Pre- and PostoperativePortrait Photography:Standardized Photosfor Various Procedures

Ravi S. Swamy, MD, MPH, Sam P. Most, MD*

KEYWORDS

� Photography � Rhinoplasty � Rhytidectomy� Blepharoplasty � Cheiloplasty � Mentoplasty� Otoplasty � Facial resurfacing

s.co

m

The famous adage ‘‘a picture is worth a thousandwords’’ could not be more fitting in the realm offacial plastic surgery. Surgical planning andassessment of successful outcomes would beimpossible without use of consistent and accuratephotodocumentation. In addition, assessments ofnovel techniques are inherently dependent onproper patient photographs and are critical topromote scientific development and surgicaleducation.1 Clinical portrait photographs havebecome as integral a part of the patient’s recordas radiographs, and it is critical that strict standard-ization of photographic technique is employed at alltimes. It is the purpose of this review to elucidatemethods to consistently achieve standardized,high-quality images for specific facial plasticsurgery procedures by describing proper equip-ment, lighting, and patient positioning.

CAMERA AND LENS

Single-lens-reflex (SLR) 35-mm cameras had beenthe gold standard for patient photodocumentation,but with the advent of digital SLR photograph tech-nology 35-mm film SLR cameras are no longer rec-ommended.2 Digital cameras offer many newadvantages such as instantaneous pictures, abilityto crop and adjust on a computer, and provision ofimages that can be easily stored and filed. Althoughpoint-and-shoot cameras are less expensive, theresolution of these models is generally lower than

Division of Facial Plastic and Reconstructive Surgery, DeStanford University School of Medicine, 801 Welch Road* Corresponding author.E-mail address: smost@ohns.stanford.edu

Facial Plast Surg Clin N Am 18 (2010) 245–252doi:10.1016/j.fsc.2010.01.0041064-7406/10/$ – see front matter ª 2010 Published by E

that of the digital SLR cameras. Digital SLRcameras also afford the ability to change lensesand adjust settings that control aperture size,shutter speed, and exposure. While digital resolu-tion technology is approaching the level of resolu-tion of 35-mm film (the equivalent of 35 millionpixels), a resolution of 1.5 million pixels (megapix-els) is acceptable for medical photography.3 Theauthors generally recommend a 5-megapixelcamera or higher.

In terms of choice of lenses, a lens with a longerfocal length, in the range of 90 to 105 mm withmacro capability, is recommended to capturepertinent details of facial anatomy.4 These lensesproduce the best balance of distortion and providethe largest depth of field to ensure the whole faceis in focus.5

LIGHTING

A single mounted camera flash, while inexpensive,will produce harsh shadows and uneven lighting.6

Therefore, a studio setup of lighting is preferred.Specifically, the quarter-light system was de-signed for medical photography, and consists of2 lights of equal intensity, positioned at 45� fromthe subject-camera axis (Fig. 1).7 The downsideof this system is cost and requirement of a largespace. The authors have used a modified versionof this system, illustrated in Fig. 2. The authorshave found that this system works well in small

partment of Otolaryngology/Head & Neck Surgery,, Stanford, CA 94305, USA

lsevier Inc. faci

alpl

asti

c.th

ecli

nic

Fig. 1. The ‘‘ideal’’ setup for photography for facialplastic surgery. The flashes are set up at 45� to thecamera-subject axis. Backlighting provides separationfrom the background, as does the distance betweenthe subject and background.

Swamy & Most246

spaces and that the backlights are not necessary.A distance of 12 to 18 inches is maintainedbetween the subject and background to minimizeshadow effects of the subject on the background.

BACKGROUND

The purpose of the background is to eliminatedistractions and place full focus on the patient. It

Fig. 2. Modified space-saving lighting setup.

is important that the background is void of shinymaterial and without folds or creases. In terms ofchoice of color, a blue background is ideal formedical photography. A blue background providessufficient contrast, is complementary to all skincolors, is pleasant to the eye, allows for a greaterdepth of field, and moderates shadows withoutoverwhelming the subject.8 A white backgroundproduces harsh shadows, whereas a black back-ground provides less contrast and diminishes theimage’s 3-dimensional quality.3

CONSENT

Consent for photodocumentation must be ob-tained prior to any photography. The consentshould include a statement describing the justifi-cation of the photographs. Patients must under-stand that their photographs are tools forsurgical planning and will become part of theirmedical record. Additional statements regardingpatient confidentiality are necessary if the photo-graphs are to be used for educational purposes,lectures, exhibits, and publications.9

