office set up for photography

Plastic Surgical Nursing ❙ October-December 2009 ❙ Volume 29 ❙ Number 4 203

If set up properly, this arrangement will minimize thedecisions that must be made by the photographer andwill provide the most consistent pictures with theleast amount of input by the person (or persons) tak-ing the pictures. Of course, not all variables can bestandardized or automated. The photographer mustknow how to position the patient reproducibly andmust remember what poses are required for each typeof procedure being documented. Another advantageof the studio setup is that the flash units are poweredby 110 V AC (alternating current), so there is essen-tially no delay necessary between flashes. Anyone whohas stood in front of an undressed patient waiting forthe flash to recycle will appreciate this.

One disadvantage of this studio setup is that aseparate room is required, and although it needs notbe large, this may be an issue in a small office. Also,the patient must be moved from the examinationroom into the photo room, which can cause logisti-cal difficulties, especially in a busy practice whenmore than one surgeon is seeing patients at thesame time. When body photographs are beingtaken, one must decide whether the patient willundress in the examination room and be escorted tothe photo room in a gown, or whether a changingarea will be provided in the photo room, in whichcase the patient may be dressing and undressingbetween rooms unnecessarily. When planning thephysical layout of an office, these types of patientflow issues must be considered.

The other option is to take the photos in eachexamination room, using a camera with an on-camera flash. This provides the convenience of nothaving to move the patient between rooms. For abusy multi-surgeon practice where space is at a pre-mium, it may be the only alternative. The downsideis that this method requires more input from the

Most clinical photographs utilized in a plastic surgicalpractice are taken in the office setting, primarily to

document surgical results. This article will discuss the vari-ous ways that the office environment can be optimized forclinical photography.

THE SETTING

The first decision that must be made is whether thepictures will be taken in a room that is dedicated tophotography only, with fixed “studio” lighting, orwhether photos will be taken in each examinationroom. There are pros and cons to each approach, butin general, it is best to have a dedicated photographyroom. As pointed out in the previous article, consis-tency is the most important element in clinical pho-tography (Hagan, 2008). The before and after picturesmust be taken in exactly the same way, with exactly thesame lighting and camera. For many reasons, this ismuch easier to achieve with a studio lighting setup ina room used only for photography. In such a room,the lighting is set in a fixed position, and the patient isplaced in the exact same location each time. The cam-era used is always the same, and even the F-stop(aperture) of the camera will always be set the same.

Setting Up Your Office for Clinical PhotographyKevin Hagan, MDMarcia Spear, ACNP-BC, CPSN, CWS

Kevin Hagan, MD, Associate Professor, Department of PlasticSurgery, Vanderbilt University, Medical Center North, Nashville,Tennessee.Marcia Spear, ACNP-BC, CPSN, CWS, Nurse Practitioner andCertified Wound, Department of Plastic Surgery, VanderbiltUniversity, Medical Center North, Nashville, Tennessee.The authors have no conflict of interest.Address correspondence to Marcia Spear, ACNP-BC, CPSN, CWS,Department of Plastic Surgery, Vanderbilt University, D-4207,Medical Center North, Nashville, TN 37232 (e-mail: [email protected]).

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204 Plastic Surgical Nursing ❙ October-December 2009 ❙ Volume 29 ❙ Number 4

photographer to achieve consistency. It is not prac-tical to install fixed flash systems in every examina-tion room, so the on-camera flash (or the flash builtinto the camera) is used. This requires the photog-rapher to remember how to properly position theflash for each pose to avoid undesirable shadows, inaddition to remembering how to set up the pose andso forth. Even with today’s automatic flash settings,these extra variables create inconsistencies that aredifficult, but are possible, to overcome. If the cam-era should break or simply wear out—common withtoday’s complex electronic digital cameras—onemay find that the new camera that replaces it has aslightly different flash color, referred to as flash tem-perature, and the new pictures will not look quitethe same as the old ones. Also, as good as today’sautomatic flash metering systems are, these systemscan be fooled by certain skin colors and clothing,creating pictures of varying brightness. That said,excellent photos can be taken in this fashion, andfor certain poses, on-camera flash actually givesbetter clinical photographs than a studio lightingsetup.

