Clinical photography for the aesthetic patient

Published on 22/05/2015 by admin

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CHAPTER 2 Clinical photography for the aesthetic patient

The world is filled with forms: objects, people and other things that we look at, identify, enjoy, define, interact with, and make judgments about. When we look at these we are not seeing the things themselves, we are seeing how they interrelate with the light that they are seen in.

The word “photography” means “light writing”. The old saying that “a picture is worth a thousand words” is simply not true; a picture contains more and different information than words could possibly express. The goal of clinical photography is to observe conditions on the body, record them and record changes that happen to them. These recordings may be made for any number of reasons, but for a plastic surgeon the usual aim is to identify pre-existing conditions, modify them and to see how the modifications worked. Pictures are invaluable in the record of patient care for both the surgeon and the patient. They are referred to on each patient visit. They may show the steps to a surgical triumph. At worst they may need to provide a defense in a court of law.

The body exhibits highly complex curvatures and shapes. Though not perceptual psychologists, we are amazed at how selective, limited and evanescent visual memory can be. It is common in our practice to have a patient say that a certain wrinkle “just appeared”, when wrinkles typically take years to emerge. We have noticed this in our own mirror. Many patients, insisting that they know every pore on their faces, for example, will be surprised when a fairly large feature is pointed out to them. With astonishing rapidity, sometimes within days, patients forget how they used to look, after an operation. The surgeon’s visual memory is frequently not much better.

A surgeon’s analytic focus may be on a particular structure while not noticing an adjacent area a centimeter away, and a certain structure or configuration may be present before treatment and not noticed until afterwards. This latter situation is frustrating to patient and surgeon alike as the patient is convinced that there is a “new” problem as a result of surgery. The surgeon cannot prove otherwise without a good visual record. Similarly, areas remote to the surgery may be problematic and without photos there is no good way to analyze them.

The desiderata of clinical photography are straightforward. One must be able to see the conditions present on a print or a screen, and one must see them in the same way at some future time. The images must be consistent over time in lighting and in position. Though simple in concept these are difficult to achieve in practice.

Digital photography has advanced quickly to become the main tool used by plastic surgeons for clinical documentation. Digital imaging is less expensive, more flexible and easier to archive than film, though backup becomes an issue. The resolution of the images continues to improve. Early in the evolution of digital photography, digital point and shoot cameras were popular; however the image quality with small zoom lenses and small image sensors left much to be desired.¹

Plastic surgery is a professional endeavor with high standards for record keeping. We prefer the use of digital SLRs (single lens reflex cameras) which use interchangeable lenses with more sophisticated flashes. Though a detailed explanation of CCD sensors, pixel dimensions and print size, and printed dots is beyond the scope of this chapter, we would note that for practical purposes the horizontal resolution (number of pixels of width of a certain image) times the vertical resolution (same) will give the pixel size of the image, usually measured in megapixels. Most commercial printers print at 300 pixels per inch for photographic quality. Thus a camera that has a resolution of 8 megapixels will be able to print at about 8 × 10 inches. Larger prints may be made with some reduction in quality. We think that a 4–5 megapixel range is a reasonable minimum for professional applications.

The use of digital technology allows the taking of large numbers of images with essentially no unit increase in costs. At the time of this writing memory storage costs have plummeted, thus making storage and backup much less expensive than even a few years ago. Patient images may be stored in specialized programs that provide archiving with other functions. An example is the Mirror System from Canfield Scientific.

Lighting

Digital photography is a continuation of traditional photography, and the rules of exposure, lighting and composition are the same as they have been for the last 170 years.

The exploration of light, shadow, form and position has been one of the triumphs of western art. Highly talented people have devoted careers to understanding these relationships and there is a sizeable literature on photography for these ends. Unlike portraiture, where the intent is to capture a face or body in a flattering way, or to reveal an essential truth about someone or something, the goals of clinical photography are not artistic. They should be an unremittingly honest designation of what is there. It is a visual transcription.²

What defines facial and bodily features in the world of daily life is the light one sees them in, or more properly the interplay of light and shadows that visually defines them. Tangential light shows wrinkles, contours and shapes in a very different way than hard anterior light or soft “wrap around” light, which flatten and minimize them (Fig. 2.1).

