ARTICLE IN PRESS

Journal of Cranio-Maxillofacial Surgery (2006) 34, 444–455

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

SUMMARY. As stated in the first 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 defined 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

Keywords: digital; photography; standards; maxillofacial; surgery; medical errors; information storage and
retrieval; computer security

INTRODUCTION patient confidentiality. Although continuous change

and advance in computer software must be expected,
The standard set of photographs for cranio-maxillo- the currently available possibilities for the storage
facial surgery described in the first part of this and retrieval of patient image data will be described
publication (Ettorre et al., 2006) requires supplemen- and compared with suggestions from other authors
tation in relation to some special topics. The aim of (Nayler, 1998; Nayler et al., 2001; Niamtu, 2004).
this second publication in the series is to introduce
picture sets for dysgnathia, cleft lip, alveolus and
palate and aesthetic surgery. ADDITIONAL PICTURE SETS FOR SPECIAL
Clinical photographs of poor quality make it TOPICS
impossible to compare pre- and post-operative
situations. Although clinical photography is widely Cranio-maxillo-facial surgery covers a wide field of
discussed in the literature and different viewpoints pathological conditions involving the various areas of
and picture sets for a range of plastic surgical the head and neck. The conventional facial picture set
procedures, rhinoplasty, dermatology, dentistry and specified in the first part of these ‘Standards’ (Ettorre
orthodontics have been introduced (Zarem, 1984; et al., 2006) does not fulfil all the requirements.
Bengel, 1985; Galdino et al., 2001, 2002; Sandler and Consequently as extra views for relatively common
Murray, 2002a; Sullivan, 2002; Ikeda et al., 2003), conditions would overstrain the basic set, additional
little information is available concerning error picture sets for these groups of diagnoses are
avoidance. Therefore the authors highlight some presented under the following headings.
technical and human pitfalls in medical digital
photography. As most of them can be avoided by
observing simple rules, some of the more common Dysgnathia and other related skull base and jaw
mistakes in clinical digital photography are described deformities
in detail and suggestions for prevention are given.
Moreover data storage can lead to significant traps Patients with grossly abnormal positions of the jaw
and must be carefully designed in view of the highly for example in skeletal and associated Angle dental
sensitive issues of data protection and security of 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
DOI of orginial articles 10.1016/j.jcms.2006.04.006, 10.1016/ deformity. Care must therefore be taken to adjust the
j.jcms.2006.08.001 head to the Frankfurt horizontal line, regardless of

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

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

the position of the maxilla or mandible. The same relaxed fashion and show the teeth while trying to
rule holds true for taking standard lateral head films. avoid any tilting of the head.
In general, a picture set for dysgnathia patients
should include lateral views in a relaxed resting Front view, lip retractor
position of the mandible and also in maximal This image is taken in the normal frontal head
intercuspation. There may also be significantly position while using a lip retractor and holding the
different profiles for example with regard to the teeth in a relaxed position to allow some judgment on
supra- and submental fold in class II patients or chin the plane of occlusion in relation to the interpupillary
position in class III cases (Fig. 1). line as mentioned in the first part of these ‘Standards’.
The set of photographs for patients with skull base,
maxillary or mandibular deformities should include Front view, spatula in occlusal plane
the following: In this photograph the spatula should be held
between the canines to demonstrate the plane of
Full face front view occlusion. The adjustments are also described in the
Profile view in relaxed and in maximum intercuspation first part of these ‘Standards’.
This comprises four pictures: right and left side, each
in the relaxed rest position of the teeth and in Submental oblique
maximum intercuspation. Figs 1A and B demonstrate As in the full face front view the interpupillary line
the noticeable difference in an enlarged display detail. should be arranged parallel to the horizontal axis and
It is advisable that the patient’s head is positioned no rotation of the occipito-mental axis should occur.
according to the lateral head radiograph in the right
lateral view. Intraoral views
Front view
Oblique view Buccal right and left
In the oblique view the patient’s head is rotated 451 to Occlusal upper and lower
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 augmenta- General note for children’s photography
tion techniques. The adjustments for this view are
described in part 1 of these ‘Standards’. Taking pictures of children is much more challenging
than for adults who generally ‘freeze’ in a specific
Front view, full smiling position for the time needed. Here digital photo-
Fig. 1C shows the front view with a full smile. The graphy has its greatest advantage as the photographs
full smiling picture is the most sophisticated photo- can be checked immediately and repeated if neces-
graph and it should appear as natural as possible. sary. The correct position for small children and
Unfortunately patients with head deformities often babies should be sitting squarely on the parent’s
feel handicapped and usually hide their smile. A full knees in front of the sky blue background, so that if
smile is generally accompanied with narrowing of the possible no other person is visible. A helping hand
eyelids. Patients are advised to smile broadly in a 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 Intraoral upper occlusal view
position is often indispensable. Sometimes the only For the intraoral view of the palate shown in Fig. 3 it
possibility for taking good pictures is at the beginning is necessary to use a small children’s mirror
of a surgical procedure when the child is already intraoperatively. The lip should be retracted with a
anaesthetized. non-reflecting instrument. In babies and small
children it is often not possible to apply lip retractors
Cleft lip, alveolus and palate because of their size. Surgical hooks, wire retractors
or wooden spatulas may be used as alternatives.
In this section a complete standard set with special
views for cleft patients is shown.
Skull deformities
Full face front view Full face front view
Fig. 2A shows a full face front view which should be Fig. 4A shows a full face front view which should be
taken with the same requirements as described in the taken according to the same rules as mentioned in the
detailed protocol for the full face front view in the description for this in part 1 of these ‘Standards’.
first part of the ‘Standards’.

