Abstract Plastic surgery relies on photography for both clinical practice and research. The Photographic Standards in Plastic Surgery laid the foundation for standardized photography in plastic surgery. Despite these advancements, the current literature lacks guidelines for genital photography, thus resulting in a discordance of documentation. The authors propose photographic standards for the male and female genitalia to establish homogeneity in which information can be accurately exchanged. All medical photographs include a sky-blue background, proper lighting, removal of distractors, consistent camera framing, and standard camera angles. We propose the following guidelines to standardize genital photography. In the anterior upright position, feet are shoulder-width apart, and arms are placed posteriorly. The frame is bounded superiorly by the xiphoid-umbilicus midpoint and inferiorly by the patella. For circumferential documentation, frontal 180 degree capture via 45 degree intervals is often sufficient. Images in standard lithotomy position should be captured at both parallel and 45 degrees above the horizontal. Images of the phallus should include both the flaccid and erect states. Despite the increasing incidence of genital procedures, there lacks a standardized methodology in which to document the genitalia, resulting in a substantial heterogeneity in the current literature. Our standardized techniques for genital photography set forth to establish a uniform language that promotes more effective communication with both the patient as well as with colleagues. The proposed photography guidelines provide optimal visualization and standard documentation of the genitalia, allowing for accurate education, meaningful collaborations, and advancement in genital surgery. In medicine, photography enables objective analysis of results by using validated scoring methods based on visual assessments. Especially in plastic surgery, a visually oriented specialty, photography plays an extremely important role in both clinical practice and research.1 Clinically, photographs are used for preoperative planning, intraoperative visual referencing, postoperative documenting, and assessing surgical outcome.1-3 In addition, photographs can be utilized in patient education to clearly communicate the surgical plan as well as provide pre- and postoperative comparisons.2 In research, photography is used in presentations and publications to demonstrate an objective analysis of applied techniques and outcomes.1,2 From a legal standpoint, photography should be an integral part of the patient’s record as it could support the defense of the surgeon in the event of litigation.2 Consistency is crucial in medical photography. Standardized photography reduces variables that can produce false postoperative comparisons as well as provides reliable reproducibility for valid photographic results in academic research.1 Studies show that minor deviations from accepted standards decreases the clinical value of the photography, thus reducing its validity in medicolegal litigation, surgical planning, and communication amongst surgeons.2,4-6 In order to ensure accurate comparisons amongst colleagues, the American Society of Plastic Surgeons and the Plastic Surgery Educational Foundation issued Photographic Standards in Plastic Surgery7 in 1991. This publication standardized photography of the face, ears, mouth, breasts, abdomen, hips/thighs, calves/feet, forearm, hands, and fingers.6,7 Despite the increasing incidence of genital procedures, there is a paucity of literature that establishes photographic standards for the genitalia. We utilize our experience in genital surgery and photography to propose standard techniques that best capture the genital anatomy in a uniform manner. GENERAL TECHNIQUES FOR PHOTOGRAPHIC STANDARDIZATION The following generic guidelines, applicable to all medical photography, are based on review of the medical literature in addition to our own personal experience. The proposed criteria include uniform background, lighting, camera positioning, patient preparation and positioning, and photo editing.1,3,8 Photography Background The standard background color in medical photography is sky blue, converted to 18% gray Kodak standard in grayscale, because it is a medium tone that contrasts with most skin colors.9 Most camera meters are calibrated to make everything medium toned, thus having a medium toned background to lock in an exposure reading that produces color tones closest to reality. By the same token, if the camera is metered to a background lighter than sky blue, the photo will be darker, and the converse holds true as well.9 In the clinic, this can be achieved through a hand-held drape, a window shade, a roll of seamless backdrop paper, or a painted wall.10 In the operating room, sterile blue towels may be used.9 Photographic Lighting In a studio