Sir: The Frankfort horizontal line is determined by the porion (upper margin of the external auditory meatus) and the orbitale (lowermost point of the inferior bony orbit). It is important in assessing preoperative photographs before rhinoplasty and mentoplasty surgery, because photographs taken in this plane allow accurate nasal tip and chin assessment. Photographs form an important part of the patient record, facilitate postoperative evaluation, and provide potential defense in case of adverse outcome. Our objective was to define acceptable error of deviation from the Frankfort plane and assess the accuracy of our service from medical photography and to improve this. Four subjects with normal noses consented to lateral rhinoplasty photography in the Frankfort plane, followed by 20 photographs in degree increments above and below this plane. Photographic conditions were identical with respect to camera focal length, magnification, and camera optics. A standard distance of 3 m was used, with camera angulation reduced by a commercial spirit level. Four rhinoplasty surgeons assessed these, which they divided into three groups: Group A: Subject has tip ptosis requiring surgical correction to increase tip projection and rotation. Group B: Subject has normal nasal tip projection, not considered for change. Group C: Subject requires tip derotation. Assessment of photographs from four subjects suggested that deviation of more than 9 degrees from the Frankfort line results in perceived alteration of nasal tip projection (Table 1).Table 1: Acceptable Range of Deviation from the Frankfort Plane (in degrees)After this, 100 photographs of patients before rhinoplasty were assessed to measure the degree of deviance from the Frankfort line in degrees (group 1). National guidelines from the Institute of Medical Illustrators1 were distributed to the medical photography department and a further 100 photographs were assessed prospectively (group 2). Another audit cycle was completed in which the photographer marked surface landmarks and photographed patients with these marks aligned (group 3). Marked variation was demonstrated, with 68 tilted in a cephalad direction and six of the 100 orientated correctly. In 24 photographs, the error exceeded 9 degrees from the horizontal plane (Fig. 1).Fig. 1.: Deviation from the Frankfort plane before intervention in group A.When national guidelines were followed, there was a statistically significant improvement in scatter of the data. However, there were only 13 photographs in the correct plane and there was an error in orientation by more than 9 degrees still evident in eight cases (Fig. 2).Fig. 2.: Deviation from the Frankfort line following intervention in group B.Statistical analysis of the results using an unpaired t test revealed a statistically significant difference between groups 1 and 2 (p = 0.018). Therefore, a significant improvement in image orientation was obtained. Further analysis of the results revealed no difference between group 1 and group 3 (p = 0.0819) or between group 2 and group 3 (p = 0.4648). Rhinoplasty photographs within 9 degrees of rotation from the Frankfort plane provide an accurate representation of the nasal tip. Awareness and reinforcement of the use of guidelines for preoperative photography significantly reduces, but does not abolish, the errors inherent in image acquisition. Surgeons should be aware of these deficiencies and make allowances for them when assessing preoperative and postoperative photographs of rhinoplasty cases. More importantly, they should not regard the photographs as a substitute for accurate and careful patient examination. DISCLOSURE No outside funds have been used to support this work. None of the authors has a financial interest in this work. Sukhbir Ahluwalia, M.R.C.S., M.Sc. Vikrant Veer, M.R.C.S. Guy S. Kenyon, M.B.A., F.R.C.S. Whipps Cross University Hospital London, United Kingdom