Clinical photography is an essential facility to support the work of cranio-maxillo-facial surgical departments. This paper highlights the requirements to ensure the highest quality and consistency of photographs taken. It also provides assistance in the selection of equipment, archival storage and error avoidance.
Clinical photography is an essential facility to support the work of cranio-maxillo-facial surgical departments. This paper highlights the requirements to ensure the highest quality and consistency of photographs taken. It also provides assistance in the selection of equipment, archival storage and error avoidance.
Clinical photography is an essential facility to support the work of cranio-maxillo-facial surgical departments. This paper highlights the requirements to ensure the highest quality and consistency of photographs taken. It also provides assistance in the selection of equipment, archival storage and error avoidance.
Journal of Cranio-Maxillofacial Surgery (2006) 34, 6573
r 2005 European Association for Cranio-Maxillofacial Surgery
doi:10.1016/j.jcms.2005.11.002, available online at http://www.sciencedirect.com Standards for digital photography in cranio-maxillo-facial surgery Part I: Basic views and guidelines Giovanni ETTORRE 1 , Martina WEBER 1 , Heidrun SCHAAF 1 , John C. LOWRY 2 , Maurice Y. MOMMAERTS 3 , Hans-Peter HOWALDT 1 1 Department of Oral and Maxillofacial Plastic Surgery (Chairperson: Prof. Dr. Dr. H.-P. Howaldt), Justus Liebig University, Giessen, Germany; 2 Department of Maxillofacial Surgery (Consultant: Prof. J.C. Lowry, FRCS, FDSRCS), Royal Bolton Hospital, Bolton, UK; 3 Bruges Cleft & Craniofacial Center (Director: Prof. M.Y. Mommaerts, MD, DMD, PhD, FEBOMS, FICS), Brugge, Belgium SUMMARY. Clinical photography is an essential facility to support the work of cranio-maxillo-facial surgical departments. This paper highlights the requirements to ensure the highest quality and consistency of photographs taken and provides a standardized set of both facial and intra-oral views that t the needs of accurate digital photo- documentation in cranio-maxillo-facial surgery. Furthermore it gives assistance in the selection of equipment, archival storage and error avoidance. These guidelines have been approved in November 2005 by the Council of the European Association for Cranio-Maxillo-Facial Surgery and are to be understood as a proposal to all our colleagues in Maxillofacial Surgery. r 2005 European Association for Cranio-Maxillofacial Surgery Keywords: digital; photography; standards; clinical; maxillofacial; surgery; guidelines INTRODUCTION Complex clinical appearances of patients in cranio- maxillo-facial surgery and facial plastic surgery are usually difcult to describe in words. Therefore, much of our professional time is spent in judging and discussing pictures and photographs. For that pur- pose standardized views and high-quality photo- graphs are fundamental for pre- and postoperative documentation. Clinical photographs are most com- monly used to assist accurate planning of a surgical procedure and to illustrate the purpose of the surgical intervention for the patient. Consistent documenta- tion of clinical diagnosis and treatment is also demanded in medico-legal cases. In addition, photo- documentation with reliable pre- and postoperative pictures are invaluable for scientic development, surgical education and staff training (Shaw et al., 2001). In the authors view high-quality clinical photographs should become an integral part of the patients record just as radiographs and other medical images. Although several publications discuss medical photography, the authors and probably most readers have had numerous disappointing experiences when searching clinical les in preparation for a lecture. Moreover, most manuscripts focus on the need of documentation in plastic surgery, dermatol- ogy and orthodontics (Zarem, 1984; Jemec and Jemec, 1981; DiBernardo et al., 1998; Becker and Tardy, 1999; Galdino et al., 2001, 2002; Sullivan, 2002; McKeown et al., 2005). In these publications, documentation of special features such as the anatomy of the nose or skin pathology by means of analogue photography are highlighted, while none of them explain the particular requirements for digital photography and the special areas of interest in cranio-maxillo-facial surgery. This paper also aims to provide assistance in the acquisition of the necessary equipment and denes a range of standard photographic views for cranio- maxillo-facial surgery. It is suggested that these picture sets may now lay the foundation for the introduction of a European-wide standard in photo- graphy for cranio-maxillo-facial surgery in order to ensure greater precision and comparability of results for treatment planning, clinical records, education and scientic congresses. DIGITAL PHOTOGRAPHY Advantages and disadvantages of digital photography Several camera manufacturers have invested consid- erable effort in the development of digital single lens reex cameras (SLR-cameras) for semi-profes- sional use and this has resulted in a progressive decrease in their prices. For example, 10 years ago a digital SLR-camera