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.

Table 30.2 Camera settings

Example of custom settings for Canon G12	C1: flash	C2: no flash
Exposure adjustment*	0	0
ASA *	400	400
Exposure	Center weighted	Center weighted
Macro	On	On
Dynamic range correction	0	0
Light source and custom color balance (blue / amber and magenta / green)	Flash	Fluorescent
	B2, M2	B3, 0
My colors	Off	Off
Bracketing	Off	Off
Single shot	On	On
Flash power adjustment	0	n/a
Flash	On	Off
Neutral density filter	Off	Off
Aspect ratio	4 : 3	4 : 3
JPEG / RAW	JPEG	JPEG
Maximum resolution	On	On

^*Exposure adjustment and ASA dials are taped down, to reduce the chance that they will accidentally be changed.

Considering that there can be substantial variation between the color of an image as it is displayed on the camera and the color of that image when printed by a color laser printer, and considering that it is the printed images that will be viewed by myself and my patients, I have found it vital to set a custom color balance in each of the settings C1 and C2 so that the color rendition of the printed images will have maximum credibility and consistency. This custom color balancing is worth the effort, considering the great value it adds to the thousands of photographs per year that are taken in a busy aesthetic practice (for example, I took about 7000 patient photographs in the first 6 months of 2011). Custom color balancing is done by taking a series of shots (Fig. 30.3) under standard lighting, varying only the color balance settings (green / magenta and blue / amber), printing out the results, picking the most accurate color rendition, then iterating if necessary until the best possible solution is found. The process is repeated to determine the best color balance for use with the built-in flash on the camera. Then the custom color balance for C1 or C2 (if you are working with a Canon G11 or G12) is set. You will probably not need to change that setting until you switch to another camera or another color laser printer, perhaps in a few years. You should carefully record a list of all of the settings on your camera, so that the settings can be restored if necessary (for example, if you send the camera away to be serviced or repaired).

Figure 30.3 Method of finding the best color balance settings for standard flash or non-flash photographs. This array of images illustrates a range of custom color balance setting. In order to determine the correct setting for accurate output on a given printer, simply shoot an array of standard photographs, carefully recording the camera settings, then after printing the images pick the most accurate print(s), and take another array of photographs with parameters tightly grouped around those used for the best photographs from the first series. After a couple of iterations, you will zero in on the ideal parameters for your lighting and your printer (see Table 30.1, Camera settings).

Printing

There are a myriad of color printers on the market. Several of my colleagues have produced excellent color prints of patient photographs (KC Smith, A Weksberg, V Bertucci, unpublished observations) using the Xerox Phaser 6500 color laser printer (which is inexpensive to purchase but has high toner costs) and the Xerox ColorQube™ 8570/DT solid ink printer (which costs more to purchase but has lower operating costs, and is capable of two-sided printing of brochures in addition to photographs).

It is a good idea to set the printing preferences in your software to print the serial number of the photograph, and the time and date of the photograph, under each image. This will add to the credibility of your images, will help to ensure that the photographs are stored in the correct chronological order (two-hole punched at the top of each page, on prongs), and the serial number will make it easy for you to retrieve the digital original from your computer for reprinting or publication.

Pearl 2

Print out the photographs at the end of every day, and initial all of them before they are filed, so that you can monitor the quality of your photography. Prints are much more practical at follow-up visits than images on a screen.

Pearl 3

Set your preferences so that the time, date, and serial number are automatically printed under every photograph. This will help your staff when they are trying to identify the occasional photograph that did not include the chart tab; it will also help you retrieve the original digital image from your computer in cases, for example, where you want to reprint the image.

Consent

When dealing with patient photographs, the issue of consent should be considered. In my practice (Ontario, Canada, 2012) verbal consent for photography is sufficient. Written consent may be necessary in some circumstances prior to publication, presentation, or dissemination of a patient’s photograph. A full discussion of consent as it relates to patient photographs is beyond the scope of this chapter, and readers are best advised to keep abreast of the laws and customs in their jurisdiction.

