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 cranAdditional picture sets and avoiding comm

ni

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; 3

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catcedaciaussorserop

cial; surgery; medical errors; information storage and

Bengel, 1985; Galdino et al., 2001, 2002; Sandler and

and must be carefully designed in view of the highly

Consequently as extra views for relatively common

for example in skeletal and associated Angle dentalclasses II or III can misguide the photographer to

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444head to the Frankfurt horizontal line, regardless ofj.jcms.2006.08.001sensitive issues of data protection and security ofdisplay the head in an inaccurate upright positionwith the risk of exaggerating or masking the truedeformity. Care must therefore be taken to adjust theDOI of orginial articles 10.1016/j.jcms.2006.04.006, 10.1016/Murray, 2002a; Sullivan, 2002; Ikeda et al., 2003),little information is available concerning erroravoidance. Therefore the authors highlight sometechnical and human pitfalls in medical digitalphotography. As most of them can be avoided byobserving simple rules, some of the more commonmistakes in clinical digital photography are describedin detail and suggestions for prevention are given.Moreover data storage can lead to signicant traps

conditions would overstrain the basic set, additionalpicture sets for these groups of diagnoses arepresented under the following headings.

Dysgnathia and other related skull base and jawdeformities

Patients with grossly abnormal positions of the jawtation in relation to some special topics. The aim ofthis second publication in the series is to introducepicture sets for dysgnathia, cleft lip, alveolus andpalate and aesthetic surgery.Clinical photographs of poor quality make it

impossible to compare pre- and post-operativesituations. Although clinical photography is widelydiscussed in the literature and different viewpointsand picture sets for a range of plastic surgicalprocedures, rhinoplasty, dermatology, dentistry andorthodontics have been introduced (Zarem, 1984;

(Nayler, 1998; Nayler et al., 2001; Niamtu, 2004).

ADDITIONAL PICTURE SETS FOR SPECIALTOPICS

Cranio-maxillo-facial surgery covers a wide eld ofpathological conditions involving the various areas ofthe head and neck. The conventional facial picture setspecied in the rst part of these Standards (Ettorreet al., 2006) does not full all the requirements.publication (Ettorre et al., 2006) requires supplemen- and compared with suggestions from other authorsHeidrun SCHAAF1, Philipp STRECKBEIN1, GiovanY. MOMMAERTS3, Hans-Peter HOWALDT1

1Department of Oral and Maxillofacial Plastic Surgery

Liebig University, Giessen, Germany; 2Department of M

FRCS, FDSRCS), Royal Bolton Hospital, Bolton, UK

M.Y. Mommaerts, MD, DMD, PhD, FEBOMFS), BrAvailable online

SUMMARY. As stated in the rst part of this publiplanning, documentation and demonstration of surgical proThis article expands the previously dened standards in ftopics are introduced and some common mistakes are discthe photographic principles are reviewed. Finally the authstorage and protection of medical photographs. The uPortfolios is introduced and recommended. r 2006 Eu

Keywords: digital; photography; standards; maxillofaretrieval; computer security

INTRODUCTION

The standard set of photographs for cranio-maxillo-facial surgery described in the rst part of thispatient condentiality. Although continuous changeand advance in computer software must be expected,the currently available possibilities for the storageand retrieval of patient image data will be describedio-maxillo-facial surgery Part II:on mistakes

ETTORRE1, John C. LOWRY2, Maurice

hairperson: Prof. Dr. Dr. H.-P. Howaldt), Justus

xillofacial Surgery (Consultant: Prof. J.C. Lowry,

Bruges Cleft and Craniofacial Centre (Director: Prof.

ge, BelgiumSeptember 2006

ion standardized clinical photographs are essential forures in craniomaxillofacial surgery (Ettorre et al., 2006).l digital photography. Additional picture sets for specialed. Guidance for the prevention of pitfalls is provided ands give recommendations for dealing with structured dataof asset management systems such as Cumuluss andean Association for Cranio-Maxillofacial Surgery

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view i ll face front view smiling.