with a resolution of 4 Mega- pixels may have cost 10,000 euros, whereas today a ARTICLE IN PRESS 65 high-quality SLR-camera with 6 or even 8 Mega- pixels may be obtained for 10001500 euros. Although digital SLR-cameras are more expensive than analogue cameras, this relatively small nancial disadvantage is now counterbalanced by the signi- cant advantages of digital photography. In contrast to the analogue technique where the photographs are displayed on a 24 35 mm lm, digital images are stored on an electronic photo- sensitive digital chip. The size of these photosensitive chips varies between manufacturers, but is generally about 1.5 times smaller than a 24 35 mm lm. Discussion about the resulting elongation of focal length is complex and can easily be avoided by increasing the distance between the camera and patient to obtain the recommended display window. Digital pictures are immediately available with neither lms nor processing being required, thereby economizing on time and costs. Moreover, direct control of the taken picture is possible, and if it is not consistent with the photo- graphers perception of what is required, it can be retaken without arranging a new appointment with the patient. This convenience is especially useful for the documentation of pathology, developmental anomalies and other diseases in small children. If necessary close-up views can easily be obtained by enlargement. This reduces the number of required pictures. Storage is quick and space saving in digital archives with the facility for pictures to be tagged with multiple indices. This facilitates rapid access when preparing lectures and other presentations. EQUIPMENT, TECHNIQUE AND REQUIREMENTS Camera, card reader, personal computer, monitor and colour printer To ensure high-quality photo-documentation, the standard equipment should include a digital SLR- camera, a digital memory chip card, a chip card reader, a personal computer (PC) with a monitor, a colour printer and a suitable program for storage of the indexed pictures as patients les. We recommend the use of a digital SLR-camera as it provides high-quality pictures combined with the possibility of variation of lenses. Most digital cameras offer the possibility of blending a grid with the viewer, thereby facilitating a more precise and reproducible presentation of the patients face re- lative to the peripheral background. If a switch from the earlier 35 mm camera equipment is planned, the existing lenses are often compatible with a digital SLR-camera body from the same manufacturer. The transfer of pictures from the camera to the PC can easily be solved by using a card reader or by direct connection of the camera with the PC and appropriate software via FireWire or USB connec- tion. To ensure fast processing and display of the pictures, the authors recommend a PC with at least 1 GHz processors combined with a 128 MB graphic card and a 40 GB hard disc to provide sufcient data space. If the display of colour varies between different monitors, it is necessary for these to be calibrated. The different image replication of TFT-displays (thin-lm transistor or at screen) compared to standard cathode ray tube monitors should be noted. For immediate prints of the photographs, a high- quality colour printer should be available. Lenses We suggest a xed focal length (90105 mm) high- quality macrolens for both facial and intra-oral pictures. High-quality lenses assure a maximum depth of eld, with the smallest possible distortion and minimal alteration of colours. The suggested focal length (known as portrait) reproduces a natural anatomy without the bulging that occurs with wide angle lenses, and provides for an adequate distance between the camera and patient. Pre- and postoperative pictures should be taken with the same lens to avoid the variation of images that occurs with different focal lengths. Although the size of the images obtained by photosensitive chips differs from those of analogue lms, it is preferred to use a 90105 mm lens to allow comparison with previously taken pictures using analogue 35 mm cameras. It is important to mention that proportions and distortion remain constant if the subject to object distance is adapted by a factor of 1.51.6 dependent on the chip size in the used digital camera. BACKGROUND AND LIGHTING In the authors opinion, a light blue (sky blue, RAL 5012) background is ideal for medical photography, as it provides a sufcient contrast to skin colour and moderates shadows. A white background produces harsh shadows, while a black background provides less contrast for dark-skinned subjects. Lighting is one of the most discussed aspects of medical photography. Regardless of the high acquisi- tion costs, a ceiling mounted, multi-ashlight instal- lation is recommended with at least two soft boxes or two umbrellas for taking facial pictures, thereby avoiding cables on the oor. This set-up offers the possibility of constant lighting conditions (intensity and angle) with even illumination of the subject when used correctly. The soft boxes should be positioned at an angle of 451, with a constant distance of 11.5 meters at either side in front of the