HOW WE DO IT

Laser-Assisted Patient Positioning: A Straightforward Method to Ensure Consistent Head and Neck Aesthetic Photographs
LINDSAY R. SKLAR, BS,* JEFFREY J. SO, MS, PA-C, CHRISTOPHER T. BURNETT, MD,* DAVID M. OZOG, MD*
AND

The authors have indicated no signicant interest with commercial supporters.

ermatologists, plastic surgeons, and otolaryngologists rely heavily upon photography as their primary means of patient documentation.1 Patient photographs and, more specically, the comparison of pre- and postoperative images are routinely used to assess surgical and nonsurgical treatment results, to evaluate standards of care, to teach for educational purposes, and for protection from possible medicolegal issues.1,2 For pre- and postoperative images to be valid, reproducible, and accurately reect treatment outcome, standardization of many variables is crucial. These variables, if not held constant, can lead to image misinterpretation and the appearance of false, invalid results. Patient positioning remains the most difcult variable for the photographer to control. Several variables in patient positioning affect the consistency of facial and neck photographs. These include any patient movement of the head, neck, or upper torso. Small changes (510 of neck exion or extension or 2 cm of neck protrusion or retrusion) can lead to noticeable changes in the perception of jaw line denition and submental soft tissue.2 Even if the head is kept constant, movement of the shoulders or torso can have a similar effect. For example, a stable head with a backward movement of the shoulders and torso will stretch the skin on the lower

face, jaw line, and neck, resulting in the appearance of less wrinkled and jowled skin. Nonuniformity in medical photodocumentation has led to criticism of before-and-after patient photographs from industry and the medical profession, with particular concerns most commonly regarding inconsistent patient positioning.2 For these reasons, a multitude of techniques have been used to minimize patient movement. Coombes and colleagues developed a bracket that attaches a slit lamp to a digital camera. The slit lamp holds the patients chin and forehead in place, ensuring reproducible positioning of the patients head.3 This apparatus serves its purpose when assessing the patients eyelids, but the slit lamp obscures the chin and forehead so the patients entire face is impossible to assess. The Frankfort Horizontal (FH), an arbitrary plane that extends from the lowest point of the infraorbital margin to the upper margin of the outer ear canal, is a method that uses anatomic landmarks to standardize head positioning, but it has been shown that the FH plane is an unsuitable technique for patients with facial asymmetry and that using the plane of the lateral semicircular canals yields more-reproducible images.4 These techniques do not address the fact that movement of the torso and neck can obscure ones subjective perception of the image, even if the

*Department of Dermatology, Henry Ford Hospital, Detroit, Michigan; Moy-Fincher Medical Group, Beverly Hills, California
2012 by the American Society for Dermatologic Surgery, Inc.  Published by Wiley Periodicals, Inc.  ISSN: 1076-0512  Dermatol Surg 2013;39:306308  DOI: 10.1111/dsu.12034
306

SKLAR ET AL

head is kept constant. We describe herein a novel, inexpensive method for ensuring consistent patient positioning that ofces conducting clinical trials and desiring accuracy in patient photographs can easily adopt. Our method consists of a commercially available laser level that projects a vertical and horizontal laser beam (Crossre; Black and Decker, Towson, MD). The X and Y1 axis are set with the intersection of these being a xed point that will be used for all photographs. For facial pictures, this could be a point where the columella meets the philtrum (Figure 1, Laser 1). This point may be marked with ink, but this may not be necessary if the point is easily recognizable and recorded. A second point

along the X axis (which becomes the Z axis as it courses posteriorly), such as the tragus, is then chosen. Fixing these two points keeps the head in a xed position along the vertical and horizontal planes, although as previously discussed, movement of the upper torso and neck can affect the appearance of the lower face. Therefore, this movement needs to be eliminated as well. This is accomplished with the use of a second device positioned laterally (Figure 1, Laser 2). Two Y2 axis points such as the tragus and the mid-shoulder, are chosen from laser 2, and the horizontal plane of this laser (X and Z axis) is aligned with the horizontal plane (X and Z axis) of laser 1, preventing any patient front-to-back (Z axis) movement of the head relative to the neck and shoulders. The initial photographs should be printed and will then serve as a reference for future laser-assisted patient positioning (Figure 2A,B). There are several benets of our system. The rst is that it may be used for any body surface area to maintain consistency in a three-dimensional plane. It can easily be used to photograph an arm, leg, or torso by marking three spots on the area of interest and lining up the two laser systems. In this example, a printed photograph that details the location of the three marked points should be kept in the record for reproducibility. An additional benet of this system is that, for split-face studies, the laser effectively divides the face for photographic comparison if desired.

Figure 1. Laser 1 ensures standardization of head placement in the vertical and horizontal dimensions. Alignment with laser 2 ensures standardization of the head relative to the neck and shoulders.

Drawbacks of this method are that additional time is needed to ensure that patients maintain their position relative to the angle and that additional
(B)

(A)

Figure 2. (A and B) Patient photographs demonstrating positioning method. These photographs can be stored in the medical record as a reference tool.

39:2:FEBRUARY 2013

307

LASER-ASSISTED PATIENT POSITIONING

time is needed to record the camera distance and respective height. Perhaps some time would be saved with a method used to standardize focal distance, such as the use of a chain or string stretched between the patients chin and the camera, a method that Niamtu proposed.5 The patient must also maintain identical height so that the height of the horizontal beam of the laser can be recorded (table for data points to be collected). In addition, it may be desired not to have the laser beam visible on the photographs. With the current set-up, the lasers can be turned off and then the photograph taken, but the patient must take care not to move during this time. Ideally, the laser positioning system would be integrated into the camera system so that, if desired, the laser beams could be selected to disappear upon compression of the shutter. The laterally based laser would need to be on an articulated arm or wirelessly connected to the camera so that it would similarly be deactivated upon compression of the shutter. Photodocumentation is truly valuable only if performed in a reproducible manner as an accurate representation of patient characteristics. The photographer cannot easily detect slight deviations in patient positioning, which result in dramatic faults in the nal outcome of the image. The laser method that we propose ensures consistent patient

positioning. Literature is lacking on mechanisms to standardize patient positioning, but in contrast to the few proposals that exist, our model takes into account other movements of the body that affect the image, even if the head remains in constant position. Our laser model provides a simple, reproducible method of patient positioning that we hope will increase the value of photodocumentation.

References
1. Niamtu J. Techno pearls for digital image management. Dermatol Surg 2002;28:94650. 2. Sommer DD, Mendelsohn M. Pitfalls of nonstandardized photography in facial plastic surgery patients. Plast Reconstruct Surg 2004;114:1014. 3. Coombes AG, Sethi CS, Kirkpatrick WN, Waterhouse N, et al. A standardized digital photography system with computerized eyelid measurement analysis. Plast Reconstruct Surg 2008;120:64756. 4. Pelo S, Deli R, Correra P, Boniella R, et al. Evaluation of 2 different reference planes used for the study of asymmetric facial malformations. J Craniofac Surg 1999;20:415. 5. Niamtu J. Image is everything: pearls and pitfalls of digital photography and PowerPoint presentations for the cosmetic surgeon. Dermatol Surg 2004;30:8191.

Address correspondence and reprint requests to: Christopher T. Burnett, MD, Department of Dermatology, Henry Ford Hospital, 3013 West Grand Blvd., Suite 800, Detroit, MI 48202, or e-mail: cburnet1@hfhs.org

308

DERMATOLOGIC SURGERY