Standards for digital photography in cranio-maxillo-facial surgery 445the position of the maxilla or mandible. The samerule holds true for taking standard lateral head lms.In general, a picture set for dysgnathia patientsshould include lateral views in a relaxed restingposition of the mandible and also in maximalintercuspation. There may also be signicantlydifferent proles for example with regard to thesupra- and submental fold in class II patients or chinposition in class III cases (Fig. 1).The set of photographs for patients with skull base,

maxillary or mandibular deformities should includethe following:

Full face front viewProfile view in relaxed and in maximum intercuspationThis comprises four pictures: right and left side, eachin the relaxed rest position of the teeth and inmaximum intercuspation. Figs 1A and B demonstratethe noticeable difference in an enlarged display detail.It is advisable that the patients head is positioned

Fig. 1 (A) Prole view in maximum intercuspation; (B) proleaccording to the lateral head radiograph in the rightlateral view.

Oblique viewIn the oblique view the patients head is rotated 451 toeither side. It gives a useful demonstration to judgefacial changes after dysgnathia operations and it isthe only view showing the effect of malar augmenta-tion techniques. The adjustments for this view aredescribed in part 1 of these Standards.

Front view, full smilingFig. 1C shows the front view with a full smile. Thefull smiling picture is the most sophisticated photo-graph and it should appear as natural as possible.Unfortunately patients with head deformities oftenfeel handicapped and usually hide their smile. A fullsmile is generally accompanied with narrowing of theeyelids. Patients are advised to smile broadly in arelaxed fashion and show the teeth while trying toavoid any tilting of the head.

Front view, lip retractorThis image is taken in the normal frontal headposition while using a lip retractor and holding theteeth in a relaxed position to allow some judgment onthe plane of occlusion in relation to the interpupillaryline as mentioned in the rst part of these Standards.

Front view, spatula in occlusal planeIn this photograph the spatula should be heldbetween the canines to demonstrate the plane ofocclusion. The adjustments are also described in therst part of these Standards.

Submental obliqueAs in the full face front view the interpupillary lineshould be arranged parallel to the horizontal axis andno rotation of the occipito-mental axis should occur.Int

Ge

Tathapogracasarbaknpoton relaxed rest position; and (C) furaoral views

Front viewBuccal right and leftOcclusal upper and lower

neral note for childrens photography

king pictures of children is much more challengingn for adults who generally freeze in a specicsition for the time needed. Here digital photo-phy has its greatest advantage as the photographsn be checked immediately and repeated if neces-y. The correct position for small children andbies should be sitting squarely on the parentsees in front of the sky blue background, so that ifssible no other person is visible. A helping handhold the attention of the child with noise or

movements to keep the head in the designatedposition is often indispensable. Sometimes the onlypossibility for taking good pictures is at the beginningof a surgical procedure when the child is alreadyanaesthetized.

Cleft lip, alveolus and palate

In this section a complete standard set with specialviews for cleft patients is shown.

Full face front viewFig. 2A shows a full face front view which should betaken with the same requirements as described in thedetailed protocol for the full face front view in therst part of the Standards.

Profile viewFig. 2B demonstrates the prole view, which under-lies the same rules as for adults.

Submental oblique viewFig. 2C shows the submental oblique view of a cleftlip patient pre-operatively. This view allows a closerview of the nasal deformity in cleft patients. This canonly be performed if the rules for the submentaloblique view are fullled (interpupillary-line parallel

Intraoral upper occlusal viewFor the intraoral view of the palate shown in Fig. 3 itis necessary to use a small childrens mirrorintraoperatively. The lip should be retracted with anon-reecting instrument. In babies and smallchildren it is often not possible to apply lip retractorsbecause of their size. Surgical hooks, wire retractorsor wooden spatulas may be used as alternatives.

