COSMETIC

Size and Perception of Facial Features with

Selfie Photographs, and Their Implication in
Rhinoplasty and Facial Plastic Surgery
Mark P. Pressler, M.D.

Background: Patients increasingly use photographs taken with a front-facing

Mikaela L. Kislevitz, B.S.N., smartphone camera—“selfies”—to discuss their goals with a plastic surgeon. The
R.N., M.D. purpose of this study was to quantify changes in size and perception of facial fea-
Downloaded from http://journals.lww.com/plasreconsurg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 03/29/2022

Justin J. Davis, M.D.
Bardia Amirlak, M.D.
Dallas, Texas
tures when taking a selfie compared to the gold standard of clinical photography.
Methods: Thirty volunteers took three series of photographs. A 12-inch and
18-inch series were taken with a front-facing smartphone camera, and the
5-foot clinical photography series was taken with a digital single-lens reflex
camera. Afterward, subjects filled out the FACE-Q inventory, once when view-
ing their 12-inch selfies and once when viewing their clinical photographs.
Measurements were taken of the nose, lip, chin, and facial width.
Results: Nasal length was, on average, 6.4 percent longer in 12-inch selfies com-
pared to clinical photography, and 4.3 percent longer in 18-inch selfies com-
pared to clinical photography. The alar base width did not change significantly
in either set of selfies compared to clinical photography. The alar base to facial
width ratio represents the size of the nose in relation to the face. This ratio
decreased 10.8 percent when comparing 12-inch selfies to clinical photography
(p < 0.0001) and decreased 7.8 percent when comparing 18-inch selfies to clini-
cal photography (p < 0.0001).
Conclusions: This study quantifies the change in facial feature size/percep-
tion seen in previous camera-to-subject distance studies. With the increasing
popularity of front-facing smartphone photographs, these data allow for a
more precise conversation between the surgeon and the patient. In addition,
the authors’ findings provide data for manufacturers to improve the societal
impact of smartphone cameras.  (Plast. Reconstr. Surg. 149: 859, 2022.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, III.

P
lastic surgeons use clinical photography
to communicate with patients about their
surgical goals. In addition, it is a tool for
exchanging clinical and academic information
with other surgeons.1,2 Standardization of lens
settings and pose are necessary to compare pho-
tographs.1 Patients commonly bring in aspira-
tional or self-obtained photographs to the office
or online consultation to discuss surgical goals.3,4
Photographs using a front-facing smartphone
camera (i.e., selfies) have increased in popular-
ity and, despite surgeons’ efforts to use standard
studio photography, have become part of the
discussion of surgical goals and impact postsurgi-
cal patient satisfaction.5,6
There is a noted relationship between the
increase in selfie photographs and an increase in
rhinoplasty requests, particularly among younger
patients.5 Plastic surgeons should seek to under-
stand both the psychosocial and the technical
considerations of this link. The distortion due
to selfie photographs has also been shown to
negatively affect an individual’s self-esteem.7 The
advent of social media has led to an increase in
requests for plastic surgery from patients due to
increased awareness of their looks, a trend that
has been increasing since 2014.8,9

From the Department of Plastic Surgery, University of Texas

Southwestern. Disclosure: This research did not receive any spe-
Received for publication March 12, 2020; accepted July 13, cific grant from funding agencies in the public, com-
2021. mercial, or not-for-profit sectors. The authors have no
Copyright © 2022 by the American Society of Plastic Surgeons financial interests to report.
DOI: 10.1097/PRS.0000000000008961

www.PRSJournal.com 859
Copyright © 2022 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

