The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

Digital images, like any other form of digital data, can be easily copied, stored, dis-
played, and accessed. These images can readily be shared with colleagues for con-
sultation purposes, either face to face or over the Internet. Images are also easily im-
ported into presentations. Multiple informational tags (such as age, date, and
procedure performed) can be stored with images to facilitate archiving, searching,
and retrieving in large image databases (for example, for instant access to and dis-
play of all blepharoplasty cases). Digital images are easily copied, so all of this can
be done without loss of the originals. These images can be easily printed so that pre-
operative photographs can be displayed in the operating room and referred to during
a procedure. An even more advanced method of having clinical photographs avail-
able in the operating room is to establish wireless connectivity between the imaging
computer and an LCD monitor, bypassing the need to print photographs.
The advantages of digital photography have also had a significant impact on patient
and resident education. With the incorporation of LCD monitors and the playback
capabilities of digital cameras, digital photography provides instant feedback on clin-
ical photographs. Any problems with lighting, patient positioning, or composition
can be immediately identified and rectified. With digital images and the proper im-
aging software, one can create simulations of operative results and facilitate patient
consultations. These image manipulations can also help the plastic surgeon with op-
erative planning and may reveal certain unwanted aesthetic effects of a surgical pro-
cedure before the procedure is performed and perhaps help to avoid undesirable out-
comes. In addition, most digital cameras are capable of recording digital video that
is easily played and can be used for teaching purposes.
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Advantages of the Digital Photography Format
 The ability to store, organize, copy, share, manipulate, and import photographs into
presentations, all with unparalleled ease
 No revolving cost of developing film
 Resident teaching and patient education and consultation are facilitated
 Immediate feedback on photographs taken so no loss of opportunity for the perfect
shot
 Digital images are stable data that do not take up physical space like prints and slides