Skull deformities

Full face front viewFig. 4A shows a full face front view which should betaken according to the same rules as mentioned in thedescription for this in part 1 of these Standards.

Profile viewFig. 4B demonstrates the prole view.

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ique

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

446 Journal of Cranio-Maxillofacial Surgeryto horizontal axis; extension of the head to align thelip-line with the upper aspect of the ears). In verysmall children it can sometimes only be obtainedunder general anaesthesia immediately before sur-gery.Additional views, for example a front view close-up

(Fig. 2D) or intraoperative submental oblique close-up (Fig. 2E) are also recommended.

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

wrinkling forehead or frowning glabella as described

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ll su

Standards for digital photography in cranio-maxillo-facial surgery 447Full supracranial viewFig. 4C depicts an additional useful picture forpatients with cranial deformities. Both ears and thetip of the nose should be seen and can serve asanatomical landmarks. When feasible children can behold by their parents in front of the blue background.

Full supracranial oblique viewFig. 4D shows an additional view in supracranialoblique position where with slight extension of thehead the nose and zygoma are more clearly demon-strated. This view can be useful in skull deformitieswith midfacial involvement.

Facial palsy

For views to assess and record the grade of facialpalsy the patient should be encouraged to grimace asmuch as possible in specic reproducible movementsas follows:

Full face front viewFig. 5A shows a full face front view which should betaken with the same adjustments as mentioned in therst part of the Standards.

Full face front view, closed eyesFig. 5B shows a full face front view with the eyesclosed and relaxed to estimate the function of just theperiorbital musculature. Tight closure of the eyelids

Fig. 4 (A) Full face front view; (B) prole view; (C) funeed not be enforced.

Front view with wrinkling of the forehead (frown)In the same position as for the front view, the patientshould frown the forehead and raise the eyebrows(Fig. 5C). This view may also be valuable for theaesthetic surgery set.

Front view smiling and front view with lips in whistlingpositionIn order to document function of the facial nerve thepatient should smile broadly (Fig. 5D) and purse thelips (Fig. 5E).in the facial palsy picture set can also be a usefuladdition to demonstrate skin texture and documentthe forehead ageing. The oblique view allows evalua-tion of the shape of the zygoma and the nose. One ofFront view with cheeks blown outThe front view with the cheeks blown out is seen inFig. 5F.

Aesthetic surgery picture set

Before aesthetic surgery such as face lifting (rhytid-ectomy), blepharoplasty, scar revision or rhinoplasty,pictures are essential for documentation. The lightexposure for aesthetic interests of the face can affectthe surgeons view point and can point out or hidedetails. For example facial wrinkles can be under-estimated by using soft boxes for illumination. Inthese cases it is preferable to use a ood light fromabove that will highlight skin lesions by producingharder shadows on the face. Moreover clear shadowsshown by oodlight on the face give better demarca-tion than that from soft light boxes of the character-istics of the nose before rhinoplasty.In addition to the full face front view a number of

close-up views from showing the forehead, eye regionand nose together with a full face plus neck front viewwill be a useful complement for the aesthetic pictureset. The close-up views can be obtained by enlarge-ment from the full face front view. The front view

pracranial view; and (D) full supracranial oblique view.the regions of interest especially before performing aface lift is the neck as it extends from the lowerborder of the mandible to the sterno-clavicular joints.The neck should be uncovered, jewellery removed,and women should remove make-up if possible.

In addition the recommended set includes:

Full face front view plus neckFig. 6A shows the front view including the neckregion. The picture should be taken with the samerequirements as the full face front view described inpart 1 of these Standards.

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448 Journal of Cranio-Maxillofacial SurgeryProfile view plus neckFig. 6B depicts the prole view including the neckregion. The patients head is positioned in a similarway as for the standard prole view.

Eyelids closed but relaxedFig. 6C demonstrates the close-up view of the eyeregion with eyelids closed and relaxed. The patientshead position is similar to the full face front view.