patient. They should be positioned as close as possible together, as this minimizes shadows on the patients face. A manual setting of exposure time and aperture setting is recommended, as through-the-lens metering is not always reliable. Under studio light conditions, ARTICLE IN PRESS 66 Journal of Cranio-Maxillofacial Surgery high aperture settings (f416) and short exposure time (o1/125 s) can easily be achieved. This guaran- tees appropriate depth of eld and prevents loss of sharpness attributable to shaking of the camera. As a result of constant quality (almost one light tempera- ture) and amount of lighting, the white balance of digital cameras can be set on the provided ashlight setting. As digital pictures can immediately be assessed, it is suggested that several pictures be taken with different aperture settings (e.g. f 16; 18, 20; trial and error) rather than using a handheld light meter. For intra-oral pictures, the ring light ash provides adequate illumination, while for an adequate depth of eld, maximal aperture settings (f427) are recom- mended. Patient consent form Patients consent is required if pictures are to be used for scientic purposes such as congresses, publica- tions, media presentation and internet-based con- sultation projects (for example the one on the Eurofaces website of the European Association for Cranio-Maxillo-Facial Surgery). The consent form should be easily understood and should not exceed one page. The patient should be informed that pictures are part of the individual le and support planning of treatment as well as the follow-up. It should be made clear that the patients permission is voluntary and withholding consent will be in no way a disadvantage regarding clinical care. Patients should have the freedom to restrict the utilization of pictures for scientic purposes. A standardized consent form in most European languages is also available on the home page of the European Association for Cranio-Maxillo-Facial Surgery (www.eurofaces.com). Data storage and presentation Data should not be stored on a local PC without backup to prevent loss that may occur in the event of a system crash. Regular backup copies should be made to a CD, DVD, external hard disc, ash drive or by server solutions. As the pictures are part of the patients le, maximum security must be assured. The databases should provide log-in facilities in order to prevent unauthorized data access. If the pictures are stored in a hospital-wide network, access for clinicians of other departments should be discussed to facilitate inter- disciplinary discussion. However, interdisciplinary availability must be gauged with sensitivity, and it is generally thought to be prudent where institution- wide networks allow individual log-in facilities for each physician for the separate data bases for each department. There are several databases in the market, which t the needs of clinical picture storage. In general they should be able to recognize the established image formats and provide the possibility to create folders and keywords. There are two general principles for the organization of clinical image data: one patient- based and the other on diagnosis or keyword. A combination of the two has several advantages. Searching is simplied as retrieval for presentations may be via special topics or alternatively via patients name for case reports or discussions with other physicians. Storage and labelling of pictures should occur immediately after taking the pictures to prevent loss of photographs or misling. In addition, doctors can easily obtain their own pictures after each program rotation, and this might increase the motivation to capture accurate photographs. As many image editing programs cause data loss when pictures are manipulated, care must be taken when selecting a suitable software program. Lectures may be prepared using an appropriate presentations graphics package such as Microsoft Power Point R . CONVENTIONAL FACIAL PICTURE SET General notes In pre- and postoperative photography the results are only comparable when the patients position is reproducible. A constant distance from the subject to camera is preferred, which is achieved by marks on the oor showing the position of the patient and photographer. Although this approach produces inter-individual differences in size due to different anatomical proportions between patients, it has several advantages: rst it is time saving to take up a predened position compared to methods when orientation is obtained by anatomical structures. Moreover, mainly intra-individual comparison is practised, e.g. preoperative vs. postoperative photo- graphs. Furthermore, standardized positions for the photographer and patient facilitate comparable results concerning reproduction ratios. To compen- sate for inter-individual differences in reproduction ratios, e.g. for lectures, digital photos can easily be adjusted in size. It is therefore suggested to obtain slightly larger image frames to allow cropping if necessary. The camera height must be at the same level as the focus point. The respective focus points are men- tioned in the detailed picture descriptions in the related chapter. In