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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4366_Библиотеки_им_академика_М_И_Перельмана
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Chapter Digital Imaging and Standardized Photography in Rhinoplasty 115
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Flash and Lighting
Lighting is critical to the production of high-quality, standardized photographs
in rhinoplasty. e brightness of the ash determines the f-stop, which can aect
the depth of eld. Proper use of the ash allows the best possible depth of eld,
whereas excessive ash can lead to inappropriate aperture settings that can result in poor color quality and images with a washed-out appearance. Variations
in lighting arrangements, light sources, and light positions can have a dramatic
eect on photographic results.
Lighting is critical to the production of high-quality, standardized photographs
in rhinoplasty.
To demonstrate subtle external anatomy, including surface defects, contours of
the tip and tip-dening points, shape and symmetry of the dorsum, and the appearance and position of the alar cartilages, photographic lighting must provide
high-contrast detail of the anatomy and highlight texture and sharp lines of demarcation. An intense light source or sources such as studio strobe lighting, oncamera ash, ring ash, or twin ash without diusion are used to obtain this
denition. is is in contrast to the so, even, diused lighting desired for facial
rejuvenation surgery.
Although on-camera ashes have a tendency to create harsh shadows and uneven lighting, it is not always possible to have a dedicated photography studio
with separate lighting. To optimize results with an on-camera ash, it is important to consider the position of the ash in relationship to the camera to eliminate shadowing. is is particularly important in rhinoplasty, because lateral
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and oblique views are essential to the analysis. To prevent a projected shadow,
the ash should be on the same side as the anterior part of the patient, eectively
casting the shadow behind the patient. e image on the le (p. ) was taken
with the on-camera ash on the same side as the anterior part of the patient to
cast the shadow behind the patient, whereas the image on the right does not
have the appropriate ash orientation, resulting in signicant shadowing of the
patient’s prole.
Ring ashes tend to create even, at lighting that does not emphasize nasal anatomy. On-camera twin ashes are portable and simulate a studio ash system, but
have a narrow ash distance.
e most common system for medical photography is the studio ash system.
To prevent a projected shadow, the ash should be on the same side as the anterior part of the patient, eectively casting the shadow behind the patient.
Computer faces wall for patient privacy
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when images are downloaded
Chair
Chapter Digital Imaging and Standardized Photography in Rhinoplasty 117
141∕2feet
45-degree angle backlights to backdrop
Light
6-foot desk with partition
45-degree angle lights to patient
Backlight
Backdrop 9feet
Patient
position
14feet
Entry
Table for printer and consent forms
(2feet 6inches by 5feet 6inches)
Light table on wall
Photographer
Light
ceiling (5feet by 2feet 6inches)
Square photo room
4feet from
patient to
main lights
Equipment cabinet/floor to
Backlight
2feet from
backlights
to patient
2feet from
backlights
to backdrop
For high quality and consistency in rhinoplasty photography, we advocate the
quarter light system as a major studio system.
,
e quarter light system consists
of two symmetrically sized lights placed at -degree angles to the patient-camera
axis, with the patient to inches from the backdrop, depending on the use
of backlighting. e use of a backlight or backlights is recommended to provide
sharp contrast with the background and to further dene nasal and facial anatomy. e horizontal angle of incidence is the angle between the patient-camera
axis and the ash. Ideally, this angle is degrees. Manipulation of this angle
can have a profound impact on the appearance of nasal tip anatomy and tipdening points. erefore it is critical to maintain consistent light positioning.
For high quality and consistency in rhinoplasty photography, we advocate the
quarter light system as a major studio system.
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Ideal lighting consists of a pure light source that produces predictable results.
When a pure light source is used, the color temperature of the light source is
known and correction can be accomplished with lters and white balancing settings. It is essential to minimize the number of light sources and compensate for
their cast with white balancing to obtain accurate and reproducible color.