Eyelids squintedFig. 6D demonstrates the close-up view with eyelidssquinted. The patients head is positioned in the sameway as for the full face front view and the patient isinstructed to slightly narrow the eyelids as if dazzledby light.

Front view neck tilted forwardFig. 6E shows the head and neck tilted forward in afull face front view position. The patient shouldincline the head slightly forward while the eyes stilllook straight into the camera lens. This picture isuseful for documentation of cervical wrinkles ordouble chin.

Fig. 5 Facial palsy picture set. (A) Full face front view; (B) full face(D) front view smiling; (E) front view whistling; and (F) front view bloProfile view neck tilted forwardFig. 6F illustrates the prole view with neck tiltedforward. The reference position for the patients headis that for the front view with neck tilted forward theimage being taken at 901.

Eyelids in upward gazeFig. 6G shows the close-up view of the eye regionwith eyes gazing upward. The patients eyes x apoint in the ceiling while the head is positionednaturally as for the full face front view. This also canbe an interesting view in patients with orbitalfractures.

Neck frontalFig. 6H constitutes the neck in frontal position. Thepatients head is tilted backwards until the linejoining both angles of the mouth (oral commissures)is aligned with the level of the upper aspects of theears in a similar way to the description for thesubmental oblique view in part 1 of these Standards.

Submental oblique, submental vertical, supracra-nial oblique and oblique view are optional and can be

front view, closed eyes; (C) front view wrinkling forehead (frown);wing-out cheeks.

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Standards for digital photography in cranio-maxillo-facial surgery 449helpful additions to the series in preparation for andreview of patients undergoing rhinoplasty.

MOST COMMON MISTAKES

Technical errors

Although most surgeons are not professional photo-graphers it should be possible to obtain technically

Fig. 6 Aesthetic surgery picture set. (A) Full face front view plus necsquinted; (E) front view neck tilted forwards; (F) prole neck tilted forcorrect pictures by following some simple rules.While it is impossible to replace vocational trainingin medical photography by a medical publication, theauthors aim in the following section to provide someguidance on the technical aspects of digital photo-graphy.

BrightnessImmediately after taking a digital picture the photo-grapher should check the overall brightness of the

k; (B) prole view plus neck; (C) eyelids closed relaxed; (D) eyelidsward; (G) eyelids in upward gaze; and (H) front view of neck.

image with the histogram function of the digitalcamera. This could provide a guide to a possiblechange of the lens aperture. For extraoral views thepeak should be in the middle of the histogram whilefor intraoral pictures it should be slightly to the rightside, consistent with a somewhat brighter image(Fig. 7). When the immediate check of a photographon the viewing screen of the camera shows surfacereections on the teeth it is a favourable sign ofadequate illumination for an intraoral view. In viewof absorption of light by the mirror used for intraoralviews, the aperture should generally be at a widersetting. The photographer should also be aware thatthere is a variation in the light absorption character-istics of different mirrors.

Colour and contrastIf the control screen on the camera shows inaccuratecolour shades a recalibration of the white balance ofthe camera might be needed.

Focus point and sharpnessSharpness and focus of a digital picture can easily bechecked immediately after taking the picture bychecking the control display. Fuzziness is an irrepar-able error and can be prevented by using manualfocus. For intraoral views the autofocus option ofmodern SLR cameras may not always be very useful.The aim should always be to obtain pictures that areas sharp as possible and in some cameras there is a

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t; (

450 Journal of Cranio-Maxillofacial SurgeryFig. 7 Intraoral pictures: (A) too ligh B) too dark; and (C) ideal histogram.

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g co

ulti

Standards for digital photography in cranio-maxillo-facial surgery 451Fig. 8 Manual sharpening of image usin