Noyes and Jenkins noted faces look more con-
vex when the lens is closer to the subject (0.2 to 3
m in their example) and flatter from afar.10 Studies
have found subjects are rated as less trustworthy,
competent, or attractive in photographs with
shorter focal lengths.11,12 Perspective distortions
(where closer objects are perceived larger than dis-
tant ones) of facial photographs have been stud-
ied, finding focal length and camera-to-subject
distance to be a source of these distortions.12,13 The
front-facing camera in a smartphone has a very
short focal length, and the pictures it captures have
a very short camera-to-subject distance. A study by
Ward et al. found the width of the nose seems 30
percent larger in photographs 12 inches from the
face compared to photographs 5 feet away.6
This study aimed to further quantify the dis-
tortion of selfies compared to gold standard clini-
cal photography. In addition, this study aimed to
test the difference in self-perceived aesthetics with
the FACE-Q inventory.
PATIENTS AND METHODS
Participants and Equipment
The Institutional Review Board at University
of Texas Southwestern, Dallas, Texas, approved
this study. This study recruited participants by
means of word of mouth from April to May of
2019. Participants were included if they were adults
capable of following study directions. Photographs
of participants were taken in a clinical photogra-
phy studio. These photographs were immediately
uploaded onto a network computer. Participants
first looked at their selfies and completed the
FACE-Q inventory. Afterward, participants filled out
the same inventory for their clinical photographs.
An Apple XR (Apple, Inc.; Cupertino, Calif.)
was used (encrypted per institutional standards)
for selfie photographs. The front-facing camera on
this smartphone has a focal length of 2.87 mm.14
The clinical photographs were taken with a Nikon
digital single-lens reflex camera, using an AF-S DX
NIKKOR 18-200  mm ED VRII lens set at a focal
length of 50  mm (Nikon, Inc., Minato, Tokyo,
Japan).15 A 50-mm focal length has been cited as
an approximation of human sight.16–18
Pictures and Photoshop
Participants were seated with their back
straight and wore a neutral facial expression in the
studio. Three sets of three photographs were taken
(using a shutter remote clicker) at 12 inches and
18 inches with the front-facing smartphone cam-
era and 5 feet using the digital single-lens reflex
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Plastic and Reconstructive Surgery • April 2022
camera. Twelve inches was chosen as an estimate
of a selfie taken with the elbow bent at 90-degree
angle. Eighteen inches was chosen as an estimate
of a selfie at arm’s length, with the wrist bent at a
90-degree angle. Five feet was chosen as the stan-
dard camera-to-subject distance used in clinical
photography at University of Texas Southwestern.
Both the smartphone and the digital single-lens
reflex camera were on a wheeled camera mount,
and the height of the lens was at eye level (Fig. 1).
The camera-to-subject distance was measured by a
ruler from the tip of the nose to the lens of the
camera. Each set included a front, a left oblique,
and a right oblique photograph. The oblique pho-
tographs were taken according to a University of
Texas Southwestern Department of Plastic Surgery
rhinoplasty protocol, lining up the dorsum of the
nose with the medial canthus of the eye.
Participants were instructed to hold a ruler
next to their face, at a facial depth halfway between
the tragus and the lateral canthus, to standardize
a “life-size” scale used for measurements (Figs. 2
and 3).19,20 The lighting of the studio was standard-
ized, using four overhead fluorescent photogra-
phy lights (temperature of 5000 Kelvin) placed
at each corner. This setup created a homogenous
light exposure and avoided shadowing.
Measurements were taken using the Adobe
Photoshop CS6 Ruler Tool (Adobe, Inc., San Jose,
Calif.) built into the software. A scale was obtained
by measuring 1  cm on the ruler (Figs.  2 and 3),
establishing the number of pixels that correspond
to 1  cm in each photograph. Measurements
(Table  1) were carefully placed both at soft-tis-
sue anatomical points and at transitions between
light and shadow, maximizing reproducibility
between each set of photographs. Clinical pho-
tography was used as the gold standard set of
images. Therefore, any change in measurements
for either the 12-inch or 18-inch set of selfies was
defined as “distortion.”
FACE-Q
The front and left oblique photographs
were viewed by participants immediately after
their photographs. They filled out two FACE-Q
inventories,21,22 the nose and facial appearance.
Participants filled out these inventories twice,
first for 12-inch selfies and then for clinical
photographs.
Statistics
Each measurement was compared between
sets of photographs (12-inch versus clinical pho-
tograph and 18-inch versus clinical photograph)
 Volume 149, Number 4 • Implications of Selfies in Rhinoplasty

Fig. 1. This figure shows the setup for both selfies and clinical photography. Twelve-inch, 18-inch, and 5-feet distances were mea-
sured with a ruler from the tip of the nose to the camera. The lens was adjusted to be at eye level for both types of photographs.
Participants held a ruler next to their face as straight as possible to allow for accurate measurements.

utilizing a paired t test. FACE-Q nose and facial
appearance inventory scores were also compared
by a paired t test. The toolpak in Microsoft Excel
(Microsoft, Inc., Redmond, Wash.) was used for
statistical analysis.
RESULTS
Demographics
Thirty people, 23 women and seven men,
sat for photographs and rated their appearance.
Average age was 34.1 ± 11.3 years (range, 24.0 to
62.3 years). Seven participants stated prior cos-
metic injectables or surgery. There was no self-
reported history of mental illness.
Measurements
Figure 4 shows the change in facial measure-
ments between 12-inch selfies, 18-inch selfies, and
clinical photography. Neither nasal width mea-
surement (the alar base or alar wing) changed sig-
nificantly when comparing either 12- or 18-inch

