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Journal of Cranio-Maxillofacial Surgery (2006) 34, 444455


r 2006 European Association for Cranio-Maxillofacial Surgery
doi:10.1016/j.jcms.2006.08.002, available online at http://www.sciencedirect.com

Standards for digital photography in cranio-maxillo-facial surgery Part II:


Additional picture sets and avoiding common mistakes
Heidrun SCHAAF1, Philipp STRECKBEIN1, Giovanni ETTORRE1, John C. LOWRY2, Maurice
Y. MOMMAERTS3, Hans-Peter HOWALDT1
1

Department of Oral and Maxillofacial Plastic Surgery (Chairperson: Prof. Dr. Dr. H.-P. Howaldt), Justus
Liebig University, Giessen, Germany; 2Department of Maxillofacial Surgery (Consultant: Prof. J.C. Lowry,
FRCS, FDSRCS), Royal Bolton Hospital, Bolton, UK; 3Bruges Cleft and Craniofacial Centre (Director: Prof.
M.Y. Mommaerts, MD, DMD, PhD, FEBOMFS), Brugge, Belgium
Available online 29 September 2006

As stated in the rst part of this publication standardized clinical photographs are essential for
planning, documentation and demonstration of surgical procedures in craniomaxillofacial surgery (Ettorre et al., 2006).
This article expands the previously dened standards in facial digital photography. Additional picture sets for special
topics are introduced and some common mistakes are discussed. Guidance for the prevention of pitfalls is provided and
the photographic principles are reviewed. Finally the authors give recommendations for dealing with structured data
storage and protection of medical photographs. The use of asset management systems such as Cumuluss and
Portfolios is introduced and recommended. r 2006 European Association for Cranio-Maxillofacial Surgery

SUMMARY.

Keywords: digital; photography; standards; maxillofacial; surgery; medical errors; information storage and
retrieval; computer security
patient condentiality. Although continuous change
and advance in computer software must be expected,
the currently available possibilities for the storage
and retrieval of patient image data will be described
and compared with suggestions from other authors
(Nayler, 1998; Nayler et al., 2001; Niamtu, 2004).

INTRODUCTION
The standard set of photographs for cranio-maxillofacial surgery described in the rst part of this
publication (Ettorre et al., 2006) requires supplementation in relation to some special topics. The aim of
this second publication in the series is to introduce
picture sets for dysgnathia, cleft lip, alveolus and
palate and aesthetic surgery.
Clinical photographs of poor quality make it
impossible to compare pre- and post-operative
situations. Although clinical photography is widely
discussed in the literature and different viewpoints
and picture sets for a range of plastic surgical
procedures, rhinoplasty, dermatology, dentistry and
orthodontics have been introduced (Zarem, 1984;
Bengel, 1985; Galdino et al., 2001, 2002; Sandler and
Murray, 2002a; Sullivan, 2002; Ikeda et al., 2003),
little information is available concerning error
avoidance. Therefore the authors highlight some
technical and human pitfalls in medical digital
photography. As most of them can be avoided by
observing simple rules, some of the more common
mistakes in clinical digital photography are described
in detail and suggestions for prevention are given.
Moreover data storage can lead to signicant traps
and must be carefully designed in view of the highly
sensitive issues of data protection and security of

ADDITIONAL PICTURE SETS FOR SPECIAL


TOPICS
Cranio-maxillo-facial surgery covers a wide eld of
pathological conditions involving the various areas of
the head and neck. The conventional facial picture set
specied in the rst part of these Standards (Ettorre
et al., 2006) does not full all the requirements.
Consequently as extra views for relatively common
conditions would overstrain the basic set, additional
picture sets for these groups of diagnoses are
presented under the following headings.
Dysgnathia and other related skull base and jaw
deformities
Patients with grossly abnormal positions of the jaw
for example in skeletal and associated Angle dental
classes II or III can misguide the photographer to
display the head in an inaccurate upright position
with the risk of exaggerating or masking the true
deformity. Care must therefore be taken to adjust the
head to the Frankfurt horizontal line, regardless of

DOI of orginial articles 10.1016/j.jcms.2006.04.006, 10.1016/


j.jcms.2006.08.001
444

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Standards for digital photography in cranio-maxillo-facial surgery 445

Fig. 1 (A) Prole view in maximum intercuspation; (B) prole view in relaxed rest position; and (C) full face front view smiling.