Fig. 9 Incorrect position of the photographer resdirect sharpening function which can be used as anoption. For processing of images following theirtransfer to a personal computer there are a number ofdifferent software programs available includingAdobe Photoshops, Corel Photopaints, PaintshopPros, Irfanviews and ACDSees. For scienticintegrity and professional ethical behaviour as wellas for security, all pictures should be stored in theoriginal unsharpened version. Mild sharpening canbe helpful and may not be considered as unreason-able cheating when used for scientic presentations.The digital sharpening process can enormouslychange the original photo and should be done equallyto every single picture in a series.Excessive automatic sharpening by the camera is

not recommended although manual sharpeningwhich 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 thepatients head. These include: failure to place thepatients head in a straight position, the eyes lookinginto the wrong direction or the back is not straight.All these mistakes lead to an incorrect position of thehead. The position of the camera and of the head ofthe photographic subject should be at the same heightmmercially available computer software.

ng in an unfavourable frontal view of the patient.otherwise unnatural and unfavourable pictures arecreated especially in the lateral view. In the frontalview the malar prominences may be diminished andthe chin prominence enhanced (Fig. 9). On occasionsit may even looks like a mismatched submentaloblique view directly into the nostrils.This emphasises the need for adjustable chairs for

both patient and photographer. The patients chairshould also have a backrest to minimize distortion ofthe spine and any malposition of the head resultingfrom this as explained in part 1 of these Standards.Adjustment of the patients head according to

Frankfurt horizontal plane for the lateral view orthe interpupillary plane and vertical midline for thefrontal view can be facilitated by using a grid in thecameras viewer. It also can be helpful to adjustthe space to the outer frame of the picture which mustnot be too small especially in the lateral view.Markings on the oor can help to keep the patientin the same distance between the soft boxes andcamera in order to achieve reproducible views.Although some positioning errors (e.g. rotation

around a sagittal axis) can be partially corrected withimage-editing programs this option should onlyexceptionally be used for example if the patient isno longer available for retaking the pictures.Basically, pictures should be checked for errorsimmediately and repeated if determined to beunsuitable.

protection, data security and patient condentiality

be stored in an encrypted and password-protected

period of time. After taking a satisfactory picture,

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452 Journal of Cranio-Maxillofacial SurgeryIrreparable mistakes are unsharpness and patientswearing glasses, jewellery or long hair that covers theears and parts of face. The same is true for headrotation around a transverse axis.

Accumulation of saliva and blood

Accumulation of saliva (Fig. 10) or blood whilsttaking pictures should be avoided by careful intraoralsuction or cleaning of the skin. For intraoperativeviews care must be taken that all visible surgicaldrapes are renewed where necessary to avoid blood-stained appearances. When using a mirror forintraoral views this should not have condensationor mist on its surface. The mirror should either beslightly warmed or suction applied close to itssurface. Alternatively an anti-condensation solution(e.g. Neo-Sabenyl) may be administered beforepositioning the mirror.

Consistent factors

Consistent factors are adjustment of lighting, ex-posure, patient positioning, the lenses used, linearscales, prospective depths of the eld, backgroundand post processing. The camera set up featuresconcerning post-processing should not be changed.Also in order to compare pre- and post-operativepictures it is important to keep these adjustments

Fig. 10 Accumulation of saliva.exactly the same on the camera both pre- and post-operatively; for example the exposure setting for thespecic position of the patient. It is advisable to storepictures with data from the camera (EXIF, IPTC andXMP) including aperture, lm sensitivity and shuttertime in order to facilitate use of the same camerasettings for a follow-up picture set. Special careshould be taken to ensure the same illumination forpre- and post-operative images.

STRUCTURED DATA STORAGE

Storage and archiving of digital images especially ofphotographs is a sensitive issue in relation to dataimmediate transfer to the PC work station and savingto the patients le is recommended. It is essential toadjust the pictures into the right position or to ipthem if a mirror was used as otherwise the right andleft 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), theIrfanviews (www.irfanview.com, Austria) free-ware graphic viewer and ACDSees (www.acdsee.com, USA) are examples of more reliable graphicadjusters.