PATIENT PREPARATION AND POSITIONING

Proper preparation for photodocumentation is crit-ical to maintaining consistency and producingphotographs that capture the essential anatomicdetails. The patient’s hair should be pulled awayfrom the face to expose the forehead and bothears, and can be accomplished with hair clips orflexible hair bands. Eyeglasses and jewelry shouldbe removed and, depending on the procedure, itmay be beneficial to have the patient wear onlya surgical gown so collars and distracting clothingdo not obscure pertinent anatomic detail.9

Although some patients may be reluctant,removal of makeup before taking photographsmay be required in cases whereby the makeup it-self is distracting or excessive. An added benefit isthat removal of makeup can reveal skin irregulari-ties or fine rhytids that can be addressed as partof the surgical plan.9

Patient positioning is critical to maintain stan-dardization between the different views. Properpositioning is difficult to master, and is often theculprit of substandard photographs. Identicalviews should be obtained for each type of surgerythat is being considered. There are 5 standardviews that apply to most, if not all, facial aestheticprocedures, comprising the anteroposterior (AP)view, the oblique view from right and left, and thelateral view from right and left (Fig. 3).

Regardless of the procedure, the level of thecamera lens should be at the same height as the

Fig. 3. (A–E) Five standard views for preoperative andpostoperative photography used for most facialplastic surgery procedures. It is important to use theFrankfort horizontal line, which extends from thetop of the tragus to the infraorbital rim, as a referenceto ensure proper head positioning (A) Anteroposte-rior (AP); (B) right oblique; (C) right lateral; (D) leftoblique; (E) left lateral.

Fig. 4. (A, B) Two basal views obtained for rhino-plasty. (A) The nasal tip is aligned with the medialcanthi. This view can help with assessing any curva-ture in the dorsum and its relationship to the alar-columellar complex. (B) Aligning the nasal tip to theglabella allows for isolated photodocumentation ofthe alar-columellar complex.

Pre- and Postoperative Portrait Photography 247

center of the area being photographed. Careshould be taken to take pictures at the patient’seye level and that the patient is exactly 90� fromthe lens. By using the Frankfort horizontal line, animaginary line from the top of the tragus to theinfraorbital rim, as a guide, the patient should be

positioned such that this line is parallel with theground.

While it is easier to maintain the Frankfort planein the AP view, maneuvers to assure that theFrankfort plane is maintained on lateral viewsinclude asking the patient to open his or hermouth, while the correct horizontal position is veri-fied by direct line of sight between the oralcommissures. An additional alignment safeguardon lateral view is achieved by superimposing theeyelashes and eyebrows.10,11

There are two descriptions on how to obtain theoblique view. Some advocate lining the nasal tipwith the edge of the contralateral cheek. Detrac-tors complain that this alignment results in overro-tation of the patient and provides a ‘‘five-sixthsview in lieu of a three-fourths view.’’ An obliqueview with less rotation of the patient can beachieved by aligning the patient’s ipsilateralmedial canthus to the oral commissure.3

The patient should be able to sit comfortably ina chair that allows them to keep his or her feet onthe floor and swivel without much effort. Picturesshould be taken at the same distance to ensureuniform magnification. Placement of the camera

Swamy & Most248

on a fixed tripod and placing marks on the floor onwhich the patient can place his or her feet will helpensure uniformity. Placement of fixed markers atspecific sites around the room may also be helpful,as they provide a visual aid for the patient to fixatethe eyes and head position so as to achieve consis-tent and uniform photographs.3

RHINOPLASTY

The standardized views for photographing therhinoplasty patient are well known and havebeen described in detail.10 However, correctexecution of these 6 views is imperative to attaina critical evaluation of the nasal anatomy. In addi-tion to the 5 standard views that include the APview, lateral view from right and left, and the obli-que view from right and left, 2 basal views providecritical information on the alar-columellar complex.One basal view is best achieved by aligning thenasal tip to the medial canthi (Fig. 4A). This align-ment allows the surgeon to appreciate the relationof the tip and nasal dorsum. The second baseview, considered a true basal view, can be at-tained by aligning the nasal tip evenly with theglabella (see Fig. 4B). It may also be beneficial toobtain a cephalic view in order to evaluate the

Fig. 5. Smiling lateral views. In some patients, smilingdocumented.

nasal dorsum, and a smiling lateral view to capturedynamic changes to the nasal tip due to tip ptosisor overactive depressor septi muscle (Fig. 5).9

RHYTIDECTOMY

Standard photographic views for rhytidectomypatients include 2 full-face AP views with thepatient in repose, and smiling, bilateral obliqueviews as well as bilateral lateral views. It is impor-tant to include the entire neck in the series ofviews. Some surgeons recommend an additionalclose-up view of the perioral area and submentalneck tissue, as well as a forcibly animated viewto document preoperative facial nerve status andplatysma action. A close-up view of each auriclewith the hair pulled back may also be beneficial,as the level of the hairline affects placement of inci-sions.10,12 The authors also recommend additionallateral views with the patient’s head turned down-ward, as this accentuates laxity and redundancy ofthe neck skin and fat (Fig. 6).