Fig. 2. Twelve-inch selfie (left), 18-inch selfie (center), and 5-foot clinical photograph (right) are shown. This figure allows visualiza-
tion of the facial changes with different camera-to-subject distances. Note the narrower facial width in the selfie photographs,
which accentuates the size of the nose. The proportion of the length of the chin, relative to the length of the whole face, is smaller
in the selfie photographs. These selfie photographs, with their ultrawide-angle lenses and short camera-to-subject distances, cre-
ate a distortion where features closer to the camera (e.g., the nose) seem larger. This study aimed to quantify this visual phenom-
enon, utilizing the ruler next to the participant to standardize measurements.

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Copyright © 2022 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

Fig. 3. An additional set of 12-inch selfie (left), 18-inch selfie (center), and 5-foot clinical photograph (right) is shown.
selfies to clinical photography (p values ranged
from 0.05 to 0.29). The five nasal length mea-
surements (Table 1) showed a 4.0 to 8.7 percent
increase in nasal length in the 12-inch selfies com-
pared to clinical photography (p values ranged
from 0.006 to <0.0001) and a 2.7 to 5.8 percent
increase in nasal length in 18-inch selfies com-
pared to clinical photography (p values ranged
from 0.006 to <0.0001). The length of the men-
ton to labiale inferius was 11.9 percent shorter
in 12-inch selfies compared to clinical photog-
raphy (p < 0.0001) and 8.8 percent shorter in
18-inch selfies compared to clinical photography
(p < 0.0001). The width of the face increased 10.3
percent in clinical photography compared to
12-inch selfies (p < 0.0001) and increased 7.1 per-
cent in clinical photography compared to 18-inch
selfies (p < 0.0001). In addition to measuring the
length of facial features in selfies, ratios were used
to test proportionality, as shown at the bottom of
Table 2. A full list of average measurement values
Table 1.  All Measurements for the Photographs of
Each Subject and the Utility of Each Measurement
Utility of
Measurement Measurement
Nasal tip to trough of Cupid’s bow Upper lip length
Alar base width Nasal width
Alar wing width Nasal width
Line of intercanthal distance to nasal tip Nasal length
Left medial canthus to left alar base Nasal length
Left medial canthus to nasal tip Nasal length
Right medial canthus to nasal tip Nasal length
Right medial canthus to right alar base Nasal length
Menton to labiale inferius Length of lower
facial third,
length of chin
Facial width Standardization
of nasal width
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Copyright © 2022 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • April 2022
and percent difference between sets of photo-
graphs are listed in Table 2.
Reliability
All facial measurements of five participants
were repeated with a second investigator to assess
interrater reliability. Lin’s concordance correla-
tion coefficient was used to compare investiga-
tors for each facial measurement independently.23
Correlation varied from 0.727 (alar base) to 0.995
(alar wing), as seen in Table 3.
DISCUSSION
Plastic surgeons at this institution anecdotally
state that selfies not only distort facial features
(Figs.  2 and 3) but also complicate discussions
with patients about their goals. The purpose of
this study was to quantify the change in facial fea-
ture size, proportionality, and perception seen in
selfies from various camera-to-subject distances.
Clinical photography was defined as the gold stan-
dard. Therefore, any difference between a set of
selfies and clinical photography was classified as
“distortion” in our study.6
Třebický et al. took photographs of par-
ticipants with a digital single-lens reflex camera
(Nikon D90) using three different focal lengths.12
The authors used different camera-to-subject dis-
tances so the face would be the same size in all
three pictures. Thus, the shorter focal lengths
required the camera to be closer to the partici-
pant. Other participants rated these different
focal length photographs on attractiveness, find-
ing the shortest focal length/shortest camera-
to-subject distance was the least attractive.12 This
study also reported changes in perspective with
shorter camera-to-subject distances, where facial
 Volume 149, Number 4 • Implications of Selfies in Rhinoplasty

Fig. 4. This figure describes the variability of measurements between the three sets of photographs. The center line in the box
represents the median, and either border of the box represents the twenty-fifth and seventy-fifth percentiles. Nasal tip to trough of
Cupid’s bow was not statistically significant, nor was alar base or alar wing width. The five measurements of nasal length (Table 1)
were significant when comparing 12-inch selfies to clinical photographs and 18-inch selfies to clinical photographs, but not signifi-
cant between 12-inch and 18-inch selfies. Menton to labiale inferius and facial width were significant for each comparison. Table 2
lists the measurements, their p values, and the percent change between sets of photographs.