RECOMMENDATIONS FOR DATA STORAGE

Accessibility of digital information depends on itsdatabase structure, archival storage and key-wording.Mistakes could end in violating the patients personalrights, chaos of clinical photographs or even dataloss. There are two options for the organization ofimage data bases: patient based or diagnosis/keywordbased. It is reasonable to attach the photographs toarea of a mass data storage device with an automaticdaily backup. Although such a professional environ-ment of IT support is most common in largehospitals, some doctors may unfortunately betempted to use their own laptop computer for storingtheir patients picture data sets. This is most unwiseand contravenes professional ethics and responsibil-ities as data protection and security cannot beensured at all times and in particular theft of thelaptop or system crash can result in partial or totaldata loss. Even if data is subsequently retrieved thismay be incomplete with consequent confusion oflabelling.

SELECTING AND ADJUSTING PICTURES

It is advantageous to select the best photographs of asession immediately before saving the les in the database in order to avoid an unnecessarily large volumeof data. In general the capacity and system stabilityof soft- and hardware solutions decrease with theamount of data. An active surgeon may need to takemore than 5000 pictures per year which leads to aneed for approximately 5GB of storage over a shortbecause uncovered faces are often mapped. Patientconsent concerning storage and use of personal datais essential. This should follow the European guide-lines for data protection as well as local requirementsin this respect. Any data base storing personal data inparticular photographs of patients faces must beprotected from unauthorized access. (It goes withoutsaying that there is permission to use the pictures ofthis paper by the persons shown).Personal non-anonymized data and pictures should

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

proposal for a keyword tree for cranio-maxillo-facialsurgery can be downloaded on the Members section

m, UK) portfolio issolution to organizey without compromis-.

19 facial and ve intraoral views in ve categories are

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Standards for digital photography in cranio-maxillo-facial surgery 453If a colleague seeks professional advice about apatient the sending of pictures by e-mail overunsecured data-lines must be avoided according tothe data protection guidelines of the EuropeanUnion. The European Association for Cranio-Max-illo-Facial Surgery developed a tool for scienticcommunication and education which includes clinicalphotographs and radiographs. This electronic con-sultation software is implemented in the protectedmember section of the website www.eurofaces.com.

DISCUSSION

Additional picture sets for special topics in cranio-maxillo-facial surgery expand the basic set. Althoughthere is a variety of recommendations for picture setsin the literature for different medical elds (Sandlerand Murray, 2001; Galdino et al., 2002; Jones andCadier, 2004) the authors have endeavoured tominimize the picture set as far as possible. Overalling security or brand quality

and access digital les quickl

a digital asset management Portfolios (www.extensis.co

PhotoStation software can organize les forprofessional photograph archiving.Cumuluss (www.canto.de, Germany) the cumu-lus software is optimized for management inmedical use and has an advanced search function.PhotoStations (www.fotoware.de, Germany)

Multi-user software (network)of the Eurofaces website at www.eurofaces.org.It should be possible to transfer the images and

their keyword information to other programs withoutlosing information in the event of changing the hardor software systems. Software solutions are availableon the market from many companies. Examples forsingle user (stand alone) and multi-user (networkbased) programmes include:

Single user software (stand alone)

ACDSees (PC/Macintosh) iViews (PC/Macintosh) iPhotos (Macintosh)Cumuluss (PC/Macintosh)digital asset management system.Whilst it is necessary to document clinical ndings

as a follow-up with the patients name it is alsoindispensable 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 includingclinical trials. This tree can grow or change with thestructure of the department and could have about 100different categories in a maximum of three levels. Aincorporated within the sets.In the literature, guidelines for various special

topics can be found. For example the Institute ofMedical Illustrators in the UK presents some baselineguides related to the treatment and surgical outcomeof cleft lip, alveolus and palate disorders (Jones andCadier, 2004). For documentation of facial nerveweakness, still and moving digital imaging is de-scribed in patients undergoing skull base surgery atan otological and neurological clinic (Barrs et al.,2001). With this current article, the authors wouldlike to create a Europe-wide standard for the mostimportant photographic views for the more commondisease patterns presenting in cranio-maxillo-facialsurgery.In order to avoid mistakes in clinical photography