The Digital Imaging Setup
The general principles and basics of photography discussed earlier apply to digital pho-
tography. There are, however, several key differences between digital and film pho-
tography, principally in the creation, storage, manipulation, and production of pho-
tographs. We will discuss the differences that are applicable to clinical photography.
Camera Systems
There are two principal types of digital cameras on the market today: point-and-
shoot models and digital SLR models. Digital point-and-shoot cameras were the first
universally available and affordable type of digital cameras and are currently in com-
mon use among plastic surgeons. Myriad models have a zoom lens, autofocus, and an
integral flash. These cameras have various levels of programmability and versatility.
The composed image is viewed on a small LCD screen and on a viewfinder in most
models. In some models the viewfinder tilts and swivels, allowing the photographer
to see the image from a different angle than the camera does. This can be particu-
larly helpful for intraoperative photography.
Digital SLR cameras are now universally available and are made by many camera
companies. Their prices have decreased considerably, making them more accessible for
the casual photographer. As with film SLR cameras, digital SLR cameras use inter-
changeable lenses, accommodate top-mounted flashes that can perform metering
through the lens, can control multiple distant flashes, and permit the user much more
versatility. With the SLR camera the photographer can use manual controls and fixed
focal length lenses, which are generally of significantly better quality than the lenses
of point-and-shoot cameras. These features make the digital SLR camera the opti-
mal device for producing standardized photographs.
Instead of film, digital cameras render images via a sensing chip. Two types of sen-
sors are common, one called a charge-coupled device (CCD) and the other a com-
plimentary metal oxide semiconductor (CMOS). The sensor is made up of a grid of
pixels (short for “picture elements”); each pixel is a single-unit representation of the
light falling on it. By comparison, on film, individual silver ions change with exposure
to light. For example, a sensor with a pixel array of 2140 by 1510 would have a to-
tal of 3.34 million pixels, which is commonly referred to as 3.34 megapixels. As men-
tioned previously, the size of the sensor in comparison to standard 35 mm film dic-
tates how images from lenses of different focal lengths will be rendered. The image
cast by a 100 mm lens onto 35 mm film will be magnified to a degree based on the
size difference between the sensor and 35 mm film. A sensor two thirds the size of
35 mm film will record the central two thirds of the image cast by a 100 mm lens
and in a sense magnify the image, thus rendering an image comparable to that
achieved with a 150 mm lens; 2⁄3  1.5  1.0, hence the conversion for most digital
SLR cameras is 1.5  focal length to get the 35 mm equivalent.
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Digital cameras are categorized by the amount of megapixels they have. The num-
ber of effective megapixels in a given camera is directly proportional to the resolu-
tion (amount of detail that can be seen in an image). The more megapixels, the greater
the resolution and the greater the detail of a given image. However, the final quality
of a digital image also depends on the quality of the lens, proper metering, focus,
and, if the images are to be printed, the printer and paper being used. In addition,
the size of the pixels contributes to perceived resolution or sharpness; a digital SLR
and a point-and-shoot may have the same megapixels, but the SLR will generally
have a larger sensor with larger pixels, which captures more light and detail. Based
on the capability to enlarge photographs and maintain detail adequate to the human
eye, 35 mm film is roughly comparable to a 6-megapixel image.
Once the sensor captures an image, it is transferred through an analog to a digital
converter for processing, a buffer, and then the storage card. During the course of
processing images for storage, the images’ raw data are compressed to varying de-
grees. Multiple compression algorithms exist, the most predominant being the JPEG
(Joint Photographic Experts Group) format. Compression reduces an image file by
8 to 10 times with nominal degradation in image quality. The first save of a JPEG
image does not cause poor quality at the highest resolution; however, any subsequent
resave of the JPEG can degrade quality significantly if the proper settings are not
used. Also to be avoided is multiple resizing of the image. Although JPEG format is
the default setting on many cameras, for images intended for use in presentations
and especially for publication, it is strongly advised that the image be saved in Tagged
Image File (TIF) format with LZW compression as an effective, lossless method of
maintaining image resolution.
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In these photographs, one image is in the raw format and the other two are JPEGs
compressed to varying degrees. No appreciable difference can be seen between the
“heavy” 9.5-megabyte raw image and the 1.2-megabyte and 380-kilobyte JPEG com-
pressed images.
9.5 mb raw
1.2 mb JPEG
380 kb JPEG

