Adherence to Photographic Standards:A Review of ASPS and ASAPS Member Surgeons' Websites

Sanniec KJ1, Velazco CS2, Macias LH3, Zuhlke TA2, Casey III WJ3, Leighton WD3, Mahabir RC3 and Rebecca AM3*

1Department of Plastic Surg ery, UT Southwestern, Dallas, TX, USA

2 Division of General Surg ery, Mayo Clinic in Arizona, Phoenix, Ariz, USA

3 Division of Plastic and Reconstructive Surg ery, Mayo Clinic in Arizona, Phoenix, Ariz, USA

*Corresponding Author:
Rebecca AM
Mayo Clinic Hospital
5777 East Mayo Blvd
Phoenix, AZ 85054, USA.
Tel: +480-342-2899
E-mail: [email protected]

Received date: April 20, 2016; Accepted date: June 13, 2016; Published date: June 22, 2016

Citation: Sanniec KJ, Velazco CS, Macias LH, et al. Adherence to Photographic Standards: A Review of ASPS and ASAPS Member Surg eons’ Websites. J Aesthet Reconstr Surg . 2016, 2:11. doi: 10.4172/2472-1905.100020

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Background: To evaluate the adherence of images on plastic surgeons' websites with the photographic standards established in 2006 by the American Society of Plastic Surgeons (ASPS) and the Plastic Surgery Foundation (PSF). Methods and findings: The membership rosters of the ASPS and the American Society for Aesthetic Plastic Surgery (ASAPS) were combined, and a random selection of 10% of these members was chosen for evaluation. Surgeons from the United States and Canada were included. Surgeons who were international members, who did not have websites or who had websites but did not have the images of interest were excluded. A total of 122 members of the 10% sample met the criteria. Breast augmentation, abdominoplasty and rhinoplasty images were reviewed and evaluated for focus, framing, positioning, presence of uniform background, absence of shadow, absence of clothing, absence of jewelry, use of photo garments, and exposure. Results: None of the websites evaluated universally adhered to the photographic standards, and the average was 66.3%. The average adherence was 76.2-77.0%, 64.6-63.8% and 57.6-58.2% for breast, face and abdominal images pre and postoperative respectively. Breast postoperative compliance was significantly improved for correct positioning, focus, and no cast shadow. Facial compliance was significantly improved for good background postoperatively whereas makeup compliance was higher preoperatively, and abdominal compliance was significantly improved for postoperative correct position although preoperative photo garments compliance was higher. Conclusion: Sixty-six percent of images on ASPS and ASAPS plastic surgeons' websites were adherent to the photographic standards, and pre and post adherence were similar.


Photographic documentation is essential in plastic Surgery. Numerous articles regarding photographic standards have been published with many of the more recent examples found in the facial plastic Surgery literature [1-5]. In order to assist plastic Surg eons in professionalism, privacy, operative planning, and documentation of pertinent anatomy without distortion or distraction, the American Society of Plastic Surg eons and the Plastic Surgery Educational Foundation (now known as Plastic Surgery Foundation (PSF) and henceforth will be referred to as PSF) (ASPS/PSF) published The Photographic Standards in Plastic Surgery in 2006 [6]. Many members of ASPS and the ASAPS (American Society for Aesthetic Plastic Surgery) host public websites where “before and after” images of patients are posted. These websites are often a prospective patient’s first exposure not only to a particular Surg eon, but also to the discipline of plastic and reconstructive Surgery. These images are therefore very important in shaping public perspective [7-9]. We examined images posted on ASPS and ASAPS member Surg eons’ websites for adherence to ASPS/PSF standards for breast, abdominal, and close up facial photo series.


After IRB approval, random selection of ten percent (n=260) of United States and Canadian member Surg eons with ASPS and ASAPS membership was performed. We excluded international members, members without a website, and members whose websites did not contain images of breast augmentation, abdominoplasty, and/or rhinoplasty. A total of 122 (4.7%) ASAPS/ ASPS member websites of the 10% sample met the inclusion criteria.

All websites were de-identified prior to evaluation. The standard views were those described in The Photographic Standards in Plastic Surgery for breast augmentation, abdominoplasty and rhinoplasty on Table 1. Images were evaluated by one of three independent trainees (KS, LM, TZ). The first and last set of “before and after” images on each website were compared with the standard views and evaluated for focus, framing, proper positioning, use of a uniform background, presence of a cast shadow, the absence of clothing and jewelry, proper exposure and use of photo garments. A uniform background was defined as any single color background surface. Images were categorized as overexposed when there was either loss of highlight detail or when parts of the image were effectively all white or washed out. Images were considered underexposed when the important dark areas were obscured or indistinguishable from the background. Excess makeup was recorded if the makeup was distracting to the reviewer. Results were entered into a database using Excel (Microsoft Corporation, Redmond, Washington). Statistical analysis was completed using paired t-test.