features closer to the camera seeming larger.12
Based on these findings, our study should find
facial features closer to the camera as larger (e.g.,
the nose), and participants should rate their
12-inch selfies as less attractive than their clinical
photography. Our study found the five measure-
ments for nasal length were 4.0 to 8.7 percent
longer in 12-inch selfies as opposed to clinical
photography (p values from 0.006 to <0.0001).
Interestingly, nasal width measurements (i.e.,
alar base and alar wing) were significantly larger
only when expressed as a ratio with facial width
(Table  2). This proportional change can be
explained by perspective distortions. Considering
the facial width alone decreased 10.5 percent in
12-inch selfies as opposed to clinical photography
(p < 0.0001), these findings suggest the width of
the face is a large contributor to the nose seem-
ing larger in short focal length photography,
namely, selfies. Table  2 shows all average mea-
surements and percent differences for 12-inch
selfies, 18-inch selfies, and clinical photography.
The length of the face was also studied as
a ratio. The length of the chin, from menton
to labiale inferius, unexpectedly decreased 12
percent in 12-inch selfies as opposed to clinical
photography (p < 0.0001). Because of this unex-
pected finding, a comparison of the nasal length
to chin length was done post hoc. The five nasal
length measurements (Table  1) were averaged
for each participant and compared to chin length
as a ratio. The nasal length to chin length ratio
was 17 percent larger in 12-inch selfies compared
to clinical photography (p < 0.0001). These dis-
tortions were noticed by participants when they
filled out the FACE-Q survey. There was a signifi-
cant increase (9.1 percent, p = 0.003) in average
FACE-Q nose score from 12-inch selfies to clinical
photography (Fig.  5). The average FACE-Q face
score from 12-inch selfies to clinical photography
(5.7 percent, p = 0.06) trended toward statistical
significance. Multiple participants stated, “my face
looks more proportional in the clinical photo-
graph.” The increased nasal width to facial width

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 Plastic and Reconstructive Surgery • April 2022

Table 2.  Average Measurement Length of Each Feature and t Percent Change of Measurements between
Different Sets of Photographs with Their P Values*
12-Inch Selfie versus 18-Inch Selfie versus
18-Inch Clinical Clinical Photograph Clinical Photograph
12-Inch Selfie Photograph
Selfie (cm) (cm) (cm) % Change p % Change p
Nasal tip to trough of Cupid’s bow 1.86 1.84 1.85 −0.66 0.65 0.74 0.61
Alar base width 2.31 2.31 2.28 −1.44 0.29 −1.36 0.20
Alar wing width 3.78 3.71 3.67 −2.82 0.05 −0.97 0.26
Line of intercanthal distance to nasal tip 4.29 4.16 3.92 −8.69 <0.0001 −5.77 <0.0001
Left medial canthus to left alar base 4.30 4.23 4.11 −4.43 0.004 −2.91 0.003
Left medial canthus to nasal tip 4.55 4.43 4.22 −7.24 <0.0001 −4.75 <0.0001
Right medial canthus to nasal tip 4.60 4.48 4.24 −7.75 <0.0001 −5.20 <0.0001
Right medial canthus to right alar base 4.29 4.23 4.12 −4.01 0.006 −2.67 0.006
Menton to labiale inferius (length of chin) 3.23 3.32 3.61 11.95 <0.0001 8.80 <0.0001
Facial width 12.53 12.93 13.84 10.48 <0.0001 7.05 <0.0001
Alar base/facial width ratio 0.18 0.18 0.16 −10.84 <0.0001 −7.81 <0.0001
Alar wing/facial width ratio 0.30 0.29 0.27 −12.11 <0.0001 −7.53 <0.0001
Average nasal length 4.41 4.31 4.12
Nasal length/length of chin ratio 1.39 1.32 1.15 −16.98 <0.0001 −12.52 <0.0001
*A positive percent change signifies the facial feature is larger in clinical photographs; a negative percent change signifies the facial feature is
smaller. In addition to measuring the length of facial features in selfies, ratios were used to test proportionality. To test the proportion of nasal
width to facial width, the alar base and alar wing measurements were compared to the width of the face for each set of photographs. In addition,
the average of the five nasal length measurements (Table 1) was compared to the menton to labiale inferius measurement (a substitute for chin
length) to test how the middle and lower facial third change between selfies and clinical photographs. The average nasal length was calculated
from line of intercanthal distance to nasal tip, left medial canthus to left alar base, left medial canthus to nasal tip, right medial canthus to nasal
tip, and right medial canthus to right alar base. This was done to compare to length of chin as a ratio.