Fig. 2.1 On the left the patient is illuminated with an on-camera detachable flash; on the right a twin umbrella set up. These are both commonly used light sources. The on-camera flash is harsher and the sides of the face are not well-exposed. The tear troughs are better visualized however. Care has been taken here to slightly underexpose the images. With overexposure both images would be unrealistically without skin shadows.

A recurring problem in the lighting of patient images is that certain details and contours are washed out or flattened so much by the light that they are not visible. Body cellulite or certain facial wrinkles are frequently not seen in anterior (flash) light, but highly visible in everyday vertical light.

In general skin irregularities are best seen in tangential light. Shapes such as breasts, or body contours are best seen in slightly shaded light. Different light shows different things and there is no single light that will show everything, so compromises have to be made. The more attractive a particular lighting setup make the person look, the less likely it is to show the issues of skin and shape that are of interest to patients and surgeons.

Lighting schemes

Many plastic surgery lighting designs have been developed. They vary from on camera flashes of different complexities to external lights in different configurations. Portrait lighting is usually asymmetrical, i.e. the sides of the face or body are lit differently for purposes of interpretation of the subject.² In general clinical lighting should be symmetrical. If time, space, and temperament of the surgeon allow, we like the use of small silver twin umbrellas, mounted higher than the patient’s eye level. This light is somewhat forgiving, but shows reasonable skin detail and by shifting the lights up or down one can see greater degrees of skin detail. The disadvantage of this lighting is that it casts shadows across the nasolabial fold (NLF) and tends to overexpose the tear troughs (Fig. 2.1).

However this lighting scheme is versatile and has enough spread to show body contours well. Even without a dedicated photo room, small slaved flash units with diffusers may be attached to the wall. More vertical light gives very accurate body skin rendition, and so the lights may be elevated or bounced off the ceiling to show skin irregularities for body shots. Light boxes may be used, though we find this light overly flattering. All of these light sources have been used successfully in different offices and all have adherents. The clinical examples shown here use twin umbrella lighting.¹

The assumptions made for the purposes of this chapter are that many surgeons do not have the room and inclination to set up external lights and most will use an on-camera flash.

We prefer the use of a separate on-camera flash. This separates flash from the lens enough to add a tangential quality to the light (the built in flash in many digital cameras is so close to the axis of the lens that the light is flattened and details in the center of the frame tend to be washed out).

If the camera is turned vertically, the lighting will fade slightly on the side of the subject opposite the flash. This is not necessarily a problem, though detail may be lost on the darker side. When a vertical orientation of the camera and flash are used it is important to have the flash pointing from anteriorly, i.e. in an oblique or lateral view the flash should be on the side of the face that the nose is pointing to, otherwise a shadow will be cast across the face.

A small diffuser on the flash may remove some of the harshness and contrast of this kind of light. As with all aspects of practice some experimentation is necessary. Reproducibility of lighting is easy with this method. All the pictures are taken the same way. Though this style of lighting does not necessarily give the prettiest images it can be highly accurate (see figures).

Other on-camera lighting systems are available and are useful for specialized applications.³ We do not think that a ring light is very useful for clinical photography of body parts other than close-ups of the skin itself. The light that it casts is co-axial with the camera lens and is flat and shadowless by design. These attributes make the ring light useful in fashion photography, but it hides too many relevant skin contours to be recommended for clinical photography other than to illuminate deep into cavities, under flaps or for dermatologic reasons.

Perspective changes occur when a three dimensional object is portrayed in two dimensions. In plastic surgery the classic example is a face taken full frame with a wide-angle lens (the distance from the subject to the camera is short) and a longer lens (the distance from the camera to the subject is greater). In the first case the central, closer part of the face will seem to bulge and the ears will seem to recede. In the second case the face will look flatter, the nose will get smaller and the ears will widen out (Fig. 2.2). This effect is commonly ascribed to the lens, but is in reality solely a function of camera to lens distance. For body and face, a taking distance of 4–6 feet is adequate. We will use a lens of 105 mm (or 105 mm equivalence for most digital cameras) at a distance of about 5 feet for the face and a lens of 50 mm (or equivalent) for body.⁴

Fig. 2.2 Perspective changes are very clear here. The image on the left was taken at 5 feet, the image below at 2 feet and the image on the right at about 14 inches. The focal length of the lens is only material in the distance it takes to fill the frame from ear to ear. This effect is actually evident if one looks closely in a mirror at similar distances.