order to allow the patient and camera to be at the same height, it is suggested to use chairs allowing adjustment of the vertical position. To reduce the need for height changes for every single picture, most of the suggested focus points are aligned to the Frankfort horizontal plane. To ensure constant positions of the spine and head, the patients chair should be equipped with a backrest. Finally, all kinds of jewellery or excessive make-up should be removed before taking clinical pictures. Long hair should be held out of the area of clinical ARTICLE IN PRESS Standards for digital photography in cranio-maxillo-facial surgery 67 interest with hairpins or hair ties, and clothing should allow the neck to be clearly seen. The following pictures are featured with a grid that resembles the grating provided in digital cameras to clarify positioning of the patient, while the focus point is illustrated by the circle in the middle of the grid. Full face front view Fig. 1A shows the full face front view. For the full face frontal view, the patients head should be aligned to the Frankfort horizontal line. Focus point and centre of the picture is the intersection between the Frankfort horizontal line and the midline of the face. The patient should look straight ahead into the lens and the interpupillary line should be horizontal. No rotation in the vertical axis should occur. Lips should be relaxed with a visible interlabial gap if existing. The lower margin is the uncovered sterno-clavicular joint and the background should be visible around the face. By enlargement, the following close-up views can be achieved of the full face front view: front view of eyes, front view of lower face and jaw, front view of nose, front view of auricles. The oblique view Fig. 1B shows the right oblique view. The patients head is positioned in a similar way as for the full face view, but rotated 451 to either side. This position is preferred as it is independent of the size of the nose in contrast to the alignment of the nose with the cheek. This might affect the postoperative position when nose correction has been performed. Constant patient position can easily be obtained by a mark xed on the wall at a 451 position on either side. Focus point and centre of the picture is on the Frankfort horizontal line at the junction with the lateral canthus. The lower margin is the sterno-clavicular joint. By enlargement, the following close-up views can be achieved from the oblique view: oblique view of eyes, oblique view of the lower face and jaw, oblique view of the nose. Prole view Fig. 1C shows the right prole view. The patients head is positioned in a similar way as for the frontal view, but rotated at 901 to either side. The contralateral eyebrow should not be visible. Lips should be relaxed and an interlabial gap should be visible. The focus point and centre of the picture is on the Frankfort horizontal line in the midline between the tragus and lateral canthus. The lower margin is the sterno-clavicular joint. By enlargement, the following close-up views can be achieved of the prole view: prole view of eyes, prole view of the lower face and jaw, prole view of the nose, lateral aspect of auricles. ADDITIONAL FACIAL PICTURES Front view, closed eyes Fig. 2A shows the front view with closed eyes. The patients head is positioned in a similar way as for the full face view with relaxed eyelid closure. This picture is felt to be useful for planning surgery on eyelids (e.g. blepharoplasty) and documentation and evaluation of facial palsy. By enlargement, close-up views can be achieved of the full face with closed eyes. Front view, smiling Fig. 2B shows the front view with smile. The patients head is positioned in a similar way as for the full face front view. Full smiling is accomplished when the eyelids are slightly narrowed, compared to the ARTICLE IN PRESS Fig. 1 Full face front, oblique, and prole views. 68 Journal of Cranio-Maxillofacial Surgery relaxed position, and patients should show a small part of maxillary gingival tissue, provided that there is a normal cranial conguration. This picture is helpful for planning orthognathic and cleft surgery, as well as documentation and evaluation of facial palsy. By enlargement, close-up views can be achieved of the full face view with smile and frontal view of the lower face with smile. Back view, with ears Fig. 2C shows the back view with ears. Reference for the patients head position is the full face front view with a 1801 turn. It is important to note that the ears should not be covered by the patients hair. This picture is thought to be useful for planning surgery on prominent or hypoplastic auricles. By enlargement, the following close-up view can be achieved of the back view with ears: back view of ears and of the neck. Front view, lip retractor Fig. 3A shows the front view with lip retractor. Reference for patients head position is the full face front view. The picture of the patient should be taken in relaxed rest position with a slightly open mouth (incisal edge distance about 5 mm) so that the occlusal plane can be seen. This picture is useful for evaluating the occlusal plane in relation