THE BACKGROUND

Regardless of which of these two setups one choos-es for the photography location, a suitable back-ground will be needed to pose the patient in frontof. A variety of colors has been used for clinical pho-tography backgrounds, and there is no one correctcolor. However, various shades of blue and gray aremost frequently used. Medium sky blue is a goodchoice because it provides a nice color contrast withskin tones, yet the difference in intensity is not hardon the eyes (Hotta, 2007). Medium to dark gray isalso a good choice. Darker backgrounds have theadvantage of minimizing the effect of visible back-ground shadows, but beware of colors that do notprovide enough contrast with dark-skinnedpatients. A black background will eliminate shad-ows completely, but in general, it is best to avoidblack and white, which can create too much con-trast and give a harsh picture. Experiment a bit,choose a color that is found satisfactory, and staywith it. Ideally, one should use a consistent back-ground color for all of pre- and post-operative pho-tos throughout one’s career.

The simplest background is a painted wall. It isimportant to use flat latex wall paint, not gloss,semi-gloss, or satin—any amount of sheen in thepaint will cause reflections of the flash and will beunsatisfactory. Choose paint from a well-knownmanufacturer, and write down the color or mixingformula so that the color may be duplicated in thefuture if the wall needs repainting or if a change ofoffices occurs. It is best to paint the wall all the way

to the floor, with minimal or no baseboard if possi-ble. The wall should be smooth, so do not use a wallwith a textured surface. The idea here is that thebackground should become “invisible” and theviewer’s eye should be drawn to the patient, not tothe background. For this reason, do not use fancy orpatterned backgrounds such as those used by por-trait photographers.

Another background option is to use a large rollof photographer’s background paper suspended bya horizontal bar. This paper comes in variouswidths and colors and has the advantage that itmay be draped onto the floor, allowing standingphotos of the feet and lower legs with a seamlessbackground. If the paper becomes soiled, it can bediscarded, and a new section can be re-advanced.This setup works well in a room dedicated to pho-tography, but appears a bit unwieldy in an exami-nation room.

A third option, which provides many of the ben-efits of photographer’s paper, but with a more ele-gant appearance suitable for an examinationroom, is to use a large custom-made windowshade. Most custom drapery and window shadedealers can fabricate these in virtually any fabriccolor. They can be made long enough to drape ontothe floor so that the patient may stand on it forlower extremity photos and wide enough toaccommodate full-body photos. A width of at least48 in., preferably 72 in. if the space permits. Whennot in use, these shades can be rolled up out of theway. Such a background shade could even be usedon a wall with a window, in which case, it will pro-vide not only a background but also privacy fromoutside viewing. The lowering mechanism can bemanual, with a looped pull cord, or it can be elec-tronic, wired to a wall switch. The current authorshave found the electronic models to be moredurable over time (Figure 1).

Figure 1. A mechanized photo screen, controlled by a wallswitch. (A) Screen rolled up into the ceiling. Note that thewindow would make this wall otherwise unsuitable for aphoto background. (B) Screen extended. This screen isonly 44 in. wide and is too narrow for certain types ofbody photographs. (C) This screen is 72 in. wide, ideal forfull-body photographs.


facial photos, the patient (and the photographer)may be more comfortable sitting on a swivel stool,again positioned above the same spot in front ofthe background.

The necessary poses needed for clinical photoswill require that the patient be positioned at 0�, 45�,90�, 135�, 180�, 225�, 270�, and 315� from the pho-tographer (Figure 2). To help orient the patient,marks can be placed on the walls at 45� on eitherside and at 90� on the opposite walls. The patient isthen told to turn and face the mark. For ease ofexplanation, the wall markings can be of differentcolors so that the patient is asked to “turn to the leftand face the red dot, turn to the right and face theblue dot,” and so forth. A more elegant and accurateway to achieve this is to have four narrow mirrorsmade (about 5 in. wide and 48 in. tall) at a frameshop. Mount the mirrors at 45� and 90�, angled sothat the patient can see herself/himself in each mir-ror when standing on the spot in front of the back-ground. For each angled pose, the patient is simplyasked to turn and look at her or his eyes in the mir-ror. If the plan is to take pictures with the patientseated on a stool, be sure that the mirror extendsdown far enough to be seen from the lower height(Figure 3). Unfortunately such wall marks and mir-rors cannot be placed on the background for theposterior angles. Another alternative is to perma-nently mark the various angles on the floor and/oron the standing stool, again using different colors,to help the patient orient herself or himself (Figure 4).To standardize the distance from which the photosare taken, the photographer should also have apoint marked on the floor on which to stand. Onemay also choose to have different distance marksfor facial, breast, and full-body shots, or if a zoomlens of adequate telephoto focal length is used, onecan shoot all photos from the furthest (full-bodyshot) distance—approximately 7–8 ft.