the position of the maxilla or mandible. The same


rule holds true for taking standard lateral head lms.
In general, a picture set for dysgnathia patients
should include lateral views in a relaxed resting
position of the mandible and also in maximal
intercuspation. There may also be signicantly
different proles for example with regard to the
supra- and submental fold in class II patients or chin
position in class III cases (Fig. 1).
The set of photographs for patients with skull base,
maxillary or mandibular deformities should include
the following:
Full face front view
Profile view in relaxed and in maximum intercuspation
This comprises four pictures: right and left side, each
in the relaxed rest position of the teeth and in
maximum intercuspation. Figs 1A and B demonstrate
the noticeable difference in an enlarged display detail.
It is advisable that the patients head is positioned
according to the lateral head radiograph in the right
lateral view.
Oblique view
In the oblique view the patients head is rotated 451 to
either side. It gives a useful demonstration to judge
facial changes after dysgnathia operations and it is
the only view showing the effect of malar augmentation techniques. The adjustments for this view are
described in part 1 of these Standards.
Front view, full smiling
Fig. 1C shows the front view with a full smile. The
full smiling picture is the most sophisticated photograph and it should appear as natural as possible.
Unfortunately patients with head deformities often
feel handicapped and usually hide their smile. A full
smile is generally accompanied with narrowing of the
eyelids. Patients are advised to smile broadly in a

relaxed fashion and show the teeth while trying to


avoid any tilting of the head.
Front view, lip retractor
This image is taken in the normal frontal head
position while using a lip retractor and holding the
teeth in a relaxed position to allow some judgment on
the plane of occlusion in relation to the interpupillary
line as mentioned in the rst part of these Standards.
Front view, spatula in occlusal plane
In this photograph the spatula should be held
between the canines to demonstrate the plane of
occlusion. The adjustments are also described in the
rst part of these Standards.
Submental oblique
As in the full face front view the interpupillary line
should be arranged parallel to the horizontal axis and
no rotation of the occipito-mental axis should occur.
Intraoral views
Front view
Buccal right and left
Occlusal upper and lower

General note for childrens photography


Taking pictures of children is much more challenging
than for adults who generally freeze in a specic
position for the time needed. Here digital photography has its greatest advantage as the photographs
can be checked immediately and repeated if necessary. The correct position for small children and
babies should be sitting squarely on the parents
knees in front of the sky blue background, so that if
possible no other person is visible. A helping hand
to hold the attention of the child with noise or

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446 Journal of Cranio-Maxillofacial Surgery

movements to keep the head in the designated


position is often indispensable. Sometimes the only
possibility for taking good pictures is at the beginning
of a surgical procedure when the child is already
anaesthetized.
Cleft lip, alveolus and palate
In this section a complete standard set with special
views for cleft patients is shown.

Intraoral upper occlusal view


For the intraoral view of the palate shown in Fig. 3 it
is necessary to use a small childrens mirror
intraoperatively. The lip should be retracted with a
non-reecting instrument. In babies and small
children it is often not possible to apply lip retractors
because of their size. Surgical hooks, wire retractors
or wooden spatulas may be used as alternatives.
Skull deformities

Full face front view


Fig. 2A shows a full face front view which should be
taken with the same requirements as described in the
detailed protocol for the full face front view in the
rst part of the Standards.

Full face front view


Fig. 4A shows a full face front view which should be
taken according to the same rules as mentioned in the
description for this in part 1 of these Standards.

Profile view
Fig. 2B demonstrates the prole view, which underlies the same rules as for adults.

Profile view
Fig. 4B demonstrates the prole view.

Submental oblique view


Fig. 2C shows the submental oblique view of a cleft
lip patient pre-operatively. This view allows a closer
view of the nasal deformity in cleft patients. This can
only be performed if the rules for the submental
oblique view are fullled (interpupillary-line parallel
to horizontal axis; extension of the head to align the
lip-line with the upper aspect of the ears). In very
small children it can sometimes only be obtained
under general anaesthesia immediately before surgery.
Additional views, for example a front view close-up
(Fig. 2D) or intraoperative submental oblique closeup (Fig. 2E) are also recommended.

Fig. 3 Cleft palate upper occlusal view, pre-operatively.

Fig. 2 (A) Full face front view; (B) prole view; (C) submental oblique; (D) front view close-up; and (E) intraoperative submental oblique
close-up view.

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Fig. 4 (A) Full face front view; (B) prole view; (C) full supracranial view; and (D) full supracranial oblique view.