Also, compare the two JPEG compressed files with the zoom insets and note that
both images are comparable with regard to resolution and detail in the magnified
portion. These images remain 1.2 megabytes and 380 kilobytes, respectively, and fur-
ther demonstrate the minimal effect of JPEG compression on image quality. How-
ever, note that all images that are printed in a publication (for example, all the im-
ages in this book) are printed in a halftone pattern (a multitude of minute, regularly
spaced dots of ink; in this case, dots of four different colors), which may obscure any
differences.
This process makes it realistically possible to store many digital images and facili-
tates handling (copying and moving) of individual photographs. There is a caveat,
however: if you make changes on a given JPEG image and then save it in a JPEG for-
mat, multiple compressions will result in loss of detail and image quality. Therefore
it is important to always save an original image and create another file for the im-
age that is being altered so that multiple compressions and loss of detail do not oc-
cur. Most modern imaging software, such as Adobe PhotoShop and Apple’s Aper-
ture, preserves the original data by applying a set of instructions to altered images
as opposed to making permanent changes, thus avoiding loss of information and
image data and saving disk space. Of course, while this can preserve image quality,
it is dependent on the user’s handling this feature correctly. In clinical photography
it is important for medicolegal reasons to always save an unaltered photograph.
Storage cards are removable storage devices housed within the camera that store
processed images from the sensor. These are principally solid-state type storage devices
as opposed to optical (CD-ROM) or magnetic (hard drive). They come in several dif-
ferent formats (such as compact flash card, secure digital card, and memory stick),
memory sizes (which dictates the number of photographs that can be stored), and
speeds (the rate at which information is written onto and read off of a card). Data
from a storage card can then be downloaded to a computer either by connecting the
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camera to the computer via universal serial bus (USB) or FireWire, or by removing
the storage card from the camera and using a card reader. The method of transfer-
ring data is important to consider, because there are significant differences in the
speed at which photographs can be downloaded. FireWire and personal computer
memory card (PCMCIA) readers are the fastest methods to date and will make a sig-
nificant difference in download times when managing many photographs at a time.
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Peripherals and Data Storage
 A back-up system for all digital photographs should be used routinely: one on-site
backed up on a daily basis and one off-site backed up on a weekly basis.
 A computer with a large-capacity hard drive should be used for storage with enough
RAM to handle large photographic image files.
 A monitor that is at least 15 inches is preferred.
 A color printer should be used; the expense of photo-quality paper should be saved for
when it is really needed.
 A pen-driven, tablet-type touch pad (for example, the Bamboo; Wacom, Vancouver,
WA) can be used for photo editing. This mimics the hand motions used in drawing
much better than a mouse making edits and morphing easier.
 A high-speed storage card that is 100 or more results in very fast photo reading and
writing times, which is especially advantageous with large image files and transfers of a
large number of photos.
 The megabyte capacity of a storage card should best suit your needs. Too large and you
may have too many photos to download at once. Just the right size and you can take
many photos but be forced to download your photos on a regular basis.
 A FireWire or USB 2.0 cable card adapter should be used to transfer photographs to
the computer. These are the fastest methods currently available. More recently, Eye-Fi
has introduced a wireless-capable SD card, obviating the need to remove the card from
the camera to transfer photos.
Digital Imaging Software
Once an image has been transferred to the computer, appropriate software is needed
to view, archive, edit, or print a photograph. Most operating systems today come
with basic storage, viewing, and photo-editing software. Many additional applica-
tions are available with advanced features for viewing, archiving, and retrieving im-
ages. Specialty software is also available that allows the surgeon to easily manipu-
late and morph (short for “metamorphose”) photographs to mimic operative changes.
A preoperative photograph can be manipulated to mimic an operative procedure,
assisting the surgeon and patient in preoperative planning and consultation. The use
of morphing software during the patient consultation will be addressed later.