Profile view Profile view

Fig. 2B demonstrates the profile view, which under- Fig. 4B demonstrates the profile view.
lies the same rules as for adults.

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 fulfilled (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 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. 3 – Cleft palate upper occlusal view, pre-operatively.

Fig. 2 – (A) Full face front view; (B) profile view; (C) submental oblique; (D) front view close-up; and (E) intraoperative submental oblique
close-up view.
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Standards for digital photography in cranio-maxillo-facial surgery 447

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

Full supracranial view Front view with cheeks blown out

Fig. 4C depicts an additional useful picture for The front view with the cheeks blown out is seen in
patients with cranial deformities. Both ears and the Fig. 5F.
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. Aesthetic surgery picture set

Full supracranial oblique view Before aesthetic surgery such as face lifting (rhytid-
Fig. 4D shows an additional view in supracranial ectomy), blepharoplasty, scar revision or rhinoplasty,
oblique position where with slight extension of the pictures are essential for documentation. The light
head the nose and zygoma are more clearly demon- exposure for aesthetic interests of the face can affect
strated. This view can be useful in skull deformities the surgeons view point and can point out or hide
with midfacial involvement. details. For example facial wrinkles can be under-
estimated by using soft boxes for illumination. In
these cases it is preferable to use a flood light from
Facial palsy
above that will highlight skin lesions by producing
harder shadows on the face. Moreover clear shadows
For views to assess and record the grade of facial shown by floodlight on the face give better demarca-
palsy the patient should be encouraged to grimace as tion than that from soft light boxes of the character-
much as possible in specific reproducible movements istics of the nose before rhinoplasty.
as follows: In addition to the full face front view a number of
close-up views from showing the forehead, eye region
Full face front view and nose together with a full face plus neck front view
Fig. 5A shows a full face front view which should be will be a useful complement for the aesthetic picture
taken with the same adjustments as mentioned in the set. The close-up views can be obtained by enlarge-
first part of the ‘Standards’. ment from the full face front view. The front view
wrinkling forehead or frowning glabella as described
Full face front view, closed eyes in the facial palsy picture set can also be a useful
Fig. 5B shows a full face front view with the eyes addition to demonstrate skin texture and document
closed and relaxed to estimate the function of just the the forehead ageing. The oblique view allows evalua-
periorbital musculature. Tight closure of the eyelids tion of the shape of the zygoma and the nose. One of
need not be enforced. 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.
Front view with wrinkling of the forehead (frown) The neck should be uncovered, jewellery removed,
In the same position as for the front view, the patient and women should remove make-up if possible.
should frown the forehead and raise the eyebrows
(Fig. 5C). This view may also be valuable for the In addition the recommended set includes:
aesthetic surgery set.

