Widespread Disregard of Photographic Documentation Standards in Plastic Surgery: A Brief Survey

Abstract

Sir: Reliable photographic documentation is fundamentally based on photographic documentary standards that were defined decades ago.1,2 In this article, we raise the question of whether articles published in the top plastic surgery journals adhere to these standards. We analyzed all publications showing photographic documents published in Plastic and Reconstructive Surgery (Lippincott Williams & Wilkins), the Journal of Plastic, Reconstructive & Aesthetic Surgery (Elsevier) and Aesthetic Plastic Surgery (Springer) in 1 year. Overall, 249 publications with patient photographs were analyzed keeping the following photographic documentary standards in view (Table 1).Table 1: Number of Articles Split into Anatomical Regions with Correct Standardized Photographic Documentation Camera angles: Obvious deviations from the standard camera angles described previously1,3 were marked as faulty. Special emphasis was put on comparability between preoperative and postoperative photographs. Posing position: Obvious deviations from the standard posing position described previously1,3 were marked as faulty. In case of differing photographic documentary standards such as the upper limb positioning in breast photographic documentation, each standard was accepted as correct, provided that the standard was consistent between preoperative and postoperative photographs. Background: Each type of monochrome background was accepted. Clothes: Absence of any piece of clothing in the photographed area was assessed as correct. Hairdo: Hair hiding parts of the face, especially the forehead, was marked as faulty. Jewelry: Absence of any piece of jewelry including watches, glasses, and hearing devices was assessed as correct. Makeup: Each obvious makeup product including lash mascara and lipstick was marked as faulty. Mimic: Each visible tension of the mimic muscles, especially smiling, was assessed as a deviation from the photographic documentary standards. Photographic section: For facial photography, we analyzed whether attention was paid to the minimal photographic section, in particular, whether the whole face, and not only close-ups, was photographed. The most important element of photographic documentation is the patient positioning and the angles of photography. Slight deviations from the standards, in particular, differences between preoperative and postoperative photographs, lead to severe distortions of the result. This point has been demonstrated by photographs of a “photographic neck lift” and a “photographic rhinoplasty.”4,5 Facial photographic documentation is most challenging. Any deviation from complete relaxed mimic musculature would clearly affect the result of the photographic documentation. Although it is not easy to detect deviations from the standard mentioned above, we still observed them in 11.3 percent of the publications. Moreover, we were astonished that in one-third of all publications, facial photographic documents with obvious makeup are shown. Of course, photographic documentary standards with regard to absence of any jewelry and clothes are more a matter of taste. Nevertheless, we observed gross negligence of style in photographic documents of the buttock with the pants partly pulled down, of the abdomen with the patient wearing over-the-knees boots, and of a patient's face with colored contact lenses with different colors in different photographs. Although standards of photographic documentation were established years ago, there appears to be a lack of adherence to them in general practice. The importance of following the standards cannot be emphasized enough (Fig. 1).Fig. 1.: Percentages of articles with deficient photographic documentation in the different categories.Stefan Riml, M.D. Agnieszka T. Piontke Lorenz Larcher, M.D. Peter Kompatscher, M.D. Department of Plastic, Aesthetic, and Reconstructive Surgery Academic Teaching Hospital Feldkirch Feldkirch, Austria