photography

1. Photography in plastic surgery
By:Dr.Amit Kumar Choudhary

2. INTRODUCTION
• Photography is not only useful, documentary,
collaborative, didactic, medical-legal, a research
tool and even promotional – it is standard of care
and a sine qua non for proper practice in plastic
surgery.
• Our specialty is highly visual and relies on accurate
representation of form, as well as function, to
diagnose, plan, treat, evaluate, and track patient
surgical outcomes.
• The photographic record contains much more
information including color, tone, texture, shape,
vascularity, bulk, spatial relationships of anatomic
structures.
• The value of images increases with time. It is
difficult to imagine our specialty without the
incredible utility of photography, as it is intrinsic to
the visual nature of what we do.

3. • The first principle of photography as a medical record is to
document the pre- and postoperative condition of the
patient.
• Preoperatively, the record is a guide in evaluating the
patient’s condition, highlighting relationships of the anatomy,
and demonstrating aspects of physiologic function for tissues
like the nose, eyes, mouth, and hand.
• Postoperatively, images record can use for patient teaching,
self evaluation for retrospective review, and assessment of
results vis-à-vis planned outcome.

4. • Decades ago, sketches were used, followed by
black and white photography, color
transparencies and film, with the modern
progression to digital images in the last 15–20
years.
• Patient teaching requires proper photographic
representation of the preoperative condition and
explanation of the changes achieved with surgical
intervention.
• The evolution of a surgical practice can be tracked
most easily over a period of years through
systematic inspection of imaging of the patients’
condition through the course of their diseases or
conditions.

5. • A particularly common phenomenon is for a patient to not
recall how she looked before surgery when critically viewingthe
postoperative result.

6. • Occasionally in reconstructive procedures and
more often in aesthetic ones, the patient’s
psychological “set point” is re-established at the
her current condition, and the desire for further
enhancement leaves her considering that not
enough progress was achieved as a result of the
surgery.
• Photos are indispensable in this setting and may
provide reassurance that goals have been
reached.

7. • Properly preserved analog images may last
decades with original fidelity and 100 years of
more with mild degradation.
• Digital images may not last much longer.
Evolution of technology lead to
-viewing problems (incompatibilities in hardware),
-scrambling issues (changes in compression algorithms),
-inter-relation limitations (expired web pages or hyperlinks),
-custodial problems (where the data resides),
-translation issues (how to read old storage with new technology) to
name a few.
• If digital concerns are solved, images could last
centuries or more.

8. • The best storage methods have changed 5–10
times in the last 20 years from floppy disk to
magneto-optical disks, magnetic tape back-up,
compact discs (CDs), digital video disks
(DVDs), DVD RAM disks, USB flash drives,
portable hard drives,network attached storage
drives, and more recently, “in the cloud,” that
is to say, online in a remote data storage
center on the internet.

9. Informed consent
• Informed consent is a key part of medical
recordkeeping, and photography is essential
to proper medical records.
• Almost every patient understands that
photographs are part of the medical records.
In fact, many insist on seeing “befores and
afters” in their initial consultation.
• Some patients have a strong need for privacy.

10. • Patients understand they have control and
options on how their pictures will be used. Some
patients allow only internal records in their
private chart, others may permit sharing with
other patients in consultation without identifying
data, and some are comfortable with unrestricted
use on the internet, in print, and television
advertising.
• A thorough, detailed consent form specifically for
the use of images is necessary for a proper
medical legal record.

11. Standards in capturing images
• The same camera should be used. Changing a digital
camera (and therefore the color and white balance)
essentially alters the pixel resolution, photonic
sensitivity and hardware image processing.
• Shutter speed and aperture must remain the same.
• Positioning of the patient and photographer in the
room should not vary.
• Guide marks on the floor may be required; flash
equipment and lighting should not vary.