Photography procedure

My usual procedure for photography is:

1. I briefly explain that before treatment I will take some photographs to help the patient see how they are responding to treatment when they return for follow-up.

2. I ask the patient to stand centered behind the photograph marker on the carpet (Fig. 30.4, inset) with their back to the window. By positioning the patient with their back to the window I eliminate window light as a variable.

3. The camera is switched to the appropriate preset mode (on my Canon G12, C1 is used for flash photographs, and C2 for non-flash photographs).

4. The camera is held at the level of the patient’s nose, at a distance of about 40 cm from the face.

5. For at least one photograph in each series, the patient’s chart tab is held close to the face, so that the patient’s name and chart number are included in the photograph (see Fig. 30.2C). This ensures positive identification when the photographs are printed. The chart tab also provides objective black and white references, which can be helpful in rare cases where a photograph is being color balanced for publication; the tab furthermore provides an objective size reference if it is necessary in the future to determine the size of a mole or other feature in the photograph.

6. Anterior and oblique photographs of the patient’s relaxed face are obtained (see Fig. 30.2), as necessary, to illustrate the features that will be treated. If fillers are to be used on the nose, lateral photographs are also taken. When the pre-jowl sulcus is to be treated, it can be helpful to take a photograph with the camera held at the level of the top of the head, at a distance of about 40 cm, pointing downward at about a 30° angle at the face (see Fig. 30.2H).

7. If treatment of the lips with fillers is anticipated, it is quick, cheap, and easy to obtain the pre-treatment series shown in Figure 30.5. Without these baseline images, follow-up visits can occasionally be stressful and difficult to resolve whether the patient notices real or imagined asymmetry, ‘duck lips’, ‘trout lips’, or ‘bumps’ along the wet–dry junction. Because many individuals eventually develop vertical lines, in particular above the vermilion border of the upper lip, it is valuable to obtain photographs of the upper lip with the camera pointing down at the upper lip, with the lips relaxed, then at full contraction, and finally with the lips partially relaxed. (This sequence seems to be the one that patients are most easily able to comprehend and cooperate with.)

8. If treatment with BoNT-A is anticipated, photographs of the face showing activity of the facial muscles are taken – for example, before treatment of the forehead the sequence would be: relax, brows up, scowl, crinkle your nose (to illustrate ‘bunny lines’). For crow’s feet, oblique photos are taken: relax, close your eyes tightly (orbicularis oculi), relax your face, now give me a big toothy smile (zygomaticus major and minor, +/− orbicularis oculi). Similarly, relaxed and full-contraction photographs are taken of other muscle groups to be treated (Box 30.1).

Figure 30.4 Examination room layout for photography. A = overhead fluorescent lights: if symmetrical overhead lights are not available, a pair of light-emitting diode panels can be installed to provide illumination during non-flash photography. B = roller blinds in front of Venetian blinds on windows, providing a neutral backdrop, and privacy if the patient disrobes; also reduces glare and heat load on bright days. C = marker on the floor, which the patient stands behind with their back to the window when being photographed before and after filler and BoNT-A treatment. The marker is equidistant between the overhead lights and is at the point determined as shown in Figure 30.1, which gives the best balance of light and shadow. It is a 5 cm square of SOLAS Marine Tape, with a label saying ‘PHOTO’ (inset). (Without the label, many patients try to peel the tape off the carpet and put it in the garbage for me.) Patients also stand behind this marker during flash photography, before and after laser and intense pulsed light treatment for telangiectasia and dyschromia.

Figure 30.5 Photographs before treatment of the lips with fillers and / or BoNT-A. Anterior (A–H) and lateral (K, L) views of the lips, with (A–D) and without flash (E–H, K, L), with the lips together and relaxed (A, E), and with the lips parted and level with the camera (B, F), from above (C, G) and from below (D, H) provide the information necessary to maximize patient satisfaction and to resolve common complaints and concerns. Where vertical lines above the lips are a potential target for treatment or for future discussion with the patient, relaxed (E), full contraction (I), and partial contraction (J) images are very valuable, both during the consultation and at follow-up.