Full supracranial view


Fig. 4C depicts an additional useful picture for
patients with cranial deformities. Both ears and the
tip of the nose should be seen and can serve as
anatomical landmarks. When feasible children can be
hold by their parents in front of the blue background.

Front view with cheeks blown out


The front view with the cheeks blown out is seen in
Fig. 5F.

Full supracranial oblique view


Fig. 4D shows an additional view in supracranial
oblique position where with slight extension of the
head the nose and zygoma are more clearly demonstrated. This view can be useful in skull deformities
with midfacial involvement.

Before aesthetic surgery such as face lifting (rhytidectomy), blepharoplasty, scar revision or rhinoplasty,
pictures are essential for documentation. The light
exposure for aesthetic interests of the face can affect
the surgeons view point and can point out or hide
details. For example facial wrinkles can be underestimated by using soft boxes for illumination. In
these cases it is preferable to use a ood light from
above that will highlight skin lesions by producing
harder shadows on the face. Moreover clear shadows
shown by oodlight on the face give better demarcation than that from soft light boxes of the characteristics of the nose before rhinoplasty.
In addition to the full face front view a number of
close-up views from showing the forehead, eye region
and nose together with a full face plus neck front view
will be a useful complement for the aesthetic picture
set. The close-up views can be obtained by enlargement from the full face front view. The front view
wrinkling forehead or frowning glabella as described
in the facial palsy picture set can also be a useful
addition to demonstrate skin texture and document
the forehead ageing. The oblique view allows evaluation of the shape of the zygoma and the nose. One of
the regions of interest especially before performing a
face lift is the neck as it extends from the lower
border of the mandible to the sterno-clavicular joints.
The neck should be uncovered, jewellery removed,
and women should remove make-up if possible.

Facial palsy
For views to assess and record the grade of facial
palsy the patient should be encouraged to grimace as
much as possible in specic reproducible movements
as follows:
Full face front view
Fig. 5A shows a full face front view which should be
taken with the same adjustments as mentioned in the
rst part of the Standards.
Full face front view, closed eyes
Fig. 5B shows a full face front view with the eyes
closed and relaxed to estimate the function of just the
periorbital musculature. Tight closure of the eyelids
need not be enforced.
Front view with wrinkling of the forehead (frown)
In the same position as for the front view, the patient
should frown the forehead and raise the eyebrows
(Fig. 5C). This view may also be valuable for the
aesthetic surgery set.
Front view smiling and front view with lips in whistling
position
In order to document function of the facial nerve the
patient should smile broadly (Fig. 5D) and purse the
lips (Fig. 5E).

Aesthetic surgery picture set

In addition the recommended set includes:

Full face front view plus neck


Fig. 6A shows the front view including the neck
region. The picture should be taken with the same
requirements as the full face front view described in
part 1 of these Standards.

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448 Journal of Cranio-Maxillofacial Surgery

Fig. 5 Facial palsy picture set. (A) Full face front view; (B) full face front view, closed eyes; (C) front view wrinkling forehead (frown);
(D) front view smiling; (E) front view whistling; and (F) front view blowing-out cheeks.

Profile view plus neck


Fig. 6B depicts the prole view including the neck
region. The patients head is positioned in a similar
way as for the standard prole view.
Eyelids closed but relaxed
Fig. 6C demonstrates the close-up view of the eye
region with eyelids closed and relaxed. The patients
head position is similar to the full face front view.
Eyelids squinted
Fig. 6D demonstrates the close-up view with eyelids
squinted. The patients head is positioned in the same
way as for the full face front view and the patient is
instructed to slightly narrow the eyelids as if dazzled
by light.
Front view neck tilted forward
Fig. 6E shows the head and neck tilted forward in a
full face front view position. The patient should
incline the head slightly forward while the eyes still
look straight into the camera lens. This picture is
useful for documentation of cervical wrinkles or
double chin.