12. • Adequate lighting is essential.
• Shutter speed should be at 1/60 of a second or faster.
• On digital cameras, keep the magnification factor the
same that is comparable with a 35 mm camera 100
mm lens for essentially all images except full body
views, where a view comparable to a 50 mm lens may
be used.
• Focus by moving the camera closer or farther from the
patient and note the position of the mechanized zoom
lens barrel in relation to the camera body.
• Do not change the white balance and keep it in synch
with the lighting used (often flash or fluorescent) on a
medium blue background.
• While modern cameras often contain 10 megapixels or
more, generally more than five are not required

13. Digital image characteristics
• Many variables affect images, and many are in
control of the plastic surgeon.
• Parker et al.8 have documented four basic ways
in which inconsistency is introduced into
photography:
(1) photographer-based;
(2) publisher based;
(3) combined; and
(4) patient-based.

14. • Category 1 [photographer-based] in their scheme includes view
(composition), background and zoom .
• Publisher-criteria, size and image labeling are less problematic.
• Combined criteria, color, brightness, contrast, and resolution .
• Category (4) criteria [patient-based ]: clothing, make-up, facial
expression, and hairstyle, are designated as patient-based, but are
substantially under the control of the photographer.
• A dark colored drape can be used over the shoulders for facial
photographs.
• Accessory apparel should be removed, as make-up, false
eyelashes, and similar accoutrements of fashion may interfere.
Hairstyle can be mitigated by using standardized hair bands or ties.

15. • Galdino categorizes factors into direct and
indirect.
• Direct variables include lens, view finder, digital
chip, resolution, compression and software
algorithms of the camera.
• Indirect are listed as lighting, metering, depth of
field, color temperature of lighting and output
method. Both categories are easily controlled by
remaining consistent techniques from visit to
visit.

16. Background
• Medium blue or 18% gray
backgrounds provide the best
skin tones and affect exposure
least.
• White or black backgrounds
affect exposure on the most
commonly used camera setting
(matrix metering), so the mode
must be changed to spot mode
metered on the skin in the
center of the field.
• Sharp contrast will not create a
natural skin coloring. Standard
blue towels used in surgery are
close enough to ideal to be used
without problems, but green
surgical towels are not ideal.

17. White balance
• Color reproduction is dependent on neutrality,
an equal distribution of colors in the white,
gray and black in the image to ensure accuracy
of hue.
• A color balanced image contains all hues in
equal proportions of illuminating white light.
Unfortunately, different types of reference
white points exist in various environments.

18. Composition and positioning

19. Full face
• In the anterior-posterior
(AP) view, the superior
border of the head must be
framed by a small amount
of background, about 10%
of the vertical height of the
image.
• The inferior border of the
image should stop near the
level of the suprasternal
notch.
• In the lateral view, the
patient’s body and head
should be facing 90° from
the focal plane of the
camera.

20. Oblique views should be taken at 45° and,
in this view; the tip of the nose should
protrude slightly beyond or rest just at the
contour of the distal malar eminence.
Five standard views are taken, an AP, two
oblique and two lateral, right and left for
each of the latter two.
When indicated, the malar eminence may
be imaged, generally the bird’s eye view is
preferred over the worm’s eye view,
unless a particular feature of anatomy is
involved.
Musculature should be relaxed in all
photographs unless otherwise specified.

21. Eyes
• The same five image views
(anterior, two laterals and
oblique views) are part of
the basic set for the eyes.
• Close-up images of the
eyes should include a
small border of forehead
skin above the eyebrows
and extend inferiorly to
the upper lip at the nasal
spine.
• For the lateral and oblique
views, positioning is
similar to the views of the
head honoring the
superior and inferior
borders herein.

22. • Additional views :
(1) closed eye view to highlight the
superior tarsal sulcus and fold
(2) upward gaze to highlight inferior
orbital fat pockets and the lower
lid margin.
A squinting view consists of open
eyelids with contracting of the
superior and inferior orbicularis
oculi to feature the impact of
muscle action on eyelid shape and
function. Occasionally, a view with
tightly-closed eyelids to highlight
the orbital orbicularis,
zygomaticus muscles and others is
required for certain surgical
procedures .