NECK REJUVENATION AND MENTOPLASTY

Patients who are candidates for neck rejuvenationprocedures or mentoplasty should still have

may cause downward tip movement and should be

Pre- and Postoperative Portrait Photography 249

photographs that include full face and neck in the 5standard views that include AP, bilateral oblique,and bilateral lateral views. Additional close-up APand lateral views from the base of the nose to clav-icles are also warranted (Fig. 7). The close-upviews are required to document the presence ofjowling, vertical platysma, and loss of a sharplydefined cervicomental angle.

The lateral view is especially important forpatients seeking mentoplasty. Chin position isideal when a vertical line (perpendicular to theFrankfort horizontal plane) is drawn down fromthe nasion and touches the pogonion.13 In agingpatients, close-up views of the chin may revealthe presence of ‘‘marionette lines’’ caused bydeepening of the labiomandibular groove,secondary to bony resorption of the mandibleand soft tissue atrophy.

CHEILOPLASTY

Patients seeking lip augmentation, regardless ofanticipated technique, should undergo standardphotodocumentation that includes the 5 standardfull-facial views. Additional close-up views of thelips should include the patient at rest, whistling

Fig. 6. (A, B) Additional views recommended for the rhytidtion provides additional assessment of the patient’s skin lax

or puckering, and smiling. Patients should alsokeep their lips slightly open at rest as this betterdemonstrates the extent of lower lip fullness(Fig. 8).9

BLEPHAROPLASTY/BROW LIFT

In addition to the 5 standard views, close-up viewsof the patient’s upper face from the nasal ala tohairline should be included. Photographs with thepatient’s eyes open, closed, looking up, and look-ing down are recommended so that pseudoher-niation of the fats pads can be better delineated(Fig. 9). Some surgeons also recommend closedeyes on oblique and lateral views to documentcompletely normal lid functioning. A close-up APview of the patient squinting may also providemore information on excess periorbital skinredundancy.

When a brow lift is considered part of thesurgical plan, close-up photodocumentation ofthe hairline should be established. Additionalviews with the brows elevated and frowning maybe helpful. It is critical to capture the brows atrest, and this can best be accomplished by askingthe patient to keep his or her eyes closed for 15 to

ectomy patient with head leaning forward. This posi-ity and redundancy to be addressed by the procedure.

Fig. 7. Standard close-up AP view for patients under-going mentoplasty or neck rejuvenation.

Swamy & Most250

20 seconds. A photograph should be taken as thepatient opens his or her eyes just enough to lookforward without raising the brows. This maneuverprovides a more accurate picture of the patient,reducing the effect of exaggerated musclecontraction.14

Fig. 8. (A–C) Close-up view of lips for cheiloplasty. Theseries should include: (A) photo with lips slightly openat rest, (B) lips puckered, and (C) smiling.

OTOPLASTY

Perioperative views for otoplasty patients shouldinclude a posterior full-head view in addition tothe standard 5 views with the patient in the Frank-fort plane. Close-up photographs are recommen-ded from the anterior and posterior views todocument the relationship of the auricle to thehead. More than other procedures, the hair mustbe pinned or taped back from the ear for propervisualization (Fig. 10).

FACIAL RESURFACING

Standardization of perioperative photography isespecially critical for patients undergoing facialresurfacing. Fine details of skin texture, rhytids,pigment irregularities, and pore size need to beassessed with highest accuracy.15 In addition,

maintaining uniformity of patient position, camerasettings, and lighting need to be unconditionallyconsistent. Five views of patients are recommen-ded with close-ups of the areas that are to specif-ically addressed. These procedures often requiremultiple sessions, and the optimal time point forfollow-up photographs is immediately beforeeach treatment.15

POSTOPERATIVE PHOTOGRAPHY

Standard views taken preoperatively apply postop-eratively as well. Photographs of patients areusually taken at 1 year after surgery, as by thenthe patient is completely healed and most of the

Fig. 9. (A–C) Standard views for blepharoplasty. Documentation of the patient with eyes open, closed, and look-ing up and down can provide vital information regarding extent of fat pseudoherniation. (A) AP views. (B) Rightlateral views. (C) Left lateral views.

Fig. 10. Standard views for otoplasty. It is importantto have the patient’s hair pinned or taped back toproperly assess the position of the auricle to the scalp.