setting, optimal illumination may be achieved by placing two lights anterior, one light posterior, and one light superior of the patient being photographed.8,11 The two anterior lights are best placed 90° apart so that each lamp is 45° with respect to the patient, one on the left side, and the other on the right.8,11 The posterior light is best placed 30 to 60 cm from the background to minimize shadows being cast onto the background.8,11 Strub et al described a similar symmetric multilight source positioning, but found it inferior to asymmetric lighting when photographing the nose.12 Asymmetric lighting increases contrast and shadowing, thus enhancing 3-dimensionality and detail rendition, both important in surgical planning of rhinoplasties.12 In genital photography, symmetric lighting is preferred, as it minimizes the shadows casted on the patient and thus reduces its distorting effect on the patient’s form.11 When selecting the light source’s bulb, color temperature must be considered. “Cold” light (≥6000 K) is preferred to “warm” light (≤3500 K), as it does not produce a soft yellow glow that “warm” light does, but rather a blueish-white quality, equivalent to the high noon sun, that produces the best representation of true color.11,13 In the clinic and in the operating room, frontal lamps in optimal positioning can be impractical. When relying on a camera’s flash for lighting, special attention should be paid to positioning the camera parallel to the area of interest in order to minimize shadows.6,11 In the operating room (OR), we turn away the adjustable lights for two reasons. First, OR lights can vary in color temperature, distance, and angle, which can alter the color, magnification, and shadowing of the subject Second, modern sensors are unable to detect the difference in intensity between the OR and ambient lighting. The camera’s automatic settings have shown to produce the truest color in the setting of mixed lighting.1 Camera Positioning To standardize magnification, the lens should be kept at a constant level and distance from the patient. When positioning the camera, anatomic landmarks and a tripod may assist with consistent distances and angles.8,10,11 The camera should be placed at the height of the desired anatomic region and placed at a distance where the appropriate bounds and magnification are achieved, thus avoiding the need for zoom.11 When possible, zoom should be avoided as it may distort the patient to look wider and adds another variable to the operator, making consistency more difficult to achieve. In cases where desired magnification cannot be accomplished mechanically, zoom may be utilized, but when doing so, the subject at hand must remain in the frame’s center in order to preserve the photograph’s focal point.11 When photographing an area 8 cm or less, place a ruler in at least one of the photographs to provide a frame of reference for true size.11 Patient Preparation and Positioning In medical photography, unobscured visualization of the area of interest is achieved through eliminating distractors, including the patient’s clothing, gown, undergarments, jewelry, glasses, piercings, and makeup.3,7,8,10,11 Position the patient approximately 3 feet in front of the background to minimalize distracting shadows.14 At this position, the patient will angle themselves to assume the 5 standard views: one AP (0°), two oblique (±45°), and two lateral (±90°). Photo Editing If photographs are not standardized at the time of capture, editing software may be utilized to zoom and crop in order to uniformize magnification, allowing for more accurate side-by-side comparisons.9,11 While photo editing is a useful tool, anytime an image is digitally manipulated, the authenticity is compromised. Thus, the photographic techniques describe should not be replaced by postproduction editing, and the attention to detail should be placed at the time of capture.11 SPECIFIC TECHNIQUES FOR PHOTOGRAPHIC STANDARDIZATION OF THE GENITALIA With the senior author’s extensive experience in performing and documenting varied genital procedures, we propose the following guidelines to standardize genital photography (C.J.S.). For the anterior-posterior image, we found that an upright standing position with the feet at shoulder-width apart is a readily acquired position for most patients in the clinical setting (Figure 1). This allows not only expeditious acquisition of the standard position, but also adequate and natural spacing between the lower extremities, thus permitting evaluation of the genital appearance in situ. Framing of the patient is somewhat arbitrary, and the authors found that the image should at least capture the xiphoid-umbilicus midpoint superiorly and the entire patella inferiorly. For the remarkably endowed male genitalia, adjustments in the framing may be made at the clinician’s discretion. The lens should be positioned in level with the