As with film cameras, digital cameras are vulnerable to the same optical distortions
mentioned earlier, in addition to a host of additional artifacts unique to digital pho-
tography. Artifacts (image distortions) based on image processing, and compression
can occur, in addition to noise (the visible effects of an electronic error). It is im-
portant to know that the possibility for these phenomena exists, but a detailed dis-
cussion of them is beyond the scope of this chapter. Suffice it to say that in clinical
digital photography these are unlikely to be encountered.
An organized approach to storage of photographs is essential. At a minimum each
patient should have a folder for all of his or her photographs, but today there are
numerous programs that allow attaching searchable key words, which can include
diagnosis and procedure as well as demographics. Although this takes additional
time during uploading of photos, it is well worth the effort later when trying to re-
trieve photos. Some examples include Canfield Scientific’s Mirror; Extensis’s Portfo-
lio; Ulead’s iPhoto; and ACDSee.
Recommendations for Photography in Plastic Surgery
The choice of digital camera should be based on several factors governing the ability
to generate high-quality standardized photographs. The camera should have man-
ual controls, accept interchangeable lenses, have the ability to control external flashes,
and mount on a tripod. As noted above, an SLR is preferable for all of these reasons.
Some point-and-shoot cameras have high-quality lenses, manual controls, multiple
flash capabilities, and can take high-quality photographs, but there is great variability
based on brand and model. Adequate clinical photographs can be taken with these
point-and-shoot cameras, but SLR cameras offer more versatility and will produce
superior images that are easier to standardize. Entry-level SLR cameras with a lens
are now priced only a little higher than point-and-shoot models.
It is imperative that the surgeon develop a method of frequent and reliable backup
of all images. A number of backup systems are currently on the market. Optimally,
backup is done daily to a large storage device that is backed up locally, and on a less-
frequent basis to a storage device physically located away from where the images are
made in the event of a catastrophe (local system failure, virus attack, fire, earthquake)
and loss of all data. Thus at a minimum the images are on three hard drives or other
storage: the primary computer or server, a backup drive on-site, and a backup off-site.
A top-mounted flash, or better yet, a studio setup with multiple floor- or ceiling-
mounted flashes, is ideal to minimize shadows and produce studio/portrait–quality
photographs. As space for a studio is not always available in all office settings, an
examination room can serve as a dedicated photography area using a painted wall
or curtain as a backdrop. Mountable twin flashes are available in lieu of floor-
mounted flashes.
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This is an example of a digital photography studio. The camera is set up with a com-
bination of floor- and ceiling-mounted flashes and a neutral background. In the dig-
ital studio, a computer with the appropriate software and a printer should be avail-
able for viewing, editing, and printing photographs. When editing digital photographs
with morphing or “paint and draw” techniques, the use of a digital tablet and sty-
lus mimics natural hand motions much better than a mouse. Using a tablet for such
tasks will greatly facilitate their execution.
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Managing Photographs and Text for Presentation
Frequently, clinical photographs are used for presentation purposes. Before any clin-
ical photograph with personal identifying features is used in presentation format,
consent must be obtained from the patient. If consent has not been obtained, the
photographs should not be used in an educational or public forum.
Any time clinical photographs are used for presentation, education, or demonstra-
tion, the photos should be clear without distracting elements, and they should be
large enough that when projected they can be easily viewed. A good rule of thumb
is that any photograph should not be less than one third of the total projected im-
age. If the photograph is too small, it cannot be adequately appreciated and will not
succeed in conveying the desired point of the photograph.
Some useful image-saving guidelines are as follows:
 For presentations/projection on a screen: The maximum pixel width of the
screen is currently 1600 pixels, so an image on half of a “slide” should be
about 800 pixels for optimal clarity.
 For print production: For each inch that you intend in printed image width,
multiply by 300 and round up. Thus a photo that is to print as 3 inches wide
 300  900 pixels wide minimum. It is also best to let the publisher down-
size and crop the image to your instructions.
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Requirements for a Digital Photography Studio
 A room at least 10 by 12 feet
 A uniform color backdrop that can be changed, depending on the patient’s skin tone
 The camera mounted on a tripod
 A swivel sitting stool so the patient can sit for facial photography
 A floor mat indicating patient foot positions for body photography at 45-degree
oblique, 90-degree lateral, and 180-degree posterior views
 Multiple floor- or ceiling-mounted flashes to eliminate shadows (two flashes for the
background and two flashes for the subject)
 A computer with appropriate storage, retrieval, and editing software, a color printer,
and stylus-driven tablet-type touchpad for photo editing
 A monitor of at least 15 inches
 A stylus-driven touch pad for photo editing (this is better at mimicking natural hand
movements than a mouse is)

Photographic Standards in Plastic Surgery
General Concepts
Many excellent articles have been written on the photographic standards for clini-
cal photography.
Whether or not your office has a studio, patients should be in a private and com-
fortable setting for clinical photography. All jewelry and makeup should be removed
for facial photographs. Long hair should be held back off the face, forehead, and
ears. Clothing should be removed, and disposable low-profile privacy garments used
in body photography. A uniform nonreflective background of blue, grey, green, or
off-white should be used. The choice of background color depends on the patient
population and should be matched to maximize contrast with skin tone. The back-
drop can be a painted wall or door, a studio backdrop, or common bed sheet or
towel easily found in the hospital setting. The subject should be positioned 18 to
36 inches from the backdrop.
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Techniques for Taking Clinical Photographs
 A dedicated photography area or studio is ideal for picture taking, if possible.
 Patients should be made to feel comfortable having their photographs taken, and per-
mission should always be solicited.
 Photographs should be taken in a private, well-lit setting; patient comfort and dignity
must be maintained.
 Recommendations for standardizing all photos of particular body regions should be
followed with regard to composition, lens choice, subject distance, and alternate views.
 An aperture of f/8 is used to lengthen the depth of field and still allow enough light for
good exposure.
 The grid screen in the viewfinder is used to help with patient positioning.
 The lens is set to a fixed focal distance; then the camera is moved to bring the subject
in focus. This helps in standardizing photographs and facilitates preoperative and post-
operative comparisons by maintaining a constant reproduction ratio.
 A uniform background will enhance the subject outline and improve contrast—darker
colors for light-skinned individuals and lighter colors for dark-skinned individuals.
 Flash position should be monitored to hide shadows.
 For intraoperative photographs, the operative field should be clean, distracting ele-
ments minimized, and technical demonstrations simplified.
 For facial photography, the patient should wear minimal or no makeup. Jewelry
and eyeglasses should be removed, and shirt collars should not obstruct the view of
the neck.
 For body photography, privacy garments should be worn, with no street clothes.
 A normal or basic JPEG setting will maintain good photo quality and keep image files
down to a manageable size (less than 1 mb, preferably under 500 kb)

