Lately I have been thinking a lot about how to create a better photographic record of my aesthetic work. Before and afters (B&A) are not only an integral part of the plastic surgery medical record, they are, along with patient reviews online, a key ingredient to our marketing campaigns. Even with white papers from plastic surgery societies on best practices for photography, many of us still struggle about how to tell an appropriate visual story to prospective and established patients. With the mushrooming of social media and the use of photo filters and collages, the standard B&A photo pair seems increasingly inadequate to captivate our patients' attention.

There are several specific issues at hand that affect our ability to create such an ideal photographic record, and while we do have some high-tech solutions to these issues, many challenges—and opportunities—remain, including:

Issue at hand: Hard-to-get postop photos

Many of us have out-of-town or otherwise difficult-to-reach patients who do not give us the chance to get a set of postoperative views that match the preoperative set.

Current high-tech solution: We can leverage our patient engagement tools—HIPAA-secure texting apps, EMR portals, customer e-blast services, etc.—to send reminders to patients to follow up in the office when possible or to furnish us with photos staged in poses similar to the preops. If your patient permits you to email, and you have a HIPAA business associate agreement (BAA) signed with your email provider, you may be able to simply send the patient her preop photos with instructions on how to shoot similar pictures.

The next big idea? Some portals can enable practices to send patient reminders for reviews. Perhaps we can send photo templates to the patients, too.

Issue at hand: Lack of space, both physical and virtual

Using a dedicated room or space in the office for photos is ideal assuming you can afford the space. Mature practices tend to get this right by allocating a full exam room-sized area with appropriate flash lighting, pedestals and floor markings to aid in the patients' posing process, not to mention back walls with a consistent paint job to ensure B&As all have the same background. In some scenarios, the cost of putting medical office space into service as a photography studio instead of a revenue generator is often prohibitive. Having at least one wall free of decorations and with enough head- and side-room can ensure some background consistency. Pull-down screens on the back of exam room doors can also be useful (I find standard doors are too narrow to allow a wide background for all angles of body photography).

Current high-tech solution: Post-production tools like Pixelmator can be used to clean up backgrounds and shadows, to pixelate tattoos, or to place logos over nipples to make photos more social media-ready. Of course, it is vitally important not to alter the substantive content of the image itself or be accused of unethical manipulation.

Tools like Watermark Plus and Picture Collage Maker can add logos, balance the perspective and zoom and copyright-protect images.

RxPhoto is a photo management suite that includes a photo “ghosting” tool on iPad, which allows the user to see the preop photo as a template behind the image being captured, to facilitate consistent distance and frame cropping of the image. This application also provides a rich library of metatags and the ability to build educational galleries for specific procedures that can be shared with patients.

The next big idea? The ability to add metatags is a critical functionality missing from some EMRs, which usually must archive at least a copy of patient photographs to have a complete “single source of truth” on the medicolegal record. Metatagging allows the same image to be labeled with multiple properties that can be used to sort multiple images across search queries to show cases similar to the prospective patient's background and goals. This also reduces the storage capacity required to maintain galleries, as the repository does not need to have duplicate images.

Canfield has been an industry leader in this arena, with its legacy Mirror program and newer photo capture and simulation tools like the Vectra device and Visia system. These programs sit at the intersection of photo archiving with simulation and compete with products like Crisalix, which provides 3D image models that can be morphed with simulation tools for patient education. It can be instructive to compare these models with the final outcome of surgery in postop patients to validate the usefulness of modeling as part of your sales process and to improve one's morphing skills and facility with these tools. Some of these systems can be connected to virtual or augmented reality headsets like the Samsung Gear VR, with Oculus Rift. Magic Leap and other technologies have potential uses for medical photography and simulation. Surgeons using these systems must disclaim that this is no guarantee of final surgical outcome for the patient.

Issue at hand: Photo-shopping for surgeons

Instagram has become a major marketing vehicle and is seemingly tailor made for sharing our photographic record. However, there are certain considerations for optimizing photos and video on this platform. First, community standards on Instagram are such that uncovered nipples or bare gluteal regions can be flagged as inappropriate; get into a habit of post-processing your raw B&As for Instagram format, including square image formats. Captioning with appropriate and commonplace hashtags will greatly increase the reach of your post. Instagram's polices and formats put it somewhat at odds with other photo sharing destinations—your own website, RealSelf, Yelp, Zwivel, etc.—meaning you need to keep various versions of the same patient's images stored for the various use cases.

Current high-tech solution: I use a platform called Picture Collage Maker, which has presets for different format photos (e.g, square for Instagram, iPad-optimized, custom shapes) and allows templates where I can substitute different images easily. This allows creation of multiple versions of slides for different distribution channels. However, the work of publishing the images to different sites still remains very manual.

The next big idea? Perhaps one of us will develop a killer app for syndication of these images to downstream destinations to simplify this workflow?

Tim A. Sayed, MD, MBA, FACS has more than a decade of experience practicing plastic surgery in Southern California and South Florida. He is Vice President of Physician Engagement at Interpreta, Inc., a health software startup in San Diego. An expert on the interface of healthcare and technology, he serves as an advisor and investor in numerous digital health and medical device companies.