mons to allow for direct focus of the genital region in relation to the abdomen and lower extremities. Figure 1. View largeDownload slide (A) Schematic illustration of a patient standing with legs shoulder width apart and the bounds for framing when taking a photograph of a patient’s genitalia in the antero-posterior (AP) view (courtesy of Priscila Sanchez, MD). (B) AP standardized view of a 53-year-old man’s external genitalia with a diagnosis of a hidden penis. (C) AP standardized view of a 26-year-old woman’s external genitalia who presents with lichen sclerosis (not visible in this view). Figure 1. View largeDownload slide (A) Schematic illustration of a patient standing with legs shoulder width apart and the bounds for framing when taking a photograph of a patient’s genitalia in the antero-posterior (AP) view (courtesy of Priscila Sanchez, MD). (B) AP standardized view of a 53-year-old man’s external genitalia with a diagnosis of a hidden penis. (C) AP standardized view of a 26-year-old woman’s external genitalia who presents with lichen sclerosis (not visible in this view). Arm positioning has little effect on the positioning of the genitalia, but the upper extremities can impede visualization, especially in the lateral views. The authors recommend that the patient’s arms and hands hang slightly posteriorly at the sides to allow for complete capture of protuberant or retracted genitalia (Figure 2). In the female patient, lateral and oblique views do not typically reveal useful information and the anterior upright and lithotomy views suffice in most instances. A unilateral upper extremity should be utilized for retraction to capture ventral views of the penis and visualization of the scrotum. Figure 2. View largeDownload slide (A) Schematic illustration of a patient standing with arms placed posteriorly in the lateral view (courtesy of Priscila Sanchez, MD). (B) Lateral view of a 53-year-old man’s external genitalia with arms placed posteriorly. (C) Lateral view of a 26-year-old woman’s external genitalia with arms placed posteriorly. Figure 2. View largeDownload slide (A) Schematic illustration of a patient standing with arms placed posteriorly in the lateral view (courtesy of Priscila Sanchez, MD). (B) Lateral view of a 53-year-old man’s external genitalia with arms placed posteriorly. (C) Lateral view of a 26-year-old woman’s external genitalia with arms placed posteriorly. In regards to differing angles of imaging, we found that frontal 180 degree capture via 45 degree intervals is often sufficient (Figure 3). Circumferential documentation can be utilized as well if further body contouring procedures are being considered. Thus 5 images should be documented for the frontal 180 degree photographs and 8 images would result from a full 360-degree circumferential series. Figure 3. View largeDownload slide A 26-year-old woman positioned at −90°, −45°, 0°, +45°, and +90° (courtesy of Natalie Joumblat). Figure 3. View largeDownload slide A 26-year-old woman positioned at −90°, −45°, 0°, +45°, and +90° (courtesy of Natalie Joumblat). Lithotomy views were also found to be critical in the documentation of genital photography. These views assist in examination, objective diagnosis, and operative planning. To achieve standard lithotomy position in the clinic and in the operating room, the hips should be flexed 80 to 100° from the torso with the thighs abducted approximately 30 to 40° from the midline (Figure 4). Stirrups should support the legs at a position roughly parallel to the trunk.15 OR lighting, as previously mentioned, is limited. Turning off the adjustable overhead lights and positioning the camera parallel to the genital’s plane is simplest technique for easily reproducible, least distorted photographs in the setting of minimal equipment. For framing, the horizontal axis should include midthigh, and the vertical axis should include the entire genitalia and inferior border of the buttocks. Figure 4. View largeDownload slide (A) Schematic illustration of a patient in standard lithotomy position (courtesy of Priscila Sanchez, MD). Hips are flexed 80 to 100°. Thighs are abducted 30 to 40° from midline. Capture images at 0° and 45° above the horizontal axis. (B) A 32-year-old woman in standard lithotomy position captured in the operating room with surgical blue towels as the background. Hips are flexed at 90° and legs are abducted 40° from the midline. Image is captured at 0° from the horizontal axis, an additional image should be captured at 45° above the horizontal (not shown). Figure 4. View largeDownload slide (A) Schematic illustration of a patient in standard lithotomy position (courtesy of Priscila Sanchez, MD). Hips are flexed 80 to 100°. Thighs are abducted 30 to 40° from midline. Capture images at 0° and 45° above the horizontal axis. (B) A 32-year-old woman in standard lithotomy position captured in the operating room with