proportion and the increased nasal length to chin
length proportion corroborate the perspective dis-
tortion findings by Třebický et al.12 The increased
nose attractiveness rating suggests that facial width
and chin length are contributors to self-perception
of the nose, in addition to the nose itself.
A set of 18-inch selfies was chosen to represent
a photograph taken with the smartphone held
at full arm extension, a common pose for self-
ies. This set was taken to see how the distortion
changes from previously studied 12-inch photo-
graphs6 compared to a common selfie pose. The
reduction in distortion from an 18-inch selfie (a
selfie at arm’s length) as compared to a 12-inch
selfie, as seen in Table  2, suggests there may be
an optimal distance for minimizing distortion. It
can guide the surgeon and the patient in their dis-
cussion of surgical goals should the distance of a
selfie be known. Our study’s nasal length and nasal
width measurement data, coupled with the lower
FACE-Q nose score when viewing selfies, connects
the well-established negative feelings toward self-
ies25,26,28–32 with the face shape change noted from
short camera-to-subject distance.10,11,27 The restora-
tion of psyche is an important tenant in plastic and
reconstructive surgery. The American Academy of
Facial Plastic and Reconstructive Surgery annual
survey has noted an interaction between selfies
and rhinoplasty requests multiple times in recent
years.8,9,24 Surgeons may find it ideal to avoid any
selfie-based discussion, intuitively seeing the pho-
tographs distort facial features. However, quantify-
ing how selfies distort photographs is important
to better understand how these negative feelings
influence a patient’s psyche, their choice in pursu-
ing plastic surgery, and their outcome.

Table 3.  Interrater Reliability for Each Facial Measurement and Second Investigator Duplicated Measurements
of Five Participants
Average Measurement and Variance (cm)
Investigator 1 Investigator 2 Lin’s CCC
Nasal tip to trough of Cupid’s bow 1.83 ± 0.11 1.92 ± 0.07 0.852
Alar base width 2.34 ± 0.14 2.22 ± 0.07 0.727
Alar wing width 3.68 ± 0.18 3.70 ± 0.16 0.995
Line of iIntercanthal distance to nasal tip 4.08 ± 0.34 4.01 ± 0.30 0.945
Left medial canthus to left alar base 4.19 ± 0.15 4.16 ± 0.15 0.979
Left medial canthus to nasal tip 4.34 ± 0.38 4.27 ± 0.32 0.945
Right medial canthus to nasal tip 4.45 ± 0.26 4.35 ± 0.23 0.923
Right medial canthus to right alar base 4.21 ± 0.15 4.18 ± 0.17 0.974
Menton to labiale inferius 3.19 ± 0.15 3.19 ± 0.15 0.993
Facial width 12.99 ± 0.72 12.93 ± 0.69 0.991
Lin’s CCC, Lin’s concordance correlation coefficient.

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 Volume 149, Number 4 • Implications of Selfies in Rhinoplasty
Fig. 5. This graph shows the change in average FACE-Q scores for the participants’ nose and facial appearance. Participants per-
ceived their noses more favorably in clinical photographs than in 12-inch selfies (p = 0.003). There was no significant change in
perception of facial appearance (p = 0.06).
Social media sites, such as Instagram, began
to test a new interface without the “like” button to
combat these negative feelings.33 Thus, the interac-
tion between selfie distortion and psyche is impor-
tant for smartphone and social media companies
to better understand the societal impact of these
prevalent selfies. This article begins to quantify
distortions colloquially seen by individuals and,
using FACE-Q, test their effect on an individual’s
opinion of their image. This can lead to a larger
discussion about the unwanted psychological
impact of distorted selfie images by psychologists,
policy makers, and smartphone manufacturers.
Perspective distortions of facial photographs
(where closer objects seem larger than distant
ones) are more pronounced with shorter camera-
to-subject distance and help explain our find-
ings.12,13 This study chose to place the lens of both
cameras at eye level, and, therefore, the nose is
closer to the camera than the chin. This perspec-
tive distortion is more dramatic for a lens at 12
or 18 inches from the face when compared to
a lens set 5 feet from the face. This can be seen
in Figures 2 and 3, where the nose is larger than
the chin in a selfie but more proportional in
Copyright © 2022 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
clinical photography. This distortion is corrobo-
rated with nasal length and nose to chin length
measurements. Perspective distortions are more
pronounced in selfies, specifically at the lateral
border of the cheek and mandible. This contrib-
utes to the face looking narrower and deeper. In
contrast, the face in clinical photography looks
more flat and proportional (Figs.  2 and 3). This
visual distortion is corroborated by the facial width
measurements and the nasal width to facial width
ratios of this study. This study begins to connect
the perspective changes seen visually in Figures 2
and 3 to the measurements in Table 2. This con-
nection can begin to quantify why selfie photogra-
phy looks different from professional photography
and can begin to facilitate a more precise discus-
sion of outcomes between surgeons and patients.
Ward et al. standardized the bizygomatic width
of all photographs before calculating nasal distor-
tion.6 Instead, our study defined the facial width
using landmarks. We chose the distance between the
hairline drawn through the lateral canthi, because
the hairline and the skin immediately anterior pro-
vided an easily distinguishable line of contrast. Our
study expressing the width of the nose as a ratio to
865