Pre- and Postoperative Portrait Photography 251

swelling has subsided. Often, photographs can betaken at shorter intervals for less invasive proce-dures. It is critical to maintain a standardization im-plemented for preoperative pictures to capture thetrue results of surgery. The authors ask patients toremove makeup and pin their hair back if necessaryso that fine relevant anatomic details may becaptured.

SUMMARY

Despite nuances associated with specifically rec-ommended views for different facial plastic surgeryprocedures, the enduring theme of photodocumen-tation in facial plastic surgery is absolute uniformity.Photographs are essential tools for surgical prepa-ration, patient communication, clinical education,and medical jurisprudence. Deviations from stan-dardization can lead to misleading results.

A study by Daniel and colleagues7 illustrated thatsmall changes in positioning of lights can changethe appearance of nasal tip anatomy in photo-graphs without surgery. These investigatorsshowed that on decreasing the angle between thesubject-camera axis and the lighting, the tip-defining points (and light reflexes in theeyes)appearcloser together. Daniel and colleagues coined theterm ‘‘photographic tip rhinoplasty’’ to describethis phenomenon when lighting is changed. Morerecently, Sommer and Mendelsohn16 found that

Swamy & Most252

small changes in patient positioning such as neckextension and jaw protrusion led the majority ofblinded judges to believe that the patients under-went successful facelift and neck liposuction. Theslight change in positions gave the appearance ofa more refined cervicomental angle and a decreasein submental tissue.

Precise standardization of equipment, lighting,and patient positioning are central to producingconsistent, high-quality, and reliable clinical pho-todocumentation. It is vital that these standardsare maintained, as clinical photography in facialplastic surgery remains the best instrument forrefining techniques, developing new ideas, andultimately making ourselves better surgeons.

REFERENCES

1. Yavuzer R, Smirnes S, Jackson IT. Guidelines for

standard photography in plastic surgery. Ann Plast

Surg 2001;46(3):293–300.

2. Persichetti P, Simone P, Langella M, et al. Digital

photography in plastic surgery: how to achieve

reasonable standardization outside a photographic

studio. Aesthetic Plast Surg 2007;31(2):194–200.

3. Kontis TC. Photography in facial plastic surgery. In:

Papel ID, editor. Facial plastic and reconstructive

surgery. 3rd edition. New York: Thieme; 2009. p.

143–52.

4. DiBernardo BE, Adams RL, Krause J, et al. Photo-

graphic standards in plastic surgery. Plast Reconstr

Surg 1998;102(2):559–68.

5. Swamy RS, Sykes J, Most SP. Principles of photog-

raphy in rhinoplasty for the digital photographer.

Clin Plast Surg, in press.

6. Schwartz MS, Tardy ME Jr. Standardized photodo-

cumentation in facial plastic surgery. Facial Plast

Surg 1990;7(1):1–12.

7. Daniel RK, Hodgson J, Lambros VS. Rhinoplasty:

the light reflexes. Plast Reconstr Surg 1990;85(6):

859–66 [discussion: 867–8].

8. Galdino GM, DaSilva And D, Gunter JP. Digital

photography for rhinoplasty. Plast Reconstr Surg

2002;109(4):1421–34.

9. Henderson JL, Larrabee WF Jr, Krieger BD. Photo-

graphic standards for facial plastic surgery. Arch

Facial Plast Surg 2005;7(5):331–3.

10. Thomas JR, Tardy ME Jr, Przekop H. Uniform

photographic documentation in facial plastic

surgery. Otolaryngol Clin North Am 1980;13(2):

367–81.

11. Davidson TM. Photography in facial plastic and

reconstructive surgery. J Biol Photogr Assoc 1979;

47(2):59–67.

12. Perkins SW, Naderi S. Rhytidectomy. In: Papel ID,

editor. Facial plastic and reconstructive surgery.

3rd edition. New York: Thieme; 2009. p. 207–26.

13. Gonzalez-Ulloa M. A quantum method for the appre-

ciation of the morphology of the face. Plast Reconstr

Surg 1964;34:241–6.

14. Graham HD, Quatela VC, Sabini P. Endoscopic

approach to the brow and midface. In:

Papel ID, editor. Facial plastic and reconstructive

surgery. 3rd edition. New York: Thieme; 2009. p.

227–42.

15. Shah AR, Dayan SH, Hamilton GS. Pitfalls of photog-

raphy for facial resurfacing and rejuvenation proce-

dures. Facial Plast Surg 2005;21(2):154–61.

16. Sommer DD, Mendelsohn M. Pitfalls of nonstandar-

dized photography in facial plastic surgery patients.

Plast Reconstr Surg 2004;114(1):10–4.