THE DEDICATED PHOTO ROOM

When planning and setting up a room in the officethat will be used primarily for photography, thereare a number of variables to consider. How largemust the room be? If the practice involves facialsurgery almost exclusively, a small closet-sizedroom will do. To avoid distortions, there must beroom for the photographer to stand at least a con-versational distance away from the subject,preferably with the camera at least 4 ft from thepatient (Malaysian Internet Resources, 2000). Ifthe photographs include breast or lower extremityshots, a longer distance will be required, perhaps5–6 ft from the subject. Finally, if the practiceincludes a significant amount of postbariatriccontouring where full-body photos will berequired, at least 6 ft and preferably 8 ft or moreshould be allowed. The width of the room will alsodepend on the type of photos that will be taken. Anarrow room will easily accommodate facial pho-tos, but full-body documentation, including fullyextended arms for brachioplasty photos, willrequire a room of at least 6 ft wide. In any case, a6- by 10-ft room is large enough for any type ofclinical photography.

The ceiling of the room should be white. Manyoffice buildings will have drop ceiling acoustical tiles,which are fine as long as they are white. To achievethree-dimensional depth in clinical photos, someoverhead lighting is helpful, and a white ceiling willhelp downwardly reflect some of the light from theflash output. A reflective silver or glossy white ceilingwould be ideal, but a bit impractical. The wall coloris not as critical, but in any case, it should be a neu-tral color, preferably white or off-white.

As discussed earlier, one wall of the room willbe used for the background. To achieve consisten-cy in photos, it is absolutely essential that the cam-era be held the same distance from the patient forboth the pre- and post-operative photos. Anychange in camera to subject distance will intro-duce distortion (Hagan, 2008). To aid in position-ing the patient at the correct distance from thebackground, make a mark on the floor in front ofthe background. This can be done with paint orcontact paper. The patient will be asked to standon that spot. The distance that this is from thebackground will depend on how much room onehas to work with. The greater the distance thepatient is from the background, the less noticeableany shadows will be on the background. An idealdistance would be about 30 in., but in a smallerroom 18 in. will do. Another option would be touse a small standing stool, placed at the same spot,on which the patient will be positioned. Maintain-ing the same distance to the background is impor-tant, especially when using on-camera flash. For

Figure 2. Proper posing will require the patient to faceseveral different angles, depending on the procedure beingdocumented.


There are several types of flash units, oftenreferred to as strobes, that can be used in a portraitstudio, but for purposes of clinical photography, thebest type to use is self-contained units called mono-lights (Figure 5). These flashes plug into a regularAC outlet and have adjustable light output. They aremounted on poles, which usually rest on a tripod onthe floor, but in the case of clinical photography,they will be mounted on the wall or ceiling. Theseunits are sold only in stores that cater to the profes-sional photographer, so if one lives in a smaller city,these units may have to be purchased by mail order.There are many excellent manufacturers, but onebrand that these authors can recommend highly ismade in the United States and sold directly by themanufacturer is Paul C. Buff (n.d.; www.paulcbuff.com). They manufacture the White Lightning andAlienBees brand flash units. Two mono-lights areneeded, and any unit with about 600 W-s of outputshould be more than sufficient. Expect to paybetween $350 and $550 per unit, but one may beable to find a two- or three-strobe kit at some costsavings. Another excellent source for all types ofprofessional photo lighting equipment, includingcameras, mono-lights, and ceiling, and wall mount-ing brackets is B & H Photo (n.d,; www.bhpho-tovideo.com). There are many other quality sources.