Profile view neck tilted forward


Fig. 6F illustrates the prole view with neck tilted
forward. The reference position for the patients head
is that for the front view with neck tilted forward the
image being taken at 901.
Eyelids in upward gaze
Fig. 6G shows the close-up view of the eye region
with eyes gazing upward. The patients eyes x a
point in the ceiling while the head is positioned
naturally as for the full face front view. This also can
be an interesting view in patients with orbital
fractures.
Neck frontal
Fig. 6 H constitutes the neck in frontal position. The
patients head is tilted backwards until the line
joining both angles of the mouth (oral commissures)
is aligned with the level of the upper aspects of the
ears in a similar way to the description for the
submental oblique view in part 1 of these Standards.
Submental oblique, submental vertical, supracranial oblique and oblique view are optional and can be

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Standards for digital photography in cranio-maxillo-facial surgery 449

Fig. 6 Aesthetic surgery picture set. (A) Full face front view plus neck; (B) prole view plus neck; (C) eyelids closed relaxed; (D) eyelids
squinted; (E) front view neck tilted forwards; (F) prole neck tilted forward; (G) eyelids in upward gaze; and (H) front view of neck.

helpful additions to the series in preparation for and


review of patients undergoing rhinoplasty.

MOST COMMON MISTAKES

correct pictures by following some simple rules.


While it is impossible to replace vocational training
in medical photography by a medical publication, the
authors aim in the following section to provide some
guidance on the technical aspects of digital photography.

Technical errors
Although most surgeons are not professional photographers it should be possible to obtain technically

Brightness
Immediately after taking a digital picture the photographer should check the overall brightness of the

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450 Journal of Cranio-Maxillofacial Surgery

image with the histogram function of the digital


camera. This could provide a guide to a possible
change of the lens aperture. For extraoral views the
peak should be in the middle of the histogram while
for intraoral pictures it should be slightly to the right
side, consistent with a somewhat brighter image
(Fig. 7). When the immediate check of a photograph
on the viewing screen of the camera shows surface
reections on the teeth it is a favourable sign of
adequate illumination for an intraoral view. In view
of absorption of light by the mirror used for intraoral
views, the aperture should generally be at a wider
setting. The photographer should also be aware that
there is a variation in the light absorption characteristics of different mirrors.

Colour and contrast


If the control screen on the camera shows inaccurate
colour shades a recalibration of the white balance of
the camera might be needed.
Focus point and sharpness
Sharpness and focus of a digital picture can easily be
checked immediately after taking the picture by
checking the control display. Fuzziness is an irreparable error and can be prevented by using manual
focus. For intraoral views the autofocus option of
modern SLR cameras may not always be very useful.
The aim should always be to obtain pictures that are
as sharp as possible and in some cameras there is a

Fig. 7 Intraoral pictures: (A) too light; (B) too dark; and (C) ideal histogram.

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Standards for digital photography in cranio-maxillo-facial surgery 451

Fig. 8 Manual sharpening of image using commercially available computer software.

Fig. 9 Incorrect position of the photographer resulting in an unfavourable frontal view of the patient.

direct sharpening function which can be used as an


option. For processing of images following their
transfer to a personal computer there are a number of
different software programs available including
Adobe Photoshops, Corel Photopaints, Paintshop
Pros, Irfanviews and ACDSees. For scientic
integrity and professional ethical behaviour as well
as for security, all pictures should be stored in the
original unsharpened version. Mild sharpening can
be helpful and may not be considered as unreasonable cheating when used for scientic presentations.
The digital sharpening process can enormously
change the original photo and should be done equally
to every single picture in a series.
Excessive automatic sharpening by the camera is
not recommended although manual sharpening
which allows control of the procedure is preferred.
Fig. 8 demonstrates different grades of sharpening
(Adobe Photoshops unsharp mask).
Wrong position of patient or camera
There are many sources of error in positioning the
patients head. These include: failure to place the
patients head in a straight position, the eyes looking
into the wrong direction or the back is not straight.
All these mistakes lead to an incorrect position of the
head. The position of the camera and of the head of
the photographic subject should be at the same height

otherwise unnatural and unfavourable pictures are


created especially in the lateral view. In the frontal
view the malar prominences may be diminished and
the chin prominence enhanced (Fig. 9). On occasions
it may even looks like a mismatched submental
oblique view directly into the nostrils.
This emphasises the need for adjustable chairs for
both patient and photographer. The patients chair
should also have a backrest to minimize distortion of
the spine and any malposition of the head resulting
from this as explained in part 1 of these Standards.
Adjustment of the patients head according to
Frankfurt horizontal plane for the lateral view or
the interpupillary plane and vertical midline for the
frontal view can be facilitated by using a grid in the
cameras viewer. It also can be helpful to adjust
the space to the outer frame of the picture which must
not be too small especially in the lateral view.
Markings on the oor can help to keep the patient
in the same distance between the soft boxes and
camera in order to achieve reproducible views.
Although some positioning errors (e.g. rotation
around a sagittal axis) can be partially corrected with
image-editing programs this option should only
exceptionally be used for example if the patient is
no longer available for retaking the pictures.
Basically, pictures should be checked for errors
immediately and repeated if determined to be
unsuitable.