The lens should be held at the same level as the area being photographed. A view -
finder equipped with a grid screen is very helpful in determining proper alignment,
as demonstrated below.
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Fixed focal length lenses should be used, avoiding the distorting characteristics of
wide-angle and zoom lenses. If a zoom lens is used, it should be high quality and
have a focal length range much larger than what would be used clinically to avoid
the distorting effects at the ends of its range. The same point on the zoom can be
used for reproducible results. The size and focal length of the lens used is based on
the part of the body being photographed. The lens choice should position the pho-
tographer at a comfortable working distance from the patient and allow for ade-
quate composition of pertinent features. The photographer should establish stan-
dard anatomic landmarks to be included in each given view. A subject distance from
the camera lens or a reproduction ratio to fill the frame with these landmarks should
also be determined. The reproduction ratio (for example, 1:2, 1:4, or 1:10) can be
found on most SLR macro lenses. These ratios represent the size of the subject and
the size of its image on film, or in other words the size scale to which the photograph
renders the subject. A 1:1 ratio represents a life-size image, and so on. These ratios
are not valid when a 35 mm lens is used with a digital SLR because of the magnifi-
cation; thus a safe rule of thumb is to set the camera 3 feet away to photograph the
patient’s face and 6 feet away to photograph the patient’s body.

As much as possible, intraoperative photographs should adhere to the recommen-
dations for photographs taken outside the operating room. The operative field should
be cleaned, fresh border towels placed to frame the subject, and any distracting items
removed from the field. Operating room lights are intense spotlights and should be
turned away from the field during photography to facilitate accurate metering and
exposure. If operative techniques need to be demonstrated and instruments are vis-
ible in the photograph, instruments with a dull finish should be used (alternatively,
bone wax can be applied to shiny surfaces) so that reflections are minimized. All
demonstrations should be simple, with minimal distracting elements. Photographs
should be taken at right angles to the patient and from the same vantage point, usu-
ally with a wider orientation photograph before any close-up photos are taken. Be-
fore any series of photographs is taken of a patient, we strongly recommend that the
patient’s name and the date be recorded. This can easily be done by photographing
the nameplate from the patient’s chart before beginning the photographic series.
The box presents a helpful mnemonic device to keep in mind while taking clinical
photos.
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All aspects of clinical photographs should be kept consistent, including use of the
same camera, lens, lighting, film, patient positioning, and image framing. By fol-
lowing the preceding guidelines and adhering to the standards that follow, you will
obtain excellent photographs, ensure reproducibility, and facilitate valid preopera-
tive and postoperative comparisons.
Mnemonic Device for Photographic Consistency
FLASHBACK
F
Framing anatomic landmarks and proper focus
L
Lighting
A
Aperture setting
S
Subject distance and shutter speed setting
H
Hold consistent reproduction ratio
BACKground

