In 2010, the Australian Health Practitioner Regulation Agency released Guidelines on Advertising, which have been relatively unchanged since. Section 6 .1 deals with ‘Use of graphic or visual representations’ which provides guidelines for before and after photography. Key components of the recommendations were:-

• photographs must only use patients that have undergone the treatment advertised or discussed and whom have provided consent for the publication of the photos
• photographs should be consistent in content, camera angle, background, framing and exposure
• ensuring consistency in posture, clothing and makeup
• ensuring consistency in lighting & contrast
• stating if photographs have been altered in any way
• confirming that the referenced procedure is the only change that has occurred for the person being photographed

I was starting my own practice in January 2010, and used these guidelines to help formulate my photographic processes and protocols.

As a junior surgeon, I had a few experiences that encouraged my passion about clinical photography and consistency.

1. Attending conferences and seeing experienced surgeons presenting with clinical photographs that vary in lighting, background and posture. Judging nuances in results is extremely difficult if the photography has not been standardised
2. Researching set up of procedure galleries and social media feeds highlighted how some well-known surgeons use inconsistency in photography to their advantage when showing before and after photographs, on a regular basis. Examples include the lack of make up on face photos before and a well made up face in the after photos, cotton undies in before photos vs. lacy ensembles in an ‘after’ image.
3. I attended a breast surgery conference in my first year of my practice and discussed a difficult case with a few colleagues and a presenter. The presenter quietly took me aside and tore my photography to shreds – terrible background, poor framing, different lighting even between photographs taken in the one session.
4. I attended a lecture by Dr Bryant Toth at the Cutting Edge Symposium in 2013 titled “Picture Perfect: The nuances of pre and post operative photographs in journals, presentations, websites and industry sponsored studies: how photographs deceive us”. Early in his lecture he showed a ‘before and after’ facelift photograph pair that had been taken seconds apart with only the lighting changed.

The combination of these experiences has encouraged me to be methodical about my clinical photography, for my patient’s education and expectations. I bought and read a few books on clinical photography and used them to help set up my clinical photography arrangements.

Within a year of starting practice, I engaged a professional photographer to assist me to set up my consulting room to standardise the photographs that I was taking. Setting up standard backgrounds and printing a mat with standard patient foot positions were both fairly easy.

Professional flashes were set up with soft boxes (to even out the lighting) at 45 degrees offset and 45 degrees above the patient. This is sometimes referred to as Rembrandt lighting. Despite those flashes, I was still struggling with some shadowing. I brought the patient position forwards from the background, and employed a third flash to stream down behind the patient and drown out the shadows. I did trial a black background, but it looked like patients were Photoshopped into the images especially if they were wearing black clothing.

In early 2017, we again adjusted photography lighting in an attempt to get similar images from all three consult rooms within the practice. It has not worked as well as hoped. Photos taken in different rooms are standardised for that room, but photographs are not directly comparable between rooms. I also had to replace my camera as cable ports had stopped working, and repairs were going to take a few weeks.

As this is written (November 2017) my surgical photography set up in my consulting room is as follows:-

Background: 50% grey (black sometimes used for consistency with old photographs)

Patient distance (centred) from background: 400mm

Photographer distance from patient (body photos): 2700mm

Body photos taken sitting on a saddle seat, routine camera lens height: 1300mm

Photographer distance from patient (face photos): 1100mm

Face photos taken with Dr Sandercoe standing, routine camera lens height: 1600mm

Short patients have their photos take with the lens approximately horizontal to their face.

Camera: Canon EOS 5D Mark 3

Lens: Canon Macro 100mm L

Aperture: 14

Shutter speed: 160

ISO: 400

Flashes: 2 x Elinchrom D-Lite. Rear facing to even out the lighting. Left side set at 4.9, right side set at 5.5. The slight difference between setting was needed to even out the lighting on subjects. This is probably due to the slightly different shelving and reflectivity on different sides of the room.

Photographs are taken at a minimum of the following positions for most procedures

1. Straight ahead
2. Left lateral
3. Left quarter view
4. Right lateral
5. Right oblique

Some procedures require additional photographs, such as a 360 panel for body lifts or CoolSculpting, or open and closed eyes for facelifts and blepharoplasty.