Front view smiling and front view with lips in whistling Full face front view plus neck
position Fig. 6A shows the front view including the neck
In order to document function of the facial nerve the region. The picture should be taken with the same
patient should smile broadly (Fig. 5D) and purse the requirements as the full face front view described in
lips (Fig. 5E). 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 Profile view neck tilted forward

Fig. 6B depicts the profile view including the neck Fig. 6F illustrates the profile view with neck tilted
region. The patient’s head is positioned in a similar forward. The reference position for the patient’s head
way as for the standard profile view. is that for the front view with neck tilted forward the
image being taken at 901.
Eyelids closed but relaxed
Fig. 6C demonstrates the close-up view of the eye Eyelids in upward gaze
region with eyelids closed and relaxed. The patient’s Fig. 6G shows the close-up view of the eye region
head position is similar to the full face front view. with eyes gazing upward. The patient’s eyes fix a
point in the ceiling while the head is positioned
Eyelids squinted naturally as for the full face front view. This also can
Fig. 6D demonstrates the close-up view with eyelids be an interesting view in patients with orbital
squinted. The patient’s head is positioned in the same fractures.
way as for the full face front view and the patient is
instructed to slightly narrow the eyelids as if dazzled
by light. Neck frontal
Fig. 6 H constitutes the neck in frontal position. The
patient’s head is tilted backwards until the line
Front view neck tilted forward joining both angles of the mouth (oral commissures)
Fig. 6E shows the head and neck tilted forward in a is aligned with the level of the upper aspects of the
full face front view position. The patient should ears in a similar way to the description for the
incline the head slightly forward while the eyes still submental oblique view in part 1 of these ‘Standards’.
look straight into the camera lens. This picture is
useful for documentation of cervical wrinkles or Submental oblique, submental vertical, supracra-
double chin. nial 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) profile view plus neck; (C) eyelids closed relaxed; (D) eyelids
squinted; (E) front view neck tilted forwards; (F) profile neck tilted forward; (G) eyelids in upward gaze; and (H) front view of neck.

helpful additions to the series in preparation for and correct pictures by following some simple rules.
review of patients undergoing rhinoplasty. 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 photo-
MOST COMMON MISTAKES graphy.
Technical errors
Brightness
Although most surgeons are not professional photo- Immediately after taking a digital picture the photo-
graphers it should be possible to obtain technically grapher 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 Colour and contrast
camera. This could provide a guide to a possible If the control screen on the camera shows inaccurate
change of the lens aperture. For extraoral views the colour shades a recalibration of the white balance of
peak should be in the middle of the histogram while the camera might be needed.
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 Focus point and sharpness
on the viewing screen of the camera shows surface Sharpness and focus of a digital picture can easily be
reflections on the teeth it is a favourable sign of checked immediately after taking the picture by
adequate illumination for an intraoral view. In view checking the control display. Fuzziness is an irrepar-
of absorption of light by the mirror used for intraoral able error and can be prevented by using manual
views, the aperture should generally be at a wider focus. For intraoral views the autofocus option of
setting. The photographer should also be aware that modern SLR cameras may not always be very useful.
there is a variation in the light absorption character- The aim should always be to obtain pictures that are
istics of different mirrors. 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 otherwise unnatural and unfavourable pictures are
option. For processing of images following their created especially in the lateral view. In the frontal
transfer to a personal computer there are a number of view the malar prominences may be diminished and
different software programs available including the chin prominence enhanced (Fig. 9). On occasions
Adobe Photoshops, Corel Photopaints, Paintshop it may even looks like a mismatched submental
Pros, Irfanviews and ACDSees. For scientific oblique view directly into the nostrils.
integrity and professional ethical behaviour as well This emphasises the need for adjustable chairs for
as for security, all pictures should be stored in the both patient and photographer. The patient’s chair
original unsharpened version. Mild sharpening can should also have a backrest to minimize distortion of
be helpful and may not be considered as unreason- the spine and any malposition of the head resulting
able cheating when used for scientific presentations. from this as explained in part 1 of these ‘Standards’.
The digital sharpening process can enormously Adjustment of the patient’s head according to
change the original photo and should be done equally Frankfurt horizontal plane for the lateral view or
to every single picture in a series. the interpupillary plane and vertical midline for the
Excessive automatic sharpening by the camera is frontal view can be facilitated by using a grid in the
not recommended although manual sharpening camera’s viewer. It also can be helpful to adjust
which allows control of the procedure is preferred. the space to the outer frame of the picture which must
Fig. 8 demonstrates different grades of sharpening not be too small especially in the lateral view.
(Adobe Photoshops unsharp mask). Markings on the floor can help to keep the patient
in the same distance between the soft boxes and
Wrong position of patient or camera camera in order to achieve reproducible views.
Although some positioning errors (e.g. rotation
There are many sources of error in positioning the around a sagittal axis) can be partially corrected with
patient’s head. These include: failure to place the image-editing programs this option should only
patient’s head in a straight position, the eyes looking exceptionally be used for example if the patient is
into the wrong direction or the back is not straight. no longer available for retaking the pictures.
All these mistakes lead to an incorrect position of the Basically, pictures should be checked for errors
head. The position of the camera and of the head of immediately and repeated if determined to be
the photographic subject should be at the same height unsuitable.
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452 Journal of Cranio-Maxillofacial Surgery