the authors agree with other publications whichregard a reproducible position of the patient as beingessential (Nayler, 2003; Niamtu, 2004). For rela-tively or less rigidly standardized images for theaverage cosmetic surgeon in private practice, con-sistency in distance, white balance, background andlightning is recommended (Niamtu, 2004). To guar-antee consistency in pre- and post-operative photo-graphs the illumination must be the same, althoughsome surgeons try to improve post-operative resultsby generating brighter pictures.Digital photography enables clinicians to take a

large number of pictures in a short time. Nonethelessappropriate care should be taken to ensure aconsistently high quality. The great advantage ofdigital photography is obviously the facility to checkthe images immediately after they have been taken.Poor quality outcomes should be detected and thepicture repeated after they have been checked by amedical professional. Poor quality pictures some-times shown in medical journals or academicpresentations should nowadays be an exception. Inspite of the additional advantages of digital photo-graphy such as timesaving, lower costs, quick andspace saving storage with easier access to thephotographs (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 chin-up or chin-down has been described (Niamtu, 2004).Other authors have described specic problems, forexample the appearance of skin lesions beingdependent on illumination (Ikeda et al., 2003) ordramatic changes of appearance of the face and jawline with extension of the neck, and protrusion of thehead which can misrepresent surgical outcome (Jonesand Cadier, 2004; Sommer andMendelsohn, 2004). Inaddition, the possibility of altering brightness, focallength, patients position and selective softening orsharpening with computer programs can be used tochange the authentic appearance of the surgicaloutcome. Unfortunately this has become much easierand less controllable in our digitized world and in theend all we can do now is to rely on each othershonesty.

The question of who should take the pictures in

photographs themselves, in 35% a clinical assistant

feasible and limited picture sets and also to point outsome pitfalls and drawbacks in digital photography.

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454 Journal of Cranio-Maxillofacial Surgeryand in 5% a professional photographer was assignedto obtain the pictures (Sandler and Murray, 2002a).The authors agree with previously published manu-scripts that correct equipment and appropriatelytrained staff are the key to good-quality accurateclinical photographs (McKeown et al., 2005).For storage and archiving of digital patient images,

authors have suggested different systems for catalo-guing the photographs by diagnosis, date, patientregistration number and type of photographic viewusing photo CDs (Nayler, 1998) or describe pro-grams such as exif viewers, dentofacial showcases

and PowerPoints as alternative methods (SandlerandMurray, 2002b). Creating a directory tree knownfrom windows explorers leading to the nal sub-folder for patients name is also described (Niamtu,2004).Better search functionality, handling and a useful

diagnosis- or treatment-tree storage of data isprovided by asset management systems such asCumuluss or Portfolios. Using these managementsystems and labelling digital images with multipleindices gains greater importance as the number ofstored photographs increases. Additionally, appro-priate storage for patients data security and protec-tion against unauthorized access is provided by theprograms as they are equipped with multi-user log-infacilities. Moreover, these programs facilitate thepossibilities for creating academic presentations orlectures to students by using the structured informa-tion attached to each picture. It should be noted thata digital picture is denitely lost if not categorizedand le saved adequately. We cannot rely anymoreon a well-trained long-term secretary who knows byheart the slides stored on large ofce shelves and incabinets if there has been a switch from analogue todigital photography.