Patient Preparation Patient disrobed above the waist
All visible jewelry removed
Patient Positioning Patient standing comfortably erect with arms at sides
Feet aligned
Distal arm should be moved slightly back on oblique views
Framing Position clavicles at top of frame
Center torso horizontally for frontal and oblique views
Center mass of proximal breast horizontally for lateral views
Distal breast should not be visible in lateral view
Patient Preparation Remove gown completely
Patient should wear a photo garment
Patient Positioning Patient standing comfortable erect with arms folded above breasts
Feet aligned
Framing Position inframammary fold at top of frame
Center torso horizontally
Close Up Face
Patient Preparation Pull hair off face and behind ears (Use black headband or small clips that hold hair without pulling)
Remove jewelry and eyeglasses
Remove heavy makeup
Cover shirt collar with black drape
Patient Positioning Seat patient on a stool adjusted to a comfortable height and placed at center of a tape mark
Have patient sit up straight with feet on either side of the tape mark
Patient should rotate entire body for oblique and lateral views
Framing Place eyebrows at top of frame
Center nose horizontally in all views

Table 1: Photographic standards.


A total of 2180 individual images (921 breast images, 432 closeup face images, and 827 abdomen images) were reviewed. Of the 122 Surg eons’ websites evaluated, there was at least one image on each site that did not meet the ASPS/PSF standard guidelines. Adherence rates varied widely ranging from 12-90% as seen on Figure 1 and improper framing was a consistent issue across all three anatomic areas. Tables 2-4 provide the details for the breast, abdominal and facial image reviews. Pre- and postoperative adherence rates demonstrated consistency with the exception of photo garments in facial series and positioning in abdominal series. Table 5 provides statistical analysis between pre- and postoperative adherence rates. For breast images postoperative compliance was improved for correct positioning (p=0.0342), focus (p=0.0178), and no cast shadow (p=0.037). Facial image review showed compliance was only improved for good background (p=0.0315) postoperatively; whereas makeup compliance was higher preoperatively (p=0.0002). Abdominal image review demonstrated improved postoperative compliance for correct position (p=0.0004), although there was higher preoperative compliance with photo garments (p=0.0308).


Figure 1: Website adherence rates by member Surg eons of American Society of Plastic Surg eons (ASPS) and the American Society for Aesthetic Plastic Surgery (ASAPS).

Adherence to Standard Total n (%) 95% Confidence Interval
Lower Upper
In Focus 763 (83%) 81% 86%
Correct Framing 603 (65%) 62% 69%
Correct Positioning 643 (70%) 67% 73%
Uniform Background 832 (90%) 88% 92%
No Cast Shadow 628 (68%) 65% 71%
No Clothing Visible 727 (79%) 76% 82%
Absence of Jewelry 724 (79%) 76% 81%
Good Exposure 720 (78%) 75% 81%
Excess Makeup NA NA NA
Photo Garment Present NA NA NA
Total Images 921 - -

Table 2: Review of breast image adherence.

Adherence to Standard Total n (%) 95% Confidence Interval
Lower Upper
In Focus 715 (87%) 85% 89%
Correct Framing 196 (24%) 21% 27%
Correct Positioning 479 (58%) 58% 62%
Uniform Background 695 (84%) 81% 86%
No Cast Shadow 496 (60%) 57% 64%
No Clothing Visible 353 (43%) 40% 46%
Absence of Jewelry 733 (89%) 87% 91%
Good Exposure 620 (75%) 72% 78%
Excess Makeup NA  NA  NA
Photo Garment Present 355 (43%) 40% 47%
Nude 125 (15%) 13% 18%
Total Images 827 - -

Table 3: Review of abdominal image adherence.

Adherence to Standard Total n (%) 95% Confidence Interval
Lower Upper
In Focus 360 (83%) 79% 87%
Correct Framing 52 (12%) 9% 15%
Correct Positioning 301 (70%) 65% 74%
Uniform Background 357 (83%) 79% 86%
No Cast Shadow 329 (76%) 72% 80%
No Clothing Visible 277 (64%) 63% 72%
Absence of Jewelry 294 (68%) 59% 69%
Good Exposure 311 (72%) 67% 76%
Excess Makeup 216 (50%) 45% 55%
Photo Garment Present NA   NA NA 
Nude NA  NA NA 
Total Images 432 - -

Table 4: Review of close up face image adherence.