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Photographing the Face
Full-face photographs should be taken with a 90 mm lens (or digital equivalent) and
should include the neck and ears. A reproduction ratio of 1:9 is used. The hair should
be pulled back, jewelry removed, and no makeup or a minimal amount worn. Shirt
collars should not obstruct the view of the neck. Anteroposterior views should in-
clude the clavicular heads and the top of the head. Eyes should be looking straight
ahead, and the mouth should be relaxed. Additional images should be taken with
the face in animation to document facial nerve function preoperatively. Oblique pho-
tographs should be taken with the medial canthus of the distal eye just meeting the
nasion (both left and right views should be photographed for oblique, lateral, and
tilted-down positions). The patient’s whole body should be turned, not just the head,

to avoid torsional changes in the appearance of the neck. Lateral views are taken
with the philtral columns aligned along the Frankfurt horizontal (a straight line from
the tragus to the infraorbital rim) and kept parallel to the lower border of the pho-
tograph, with the eyes looking straight ahead. If a single flash is used, the flash should
be oriented on the same side as the nose to avoid shadows.
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An additional lateral tilted-down view is taken with the patient gazing downward
to create a double chin.
Close-up views of the face are obtained with the same-size lens, using a reproduc-
tion ratio of 1:4. These views are better at demonstrating facial rhytids and more de-
tail about specific facial areas. The face is divided into upper and lower halves. The up-
per half is from just above the brows to the upper lip. This provides a closer look at
the eyes, cheeks, and nose. Consider photographing the eyes with a lower flash setting
or using only ambient light for improved detail of periocular structures. A smaller
aperture (f/11 or f/16) will give better depth of field at closer range. Photographs of
the lower half of the face extend from the middle of the nose to just below the chin,
giving close-up views of the nasal tip, mouth, chin, and neck. The same guidelines
apply to patient positioning as for full-face views.

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Photographing the Nose
Photographs of the nose will also require a 90 mm lens. The same rules for the face
apply for the anteroposterior, lateral, and oblique views of the nose, the only differ-
ence being that the framing is closer, from the top of the forehead to the bottom of
the chin, with a reproduction ratio of 1:4. A basal view of the nose should also be
included. This is done by lining up the top of the nasal tip with the medial canthi,
and provides information about nasal base width, the nasal tip, and the dorsum. Ad-
ditional views specific to the nasal tip can be obtained with the “worm’s eye” (basal)
view, lining up the top of the nasal tip with the level of the upper eyelid crease. This
view obstructs the dorsum but can provide more information about the columella,
septum, nasal sills, and tip symmetry. A lateral smiling view can be done to help as-
sess the effects of facial animation on the nasal tip.

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Photographing the Ears
Photographs of the ears include the standard anteroposterior facial shot in addition
to a posterior view with the hair pulled up. Close-up lateral views of the ears with a
reproduction ratio of 1:3 show details of the helixes, concha, tragus, and lobule.
Photographing the Teeth
Quality standard photographs of the teeth and occlusal relationships can only be
obtained with a ring flash and cheek retractors. Anteroposterior and oblique views
should include the nasal tip and chin.
Photographing the Body
Because photographs of the body cover a larger area than those of the face, a 50 mm
focal length lens at a distance of about 3 to 6 feet from the subject is used. The same
recommendations for lighting, flash position, and background apply. Because pa-
tients will be in varying states of undress, it is very important to ensure a comfort-
able and private environment for photography. Standard disposable cover garments
are used so that aesthetic features and body contours can be more easily seen while
simultaneously maintaining patient dignity.
For the majority of body photographs, a reproduction ratio of 1:12 is used. A floor
mat that has various feet positions marked for oblique, lateral, and posterior views
is helpful. In this way patients can simply place their feet in the specified areas so
they are lined up properly for the photographs.

Photographing the Breasts
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When the patient’s breasts are to be photographed, the patient should be instructed
to hold her arms comfortably at her sides with her back straight and shoulders
slightly rolled back but not pulled upward. The shoulders and clavicles should be in-
cluded, as well as sufficient space below the bottom edge of the breast. Anteropos-
terior, lateral, and oblique (the patient turned 45 degrees) views should be obtained.
Patients should turn their whole body rather than twist at the hips for oblique views.
In a transverse rectus abdominis myocutaneous (TRAM) reconstruction, the breasts
and abdomen down to the level of the upper thigh should be included so the um-
bilicus and pubis can be seen.