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452 Journal of Cranio-Maxillofacial Surgery

Fig. 10 Accumulation of saliva.

Irreparable mistakes are unsharpness and patients


wearing glasses, jewellery or long hair that covers the
ears and parts of face. The same is true for head
rotation around a transverse axis.
Accumulation of saliva and blood
Accumulation of saliva (Fig. 10) or blood whilst
taking pictures should be avoided by careful intraoral
suction or cleaning of the skin. For intraoperative
views care must be taken that all visible surgical
drapes are renewed where necessary to avoid bloodstained appearances. When using a mirror for
intraoral views this should not have condensation
or mist on its surface. The mirror should either be
slightly warmed or suction applied close to its
surface. Alternatively an anti-condensation solution
(e.g. Neo-Sabenyl) may be administered before
positioning the mirror.
Consistent factors
Consistent factors are adjustment of lighting, exposure, patient positioning, the lenses used, linear
scales, prospective depths of the eld, background
and post processing. The camera set up features
concerning post-processing should not be changed.
Also in order to compare pre- and post-operative
pictures it is important to keep these adjustments
exactly the same on the camera both pre- and postoperatively; for example the exposure setting for the
specic position of the patient. It is advisable to store
pictures with data from the camera (EXIF, IPTC and
XMP) including aperture, lm sensitivity and shutter
time in order to facilitate use of the same camera
settings for a follow-up picture set. Special care
should be taken to ensure the same illumination for
pre- and post-operative images.
STRUCTURED DATA STORAGE
Storage and archiving of digital images especially of
photographs is a sensitive issue in relation to data

protection, data security and patient condentiality


because uncovered faces are often mapped. Patient
consent concerning storage and use of personal data
is essential. This should follow the European guidelines for data protection as well as local requirements
in this respect. Any data base storing personal data in
particular photographs of patients faces must be
protected from unauthorized access. (It goes without
saying that there is permission to use the pictures of
this paper by the persons shown).
Personal non-anonymized data and pictures should
be stored in an encrypted and password-protected
area of a mass data storage device with an automatic
daily backup. Although such a professional environment of IT support is most common in large
hospitals, some doctors may unfortunately be
tempted to use their own laptop computer for storing
their patients picture data sets. This is most unwise
and contravenes professional ethics and responsibilities as data protection and security cannot be
ensured at all times and in particular theft of the
laptop or system crash can result in partial or total
data loss. Even if data is subsequently retrieved this
may be incomplete with consequent confusion of
labelling.
SELECTING AND ADJUSTING PICTURES
It is advantageous to select the best photographs of a
session immediately before saving the les in the data
base in order to avoid an unnecessarily large volume
of data. In general the capacity and system stability
of soft- and hardware solutions decrease with the
amount of data. An active surgeon may need to take
more than 5000 pictures per year which leads to a
need for approximately 5 GB of storage over a short
period of time. After taking a satisfactory picture,
immediate transfer to the PC work station and saving
to the patients le is recommended. It is essential to
adjust the pictures into the right position or to ip
them if a mirror was used as otherwise the right and
left sides of a patient can be easily be mixed up.
As many image editing programs cause data loss
when pictures are adjusted (e.g. rotated or ipped)
care must be taken in selecting suitable software.
Firegraphics (www.regraphic.com, USA), the
Irfanviews (www.irfanview.com, Austria) freeware graphic viewer and ACDSees (www.acdsee.
com, USA) are examples of more reliable graphic
adjusters.
RECOMMENDATIONS FOR DATA STORAGE
Accessibility of digital information depends on its
database structure, archival storage and key-wording.
Mistakes could end in violating the patients personal
rights, chaos of clinical photographs or even data
loss. There are two options for the organization of
image data bases: patient based or diagnosis/keyword
based. It is reasonable to attach the photographs to