Photographs are taken of patients pre-operatively, at marking, and at 3 months post operatively. Sometimes earlier photos are taken, but experience in my earlier years (when I would routinely take photos at 1 week and 1 month post operatively) showed that early post operative photos were not very predictive of the final results. With further experience, I have learnt that there is minimal change between 3 and 6 month follow up photos if everything is proceeding normally.

I ask patients to have a final 1 year review to allow me to get a feel for their final result. Most scars have burnt out by 12 months post operatively. Clinical photos at this time often show a better scar than at 3 months, but are more subject to patient weight changes etc than 3 month photos. Some scars such as brachioplasty scars take more like 2-3 years to completely fade. It s uncommon for patients to continue seeing me past one year unless we are working on multiple procedures over time, but those that do will often have their photos updated to reflect the increased scar maturity.

At the three month follow up, we ask patients to sign a photo release form. This form allows us to send the patient their before and after photos, as well as any intra-operative photos that are taken. We also request that they allow us to use their de-identified photos to show other patients and in our website gallery. The photos are first sent to the patient to ensure that the images are de-identified as much as possible for the patient. Some patients request watches, necklaces or tattoos are blurred out. If we choose to use those photos in the rooms or on the website, we state on their photos what adjustments have been made to the photo.

Photos are clipped to standard frames (for instance breast surgery photos should encompass from the neck down to the hips). The photo pairs are usually arranged in a minimum panel of 3 photos – one front on, one lateral and one quarter view. The choice of left or right views is usually determined by photography consistency. The left views are slightly more subject to lighting changes due to the windows on that side.

Once photos have been approved by the patient, the photos are then passed via my quality control. Reasons that photos do not make if from the rooms to the website include:-

1. Lighting changes, such as experienced before and after January 2017 photography adjustments
2. Inconsistent body position – although the feet are always standard, postural changes can adjust body, breast and neck shapes. Brachioplasty is a procedure that has recently shown me that I need to be more militant about positioning, and I have culled about half of my brachioplasty photos due to differences in arm position, especially in the Victory or 90/90 position – the single photo that demonstrates a result the best.
3. Weight fluctuation. A 10kg weight gain after an abdominoplasty shows a different long term result than someone whom has remained weight stable, or dropped weight to reflect the amount that was removed during the procedure
4. Changed positioning standards. It took me a while to realise that most of my colleagues were posting their body contouring before and afters with the scars covered
5. Inadequate numbers to open a gallery on that procedure. In my mind, a gallery that has only a few images is open to criticism. I do have a few galleries like this that I have decided to open despite my misgivings. A good example is my liposuction gallery. Although I do a lot of liposuction as part of abdominoplasties and fat transfer, I do not do much liposuction as a stand alone procedure. Facelifts are another procedure that is difficult for us to get consent to publish photos, as patients that see me are usually seeing me with discretion being a common request. I also perform many more revision facelifts than primary facelifts, so those photos are not suitable for a facelift gallery.
6. Procedures that I do not wish to encourage. There are some procedures that I do perform, but do not enjoy much. Those patients and procedures need to see my results during a consultation.
7. Procedures that I think are best kept within the server, such as labioplasty.
8. Poor result. These photos remain on the server in a folder that I use to educate patients about surgical complications such as poor scars, infections and haematoma/seromas. Procedures with inconsistent results also have a folder of multiple patients that show varying results.
9. Sometimes results are poorly shown on photography, such as improvements in skin quality after chemical peels. These procedures are difficult to provide baselines of patient expectation for results.

After all of that quality control, it is easy to see how only 10-25% of all photos make it into my galleries. If a gallery has 20 patients in it, there are often another 20 patients that have agreed to have their photos shown in the rooms only.

Every few years, I go through my website gallery and remove photos that I believe are not up to scratch with my photography standards. Those photos were necessary in my early years to get a gallery up and going, but now are no longer reflective of my surgery or photography.

Photo guidelines from Facebook and other social media platforms have lead to another variation in photography. The need to cover nipples in breast photographs has lead to further inconsistencies in before and after photographs. Nipple position on a breast is an important part of breast aesthetics, and can’t be shown on these platforms. A great result in a bra is not necessarily a great result nude, and if the patient (posting) is ok with that, then good for them but some patients seeing their photos will be unaware of that issue. The consistency in bra type and good fitting will also have an impact on the visualised result.

Thanks for reading my rant, and I hope that you’ve learnt something about the processes involved in quality clinical photography and have learnt to start looking for signs of photographic deception.