protection, data security and patient confidentiality

because uncovered faces are often mapped. Patient
consent concerning storage and use of personal data
is essential. This should follow the European guide-
lines 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 environ-
ment of IT support is most common in large
Fig. 10 – Accumulation of saliva. hospitals, some doctors may unfortunately be
tempted to use their own laptop computer for storing
Irreparable mistakes are unsharpness and patients their patients’ picture data sets. This is most unwise
wearing glasses, jewellery or long hair that covers the and contravenes professional ethics and responsibil-
ears and parts of face. The same is true for head ities as data protection and security cannot be
rotation around a transverse axis. 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
Accumulation of saliva and blood may be incomplete with consequent confusion of
labelling.
Accumulation of saliva (Fig. 10) or blood whilst
taking pictures should be avoided by careful intraoral
suction or cleaning of the skin. For intraoperative SELECTING AND ADJUSTING PICTURES
views care must be taken that all visible surgical
drapes are renewed where necessary to avoid blood- It is advantageous to select the best photographs of a
stained appearances. When using a mirror for session immediately before saving the files in the data
intraoral views this should not have condensation base in order to avoid an unnecessarily large volume
or mist on its surface. The mirror should either be of data. In general the capacity and system stability
slightly warmed or suction applied close to its of soft- and hardware solutions decrease with the
surface. Alternatively an anti-condensation solution amount of data. An active surgeon may need to take
(e.g. Neo-Sabenyl) may be administered before more than 5000 pictures per year which leads to a
positioning the mirror. need for approximately 5 GB of storage over a short
period of time. After taking a satisfactory picture,
Consistent factors immediate transfer to the PC work station and saving
to the patient’s file is recommended. It is essential to
Consistent factors are adjustment of lighting, ex- adjust the pictures into the right position or to flip
posure, patient positioning, the lenses used, linear them if a mirror was used as otherwise the right and
scales, prospective depths of the field, background left sides of a patient can be easily be mixed up.
and post processing. The camera set up features As many image editing programs cause data loss
concerning post-processing should not be changed. when pictures are adjusted (e.g. rotated or flipped)
Also in order to compare pre- and post-operative care must be taken in selecting suitable software.
pictures it is important to keep these adjustments Firegraphics (www.firegraphic.com, USA), the
exactly the same on the camera both pre- and post- Irfanviews (www.irfanview.com, Austria) free-
operatively; for example the exposure setting for the ware graphic viewer and ACDSees (www.acdsee.
specific position of the patient. It is advisable to store com, USA) are examples of more reliable graphic
pictures with data from the camera (EXIF, IPTC and adjusters.
XMP) including aperture, film sensitivity and shutter
time in order to facilitate use of the same camera
settings for a follow-up picture set. Special care RECOMMENDATIONS FOR DATA STORAGE
should be taken to ensure the same illumination for
pre- and post-operative images. Accessibility of digital information depends on its
database structure, archival storage and key-wording.
Mistakes could end in violating the patient’s personal
STRUCTURED DATA STORAGE rights, chaos of clinical photographs or even data
loss. There are two options for the organization of
Storage and archiving of digital images especially of image data bases: patient based or diagnosis/keyword
photographs is a sensitive issue in relation to data 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 file by name as well as saving them in a 19 facial and five intraoral views in five categories are
digital asset management system. incorporated within the sets.
Whilst it is necessary to document clinical findings In the literature, guidelines for various special
as a follow-up with the patient’s name it is also topics can be found. For example the Institute of
indispensable to store them based on keywords. Medical Illustrators in the UK presents some baseline
A reasonable organizing system is a keyword tree guides related to the treatment and surgical outcome
based on main groups such as diagnosis, procedures, of cleft lip, alveolus and palate disorders (Jones and
regions, complications or special interests including Cadier, 2004). For documentation of facial nerve
