Rhinoplasty photography

What repeats

Five findings that hold across the literature.

The photographs are a fixed set, taken the same way every time

Photodocumentation is the record used for counselling, for planning, for judging the result, and in a dispute. The standard rhinoplasty set is six angles, shot at a fixed camera height, a fixed distance and a fixed background, so that the picture taken a year later can be laid against the one taken at the consultation. The value of the comparison comes from the settings being identical, not from the camera being expensive. The published standards name the equipment. Facial plastic surgery photography was specified as a 35 mm single lens reflex body with a grid viewing screen, a 90 to 105 mm lens to avoid distortion, a sky blue non-glare background and the Frankfort plane held horizontal, and the resulting picture serves as the clinical record, the medicolegal record and the teaching file at once. The plastic surgery standard adds a second lens of 50 to 60 mm and two or more flash units. Digital capture brought colour, resolution and compression in as further variables, and the tip-defining points are the first detail to disappear from a frontal or base view when they are wrong. A smartphone application built on the American Society of Plastic Surgeons guidelines now holds the alignment itself, turning its on-screen frame green before it will capture.

Rests on: Thomas et al., uniform photographic documentation · DiBernardo et al., photographic standards · Galdino et al., digital photography for rhinoplasty · Kim and Most, photodocumentation · Golinko et al., automated standard views · Taritsa et al., studio lighting.

Lighting decides whether an irregularity is visible at all

Forty rhinoplasty candidates were photographed twice, once with the standard two-flash arrangement and once lit from above. Lay judges rated the nose as more irregular or more deviated in the overhead-lit photograph in 30 of 40 pairs, equal in 3 and less in 7, and the mean rating rose from 1.86 to 2.47. A separate comparison of flash against continuous light found the measurements taken off the photograph came closest to caliper measurements on the patient when the lights sat at 45 degrees. Adding two side lights behind the subject held colour accuracy at 97% in the frontal view and was judged better for clinical fidelity in 87.5% of paired angles.

Rests on: Tasman, lighting from above · Fernandez-Pellon et al., lighting options · Taritsa et al., LED panels.

A phone held at arm's length lengthens the nose and shrinks it against the face

Twelve subjects were photographed with a smartphone and with a full-frame camera across six distances and seven focal lengths, with the full-frame photograph at 60 inches taken as the reference. Focal lengths of 24, 35 and 50 mm at 8 inches stretched the midface vertically by 12% to 19%. The smartphone stretched it 18% at 8 inches and 12% at 12 inches. Volunteers photographed with a front-facing phone camera at 12 inches and at 18 inches, and with a clinical camera at 5 feet, measured 6.4% longer in nasal length in the 12-inch photograph and 4.3% longer at 18 inches. Alar base width did not change, so the ratio of nose width to face width fell 10.8% at 12 inches and 7.8% at 18 inches. The phone photograph a patient brings to a consultation is not the nose the surgeon will operate on, and the aesthetic photography reviews say to use phone images cautiously for that reason.

Rests on: Derakhshan et al., quantified facial distortion · Pressler et al., selfie photographs · Parsa et al., current photography techniques.

Computer imaging is standard practice, and most surgeons do it themselves

Facial plastic surgeons were surveyed on computer imaging at rhinoplasty consultations. Of 238 respondents, 150 used it, 92% of those did the morphing themselves, and about two-thirds handed the patient a printout afterwards.

Rests on: Singh and Pearlman, survey of practice · Lekakis et al., computer imaging.

The simulation is close on the profile and optimistic at the tip

A blinded panel graded preoperative, simulated and actual photographs for 40 patients. The actual result was preferred over the simulation in 77.5% of cases, and the real tip ended more projected than the simulated tip in both sexes. In a series of 224 Asian rhinoplasty patients, 68 of whom had a simulation, a panel rated the simulation identical to the result in 41.2% of cases, similar in 44.1%, approximate in 13.2% and poor in 1.5%. Satisfaction and revision rates did not differ between the patients who saw a simulation and those who did not.

Rests on: Persing et al., simulated versus actual · Yu and Jang, simulation accuracy.

By how the nose is recorded

Four ways to capture the same nose, each with a different use.

Two-dimensional photographs

The working record. Measurements read off standard photographs agreed with surface laser scanning and with computed tomography on nasal dorsum length index, nasofrontal angle and tip rotation angle in a comparison of 42 observations, which is why the flat photograph is still the planning document.

Rests on: Rendon-Medina et al., 2D against 3D and CT · and nasal anatomy.

Three-dimensional surface imaging

Patients rated a three-dimensional simulation as an addition worth having over the flat one. Among patients requesting revision surgery, 84% said the three-dimensional simulation helped them understand the aim of the operation, against 61% of first-time patients. Pooled across twelve studies of 595 patients, surgeons reported higher satisfaction and higher precision with three-dimensional planning, while reoperation rate and operating time did not differ and the equipment cost more. Accuracy has been measured on the nose itself. A portable stereophotogrammetry system scanned 41 volunteers against scans of plaster models across 22 perinasal and perioral landmarks, and the mean root mean square error between the two surfaces was 0.89 mm. Columella length at 0.686 and left nostril width at 0.636 were the least repeatable measurements in the set.