23. Glabella
• Images of the corrugator muscles may be taken at rest and on full contraction
to document wrinkling on the validated four-part glabellar rhytid scale .
• Full face images are often used; however, the superior border is best cut off at
the location (or former location in baldness) of the anterior hairline and the
inferior border is often positioned midway between the radix and the tip of the
nose on a horizontal line through the lower margin of the malar eminence.
• The closer view provides more detail of pore size, eyebrow position and skin
texture. Oblique and lateral views are generally not necessary.

24. Nose
• The superior margin of
the nasal view is
essentially the same as
for the eyes – just above
the eyebrows. However,
the inferior margin is at
the upper lip or between
the closed lips.
• In addition to the five
basic views, worm’s eye
view or chin-up view is
included .
• The superior and inferior
borders are the anterior
scalp line and the
mentum, respectively.

25. Lips, nasolabial folds, and mentum
• The superior border is on a line just above the nasal tip and
includes the alar base, while the inferior border allows a small
amount of background to show below the chin .

26. • The lips should be slightly parted to detect features in the mucosal
surfaces near the intersection of the upper and lower borders.
When injections into vertical lip lines are performed, the pursed lip
or orbicularis-contracted view is added.
• Additional views may include contraction of the mentum when
toxins or soft tissue fillers are part of the therapeutic intervention

27. Dental occlusal views
• When intraoral or two-jaw surgery is
considered, dental occlusal views are required
and cheek retractors must be utilized.

28. Ears
• Adequate visualization of the ears requires that
the hair must be out of the way. Anterior and
posterior views should include the full head and
supplemental midrange views should extend
from the upper neck to above the occipital ridge
to bring the ear more fully into the image.
• Lateral images should include close-up
composition with the vertical height roughly
twice the height of the ear itself.

29. Chest and breast
• Vertical borders should
range from above the
suprasternal notch in the
lower third of the neck
to below the mid-costal
margins.
• There are three basic
variations in arm
positioning on the lateral
view of the breast:
(1) arms at side;
(2) arms on hips;
(3) arms behind the
lower back.

30. • Oblique views may
be taken in
positions one and
two above, while
occasionally AP
views are taken
with arms taken
above the head.

31. Lower trunk, abdomen, and buttocks
• The five standard views
are supplemented with a
posterior view .
• When the buttocks are
the focus of the image,
no panties are used. It is
essential to use
disposable, blue paper
photographic panties to
standardize the clothing,
color and white balance.
• Legs should be slightly
apart to allow viewing of
the groin against the
light background.

32. Lower extremity
• The five standard views should also be supplemented
by a posterior view .
• For a full view, the upper margin should be found at
the level of the umbilicus and the lower margin inferior
to the toes or heel depending on the view.
• For the half upper or lower view, the lower or upper
margin respectively should be just below the knee at
the level of the inferior popliteal fossa or just above
the patella.
• The photographic background must extend onto the
floor, all the way out of the frame for the lower view.

33. Hands and feet
• A full dorsal and volar
view is required. In
some patients,
oblique views are
required as well.
• Dynamic views in
flexion and extension
are an essential
component of the
complete medical
record .

34. In the hospital and operating room
• Operating room lights vary from hospital to hospital
and even from room to room.
• Standardized use of auto white balance without a flash
in a compact camera is a standard choice. Macro-mode
or close-up focusing may put sterility of the operative
field at risk and is more problematic.
• Anatomic landmarks should be included at the borders
of the frame. Shiny instruments, stained surgical
drapes, gauze or glare from overhead lights must be
eliminated or covered.
• Often the lighting is harsh and must be removed from
the field to prevent oversaturation of the image.

35. Archiving and image management
Cameras
• A plastic surgeon only requires a 50 mm
equivalent and a 100 mm equivalent lens setting.
• Professional dSLRs are larger, heavier, machined
to precise specifications, resistant to moisture,
impact and sturdy with full-frame 36 × 24 mm
sensors that can potentially capture up to 25
megapixels in one image.
• Recording video of 30 s to 1 min, this is entirely
adequate for documenting repeated key steps in
an operative procedure.