to the interpupillary line when orthognathic surgery is planned. Furthermore, complex facial skull deformi- ties can be documented (e.g. hemifacial microsomia). Front view, spatula in occlusion plane Fig. 3B shows the front view with the spatula in occlusal plane. The spatula should be placed between the canine teeth. Although the display of the occlusal plane is not always accurate because of dental anomalies (e.g. asymmetrical abrasion, asymmetrical dental hypoplasia), the front view with the spatula in ARTICLE IN PRESS Fig. 3 (A) Front view with lip retractor; (B) front view with spatula in occlusal plane and (C) submental oblique view. Fig. 2 Front views with closed eyes (A), smiling (B); back view with ears visible (C). Standards for digital photography in cranio-maxillo-facial surgery 69 occlusion together with the front view with lip retractor provides a valuable tool for planning orthognathic surgery and the documentation of complex facial skull deformities. Submental oblique view Fig. 3C shows the submental oblique view. As in the frontal view, the interpupillary line should be ar- ranged parallel to the horizontal axis, and no rotation to the occipito-mental axis should occur. The focus point and the centre of the picture is the junction between the lip-line and the midline of the columella. The head is retroclined until an imaginary line joining both corners of the mouth reaches the level of the upper edges of the ears. The patient should x a point on the ceiling. The lower margin is the sterno- clavicular joint. This view is useful for documentation and evaluation of enophthalmos or exophthalmos and the planning of rhinoplasty. By enlargement, the following close-up views of the submental oblique view can be achieved: close-up of the nose in submental oblique view, close-up of the zygomatic complexes and eyes in the submental oblique view, close-up of the neck. Submental vertical view Fig. 4A shows the submental vertical view. Like in the submental oblique view, the interpupillary line should be horizontal and no rotation in the occipito- mental axis should occur. The focus point and the centre of the picture is the junction between the lip- line and the midline of the columella. The head is retroclined until the nasal tip reaches the edge of the forehead. The patient should x a point on the ceiling and must not try to look into the camera. The lower margin of the display window is the posterior edge of the ears, and the picture is arranged in landscape view. Together with the submental view, this picture provides an excellent tool for the documentation and evaluation of enophthalmos or exophthalmos, sym- metry of the zygomatic complexes, and the planning of rhinoplasty. By enlargement, the following close-up views of the submental vertical view can be achieved: close-up of the nose in submental vertical view, close up of the eyes and zygomatic complexes in the submental vertical view. Supracranial oblique Fig. 4B shows the supracranial oblique view. In the same way as for the submental oblique view the interpupillary line should be horizontal and no rotation in an occipito-mental axis should occur. The focus point and the centre of the photograph is the junction between the midline of the nose bridge and the centre of the glabella. Like the submental vertical view, the picture is arranged in landscape view. The patient inclines the head backwards until the nasal tip is aligned with the chin. The forehead should act as the base of the picture. It is suggested that this view is for the evaluation of the shape of the zygoma, although it may also serve as an additional tool for planning and evaluation of rhinoplasty. By enlargement, the following close-up view can be achieved of the submental vertical view: close-up of the nose in supracranial oblique view. INTRA-ORAL PICTURES General notes The oral cavity is hard to access for accurate clinical photography. Therefore, several measures have to be taken to achieve satisfactory results. To obtain a full view of the dentition or the alveolar ridge, lip retractors should be used to keep the lips out of focus. There are different types of lip retractors on the market, for example one that is single-piece self- retaining (Lip and Cheek Retractor (SDI), adult size and child size, Hager & Werken, Duisburg, Ger- many) or alternatively two separate retractors for each side (Cheek Retractor Mirahold, adult size and child size, Hager & Werken, Duisburg, Germany). The disadvantage of the latter is that an additional person is needed for positioning. However, the patient may hold the instruments, although this may lack precision. To avoid excessive tissue covering by the retractor itself, the authors advise the usage of clear lucent self-holding retractors. Additionally, a black spatula is necessary to prevent coverage of the front teeth by the lips. ARTICLE IN PRESS Fig. 4 (A) Submental vertical view and (B) supracranial oblique. 