Introduction

Credible, consistent photographs of patients have been of great value to my patients, to my development as a physician specializing in the aesthetic care of patients, and to the development of my practice.

Credible photographs accurately and reproducibly represent the true state of the patient. This requires a consistent and systematic approach to photography, which in the end is also most efficient and effective. Photography of patients always involves a tradeoff between technical perfection and practical efficiency. In making this tradeoff, I have taken comfort from Voltaire’s observation: ‘Le mieux est l’ennemi du bien’ (‘The perfect is the enemy of the good’). When applied to routine daily photography of patients, this means that excessive concern for ‘perfect’ lighting, the ‘perfect’ camera, the ‘perfect’ angle, etc. will seriously interfere with obtaining large numbers of routine high-value-but-not-‘perfect’ photos.

As a practical matter, over the past 20 years, taking tens of thousands of patient photographs, I have found that the most important thing is to get the photograph: quality and consistency are important, but should not be allowed to detract from ‘getting the shot’. The only photographs I have regretted have been the photographs I did not get. I feel naked and uncomfortable without my camera in my pocket – to the point where I keep a spare camera in the office, in case my primary camera is broken or misplaced. Every week credible, consistent photographs help to enhance and consolidate patient satisfaction with my treatment and care. In other situations, credible consistent photographs have helped to resolve misunderstandings, disappointments, or complications of treatment.

Pearl 1

Choose a camera you can comfortably carry in your pocket all day, because if the camera is not in your pocket you will fail to take many of the photographs that are necessary for the proper care of the aesthetic patient.

Technical considerations

Lighting

Consistent, symmetrical overhead lighting is vital for credible pre- and post-treatment photography of both the filler patient and the patient being treated with botulinum neuromodulator type A (BoNT-A). This can be done in many offices by finding a point in each examination room where the patient will be standing equidistant between two overhead fluorescent lights (Fig. 30.1 and Video 1), and in a position where the lines and contours of the face will be properly lit. If the overhead lights in your office are not suitable, an electrician can install a couple of light-emitting diode (LED) panels on a single light switch to provide symmetrical illumination for patients standing in a predetermined location in each examination room and / or treatment room (search for the key words ‘led panels ephoto photography’ on www.amazon.com to see a selection of such panels). LED panels have the advantages of very long life (thousands of hours of use), low energy consumption, stable color temperature immediately after being switched on, diffuse light output, and small size.

Figure 30.1 Method of finding a standard position for a subject to stand while being photographed. Markers are placed at 20 cm intervals along a line midway between two fluorescent overhead lights. A subject is then photographed at each position, and the photographs are printed and compared. It was determined that position C in this series produced the best balance of light and shadow. This procedure can then be repeated in additional rooms, and the final markers adjusted so that very similar photographs will result when photographs are taken in any of the rooms. A pair of light-emitting diode panels can be mounted on the ceiling in cases where the orientation of fluorescent lights does not produce suitable symmetrical lighting.

It is important not to use a camera-mounted flash when photographing patients before or after fillers or BoNT-A, because the flash will fill in and obscure facial lines, creases, and contours (Fig. 30.2, compare C versus D; Table 30.1). Flash photography is excellent for the assessment of skin color and telangiectasia, and so is essential in that aspect of the management of the aesthetic patient.

Figure 30.2 Facial views commonly obtained before treatment with fillers. Camera about 40 cm from the subject, and held at the level of the subject’s nose, except in (H). (A, E) Tip of the nose aligned with the edge of the cheek. (B, F) Tip of the nose aligned with the infraorbital foramen. (C) Anterior: this image also illustrates inclusion of the chart tab showing the patient’s name and chart number, so that the individual in the series will be positively identified. The chart tab also provides objective black and white references to assist with color balancing for publication; and elements in the chart tab also provide an objective size reference, in case that is needed. (D) Photograph taken using a built-in flash on the camera. Note that the flash fills in and obscures facial lines, creases and contours, and skin texture, compared with the non-flash image shot (C) under symmetrical overhead lighting. (G) Photograph taken with the subject seated in the examination room, rather than standing (C) behind the photograph marker, centered between two overhead fluorescent lights. When compared with (C), we see that the appearance of the subject is altered and softened by asymmetrical and diffuse lighting, so that comparison of standard photographs (A–F) with the patient at follow-up can be misleading for the patient and the clinician unless the patient is standing in the same position as was used for photography when the comparison with pre-treatment photos is made. (H) Superior view, taken with the lens at the level of the top of the head, aiming down at an angle of about 30°. This illustrates pre-jowl sulcus, and sometimes also is useful to demonstrate mid-cheek volume loss related to aging or to disease.

Table 30.1 Flash versus no flash

Characteristic of photograph	Camera-mounted flash	No flash, symmetrical overhead lighting
Color rendition	Best	Good
Fine detail	Best	Good
Contour	Poor – filled in by flash	Good when properly lit
Lines and creases	Poor – filled in by flash	Good when properly lit

Color

Credible and consistent color reproduction is vital for effective use of photographs during follow-up. I have found it very practical to use a camera which has two ‘custom’ settings – allowing me to have one custom setting for flash photography (skin color and telangiectasia) and a second custom setting for filler and BoNT-A patients. These custom settings control every aspect of camera operation (macro, flash, image stabilizer and focusing, color balance) so that I can simply and efficiently switch between the custom settings C1 and C2, depending on whether I want a flash or non-flash photograph. There are only a few pocket-sized cameras on the market that have two custom settings. I have found the Canon G11 and G12 cameras to be very satisfactory, and superior to a variety of other cameras I have used over the years. They can be carried comfortably in the hip pocket of my scrub shirt or laboratory coat all day long (Video 2), and have excellent lens, sensors, and long battery life.

To ensure consistent color rendition, the settings I use are detailed in Table 30.2. You will note that a relatively high ASA of 400 is used, in order that the shutter speed will be at least second during handheld non-flash shots, thus minimizing the effect of motion. I have found it useful to apply Scotch-Tape® over the ASA and exposure adjustment dials on the camera body, to reduce the chance that the settings will be accidentally changed over the course of thousands of photographs.