clinical trials. This tree can grow or change with the weakness, still and moving digital imaging is de-
structure of the department and could have about 100 scribed in patients undergoing skull base surgery at
different categories in a maximum of three levels. A an otological and neurological clinic (Barrs et al.,
proposal for a keyword tree for cranio-maxillo-facial 2001). With this current article, the authors would
surgery can be downloaded on the Members’ section like to create a Europe-wide standard for the most
of the Eurofaces website at www.eurofaces.org. important photographic views for the more common
It should be possible to transfer the images and disease patterns presenting in cranio-maxillo-facial
their keyword information to other programs without surgery.
losing information in the event of changing the hard In order to avoid mistakes in clinical photography
or software systems. Software solutions are available the authors agree with other publications which
on the market from many companies. Examples for regard a reproducible position of the patient as being
single user (stand alone) and multi-user (network essential (Nayler, 2003; Niamtu, 2004). For ‘rela-
based) programmes include: tively’ or less rigidly standardized images for the
average cosmetic surgeon in private practice, con-
Single user software (stand alone) sistency in distance, white balance, background and
lightning is recommended (Niamtu, 2004). To guar-
! ACDSees (PC/Macintosh) antee consistency in pre- and post-operative photo-
! iViews (PC/Macintosh) graphs the illumination must be the same, although
! iPhotos (Macintosh) some surgeons try to improve post-operative results
! Cumuluss (PC/Macintosh) by generating brighter pictures.
Digital photography enables clinicians to take a
Multi-user software (network) large number of pictures in a short time. Nonetheless
! Cumuluss (www.canto.de, Germany) – the cumu- appropriate care should be taken to ensure a
lus software is optimized for management in consistently high quality. The great advantage of
medical use and has an advanced search function. digital photography is obviously the facility to check
! PhotoStations (www.fotoware.de, Germany) – the images immediately after they have been taken.
PhotoStation software can organize files for Poor quality outcomes should be detected and the
professional photograph archiving. picture repeated after they have been checked by a
! Portfolios (www.extensis.com, UK) – portfolio is medical professional. Poor quality pictures some-
a digital asset management solution to organize times shown in medical journals or academic
and access digital files quickly without compromis- presentations should nowadays be an exception. In
ing security or brand quality. spite of the additional advantages of digital photo-
graphy such as timesaving, lower costs, quick and
If a colleague seeks professional advice about a space saving storage with easier access to the
patient the sending of pictures by e-mail over photographs (Trune et al., 1995; Ettorre et al., 2006)
unsecured data-lines must be avoided according to some drawbacks must be pointed out.
the data protection guidelines of the European A manipulated appearance of surgical results by
Union. The European Association for Cranio-Max- changing the patient’s position, for example to chin-
illo-Facial Surgery developed a tool for scientific up or chin-down has been described (Niamtu, 2004).
communication and education which includes clinical Other authors have described specific problems, for
photographs and radiographs. This electronic con- example the appearance of skin lesions being
sultation software is implemented in the protected dependent on illumination (Ikeda et al., 2003) or
member section of the website www.eurofaces.com. 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
DISCUSSION and Cadier, 2004; Sommer and Mendelsohn, 2004). In
addition, the possibility of altering brightness, focal
Additional picture sets for special topics in cranio- length, patient’s position and selective softening or
maxillo-facial surgery expand the basic set. Although sharpening with computer programs can be used to
there is a variety of recommendations for picture sets change the authentic appearance of the surgical
in the literature for different medical fields (Sandler outcome. Unfortunately this has become much easier
and Murray, 2001; Galdino et al., 2002; Jones and and less controllable in our digitized world and in the
Cadier, 2004) the authors have endeavoured to end all we can do now is to rely on each others
minimize the picture set as far as possible. Overall honesty.
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454 Journal of Cranio-Maxillofacial Surgery