70 Journal of Cranio-Maxillofacial Surgery To obtain high-quality intra-oral pictures the use of mirrors is essential. The authors use mirrors of the following brands Rocky Mountain, Dent Care, Brunntal, Germany and Spiegel Dental-Fotograe, Dent-o-care, Ho henkirchen, Germany. Sometimes long-handle mirrors can be recom- mended (Long-handle mirror, Aesculap, Melsungen, Germany). Although signicantly more expensive, the use of front-silvered glass mirrors is preferred to polished metal mirrors because of their superior optical properties and higher resistance to scratches. To prevent fogging, the mirrors should be warmed before use. Cleaning with a surface tension reducer, such as Neo-Sabenyl R (Qualifar), or suction near the mirror immediately before taking the picture is a useful alternative. As mirrors are known to absorb light, accurate light adaptation is necessary. It is therefore advisable to adjust local-aperture settings by at least one step. Due to the small distance between the lens and the photographed object and high magnication, accu- rate setting of the focus point and maximal focal depth are required to prevent bluntness. Aperture settings of f422 are suitable for intra-oral pictures and can easily be reached if a ring light ash is used. Compared to all point ash solutions, a ring light ash ensures even illumination of all areas of interest. LED lights might cause a bluish cast, and they should be used with care. As auto-focus is not reliable in the oral cavity, we consider manual focus as the best way to reach adequate focus point setting. It is important to note that the depth of eld is distributed about one-third in front of and two-thirds behind the focal plane. Therefore, the centre of the picture will not match the focus point in intra-oral photography. All intra-oral pictures should be taken in landscape view, and the image window should be slightly larger than compar- able facial pictures to allow cropping if needed. When mirrors are used, they should be positioned at an angle of 451 to the occlusal plane, as this provides a 901 view of the area of interest. Finally, saliva should be carefully aspirated before taking the pictures. The following pictures show the intra-oral views. In a similar way as for the facial photographs, a grid is inserted, and the circle represents the centre of the picture. The asterisks indicate the focus point. INTRA-ORAL PICTURE SET Front view To obtain reproducible results, the camera is posi- tioned parallel to the occlusal plane. The centre of the picture is the junction between the occlusal plane and the midline between the rst upper incisors (Fig. 5 centre). The focus point should be set on the cusps of the canines. If the retractors are placed well, all front teeth and at least the rst molars should be visible on the intra-oral front view. Buccal right and left The lateral views (Fig. 5 second row) show the upper and lower jaws with the teeth in full occlusion, and the picture is extended from the second molar as far as to the canine of the opposite side. In order to achieve a complete photograph, it is recommended to use a narrow mirror in the buccal corridor combined with a single ended cheek retractor. The centre of the picture is the cusp of the upper canine, and the focus point should lay on the cusps of the rst premolar. Occlusal upper and lower In order to obtain symmetrical views of the upper and lower occlusal surface, it is vital to use intra-oral mirrors. The camera should be positioned perpendi- cular to the occlusal plane so that the front teeth are viewed at their incisal edges. At least the rst molar should be visible on the picture and ideally all erupted teeth should be visible. To full these requirements, maximal mouth opening by the patient is essential. For the pictures of the lower jaw, the tongue should be elevated to the hard palate and gently pushed back out of view with the mirror. The centre of the picture of the upper jaw is the junction of a horizontal line between the second premolars and the middle of the palate (or the midline between the rst incisors in the lower jaw). The focus point is on the occlusal surface of the second premolars in both lower and upper jaws (Fig. 5 top and bottom). DISCUSSION Photographic standards are well dened and dis- cussed for several medical elds, for example, plastic surgery and orthodontics (Zarem, 1984; DiBernardo et al., 1998; Sandler and Murray, 2001), and also topics including anatomy of the nose and skin lesions (Galdino et al., 2002; Sullivan, 2002; Ikeda et al., 2003; McKeown et al., 2005). However, there is no publication available emphazising the special aspects of digital photography in cranio-maxillo-facial sur- gery. This paper demonstrates the important issues of digital photography, provides assistance in the selection of suitable software and hardware and offers dened picture sets for both intra-oral and facial photographs. It might therefore serve as a guide for the development of a Europe-wide standard for digital patient documentation in cranio-maxillo- facial surgery. Nevertheless, the authors recognize that there are several previous publications describing ways to obtain high-quality clinical photographs. The previously discussed advantages of digital photography have led to its broad acceptance and ARTICLE IN PRESS Standards for digital photography in cranio-maxillo-facial surgery 71 widespread