DIGITAL PHOTOGRAPHY AND DIGITAL IMAGING SETUP
e quality, resolution, and convenience of digital photography have made it the
standard in most rhinoplasty surgeons’ practices today. e ability to eliminate
the cost of lm development and the physical storage space for prints and slides
has been a major factor in the movement toward digital technology.
Space and Background
Although not always possible, having dedicated studio space improves eciency,
consistency, and patient privacy. Ideally, this space should measure at least by
feet, and the walls should be a neutral color such as so white. External light
from windows should be blocked. Most experts agree that a medium or light blue
tone is ideal for the background, because these colors are nondistracting and generally complement all skin tones. Furthermore, blue facilitates separation from
the background for patients with dark hair and dark complexions.
Most experts agree that a medium or light blue tone is ideal for the background,
because these colors are nondistracting and generally complement all skin tones.
Memory Card
Memory cards function as digital lm that can be reused thousands of times before being replaced. Rapid advances in technology have made digital images easy
to store, transfer, and copy with diminishing cost. ese images can be printed
and used in the operating room as a reference for the operative plan and the desired aesthetic goals. Furthermore, images can be readily accessed for resident
education, presentations, and consultation with colleagues. With proper imaging
soware, postoperative simulations can be created to facilitate patient consultation and dene the aesthetic goals.
Chapter Digital Imaging and Standardized Photography in Rhinoplasty 119
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Cameras
e digital point-and-shoot and the digital single-lens reex (DSLR) cameras are
the two principal types of digital cameras on the market today. DSLR cameras
use interchangeable lenses and can accommodate top-mounted ashes. Additionally, with a DSLR camera, photographers can use manual controls and xed
focal length lenses, which make the DSLR camera optimal for the production of
standardized photographs.
,
Digital cameras are stratied by their quantity of megapixels. A higher number
of megapixels translates into greater resolution, which is the amount of detail in
an image. erefore more megapixels will lead to greater resolution and better
image quality, and the size of the pixels contributes to the resolution. Although
digital point-and-shoot cameras and DSLR cameras can have the same number
of megapixels, the DSLR will generally have larger pixels. ese larger pixels
gather more light, creating an image with greater tonal range and resolution.
,
Digital Imaging Soware
Most operating systems today come with soware for basic needs of storage,
viewing, and editing images. However, several additional applications oer advanced features for viewing, archiving, and retrieving images. In addition, specialty soware is available that allows surgeons to morph images to simulate
operative changes.
Organization is essential for storing digital images. For each patient, an individual
le should be maintained. Several advanced programs are available that allow
searchable key words to be attached to images, including diagnosis, procedure,
demographics. Examples include Mirror by Caneld Scientic, Inc. (Faireld,
NJ), Portfolio by Extensis (Portland, OR), Apple iPhoto (Cupertino, CA), and
ACDSee (ACD Systems, Seattle, WA).
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PHOTOGRAPHIC STANDARDS IN RHINOPLASTY
Standardized, high-quality photographs of the nose are imperative for preoperative planning, postoperative comparison, and demonstration of surgical results.
is calls for standardized lighting, proper patient positioning and views, prevention of lens distortion, and consistent camera-to-subject distances.
Focus
To achieve reproducible, standardized photographs, the use of a set distance is
recommended rather than autofocus. e camera’s position can be manually adjusted to obtain a sharp focus. e reproduction ratio, which is the scale to which
the photograph renders the subject, can also be used to obtain consistent results.
Patients tend to vary in size; therefore using a standard subject-to-camera distance will not provide consistent anatomic pictures. Anatomic framing can be
used to overcome this problem and achieve consistency. is is done by framing
the subject, using the hairline superiorly and the sternal notch or thyroid cartilage prominence inferiorly. Some authors emphasize placing a ruler at the side of
the face as an index of magnication to obtain life-size photographs for accurate
denition of the aesthetic goals and surgical planning.
Focal Point
In determining the focal point, it is oen easiest to use denitive structures with
sharp lines such as the eye. e use of a high aperture setting to create a large
depth of eld with focus on the eye is recommended. e subject is then adjusted
in the frame aer focusing is completed. If autofocus is employed, the center
circle focal point is locked on the eye, and the subject can then be reframed in
the viewnder.
