by Anna Steve, MD (@annakstevemd)
Clinical photographs have the ability to capture a rich amount of data in an image, forming an integral part of consultation, medical education, and publication in plastic surgery. Photographs can be used to transfer information between health care providers, compare pre-and post- operative photos and to follow wounds over time.  However, guidelines for standardizing the angle, lighting, and focus of photos are essential for enabling accurate comparisons over time. [2, 3]
Original guidelines for clinical photography were meant for analogue cameras and focused on how to take clinical photos in a controlled setting.  The reality is that plastic surgeons work within a number of environments that do not offer the same luxuries as a studio. Photos taken in the trauma bay and intra-operatively do not allow for standardized backlights or sky blue backdrops suggested in early guidelines. 
More recent recommendations have redefined standards for digital photography on a hand-held camera, broadening their application. However, up to 89% of plastic surgeons and 100% of medical trainees are using smartphones for clinical photography.  Advances in technology have allowed for wide availability of high quality cameras on smartphones. Smartphone applications that provide safe encryption, storage, and transmission of photographs have allowed physicians to use smartphones for clinical photography while maintaining patient privacy and confidentiality. 
Clinical photographs taken with a smartphone should also be subject to standardized guidelines to preserve the ability to use the images for accurate comparisons over time, medical education, and publication. The following 10 recommendations are suggested for standardization of clinical photographs using smartphones:
- Obtain informed consent, including permission to use images for medical education, transmission, and publication.
- Use the same smartphone for photos meant for comparison over time (ex pre-and post-operative photos.
- Add rulers within the photo to provide dimensional context.
- Remove distracting jewelry, eyeglasses, makeup, background instruments, blood and bodily fluids (Figure 1) or cover with a surgical towel as necessary.
- Use anatomic landmarks to avoid taking photos from non-standard angles (Figure 2).
- Avoid the use of flash. Colour temperature and length of smartphone flash lead to poor quality photos (Figure 3).
- Optimize room lights as necessary to avoid background shadows (Figure 4).
- Keep your camera lens clean to avoid dark or hazy images (Figure 5).
- Avoid the use of digital zoom.
- Ensure adequate encryption for photos that are intended to be stored or transmitted via smartphone.
[2, 3, 5, 6]
Examples of some of the pitfalls that should be avoided are demonstrated in Figures 1-5. An example of a standardized photo taken following the above recommendations is shown in Figure 6.
- Mieke Heyns, A.S., ShareSmart: An Application for Clinical Photography Using Smartphones, in PRS Resident Chronicles, R. Rohrich, Editor. 2017.
- DiBernardo, B.E., et al., Photographic standards in plastic surgery. Plastic & Reconstructive Surgery. 102(2): p. 559-68.
- Krause, J.L., Jr., Digital photographic standards. Plastic & Reconstructive Surgery. 112(4): p. 1177-8.
- Chan, N., et al., Should ‘smart phones’ be used for patient photography? Plastic Surgery. 24(1): p. 32-4.
- Sheisser, T., 10 Tips for Good Smartphone Photography.
- Horaczek, S., Photo Tips: 10 Ways to Take Better Photos With Your Smartphone. 2012: Popular Photography.