The question of who should take the pictures in feasible and limited picture sets and also to point out
daily clinical work is controversial. Some authors some pitfalls and drawbacks in digital photography.
suggest delegating the supervision and picture taking By knowing cause and effect of such mistakes,
to staff members (Christensen, 2005) but the purpose challenges can be handled much more professionally.
and viewpoint of the image is not the same for every Technical errors, mistakes in positioning the patient
photographer. It is therefore recommended that the and difficulties in intraoral and children’s photo-
responsible surgeon should personally take the graphy are presented.
pictures directed towards the main points of interest Medical progress has always been dependent on an
of a patient’s medical problem and the aim of exchange of experiences. Modern communication
treatment. If a professional photographer is em- facilitates interdisciplinary discussion if used appro-
ployed medical knowledge is required. In a survey priately. The authors therefore encourage all collea-
which included 68 orthodontists, 60% took the gues to consider investing appropriate time and effort
photographs themselves, in 35% a clinical assistant in accurate photo-documentation. This together with
and in 5% a professional photographer was assigned honesty, adequate data protection and platforms
to obtain the pictures (Sandler and Murray, 2002a). such as www.eurofaces.com it is hoped that progress
The authors agree with previously published manu- in our profession might be accelerated for the benefit
scripts that correct equipment and appropriately of both patients and surgeons.
trained staff are the key to good-quality accurate
clinical photographs (McKeown et al., 2005). Addresses of companies mentioned:
For storage and archiving of digital patient images,
authors have suggested different systems for catalo- ACDSees (www.acdsee.com) ACD Systems Inter-
guing the photographs by diagnosis, date, patient national Inc., Saanichton, British Columbia, Canada
registration number and type of photographic view Adobe Photoshops (www.adobe.com) San Jose,
using photo CDs (Nayler, 1998) or describe pro- California, USA
grams such as exif viewers, dentofacial showcases Cumuluss (www.canto.de) Canto GmbH, Berlin,
and PowerPoints as alternative methods (Sandler Germany
and Murray, 2002b). Creating a directory tree known Corel Photopaints, Paintshop Pros (www.corel.
from windows explorers leading to the final sub- com) Corel Corporation, Ottawa, Canada
folder for patient’s name is also described (Niamtu, Dentofacial showcases (www.dentofacial.com)
2004). exif viewers, Ludwigshafen, Germany
Better search functionality, handling and a useful Firegraphics (www.firegraphic.com)
diagnosis- or treatment-tree storage of data is IMI, The institute of medical illustrators (www.
provided by asset management systems such as imi.org.uk) London, UK
Cumuluss or Portfolios. Using these management Irfanviews (www.irfanview.com), Irfan Skiljan,
systems and labelling digital images with multiple Wiener Neustadt, Austria
indices gains greater importance as the number of iPhotos, Apple, Cupertino, CA, USA
stored photographs increases. Additionally, appro- iViews, (www.application-systems.de) Application
priate storage for patients’ data security and protec- Systems Heidelberg Software GmbH, Germany
tion against unauthorized access is provided by the Neo-Sabenyls, Qualiphar (www.qualiphar.com),
programs as they are equipped with multi-user log-in Antwerp, Belgium
facilities. Moreover, these programs facilitate the PhotoStations (www.fotoware.de), FotoWare
possibilities for creating academic presentations or GmbH, Geesthacht, Germany
lectures to students by using the structured informa- Portfolios (www.extensis.com), Extensis UK, The
tion attached to each picture. It should be noted that Lakes, Northampton, UK
a digital picture is definitely lost if not categorized Photo CDs Kodak, Stuttgart, Germany
and file saved adequately. We cannot rely anymore PowerPoints, Microsoft, Redmond, USA
on a well-trained long-term secretary who knows by Windows explorers, Microsoft, Redmond, USA
heart the slides stored on large office shelves and in
cabinets if there has been a switch from analogue to
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