36. Storage
• Digital memory cards come in a variety of types. The most
common are compact flash, which are large, sturdy, and
found in larger or pro models. They are capable of
transferring data at up to 30 Mb/s for high resolution
Secure digitals come in a regular or high capacity format
(SD or SDHC).
• Recently, 64 GB and even 128 GB models are available with
speed adequate to capture video at high resolution. Micro-
SD cards are generally relegated to cell phone cameras and
data storage.
• Data can be uploaded to a computer via a cable attached to
the camera from the computer, usually USB. However, it is
quite common to remove the card, insert a spare into the
camera and read the data from a card reader.

37. File formats
• commonly used: tiff, jpg (or jpeg for joint photographic
experts group), Photoshop, gif and raw.
• Software will convert one still image type to another.
However, it is important to understand their advantages
and disadvantages.
• TIFF is best used for print reproduction because it is a bit-
mapped (like a printer) or raster Tag Image File Format
• JPEG (jpg) is perhaps the most common file type and it is
“lossy.” Compression can be chosen from a 12-part scale
from none to as much as 90%, while data quality diminishes
accordingly.
• For quick exchange of images via email this is ideal.
Minimal compression almost retains original image fidelity.

38. Image attributes, metadata, and
retrieval
• As the images are safely transferred to storage
media,critical new information must be attached to the
data.
• Up-to-date cameras use a format called EXIF for
recording camera type, lens, date, time, shutter,
aperture, and many other items.
• Even more critical for plastic surgery is information like,
patient age, sex and weight, ICD9 diagnostic codes, CPT
operative codes, type of implant used, pre- or
postoperative status, date of original surgery and other
critical pieces of medical data.

39. Digital image processing
Measurement and analysis
• Measurements were made directly on photographs or
transparencies and taken to the operating room to
guide surgical procedures. Now these measurements
can be made directly on the digital image.
• Identifying and highlighting anatomic landmarks for
the medical record in breast augmentation surgery
increasingly has become a part of the preoperative
consultation.
• It is the first step in building a predictive model for
planning pocket dissection, choosing implant size,
evaluating postoperative size and may lead over time
to reduced rates of reoperation.

40. Planning and simulation
• The term surgical simulation has been broadly defined to
include anything from computer-assisted tutorials to
interactive learning to engaging in mock surgery with haptic
feedback and complete with unexpected complications.
• Institute of Medicine Report, To Err Is Human: Building a
Safer Health System in 2000. It has been estimated that 44
000 deaths occur yearly, the seventh leading cause of
death, due to medical errors.
• Many of these occurred during surgery, as a result of
surgical planning or postoperative care.
• Computer-based surgical planning is generally available in
plastic surgery from commercial companies (NexTech,
Canfield, and Crisalix).

41. The future
Three-dimensional imaging
• 3D technology began almost at the same time as photography itself,
when David Brewster invented the Stereoscope in 1844. It was
refined by Louis Jules Duboscq when he took a picture of Queen
Victoria and displayed it at the Great Exhibition in 1851, where it
became very well known throughout the world.
• Stereoscopic cameras started being more common tools, even for
personal use, by the Second World War.
• Several commercial techniques for 3D visualization in movies were
later developed, from “Natural Vision” in the 1950s; “Space-vision”
in the 1960s; “Stereovision” in the 1970s; polarized glasses in the
1980s, and later in the 1990s using IMAX 3D technology, until the
last boom of 3D movies culminating in the release of the movie
Avatar in 2010.

42. • Today, 3D physics-based finite element analysis
(FEA) technology can provide patients with a
simulated view of their anatomy in a
postoperative condition.
• State of the art technology allows patients to see
themselves from varying angles in 3D before the
operation, increasing communication with the
surgeon by interacting collaboratively with the
image, and simulating the outcome of the
surgical procedure.

43. THANK YOU