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Standards for digital photography in cranio-maxillo-facial surgery 453

the patient le by name as well as saving them in a


digital asset management system.
Whilst it is necessary to document clinical ndings
as a follow-up with the patients name it is also
indispensable to store them based on keywords.
A reasonable organizing system is a keyword tree
based on main groups such as diagnosis, procedures,
regions, complications or special interests including
clinical trials. This tree can grow or change with the
structure of the department and could have about 100
different categories in a maximum of three levels. A
proposal for a keyword tree for cranio-maxillo-facial
surgery can be downloaded on the Members section
of the Eurofaces website at www.eurofaces.org.
It should be possible to transfer the images and
their keyword information to other programs without
losing information in the event of changing the hard
or software systems. Software solutions are available
on the market from many companies. Examples for
single user (stand alone) and multi-user (network
based) programmes include:
Single user software (stand alone)






ACDSees (PC/Macintosh)
iViews (PC/Macintosh)
iPhotos (Macintosh)
Cumuluss (PC/Macintosh)
Multi-user software (network)





Cumuluss (www.canto.de, Germany) the cumulus software is optimized for management in


medical use and has an advanced search function.
PhotoStations (www.fotoware.de, Germany)
PhotoStation software can organize les for
professional photograph archiving.
Portfolios (www.extensis.com, UK) portfolio is
a digital asset management solution to organize
and access digital les quickly without compromising security or brand quality.

If a colleague seeks professional advice about a


patient the sending of pictures by e-mail over
unsecured data-lines must be avoided according to
the data protection guidelines of the European
Union. The European Association for Cranio-Maxillo-Facial Surgery developed a tool for scientic
communication and education which includes clinical
photographs and radiographs. This electronic consultation software is implemented in the protected
member section of the website www.eurofaces.com.

DISCUSSION
Additional picture sets for special topics in craniomaxillo-facial surgery expand the basic set. Although
there is a variety of recommendations for picture sets
in the literature for different medical elds (Sandler
and Murray, 2001; Galdino et al., 2002; Jones and
Cadier, 2004) the authors have endeavoured to
minimize the picture set as far as possible. Overall

19 facial and ve intraoral views in ve categories are


incorporated within the sets.
In the literature, guidelines for various special
topics can be found. For example the Institute of
Medical Illustrators in the UK presents some baseline
guides related to the treatment and surgical outcome
of cleft lip, alveolus and palate disorders (Jones and
Cadier, 2004). For documentation of facial nerve
weakness, still and moving digital imaging is described in patients undergoing skull base surgery at
an otological and neurological clinic (Barrs et al.,
2001). With this current article, the authors would
like to create a Europe-wide standard for the most
important photographic views for the more common
disease patterns presenting in cranio-maxillo-facial
surgery.
In order to avoid mistakes in clinical photography
the authors agree with other publications which
regard a reproducible position of the patient as being
essential (Nayler, 2003; Niamtu, 2004). For relatively or less rigidly standardized images for the
average cosmetic surgeon in private practice, consistency in distance, white balance, background and
lightning is recommended (Niamtu, 2004). To guarantee consistency in pre- and post-operative photographs the illumination must be the same, although
some surgeons try to improve post-operative results
by generating brighter pictures.
Digital photography enables clinicians to take a
large number of pictures in a short time. Nonetheless
appropriate care should be taken to ensure a
consistently high quality. The great advantage of
digital photography is obviously the facility to check
the images immediately after they have been taken.
Poor quality outcomes should be detected and the
picture repeated after they have been checked by a
medical professional. Poor quality pictures sometimes shown in medical journals or academic
presentations should nowadays be an exception. In
spite of the additional advantages of digital photography such as timesaving, lower costs, quick and
space saving storage with easier access to the
photographs (Trune et al., 1995; Ettorre et al., 2006)
some drawbacks must be pointed out.
A manipulated appearance of surgical results by
changing the patients position, for example to chinup or chin-down has been described (Niamtu, 2004).
Other authors have described specic problems, for
example the appearance of skin lesions being
dependent on illumination (Ikeda et al., 2003) or
dramatic changes of appearance of the face and jaw
line with extension of the neck, and protrusion of the
head which can misrepresent surgical outcome (Jones
and Cadier, 2004; Sommer and Mendelsohn, 2004). In
addition, the possibility of altering brightness, focal
length, patients position and selective softening or
sharpening with computer programs can be used to
change the authentic appearance of the surgical
outcome. Unfortunately this has become much easier
and less controllable in our digitized world and in the
end all we can do now is to rely on each others
honesty.

