The use of medical illustrations for clinical documentation dates back several hundred years, as evidenced by artists’ engravings of pathologic skin conditions in fourteenth-century Europe.1 Clinical photography has since emerged as an important instrument for communication regarding a patient’s medical condition, particularly in the smartphone era. Compared to verbal or written descriptions, photographs convey superior clinical detail and understanding. In addition, clinical photography effectively mediates timely medical care and has been applied successfully in numerous specialties.2 Three categories typically define uses of medical images: clinical documentation, publication, and education. In plastic surgery, medical photography is used as an adjunct to clinical examination, for example, by facilitating visual demonstration of notable physical features by the surgeon to the patient in the preoperative and postoperative settings. In addition, it is used to substantiate research findings and also to teach trainees and surgeons about clinical management and surgical techniques. Occasionally, clinical photographs are also used for nonmedical purposes such as advertising and marketing.3 Despite the myriad benefits of clinical photography, several ethical issues must be considered (Table 1).1,4,5 These include informed consent regarding benefits, risks, and intended uses of patient photographs; privacy/confidentiality; appropriate distribution/storage; standardization of photographic procedure to facilitate consistent outcomes and equitable care; and use in social media. As a result, authors have proposed standards to facilitate appropriate and ethical implementation of clinical photography (Table 2).2,4 Table 1. - Ethical Considerations in Clinical Photography Principle Ethical Concern Description/Example Beneficence Photographs obtained to facilitate intended benefits Patients should benefit from photography (e.g., tracking response to intervention) or a secondary benefit (e.g., research) must be identified Nonmaleficence Patients not harmed by medical photography Patients should not be harmed by use of photographs (e.g., reduced confidentiality with inappropriate use) Patient autonomy Informed consent Patients educated on risks/benefits of medical photography and aware of intended uses (e.g., clinical care, research, marketing) Privacy Ensuring confidentiality and appropriate storage/dissemination Social media Inability to revoke consent once published by means of social media/Internet Justice Equitable use of medical photography Standardization of photographic procedure with consistent technology, lighting, distances, views, angles, camera settings Table 2. - Suggested Practices for Appropriate Clinical Photography • Informed consent should be sought before obtaining photographs; patients should be given the opportunity to consent to each use of their images • Consent may be withdrawn at any time • Patients should be made to feel comfortable by the photographer and medical team • Patient autonomy and dignity must be respected at all times • Complete anonymity should be attempted; if impossible, minimal identifiable exposure is recommended • Images must be stored in an environment that is safe, protected, and regulated • Photographic data should be deidentified and should be discarded securely when no longer needed • Photographic procedure should be standardized • Patients should be made explicitly aware of whether primary intended use is marketing, advertising, or social media; additional consent should be obtained • Provide appropriate photographs most similar to expected results and offer standardized photographic examples of complications Despite previous analyses of ethical concerns and promotion of good practices in clinical photography, there remains an important ethical consideration yet to be discussed. A common use of clinical photography by plastic surgeons is display of preoperative and postoperative photographs (online or in person) of prior patients for education and marketing to prospective patients. Generally, surgeons provide examples of successful cases, but do not offer unfavorable examples. We believe this is misleading and that both positive and suboptimal results ought to be provided to interested patients. We contend that this practice is ethically superior and may also improve patient care. First, providing both favorable and unfavorable case examples would facilitate a more comprehensive discussion of potential outcomes and risks, thereby augmenting the informed consent process. Although possible approaches to this practice (e.g., photographs of suboptimal results versus common complications; standardized photographic examples versus surgeon’s personal outcomes) require further investigation to identify best practice, a potential strategy would consist of showing appropriate photographs most similar to expected results for an individual patient and to offer standardized photographic examples of complications. This improved communication is also likely to advance the patient-physician relationship. In addition, surgeons may benefit, as patients would be less likely to suggest that preoperative discussions of potential complications were inadequate. Certainly, valid concerns exist with offering unfavorable case examples, including the theoretical risk of losing prospective patients. In addition, patients suffering poor outcomes may be less willing to consent to use of their photographs. Nevertheless, we believe that if photographs of successful outcomes are shown, ethical practice also compels provision of examples of unfavorable outcomes to interested patients, which will ultimately serve to improve patient care. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No funding was received for this work.

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