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Photographic Anatomy
e goals of photo documentation for rhinoplasty patients are to dene the existing nasal anatomy, the aesthetic goals, and the operative plan. Photo documentation must be thorough and include the following:
■
Nasal dorsum: Deviations, nasal bone height, width, and transition into
the nasal tip
■
Nasal tip: Tip shape, tip-dening points, height of the infratip lobule, alarcolumellar relationship, and nasal base width
■
Prole: Radix, dorsal height, dorsal irregularities, supratip break point, tip
projection, nasal length, columellar-labial angle, columellar-lobular angle,
alar-columellar relationship, and the position of the lateral crura
■
Nasal base: Nostril size and symmetry, nostril-lobule ratio, nasal width,
columellar width, alar width, alar position, so tissue triangle, and scars
from previous open rhinoplasties
■
Full face view: Relationship of the nose to other facial features
Standard Views for Rhinoplasty Photography
e six standard views necessary to critically evaluate nasal anatomy and the underlying nasal framework are the frontal, prole (le and right), oblique (le and
right), and basal views. Although some variations in positioning are preferred
for the oblique and basal views, it is important to maintain consistency when
obtaining these images. For additional analysis, dynamic views can be obtained
to assess the dynamics of the nasal tip and alar base during smiling, and the cephalic view to further highlight existing deviations.
e six standard views necessary to critically evaluate nasal anatomy and the
underlying nasal framework are the frontal, prole (le and right), oblique (le
and right), and basal views.
Head Position
To standardize views, careful attention must be given to head position, because
changes can aect the appearance of the nose. All jewelry and makeup should
,
be removed.
in the smiling views.
e patient should be relaxed with no facial expressions, except
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e patient needs to look straight ahead with the head positioned in the natural
horizontal facial plane. Gaze is directed at a xed object in the room that is located at eye level to maintain consistency. e position of the earlobes with respect to the base of the nose should be noted. is can help to determine head
tilt or rotation when comparing photographs. Subtle changes in head rotation
and tilt can mask asymmetries if they are not recognized.
,
Some authors advocate use of the Frankfort horizontal plane to standardize head
position. However, in patients with low-set ears, this reference plane can cause
the chin to appear weak and create the illusion of a more acute nasolabial angle.
When using the Frankfort horizontal plane to determine head position, an additional point of reference can be obtained by placing an easily removable sticker
or marker at the level of the infraorbital rim (red dot) to dene the true Frankfort horizontal plane.
Frontal View
For the frontal view, the patient should look
straight into the lens. e head is in the natural
horizontal facial plane with the camera at eye
level. e patient is anatomically framed using
the top of the hairline as the superior border
and the thyroid cartilage prominence as the
inferior border. Reproduction ratios of : for
full face views or : for close-ups are recommended.
Lateral View
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Chapter Digital Imaging and Standardized Photography in Rhinoplasty 123
e lateral view is obtained with the patient looking straight ahead and the head
positioned in the natural horizontal facial plane.
Oblique View
e oblique view can aid in further characterizing asymmetries of the dorsum
and supratip area. e patient is turned to line up the tip of the nose with the
lateral cheek, or to line up the dorsum with the medial eye.
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Basal View
e basal view can be obtained using the full basal view or the half basal view.
e head is tilted back, and the head and chin make up the anatomic frame superiorly and inferiorly, respectively. In a full basal view, the tip is lined up between
the eyebrows. In the half basal view, the nasal tip is lined up with the medial canthi. ese views provide information on nasal base width and symmetry, nostril
size, and tip width. Characteristics of the dorsum can also be highlighted in the
half basal view.
Cephalic View
e cephalic or overhead view can highlight subtle external nasal deformities and
reveal deviations that are not obvious on frontal view. In this view, the eyebrows
are used to align the patient horizontally.
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