able to take technically proficient photographs by following standardized rules. An understanding of the various possible pitfalls in nonstandardized photography is necessary to interpret others’ work and improve one’s own uniformity.

Equipment

Camera

Digital single-lens-reflex (SLR) cameras have replaced film cameras for most medical photography because the photos can be viewed and evaluated immediately; many more images can be taken without additional cost; close-up views are easy to obtain by enlarging the photo; and storage and access is quick and compact. There is often much discussion regarding the number of megapixels required for medical photography. Any modern digital SLR camera should have sufficient megapixels for the purposes of the facial plastic surgeon.

Most professional digital cameras, when used with a high-quality lens, will produce photos of sufficient quality for medical photography. However, individual cameras vary in contrast, color, and grain, just like different film types ( Fig. 1 ). Therefore, the same camera must be used before and after surgical procedures for accurate comparison.