CONCLUSION

As a supplement to the rst part of Standards fordigital photography in cranio-maxillo-facial surgery(Ettorre et al., 2006) ve additional picture sets areintroduced. These special picture sets can be adaptedto complement the spectrum of clinical activity andstructure of a particular department. A task force ofthe European Association for Cranio-Maxillo-FacialSurgery (EACMFS) has endeavoured to establishdaily clinical work is controversial. Some authorssuggest delegating the supervision and picture takingto staff members (Christensen, 2005) but the purposeand viewpoint of the image is not the same for everyphotographer. It is therefore recommended that theresponsible surgeon should personally take thepictures directed towards the main points of interestof a patients medical problem and the aim oftreatment. If a professional photographer is em-ployed medical knowledge is required. In a surveywhich included 68 orthodontists, 60% took theBy knowing cause and effect of such mistakes,challenges can be handled much more professionally.Technical errors, mistakes in positioning the patientand difculties in intraoral and childrens photo-graphy are presented.Medical progress has always been dependent on an

exchange of experiences. Modern communicationfacilitates interdisciplinary discussion if used appro-priately. The authors therefore encourage all collea-gues to consider investing appropriate time and effortin accurate photo-documentation. This together withhonesty, adequate data protection and platformssuch as www.eurofaces.com it is hoped that progressin our profession might be accelerated for the benetof both patients and surgeons.

Addresses of companies mentioned:

ACDSees (www.acdsee.com) ACD Systems Inter-national Inc., Saanichton, British Columbia, CanadaAdobe Photoshops (www.adobe.com) San Jose,

California, USACumuluss (www.canto.de) Canto GmbH, Berlin,

GermanyCorel Photopaints, Paintshop Pros (www.corel.

com) Corel Corporation, Ottawa, CanadaDentofacial showcases (www.dentofacial.com)exif viewers, Ludwigshafen, GermanyFiregraphics (www.regraphic.com)IMI, The institute of medical illustrators (www.

imi.org.uk) London, UKIrfanviews (www.irfanview.com), Irfan Skiljan,

Wiener Neustadt, AustriaiPhotos, Apple, Cupertino, CA, USAiViews, (www.application-systems.de) Application

Systems Heidelberg Software GmbH, GermanyNeo-Sabenyls, Qualiphar (www.qualiphar.com),

Antwerp, BelgiumPhotoStations (www.fotoware.de), FotoWare

GmbH, Geesthacht, GermanyPortfolios (www.extensis.com), Extensis UK, The

Lakes, Northampton, UKPhoto CDs Kodak, Stuttgart, GermanyPowerPoints, Microsoft, Redmond, USAWindows explorers, Microsoft, Redmond, USA

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Prof. H.-P. HOWALDTKlinik und Poliklinik fur Mund-, Kiefer und GesichtschirurgiePlastische Operationen Klinikstrasse 2935385 GiessenGermany

E-mail: HP.Howaldt@uniklinikum-giessen.de

Paper received 16 February 2005Accepted 11 April 2006

ARTICLE IN PRESS

Standards for digital photography in cranio-maxillo-facial surgery 455

Standards for digital photography in cranio-maxillo-facial surgery - Part II: Additional picture sets and avoiding common mistakesIntroductionAdditional picture sets for special topicsDysgnathia and other related skull base and jaw deformitiesFull face front viewOblique viewFront view, full smilingFront view, lip retractorFront view, spatula in occlusal planeSubmental obliqueIntraoral views

General note for childrenaposs photographyCleft lip, alveolus and palateFull face front viewProfile viewSubmental oblique viewIntraoral upper occlusal view

Skull deformitiesFull face front viewProfile viewFull supracranial viewFull supracranial oblique view

Facial palsyFull face front viewFull face front view, closed eyesFront view with wrinkling of the forehead (frown)Front view smiling and front view with lips in whistling positionFront view with cheeks blown out

Aesthetic surgery picture setFull face front view plus neckProfile view plus neckEyelids closed but relaxedEyelids squintedFront view neck tilted forwardProfile view neck tilted forwardEyelids in upward gazeNeck frontal

Most common mistakesTechnical errorsBrightnessColour and contrastFocus point and sharpness

Wrong position of patient or cameraAccumulation of saliva and bloodConsistent factors

Structured data storageSelecting and adjusting picturesRecommendations for data storageDiscussionConclusionReferences