surgical blue towels as the background. Hips are flexed at 90° and legs are abducted 40° from the midline. Image is captured at 0° from the horizontal axis, an additional image should be captured at 45° above the horizontal (not shown). We found that that the genital images should be captured on a level parallel and in line with trunk as well as 45 degrees above the horizontal axis. These 2 views allow for evaluation of the mons, clitoris, clitoral hood, and labial tissues in females, and the ventral penis and scrotum in males. Retraction of specific anatomic regions of the genitalia or the surrounding skin is often necessary by the patient or the clinician to expose key aspects of the exam. In the female patient, retraction of the clitoral hood and labial tissues exposes key aspects including the introital characteristics, labial length, interstices, and genital wounds/scars. In cases of labia minora hypertrophy, it is important to document the length of the labia minora from base to distal edge, to facilitate acquisition of insurance coverage for the operation. In the male patient, retraction of the foreskin and elevation of the scrotal skin exposes the glans penis and perineal region, respectively. Photography of the male phallus should be done in both the flaccid and erect state. In the office, the erect length can be approximated by applying outward traction to the penis and measuring from the phallus base to the most distal tip of the glans.16 Otherwise, we accept the patient providing photographic documentation of their truly erect penis obtained in the privacy of their own home. The latter may prove more useful in circumstances where the phallus appears as a micropenis in the flaccid state, and only in the truly erect state does it become of normal length (5.5 to 6 inches), in addition to Peyronie’s disease evaluation. In cases of excessive body and genital hair we ask our patients to depilate these areas. Often, abundant hair not only conceals potential pathology, but obscures a clear view of the genital anatomy, thus compromising the operative plan. DISCUSSION Surgery of the genitalia, especially aesthetic procedures, has grown exponentially since the early 2000s, with some of the most popular procedures including the labiaplasty, vaginal rejuvenation, labia majora resection, mons lift, clitoral hood reduction, and volume augmentation of the mons pubis and labia majora.17 According to the American Society for Aesthetic Plastic Surgery’s Cosmetic Surgery National Data Bank Statistics, vaginal rejuvenation procedures increased by 12.5% between 200718 and 2013,19 and labiaplasty procedures increased by 43% between 201420 and 2016.21 Despite the increasing incidence of genital procedures, the current literature does not include any clear guidelines for photography of the male and female genitalia.7,15 As a consequence, genital photography is substantially varying, as evidenced in peer-reviewed literature as well as national and international meetings. With a busy practice caring for patients with aesthetic and functional problems of the genitalia, the authors believe that genital photographic standards are vital in communication with both the patient as well as with colleagues. Uniformity in pre- and postoperative photography minimizes distractors and allows surgeons to more effectively educate the patient on their surgical outcomes.22 Reproducible guidelines enable surgeons to standardize genital photography, thus generating a homogenous language in which meaningful comparisons can be made, multicenter studies performed, and further advancement in genital surgery achieved. CONCLUSION The proposed photography guidelines provide optimal visualization and standard documentation of the genitalia, allowing for accurate education, meaningful collaborations, and advancement in genital surgery. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Galdino GM, Vogel JE, Vander Kolk CA. Standardizing digital photography: it’s not all in the eye of the beholder. Plast Reconstr Surg . 2001; 108( 5): 1334- 1344. Google Scholar CrossRef Search ADS PubMed 2. Aveta A, Filoni A, Persichetti P. Digital photography in plastic surgery: the importance of standardization in the era of medicolegal issues. Plast Reconstr Surg . 2012; 130( 3): 490e- 491e; author reply 491e. Google Scholar CrossRef Search ADS PubMed 3. Gherardini G, Matarasso A, Serure AS, Toledo LS, DiBernardo BE. Standardization in photography for body contour surgery and suction-assisted lipectomy. Plast Reconstr Surg . 1997; 100( 1): 227- 237. Google Scholar CrossRef Search ADS PubMed 4. Riml S, Piontke A, Larcher L, Kompatscher P. Quantification of faults resulting from disregard of standardised facial photography. 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Aesthetic Surgery Journal – Oxford University Press
Published: Feb 6, 2018
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