facial width is essentially the same standardization
process as fixing a bizygomatic width for all pic-
tures. The advantage of width described as a ratio
is it does not require any alteration of photographs
(e.g., changing the size of the images to equalize
the bizygomatic width), nor does it require any in-
person anthropometric measurements. In addition,
Ward et al. did not use a front-facing smartphone
camera to take their 12-inch photographs.6
There are limitations to our study. Participants
were instructed to look at the camera lens, and
camera lenses were placed at facial level per pho-
tographic standards described by DiBernardo et
al.1 This largely mitigated error brought on by
a person’s pose. Despite our efforts to keep the
head stable, participants could have tilted their
head up or down slightly, introducing some mea-
surement error of the chin or length of the nose.
Also, using a participant-held ruler as a measure-
ment scale introduces some error if the ruler tilts
between sets of photographs. Another limitation
is this study’s use of only one smartphone, con-
sidering the continuously updating smartphone
market. The FACE-Q and NOSE-Q inventories
were administered only for the 12-inch selfies and
clinical photographs. This was done to limit the
time requirement from participants, but it does
not allow this study to compare the perception
of 18-inch selfies to clinical photographs. Finally,
although there was a decreasing trend in average
FACE-Q face scores from 12-inch selfies to clinical
photographs (5.7 percent, p = 0.06), this did not
achieve statistical significance. A larger sample
size could potentially solidify this difference.
Selfies are taken at a variety of angles and
in different lighting to find the most flattering
pose.34 In addition, there are a multitude of filters
that also flatter.35,36 Future studies could utilize lat-
eral and oblique photographs to further describe
the distortion a selfie brings to the face and to
the body. In addition, selfies could be captured
before and after facial plastic surgery, such as a
face lift or rhinoplasty, to study the effect of surgi-
cal interventions through the lens patients utilize
the most. Comparing selfies and clinical photo-
graphs to three-dimensional photography will also
be pursued in future studies. Understanding the
changes in facial features from a selfie is impor-
tant not only in rhinoplasty but also in other facial
procedures. The surgeon can have informed dis-
cussions with the patient based on selfies during
preoperative and postoperative consultation if
they understand the inherent distortions with self-
ies. In addition, variability of photographs from
patients can be reduced by having standardized
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Copyright © 2022 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • April 2022
instructions for patients to send in photographs
before and after surgery to minimize the distor-
tions. The effect of selfies is unavoidable in other
circumstances, such as patients sharing their own
preoperative and postoperative pictures on social
media. Social media can drive online traffic toward
or away from a surgeon’s practice. Therefore, an
understanding of these distortions is necessary
to have these unavoidably public pictures judged
without bias.
CONCLUSIONS
This is the first study to use a smartphone cam-
era to investigate camera-to-subject distance and
the distortion selfies create.6,10,12 It begins to quan-
tify the distortion seen with selfies at two different
distances as compared to standard clinical pho-
tography. As the popularity of selfies increases, it
is crucial to understand how they distort facial fea-
tures and how patients use them to communicate.
Further study will elucidate how changes between
different photography settings further contribute
to distortions and perceptions in plastic surgery.
Bardia Amirlak, M.D.
Department of Plastic Surgery
University of Texas Southwestern
1801 Inwood Road
Dallas, Texas 75390
bardia.amirlak@utsouthwestern.edu
Instagram: dramirlak
PATIENT CONSENT
Patients provided written informed consent for the
use of their images.
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G. Photographic standards in plastic surgery. Plast Reconstr
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