Though highly sophisticated metering is available for modern cameras and is commonly used, for the purposes of lighting in a known room at a known distance we favor the use of manual exposures. The light and shutter speed are always the same, and the distances are constant. We think that an f-stop of a least 11–16 is necessary for enough depth of field to assure that the back and the front of the subject are in focus. For facial images we focus on the eyes.

Position

Standardization is easy when it comes to exposure and camera to subject distance. Standardization of position is very difficult. As with anything that is difficult, many attempts have been made to achieve similarity in position. For most clinical purposes we find that simply paying close attention to the preoperative position and carefully trying to match it by comparing photo to patient works well for the typical clinical situation. In attempting to match a patient to a photograph the tendency is to exaggerate the rotation. Rotation is usually easier to match than vertical position.

Clinical pictures should have a strong element of ritual to them and should always be taken the same way. We put the patient on a rotating stool and once the AP is taken have her rotate without tuning the neck. For both face and body photography we find it helpful to place numbered cards or markers on the wall at 45 degree increments to help the patient face the appropriate direction.⁵

Faces

For faces we prefer five basic images: AP right and left obliques, and both laterals. These views contain most of the necessary information about the face. We repeat this basic sequence as necessary for follow-up photos. Because the face is a mobile structure and because patients will animate in their mirrors and misremember how they looked in the past, we take smiling views in the AP obliques and lateral. These are valuable for general purposes and to show smiling induced chin ptosis. We will include as many dynamic images as necessary to show preoperative nerve function.

We also take an AP of the neck from below with the platysma in repose and in animation and any other special views that the case may call for (Fig. 2.3).

Fig. 2.3 One half of the face series is shown. We like to take the oblique with the nasal tip at the mid-pupillary line. A smiling image is taken in each of the cardinal positions (not shown). Platysma views are taken as shown in repose and with animation and close-up views are taken of any other area of interest. Any other animation views are included as desired. Ears should be visible in pre- and postoperative images. Though it is frequently difficult to persuade patients to remove makeup, most can be convinced into clipping their hair back. These pictures should be ritualistic in their position.

Eyelids are taken with the face pictures and in close-up in the AP in superior gaze as well as laterals (Fig. 2.4).

Fig. 2.4 A–C, Eyelid close-ups are illustrated.

Photography of the nose is contained in the facial series. Anteroposterior images are taken (ensuring that the ears are equally visible to control rotation), obliques and lateral. In addition smiling views are taken of the AP and the lateral images to demonstrate the effect of the lip on the nose. In addition basilar views are taken, one looking directly up the dorsum and one with more head uptilt for a true basilar view.^3,⁶^–⁸ Camera viewfinders with grids are useful to align the eyes or ears for uniformity in position (Fig. 2.5).

Fig. 2.5 The nose series is contained in the face series, with AP oblique and lateral images. Smiling images are included in the AP and lateral. The only different view is the two basilar views of the nose, one looking up the dorsum and one more angled to look at the nasal base.

Breast images

These are simply AP obliques and laterals. We also include a relaxed and pectoralis contracting view such as pushing the hands on the hips, in the case of breast implants. Sometimes a forward leaning view is useful to demonstrate asymmetry (Fig. 2.6A–D).

Fig. 2.6 A–D, Half of a breast series. The forward leaning view is helpful to show asymmetries.

Body contouring views

Here is where some flexibility with lighting can be helpful. The overall shape of the body is best seen in even light, but the quality of the skin is best seen with more vertical light. Umbrellas with slaved strobe light are very useful here as they may be elevated and lowered to show the desired contours.

PA

Additional detail images are taken of the knees, medial thighs and arms as necessary. We have the patient stand on a designated spot and then face markers on the wall of the room at 45 degrees apart for consistency of position. In some patients with excess skin a “diver’s view” is helpful to look at redundant skin. We think that the arms should be included in the pictures as arm position can influence the way the skin drapes on the torso and the torso may be made to look artificially good if the arms are elevated out of the picture area (Fig. 2.7).