Rests on: Lekakis et al., 3D morphing · Ritschl et al., stereophotogrammetry accuracy · Werathammo et al., meta-analysis of 3D technology · and revision rhinoplasty.

The morphed image used as a filter

Consecutive patients imaged at consultation were divided by whether surgeon and patient reached agreement on the simulated result. Where they did not, 13.2% were turned down. Of the 290 accepted, 178 went ahead and 38 cancelled. Dissatisfaction with the simulation was reported by 42% of the patients who postponed and 16% of those who were operated on.

Rests on: Lekakis et al., morphing as a selection tool · and the consultation.

The measured plan

Anthropometric planning and photograph manipulation do not prescribe the same nose. Across 97 consecutive patients, the surgeon's manipulated photographs left nasal length near the original at 100.3% while the published ratio analysis cut it to 88.2%, and called for a smaller increase in radix projection, 100.5% against 109.3%.

Rests on: Lisiecki and Gilman, anthropometrics against manipulation · and the dorsal hump.

What to ask about rhinoplasty photography

Questions the evidence supports asking.

Will you take my photographs here, in your own studio

Ask whether the practice shoots a standard six-angle set at a fixed distance under fixed lights, and whether the same setup is used for the follow-up photographs. Comparison depends on it.

Rests on: Kim and Most · Taritsa et al..

Can I have a copy of the simulated images

Roughly two-thirds of surgeons who image give the patient a printout. Ask for one, and ask the surgeon to say in writing that it is a plan rather than a promise.

Rests on: Singh and Pearlman · Lekakis et al., computer imaging.

How close does your simulation usually land

Published accuracy is measured against the surgeon's own results. Ask to see the simulation and the one-year photograph for several past patients, in the same views.

Rests on: Persing et al. · Yu and Jang.

What happens if I do not like the simulation

Disagreement at the imaging stage is a recognised reason not to operate. Ask what the surgeon does when no version satisfies the patient.

Rests on: Lekakis et al., morphing as a selection tool · and the psychology of rhinoplasty.

Should I stop judging my nose on my phone

Nasal length reads longer and the nose reads smaller against the face on a front-facing phone camera at arm's length. Bring the phone picture, then look at the studio picture beside it.

Rests on: Pressler et al..

The terms, defined

The words used about rhinoplasty pictures.

• Standard views: the fixed set of camera angles shot at every visit, frontal, both obliques, both laterals and the base view. [34782131]
• Morphing: editing the patient's own photograph to show a proposed result. [26862968]
• Computer imaging: the practice of morphing at the consultation, done in most facial plastic surgery offices. [28432415]
• Three-dimensional surface imaging: a camera system that records the surface of the face as a measurable model rather than a flat picture. [39038800]
• Anthropometric analysis: planning by published ratios of nasal length, tip projection and radix projection to face height. [34498141]
• Nasofrontal angle: the angle where the nose meets the forehead, measured off the lateral view. [37153340]
• Alar base width: the width of the nose at the nostril bases, measured on the frontal view. [35139046]
• Colour fidelity: how closely the colours in the photograph match the subject under the lights used. [41136704]
• Frankfort plane: the head position used for every clinical view, held horizontal so that two photographs of the same patient can be compared. [7393578]

Where else this is documented

Sources outside the journals, each one free to read.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries a chapter on photography and one on the consultation the photographs are taken at. Both are written for surgeons and cover camera settings a patient page does not need.

• Photography for Rhinoplasty
• The Rhinoplasty Consult: Patient Evaluation

The reference summary

Rhinoplasty in StatPearls, on the National Library of Medicine's Bookshelf, sets out the preoperative evaluation, including the photographic record, in full text at no charge.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information. See associations.

The trials in progress

Automated reading of rhinoplasty photographs is under test.

• AI in Assessing Aesthetic Outcomes in Rhinoplasty, not yet recruiting, 20 participants.

What is not settled

• No trial tests whether showing a simulation changes satisfaction. The accuracy studies compare a simulation with a result, not one counselling method with another. [29789868] [25158684]
• Surgeons and patients value three-dimensional imaging differently, and the pooled evidence shows no difference in reoperation rate or operating time against flat photography. [39038800] [30859032]
• Whether a simulated image becomes a contract is argued, not measured. The imaging literature reports practice patterns rather than legal outcomes. [28432415] [26862968]
• The lighting studies are small, single-centre and judged by panels. The overhead-lighting trial rated 40 pairs of photographs, and the LED panel study rated one studio setup. [32614619] [41136704]
• Anthropometric ratios and surgeon-drawn simulations prescribe different noses in the same patient, and no outcome study says which prescription ends better. [34498141]