Box 30.1

Standard poses

Except as otherwise noted, all images are obtained with the patient standing behind the ‘photo’ marker on the floor with light falling symmetrically from above on the patient’s face, the lens at the same height as the patient’s nose, the camera about 40 cm from the patient’s nose, and the patient with head level and looking straight ahead.

Anterior view

*Relaxed – to illustrate relaxed state, and to visualize static lines and creases, and areas of volume depletion or excess, alignment, and contours of the nose and lips

*Brows up – frontalis

*Frown – glabellar complex

Crinkle nose – bunny lines: nasalis and levator labii superioris alaeque nasii

Perioral wrinkles – orbicularis oris

Clench chin – mentalis

Turn corners of mouth down – depressor angui oris and platysma

Clench neck muscles – platysmal bands

Anterior–superior view (similar to Towne’s view in radiology)

The patient is standing in the standard position, looking straight ahead, relaxed. The photograph is taken from above at a 30° angle pointing downward, patient relaxed, to illustrate in particular the pre-jowl sulcus, and upper medial cheek volume loss related to the malar fat pad. As a practical matter, like other photographs this is taken from a distance of about 40 cm from the patient’s nose, and for this photograph the camera is held so that the lens is at the level of the top of the patient’s head, instead of at nose level

Right and left oblique view

The lens is at nose height, the tip of the nose aligned with the edge of the cheek, the patient’s head level:

*Relaxed – static lines and creases, areas of excess and deficient volume, contours of the nose and lips, contours of nose

*Close eyes tightly – orbicularis oculi

*Open eyes, big toothy grin – zygomaticus major and minor, and orbicularis oculi

Crinkle nose – bunny lines: nasalis and levator labii superioris alaeque nasii

Perioral wrinkles – orbicularis oris

Clench chin – mentalis

Turn corners of mouth down – depressor angui oris and platysma

Clench neck muscles – platysmal bands

Oblique view

The lens is at nose height, the tip of the nose aligned with the location of the infraorbital foramen in mid-cheek, the patient’s head level:

Visualize the ogee curve, and malar cheek, contours of the nose and lips, post-jowl sulcus, and inframalar volume status, static lines, and creases

Lateral view

The lens is at nose height, centered on the cheek midway between the tip of the nose and the antitragus of the ear, the patient looking straight ahead:

To visualize areas of volume depletion or excess, contours of the nose and lips, static lines and creases

Handheld oblique lighting (for example, using a Streamlight Stylus pro pocket LED light)

Used to better visualize scars from acne or injuries; handheld oblique lighting is useful both for photography and sometimes during injection of scars with fillers

^* Denotes baseline images obtained routinely on almost all patients.

Pearl 4

Hold the chart tab, with the patient’s name and chart number, close to the area being photographed in at least some photographs in each session, so that there will be no confusion as to the identity of the patient.

Makeup

Makeup is not generally removed before non-flash photographs that will be used for follow-up of filler or BoNT-A treatment. Photographs without makeup would be ‘perfect’, but as a practical matter add little value and patients often do not wish to remove their makeup.

Removal of makeup is essential before flash photographs that will be used to illustrate erythema, telangiectasia, and / or dyschromia.

Viewing photographs at follow-up

Patients who are allowed to view their pre-treatment photographs seem to estimate their degree of improvement as being greater, and have higher satisfaction, than patients who are not allowed to view their pre-treatment photographs. It is often helpful to give the patient a large, square hand mirror (Fig. 30.6) and to hold the pre-treatment photograph beside the patient’s face, so that the patient can look in the mirror and simultaneously see their face and also their pre-treatment image (which will be reflected in the mirror so that the right side of the image will be on the patient’s right-hand side, and the left side of the image will be on the patient’s left). This helps many patients to assess their response to treatment, and to discuss additional treatment. For the most accurate comparison, the patient is sometimes invited to stand at the same point in the room under symmetrical lighting where the pre-treatment photographs were shot, so that post-treatment lighting will be very similar to that used when the photographs were taken.