Professional photographers usually use devicesattached to the flash that are designed to disperse orsoften the light. These devices are intended to createa softer, more pleasing portrait and make fine wrin-kles and blemishes less noticeable. They also addthree-dimensional depth to the photo and may beparticularly helpful for breast and body photos.There are generally two types. The first is called anumbrella, and it is designed to scatter and reflectthe light from the strobe back on to the subject. Theflash is actually aimed backward at the umbrella,

STUDIO LIGHTING FOR THE PHOTO ROOM

The biggest advantage of the dedicated photo roomis that the lighting is permanently placed andremains consistent. This is unlike a portrait studio,where the lighting is typically moveable and vari-able, often held in position by floor stands that areeasily moved. The portrait photographer uses thisadjustable, asymmetrical lighting to create moodand character in his photos. For clinical photogra-phy, neither is appropriate. The lighting must beconsistent and symmetrical, which allows one topermanently mount the lights from either the ceilingor the walls. Doing so removes clutter from the floorand keeps the lights in the same position always.

Figure 3. Placement of strobe lights and wall targets. Notethat the flash units should be a maximum of 45� apart.

Figure 4. Patient step stool with color-coded positioningmarks on stool and floor. (Photo courtesy by The PlasticSurgery Center of Nashville.)

Figure 5. A mono-light strobe flash. These powerful unitsplug directly into AC outlets and provide almost instantrecycle times.


and the light then reflects forward toward the sub-ject. A silver-coated umbrella gives the most con-centrated light, and a white umbrella gives a softerlook. The larger the umbrella, the more the light isscattered, and the greater the softening effect. Thesecond type of diffuser is called a soft box. Thisdevice is attached to the end of the flash, which ispointed toward the subject. The light from the flashis forced to shine through a white fabric panel onthe end of the soft box, which has the effect of dif-fusing and softening the light. Again, the larger thesoft box, the greater the softening effect (Yavuzer,Smirnes, & Jackson, 2001; Figure 6).

Because the goal of clinical photography differsfrom that of the portrait photographer, the use ofvery large diffusion devices may be counterproduc-tive, especially when taking facial or nasal photo-graphs (Yavuzer et al., 2001). The softening effect ofthe diffuse lighting often obscures facial details orimperfections that need to be seen from a clinicalstandpoint. Nevertheless, some light diffusion doesgive an improved three-dimensional view in breastand body photos, and the overhead illuminationprovided by the diffused light that bounces downfrom the white ceiling will provide some additionaldefinition of infra-orbital fat pads and others. It isnot essential to use umbrellas or soft boxes in a stu-dio setup, but if one chooses to do so, the umbrellasand soft boxes should be kept small. A 32-in. whiteor silver umbrella or a 15- � 18-in. soft box shouldbe all that is needed.

The next step in setting up a clinical photographystudio is positioning the flashes. It is best to keep

the flash units fairly close together or at a fairlytight angle to the midline. Some articles suggestthat the lights should be at 45� angles to the patient(90� angles to each other), but this is too far spreadapart and often results in unnatural shadows, over-accentuating the nasolabial folds (Galdino, DaSilva,& Gunter, 2002; Figure 7). It is recommended byplacing the flashes just above and lateral to the pho-tographer. This will usually result in an angle of15�–22� from the midline or 20�–45� from eachother (Figure 3). Experiment, purchase an inexpen-sive set of tripod stands, and place the lights in var-ious positions. Take some pictures, and note espe-cially the shadowing created on either side of thenose on the front nasal view. The less shadow seenhere, the better.

Most mono-lights have modeling lights built in.These are incandescent lights that can be turned onto see what type of illumination the flash will givewithout having to actually take a picture. They arenot nearly as bright as the flash itself, so to use themeffectively all the room lights must be turned outand remove as much ambient light as possible.Then position a subject and see what type of illumi-nation results when the flash goes off. One can alsosee what shadows may be visible on the back-ground. By moving the flash units around, the dif-ferent effects of flash placement can be observed.There is really no reason to get too fancy herethough. Placement of the units as described abovewill give good results. Once one has chosen the bestplacement for the flashes, it can be determinedwhere the ceiling mount must be placed. The lengthof the mounting poles may be adjustable, but theceiling positioning usually is not (Figure 8). Theseflashes run on standard AC. Because they will bemounted fairly high, it is best if one can have anelectrician wire his or her outlet box to a wall switchso that all units can be turned on and off with a flip of a single switch. Once the flash units are

Figure 7. Photo taken with lights 90� from each other, 45�from the midline. Note that the unnatural shadows fromthe nose inaccurately accentuate the nasolabial folds.