  Category/Standard Preoperative Postoperative P-value*
N Mean SD Median N Mean SD Median
Breast image (oblique+lateral +frontal) Correct Framing 122 2.41 1.54 2 122 2.53 1.62 3 0.1243
Correct Position 122 2.55 1.51 2 122 2.72 1.46 3 0.0342
Good Background 122 3.41 1.61 4 122 3.41 1.59 4 1.0000
Good Exposure 122 2.96 1.6 3 122 2.94 1.78 3 0.8795
In Focus 122 3.07 1.65 3 122 3.23 1.58 4 0.0178
No Cast Shadow 122 2.67 1.53 2 122 2.48 1.39 2 0.0137
No Clothing 122 2.99 1.63 3 122 2.97 1.6 3 0.7596
No Jewelry 122 2.98 1.43 3 122 2.96 1.49 3 0.8719
Face image (oblique + lateral + frontal) Correct Framing 69 0.38 0.89 0 69 0.38 0.81 0 1.0000
Correct Position 69 2.22 1.44 2 69 2.14 1.28 2 0.539
Good Background 69 2.49 1.61 2 69 2.68 1.44 3 0.0315
Good Exposure 69 2.25 1.52 2 69 2.26 1.5 2 0.9301
In Focus 69 2.58 1.54 3 69 2.64 1.53 3 0.5675
No Cast Shadow 69 2.35 1.34 2 69 2.42 1.34 2 0.2543
No Clothing 69 1.96 1.19 2 69 2.06 1.17 2 0.3576
No Jewelry 69 2.12 1.46 2 69 2.14 1.41 2 0.8249
No Make Up 69 1.88 1.57 2 69 1.26 1.21 1 0.0002
Abdominal image (oblique + lateral + frontal) Correct Framing 113 0.92 1.21 0 113 0.82 1.1 0 0.2609
Correct Position 113 1.95 1.71 2 113 2.3 1.68 2 0.0004
Good Background 113 3.06 1.77 3 113 3.06 1.71 3 1.0000
Good Exposure 113 2.66 1.7 3 113 2.83 1.68 3 0.1588
In Focus 113 3.15 1.47 3 113 3.19 1.48 3 0.5375
No Cast Shadow 113 2.24 1.51 2 113 2.17 1.48 2 0.4307
No Clothing 113 1.55 1.61 1 113 1.58 1.65 1 0.7591
No Jewelry 113 3.31 1.38 3 113 3.19 1.48 3 0.1788
Nude 113 0.54 1.17 0 113 0.57 1.2 0 0.6331
Photo Garments 113 1.68 1.87 1 113 1.46 1.83 0 0.0308

Table 5: Preoperative and postoperative adherence.


In our random sample of websites there was a disparity from the ASPS/PSF published standards. This study was unable to resolve whether these variations were a result of Surgeon preference, different protocols, flawed photographic technique, or patient positioning instructions. In the future, it may be of interest to examine provider websites with photo recognition software to see if compliant photographs were industry provided vs. the practitioner taking photographs.

The most common deviation from the ASPS/PSF guidelines encountered was in framing the photograph. Only 12% of facial, 24% of abdomen, and 65% of breast images were framed correctly. Most of the rhinoplasty before and after images was not framed or cropped close enough and showed too much of the face. Of the abdominal images the inframammary fold was either not visible in the top of the frame or too much of the breasts were included. The breast images were either framed too high, showing the chin, or too low, not showing the clavicles. Many images were clearly framed without a standard framing method; others were simply framed based on preference. Historically, a variety of standards have been proposed and taught in training; therefore, it was not surprising that there were images not conforming to the ASPS/PSF standards [10-16].

The next most common divergence from the guideline was in patient positioning. The patients in the abdominal images were less likely to be positioned properly (58% correct); whereas the breast and face patients were slightly more likely to be positioned as per the ASPS/PSF standards (70%). However, on comparison between pre- and postoperative abdominal and breast positioning, we report statistical differences which may bias Surgical outcome. The most common error noted in the positioning of the abdomen pictures was having the arms visible in the photograph. The best position for the arms is to be raised superiorly, out of the frame, and holding the breasts up and out of the frame, if necessary, demonstrating the inframammary folds. The most common error in breast patient positioning was in the oblique view with visibility of the arm furthest from the photographer.