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The question of who should take the pictures in


daily clinical work is controversial. Some authors
suggest delegating the supervision and picture taking
to staff members (Christensen, 2005) but the purpose
and viewpoint of the image is not the same for every
photographer. It is therefore recommended that the
responsible surgeon should personally take the
pictures directed towards the main points of interest
of a patients medical problem and the aim of
treatment. If a professional photographer is employed medical knowledge is required. In a survey
which included 68 orthodontists, 60% took the
photographs themselves, in 35% a clinical assistant
and in 5% a professional photographer was assigned
to obtain the pictures (Sandler and Murray, 2002a).
The authors agree with previously published manuscripts that correct equipment and appropriately
trained staff are the key to good-quality accurate
clinical photographs (McKeown et al., 2005).
For storage and archiving of digital patient images,
authors have suggested different systems for cataloguing the photographs by diagnosis, date, patient
registration number and type of photographic view
using photo CDs (Nayler, 1998) or describe programs such as exif viewers, dentofacial showcases
and PowerPoints as alternative methods (Sandler
and Murray, 2002b). Creating a directory tree known
from windows explorers leading to the nal subfolder for patients name is also described (Niamtu,
2004).
Better search functionality, handling and a useful
diagnosis- or treatment-tree storage of data is
provided by asset management systems such as
Cumuluss or Portfolios. Using these management
systems and labelling digital images with multiple
indices gains greater importance as the number of
stored photographs increases. Additionally, appropriate storage for patients data security and protection against unauthorized access is provided by the
programs as they are equipped with multi-user log-in
facilities. Moreover, these programs facilitate the
possibilities for creating academic presentations or
lectures to students by using the structured information attached to each picture. It should be noted that
a digital picture is denitely lost if not categorized
and le saved adequately. We cannot rely anymore
on a well-trained long-term secretary who knows by
heart the slides stored on large ofce shelves and in
cabinets if there has been a switch from analogue to
digital photography.
CONCLUSION
As a supplement to the rst part of Standards for
digital photography in cranio-maxillo-facial surgery
(Ettorre et al., 2006) ve additional picture sets are
introduced. These special picture sets can be adapted
to complement the spectrum of clinical activity and
structure of a particular department. A task force of
the European Association for Cranio-Maxillo-Facial
Surgery (EACMFS) has endeavoured to establish

feasible and limited picture sets and also to point out


some pitfalls and drawbacks in digital photography.
By knowing cause and effect of such mistakes,
challenges can be handled much more professionally.
Technical errors, mistakes in positioning the patient
and difculties in intraoral and childrens photography are presented.
Medical progress has always been dependent on an
exchange of experiences. Modern communication
facilitates interdisciplinary discussion if used appropriately. The authors therefore encourage all colleagues to consider investing appropriate time and effort
in accurate photo-documentation. This together with
honesty, adequate data protection and platforms
such as www.eurofaces.com it is hoped that progress
in our profession might be accelerated for the benet
of both patients and surgeons.
Addresses of companies mentioned:
ACDSees (www.acdsee.com) ACD Systems International Inc., Saanichton, British Columbia, Canada
Adobe Photoshops (www.adobe.com) San Jose,
California, USA
Cumuluss (www.canto.de) Canto GmbH, Berlin,
Germany
Corel Photopaints, Paintshop Pros (www.corel.
com) Corel Corporation, Ottawa, Canada
Dentofacial showcases (www.dentofacial.com)
exif viewers, Ludwigshafen, Germany
Firegraphics (www.regraphic.com)
IMI, The institute of medical illustrators (www.
imi.org.uk) London, UK
Irfanviews (www.irfanview.com), Irfan Skiljan,
Wiener Neustadt, Austria
iPhotos, Apple, Cupertino, CA, USA
iViews, (www.application-systems.de) Application
Systems Heidelberg Software GmbH, Germany
Neo-Sabenyls, Qualiphar (www.qualiphar.com),
Antwerp, Belgium
PhotoStations (www.fotoware.de), FotoWare
GmbH, Geesthacht, Germany
Portfolios (www.extensis.com), Extensis UK, The
Lakes, Northampton, UK
Photo CDs Kodak, Stuttgart, Germany
PowerPoints, Microsoft, Redmond, USA
Windows explorers, Microsoft, Redmond, USA
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Prof. H.-P. HOWALDT


Klinik und Poliklinik fur Mund-, Kiefer und Gesichtschirurgie
Plastische Operationen Klinikstrasse 29
35385 Giessen
Germany
E-mail: HP.Howaldt@uniklinikum-giessen.de
Paper received 16 February 2005
Accepted 11 April 2006