purposes.” Is it planned to use these photos in a closed “in house” teaching event or for use in a conference? Or is it “education” for potential new patients?

Practical Tips for Consent for Photography

Patients should be asked to consent specifically to the use of their photos for particular purposes:

1.The doctor’s own clinical record

2.For use in the doctor’s or nurse’s office as talking points for other patients

3.Display of the photographs in the waiting room

4.Use of the photos for medical conference presentations in projected slides

5.Publication of photos in magazines, books, newspaper, TV advertisements

6.Publication of photos on the practice website or other internet options

All of these scenarios need to be explored specifically with the patient. If this is neglected then the patient will most likely have a strong case against you if they decide to follow legal pathways.

Consent also needs to address the issue of time frame. Is it reasonable to use an image taken and its use consented to several years past? Circumstances may have changed with the patient and a previously given consent may be long forgotten. This may cause difficulties for both the patient and the practitioner. I would urge anyone planning to use an identifiable image of a patient to make sure they have specific, written consent for its use. Secondly, inform the patient that you are about to use their image in the particular format so that they are not caught by surprise by any of their friends who sees the image before they themselves do.

9.9 Special Problems with Consent

Many patients are only too willing to allow their image to be used in a medical teaching format such as a presentation at a medical conference. However, it is becoming more frequent for others in the audience to video or at least take still photos of the presentation. This is a breach of trust; firstly against the doctor presenting the material and secondly against the patient.

The patient gave their permission to their trusted medical practitioner with specific conditions. That consent does not extend to the unknown doctor in the audience who “steals” that image. I personally have had the experience whereby a photo in one of my presentations featured in another doctors advertising.

Another area where one can be caught is with tattoos or particular items of clothing. Although a patient’s face may be obscured or another part of the body featured in the photo, distinctive tattoos, a particular piece of jewelry (bracelet, necklace, pendant, etc.) may be identifiable. While it might be argued that even though the patient (or family) might recognize the subject, others would not and thence confidentiality has been honored; the fact that the patient can recognize themselves may translate into a sense of betrayal of trust and lead to serious consequences. We must remember that many of our patients are vulnerable, and with a heightened sense of fear.

9.10 Radiology

No chapter on facial imaging would be complete without some mention of the more purely clinical imaging techniques.

X-ray is the traditional imaging technique which has served very well for many years. It is useful as a quick initial radiologic examination of the facial bones for fractures or in assessing placement of screws/alignment post-surgery (Fig. 9.11). X ray utilizes a high energy electromagnetic beam that penetrates the anatomy in question and impacts onto the x-ray sensitive film plate. Dense structures, such as bone, attenuate the x-ray (block), whereas soft tissue structures let it pass through. The resultant image is one of shades or white/grey. Certainly, soft tissues can be imaged to a degree by lowering the intensity of the beam but this will also sacrifice clarity. Both figures display the clear outline of the bony anatomy but suffer from a confusion of overlying and surrounding anatomical structures making interpretation of anatomy off the main axis of focus much more difficult.

9.10.1 Computed Tomography (CT)

Computed tomography (CT) is an excellent imaging technique for imaging the bones and their alignment in the face (Fig. 9.12). A plain CT shows slices in coronal

or sagittal or even horizontal planes. For composite images, an x-ray source rotates around the face, with x-ray sensors opposite the source collecting the data. The patient continuously moves through the CT tube, whilst the x-ray tube and detectors rotate around the face, enabling three-dimensional data to be acquired. This data in turn can be visualized from multiple orientations. The obvious advantage of CT of the face is the exquisite delineation of bony anatomy with high resolution, with no superimposition of anatomy as per x-ray.

9.10.2 Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging (MRI) is the modality of choice for imaging the soft tissue structures of the face (Fig. 9.13). MRI utilizes a strong magnetic field together with radiofrequency pulses on the resonant frequency of hydrogen to obtain the images. The RF pulses excite the hydrogen atoms of the tissues and in turn these tissues emit a signal which the MRI machine collects to form an image. MRI has excellent definition

of soft tissue structures, with better soft tissue characterization than all other imaging modalities. MRI is used primarily to look for soft tissue masses, bony masses, soft tissue anatomy, nerves of the face, and orbits. It is not used for imaging cortical bone, as it has no hydrogen component and appears black (hypodense)

on the MRI pictures. CT is best if looking for fractures, bony alignment, etc. MRI is the imaging modality of choice if looking for perineural spread of SCC and can identify extensions into the orbit or oral cavity of this dermatologic tumor. So, as a planning tool, it is very useful in surgery.