For the close-up face images, positioning deviations were noted in bird’s eye views and in failure to pull the hair back and out of the way. Use of hair clips or pins in order to place hair out of the way, and exposing the entire forehead, neck and ears is extremely helpful. Of note, the ASPS/PSF guideline does not discuss the patient’s Frankfort horizontal line. Other guidelines have cited this as important for standardizing the tilt of the head [17, 18]. Remi et al. demonstrated that even small deviations in patient positioning in facial photography can lead to significant deviations from photo documentary standards, leading to photographic faults [19]. Specifically, patient positioning and angles of photography can lead to a “photographic neck lift” or “rhinoplasty” distorting perceived outcomes following Surgery [19, 20]. The inconsistencies of preoperative and postoperative compliance of good background and no makeup in our study may also provide observer bias for postoperative outcomes. When ASPS revisits the publication, consideration could be given to including the use of the Frankfort horizontal line in the photographic standards.

The presence of a shadow is preventable with appropriate lighting. A straightforward method is to use a dual lighting source placed at 45-degree angles from the patient. Even then, faint shadows may still be appreciated. A small flash illuminating the background will eliminate shadows completely [2, 12, 18]. Some have advocated using a black background in order to eliminate the cast shadow, but this is not necessary with appropriate lighting. Black backgrounds can make it difficult to distinguish the patient with darker complexions and hair from the background. Most standards agree that a consistent color background should be used, with most advocating a blue color. These can vary from a felt background to a wall or wide door painted with flat paint, or a traditional, even-colored studio backdrop [12, 18].

A study by Lau et al. found that most patients consider medical photography acceptable, especially if the images are de-identified (patient not recognizable) [10]. The removal of jewelry not only makes the photo appear more professional and less distracting, but it also helps protect patient confidentiality. Jewelry was noted in 11% of patients on the wrists or hands and was visible due to inappropriate positioning; the only exception to this was occasional umbilical jewelry being visualized.

Of particular relevance to facial images is the use of makeup. Our evaluation of presence of make-up was subjective, as we noted when the makeup appeared to be “heavy” or distracting. Ideally, the patient would be photographed with no visible makeup. In practice this is difficult as many patients come to postoperative appointments with makeup already applied and are unwilling or unprepared to remove and reapply their make-up. Despite instructing patients to come to appointments without makeup applied, adherence remains an issue. Nonetheless, every effort should be taken to have the patient remove make-up prior to photographic documentation. Similarly, Riml et al. found that in one third of photographs published in three major plastic and reconstructive journals demonstrated patients wearing makeup [19]. We found that patients’ photographs were likely to adhere preoperatively to no makeup than postoperatively, again influencing Surgical outcome.

Patient’s personal clothing is seen in many of the images, including personal undergarments in body images, pants or skirts in breast images and shirts not covered in facial photography. In addition to making the images look less professional, the clothing also increases the likelihood of being able to identify a patient. Differences in the clothing, especially undergarments, worn on the different days complicates the comparison of the before and after images. Some members have used nude patients and posted them with exposed genitalia, while others have superimposed a blackout of the area. Although the completely nude photo is the most desirable for comparison of before and after body images, the use of photo undergarments helps with standardizing the exposed areas while maintaining some modesty for the patient.

Exposure is a result of ambient light (light on the subject) being reflected to the digital sensor of the camera. Over- or underexposure may be due to too much light from a flash, lack of use of a flash or inappropriate setting on the camera for the available light. Thanks to advancements in digital photography, today’s plastic Surg eon cannot claim naivety and should be able to get consistent exposures in an office setting. In the literature there are numerous papers that have discussed how to obtain consistent images. These vary from simple office set-ups to near studio-style arrangements. Some attention to detail and a small investment of time and money will lead to professional, quality, standardized images that we should strive to obtain.

We believe that adherence to the published photographic standards would help to distinguish ASPS/ASAPS member plastic Surgeons, promote professionalism, reduce errors, and provide appropriate documentation. Accessibility to photographic standards and guidelines should be facilitated by the societies, but it is incumbent on plastic Surg eons to continually update themselves on photographic standards, review their websites, and strive for adherence with those standards. Adhering to standardized photographic guidelines would allow Surg eons to critically analyze their Surgical outcome measures (aesthetic results), review results (quality assurance) and compare outcomes (research). The authors encourage Surg eons to both review and adopt the published standards for their individual websites.


Sixty-six percent of images on ASPS and ASAPS plastic Surg eons’ websites were adherent to the ASPS/PSF photographic standards and pre and post adherence was similar. Adherence to guidelines allow for consistent images that facilitate documentation and critique of a Surg eon’s outcomes.

Conflicts of Interest

The authors have no conflicts of interest to disclose.


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