Fig. 2.7 The skin contours can be most accurately judged if the lights can be elevated in a series like this. The pictures are taken in 45-degree increments with the patient facing markers on the walls of the room. In this case the breasts were imaged as well as the body. We find it helpful to take pictures of the knees and inner thigh separately. The arm position should be visible in the images.

Arms are photographed in abduction with the elbow flexed vertically. When the arm is photographed end on from and below the elbow any redundancy in the skin is instantly visible. Focus is at the mid-arm (Fig. 2.8).

Fig. 2.8 The arms are taken in AP and PA views. The non-standard lateral view shows much more detail of the curvature of the inferior skin than the standard views.

Standardization of color is difficult in digital photography. Even with correct exposure the images may be flat muddy or off color as they are downloaded from the camera.

If we are using images for publication or presentation we will modify color and contrast to make the images look the same. Since as surgeons, we are usually looking at contours and not colors we try to make the skin tone as realistic as possible. As a point of photographic integrity we never change morphogenic pixels.

There are numbers of programs that will allow editing of photos. The industry standard is Adobe Photoshop (Adobe Systems, San Jose, CA), a large complex program. A useful program at the time of this writing is Adobe Photoshop Elements, which is less expensive yet has all the functionality necessary for routine editing of images.

Integrity in photography

In the increasingly competitive world of cosmetic surgery where surgeons are trying to influence future patients, or in presentations for peers, or for other reasons, there is and has always been the temptation to alter photographs to make the results look better than they really are. Clinical photography is not designed to flatter the patient (or the doctor). It is a legal document designed to be a part of a medical record and show the conditions that existed at one or more points in time.

Different light shows different things. Wrinkles hollows and other imperfection on the face and body are defined by the shadows that they cast. In the absence of shadows, wrinkles disappear and results can look miraculous. It is very possible to make the skin and other contours look far better than they really do by altering the direction, quality and brightness of the light, a practice sometimes seen in books, journals and presentations, where on occasion most of the clinical result is from the difference in photography. This may sometimes be a naïve mistake, but in fact most of the unflattering images are seen in the preoperative pictures and the better ones in the postoperative ones.

It is not uncommon to see eyelid surgery presented with the light coming more vertically in the preoperative picture accentuating the upper lid shadow and tear trough and the postoperative lights coming from straight anterior, flattening these shadows.⁹ Strangely both patients and doctors continue to be fooled by elementary tricks like this and be impressed with the results that they purport to show. The lighting and position should be the same. The ability of photo editing programs to alter images is a frightening part of the brave new digital world.

Cosmetic surgery is still surgery, its practitioners went to medical school and did internships residencies and fellowships. They should be expected to maintain the ethical standards that they learned there. The light that is used for the preoperative photos should be used for the postoperative ones, and digital modifications to images should not include changing any morphogenic elements.

The future of clinical photography

The next step in fusing digital photography, computers and the patient will probably be in the use of 3-D cameras. These are highly sophisticated devices which capture the points that comprise the surface of an object and can reproduce them in any position and orientation. Changes can be made in perspective to match a 3-D to a 2-D image. Currently, accuracy of the surface image of such cameras is about a millimeter. Measurements can be taken along the surface of an image or point to point. In some applications volume differences may be measured. Clearly the quality and range of results that will be documented will be remarkable.

1. Galdino GM, Vogel JE, Vander K, Craig A. Standardizing digital photography: it’s not all in the eye of the beholder. Plast Reconstr Surg. 2001;108(5):1334–1344.

2. Upton B, Upton J. Photography. Boston: Scott, Foresman and Company; 1989.

3. Galdino GM, DaSilva D, Gunter JP. Digital photography for rhinoplasty. Plast Reconstr Surg. 2002;109(4):1421–1434.

4. Dickason WL, Hanna DC. Pitfalls of comparative photography in plastic and reconstructive surgery. Plast Reconstr Surg. 1976;58:166.

5. DiBernardo BE, Adams RL, Krause J, et al. Photographic standards in plastic surgery. Plast Reconstr Surg. 1998;102(2):559–568.

6. Rohrich R, personal communication, February 2008.

7. Daniel R, personal communication, February 2008.

8. Guyuron B, personal communication, February 2008.

9. Sommer DD, Mendelsohn MMD. Pitfalls of nonstandardized photography in facial plastic surgery patients. Plast Reconstr Surg. 2004;114(1):10–14.

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