Figure 6. An umbrella (left) and a soft box (right). Thesedevices are used to soften and diffuse the light from thestrobe flashes.


wide angle reflector or a soft box so that it does notcause “hot spots” or overly bright areas on the back-ground. In general, such backlighting can work wellwhen photographing a limited area, such as the heador above the waist, but it is very difficult to achieveeven background illumination for large areas.

As previously mentioned, overhead light is oftenhelpful to enhance the visualization of certaindetails such as wrinkles, infra-orbital skin laxity, etc.One technique that can be useful is to use a thirdflash mounted in the center of the room and aimedup at the ceiling to bounce light from the white ceil-ing above back to the subject. This increases theamount of overhead lighting in the photo. If thisthird flash is used, the flash must be used on all yourphotos, both pre- and post-operative.

USING THE EXAMINATION ROOM AS THE PHOTO STUDIO

If one has chosen to take clinical photographs in theexamination rooms, a background will need to beprovided in each room that will be used for photog-raphy. As mentioned previously, a painted wall willsuffice as long as the wall is flat with no distractionssuch as pictures, window, otoscope, light switch,and so forth. A custom motorized shade can be usedon a wall with a window and will have the addition-al advantage of providing some privacy from out-side viewing. However, beware of using such ashade over a door that opens inward because aninadvertent door opening may damage the screen.

It will be the individual’s choice to decide ifmarks or mirrors will be used on the wall for help inpatient positioning. In any case, it is very helpful toinclude the floor marking spots for both the patientand the photographer to ensure consistent distancebetween photographs.

permanently poisoned, the modeling lights will beunnecessary, but one might want to leave themenabled so that one will be aware of when the flash-es are powered on. For longevity of the flashes, it isbest not to leave them powered all the time—justflip the wall switch when needed.

The flash units must somehow receive a signalfrom the camera that tells them that the camerashutter is opening, and it is time for the flash illu-mination to occur. The simplest way to achieve thisis with a thin electrical cord, called a sync or PC.Both devices are used to connect a flash unit to acamera. Purchase a long one of these when themono-lights are purchased. There are other moresophisticated (and expensive) ways to accomplishthis, such as the use of an infrared or radiofrequen-cy triggering devices, but the synch cord is simple,inexpensive, and very reliable. Most mono-lightunits have a built-in light sensor, which senses whenanother flash has gone off and immediately triggersthe flash to fire, so the signal only needs to be givento one strobe and all of the others will flash auto-matically.

Some clinical photographers choose to use addi-tional flash units to illuminate the background oreven lights specifically aimed to highlight the hair.These are techniques used by portrait photographersand are unnecessary for clinical photography. Theless background clutter and distraction created, thebetter. However, if problems are experienced withvisible background shadowing, a light mountedbehind the subject, pointed back to the backgroundmay be helpful (Figure 9). Be certain that it has a

Figure 8. Flash with umbrella mounted to ceiling. Notepower cord that is plugged into ceiling receptacle, whichis controlled by a wall switch.

Figure 9. A flash used as a backlight to illuminate thebackground.


CONCLUSION

This article has discussed aspects of clinical photogra-phy, with the exception of the camera, including light-ing, photography setting, background, and accessories.Camera selection will be discussed in the next article.

REFERENCESB & H Photo. (n.d.). Retrieved February 24, 2009, from

http//www.bhphotovideo.comGaldino, G. M., DaSilva, D., & Gunter, J. P. (2002). Digital

photography for rhinoplasty. Plastic and ReconstructiveSurgery, 109(4), 1421–1434.

Hagan, K. F. (2008). Clinical photography for the plastic sur-gery practice—The basics. Plastic Surgical Nursing, 28(4),188–192.

Hotta, T. (Ed.). (2007). Core curriculum for plastic surgicalnursing (3rd ed.). Pensacola, FL: American Society ofPlastic Surgical Nurses.

Malaysian Internet Resources. (2000). Photography: The resourcepage. Retrieved February 24, 2009, from http://www.mir.com.my/rb/photography/fototech/apershutter/aperture.htm

Paul C. Buff. (n.d.). Retrieved February 24, 2009, fromhttp//www.paulcbuff.com

Yavuzer, R., Smirnes, S., & Jackson, I. T. (2001). Guidelinesfor standard photography in plastic surgery. Annals ofPlastic Surgery, 46(3), 293–300.

For more than 9 additional continuing education articles related to physical

assessment/diagnostic, go to NursingCenter.com/CE.

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