use in clinical documentation. However, some problems could arise by switching from analogue to digital photography. If digital pictures are not accurately tagged with patients personal les and the database is not maintained regularly, the search for the required pictures might become difcult or impossible. One should be aware of the fact that, for example, the habitual search for slides in the familiar slide collection by ipping through the slide panels could become signicantly more difcult in a database containing thousands of digital photo- graphs. Moreover, if a complete switch to digital technology is intended, all analogue les should be digitized, for example, by scanning, and this can be very time consuming. While there is a general agreement about the image frame and set-up for intra-oral pictures, including the use of cheek retractors, mirrors and ring light ash (Zarem, 1984; Bengel, 1985; Sandler and Murray, 2002), a number of alternative set-ups for facial pictures have been advocated. For example, Mene- ghini (2001) suggests that high-quality pictures can be taken with a single ashlight (mono light) in a small ofce, and Zarem (1984) recommends constant reproduction ratios by deriving the display window from anatomical borders. For highly trained and experienced practitioners this might be an issue, but this is generally not the case for the novice. The authors favour a multi-ash-light solution in a separate room, with constant positions for the photographer and patient. This guarantees unchan- ging ambience and is both time saving and reliable. However, for certain purposes, such as planning of rhinoplasty and documentation of scars or skin lesions, the even illumination with little shadowing might affect the evaluation of the object of interest, and therefore illumination by spot lights or point ash, both of which produce harsh shadows, may be advisable (Galdino et al., 2002; Ikeda et al., 2003). This approach might also reduce the light reexes on the patients cornea produced by the soft boxes. Furthermore, a number of clinical situations might require different approaches. For example, handi- capped or immobilized patients will not always be able to take up every suggested position. CONCLUSION The authors consider a clearly arranged picture set for routine purposes. It consists of three dened facial views, ve intra-oral views and an additional set of six facial views for special topics that are sufcient and helpful in the majority of patients for cranio- maxillo-facial surgery. This emphazises the important issues of consis- tency of illumination, reproduction ratios and patient positioning for pre- and postoperative pictures to allow both reproducibility and the possibility of integration into daily routine. Many may have observed during presentations a remarkable correlation between the speakers surgical competence and the quality of clinical pictures shown. This should encourage all colleagues to pay signicant attention to the quality of clinical photo- graphs, which should ideally be taken personally by the responsible surgeon. Addresses for supply of cheek retractors and mirrors: Masel Orthodontics, 2701 Bartram Road, Bristol, PA 19007, UK http://www.maselortho.com/ Ortho Organizers, 58-60 Ashley Road, Hampton, TW12 2HU, UK http://www.orthoorganizers.co.uk/ Hager & Werken GmbH & Co. KG, AckerstraXe 1, 47269 Duisburg, Germany http://www.hagerwer ken.de ARTICLE IN PRESS Fig. 5 Intraoral views. Asterisk ( * ) indicates focus point: Top: upper occlusal surface, 2nd row (from left): buccal left, frontal, and buccal right views, Bottom: lower occlusal surface. 72 Journal of Cranio-Maxillofacial Surgery HAGER Worldwide, Inc., 13322 Byrd Drive, Odessa, FL 33556, USA www.hagerworldwide.com ACKNOWLEDGEMENTS The authors wish to thank Mr. John Carr, Dr. H. Kerkmann, Mr. H. Meyer and The Department of Medical Photography at the Royal Bolton Hospital for the excellent technical support. References Becker DG, Tardy Jr ME: Standardized photography in facial plastic surgery: pearls and pitfalls. Facial Plast Surg 15: 9399, 1999 Bengel W: Standardization in dental photography. Int Dent J 35: 210217, 1985 DiBernardo BE, Adams RL, Krause J, Fiorillo MA, Gheradini G: Photographic standards in plastic surgery. Plast Reconstr Surg 102: 559568, 1998 Galdino GM, Vogel JE, Vander Kolk CA: Standardizing digital photography: its not all in the eye of the beholder. Plast Reconstr Surg 108: 13341344, 2001 Galdino GM, DaSilva AD, Gunter JP: Digital photography for rhinoplasty. Plast Reconstr Surg 109: 14211434, 2002 Ikeda I, Urushihara K, Ono T: A pitfall in clinical photography: the appearance of skin lesions depends upon the illumination device. Arch Dermatol Res 294: 438443, 2003 Jemec BI, Jemec GB: Suggestions for standardized clinical photography in plastic surgery. 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HOWALDT Klinik und Poliklinik fu r Mund-, Kiefer- und Gesichtschirurgie - Plastische Operationen Klinikstrasse 29, D-35385 Giessen, Germany E-mail: HP.Howaldt@uniklinikum-giessen.de Accepted 21 November 2005 ARTICLE IN PRESS Standards for digital photography in cranio-maxillo-facial surgery 73