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Photographing the Abdomen
The abdomen is framed from the inframammary fold to the upper thigh. The arms
are held above the level of the photograph, folded across the chest. Anteroposterior,
lateral, and oblique views are taken. Additional lateral views with the patient bent
30 degrees at the waist can be helpful for assessing excess skin and overhang. Pri-
vacy garments should not cover the location of any incisional scars.

Photographing the Hips and Thighs
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When photographing the hips and thighs, the patient’s arms are held folded across the
chest, and the feet are separated to show the full contour of the medial thigh. The
hips and thighs are framed from just above the umbilicus to just below the knees.
Anteroposterior, lateral, oblique (of the front and back), and posterior views are
taken.

Photographing the Arms
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Part I  Fundamentals
The arms are photographed individually while the patient is bent 90 degrees at the
elbows and abducted 90 degrees at the shoulders. The patient should be upright, and
anterior and posterior views should be taken. The head is cropped to maintain
anonymity and focus attention on the arms.
Digital Imaging and Morphing
Imaging and morphing software can be an excellent teaching tool for use with a pa-
tient who will be undergoing plastic surgery. If a digital format is used and imaging
software is part of the patient consultation, the surgeon should sit down with the
patient at the computer monitor after all appropriate photographs have been taken.
Viewing the photographs with the patient allows the surgeon and patient the oppor-
tunity to analyze areas of concern and joins them in preoperative decision-making.
With effective use of a software program, the surgeon can demonstrate the possibil-
ities and limitations of a surgical procedure in a very realistic visual manner. Some-
times these consultations can expand a patient’s desire for additional procedures.
Caution and judicious use of manipulating software must be exercised so that one
does not create unrealistic expectations and undermine the efforts to educate and

prepare patients for their surgical procedure and postoperative prospects. It is manda-
tory that the original images be saved in an unedited format.
Legal Issues
Clinical photographs, although considered a part of the medical record, represent a
unique incursion into a patient’s privacy. Therefore plastic surgeons should recog-
nize that patients have specific rights that apply to the taking and use of these pho-
tographs. Consent for taking photographs or video recordings of any sort should be
obtained and kept on record. This should also include the consent for publication
and display of these photographs. An example of photographic consent forms is
shown on pp. 144 and 145. In general, publication in a journal, textbook, or web-
site should be done with the patient’s specific consent for that use as well as the gen-
eral consent form obtained in the office. It is recommended when obtaining consent
to publish patient images on the Internet that the precise name of the website be in-
cluded in the consent form. Any images submitted to be displayed on the web should
be rid of any metadata that could identify the patient. It is safest to simply rename
all image files with generic terminology and indexing, and never use names.
There have been cases of photographs being taken of unconscious patients without
their consent; these are a clear invasion of the patient’s privacy. The person who takes
the photographs has legal ownership of the photographs unless the photographer is
in the employ of the plastic surgeon. Computer images are considered part of the
medical record and as such should not be deleted or destroyed. To do so can incur
civil or even criminal charges.
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Legal Safeguards
 Consent should be obtained for all clinical photography.
 Specific expressed consent should be included for publication, display, or presentation
of any photographs, especially those with identifiable elements (this includes tattoos
or birthmarks as well as facial features).
 Special measures should be taken for photographs to be published online.
 A statement should be included with any altered or morphed image given to a patient
that it is not a guarantee of an operative outcome; in addition, a method of authentica-
tion should be used.
 All patient photographs should be kept as a part of their medical record and treated
as such.
 Patient photographs should not be destroyed.

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PLASTIC SURGERY PHOTOGRAPHY CONSENT
Page 1 of 2
I hereby voluntarily grant permission to
and/or their designated employees to take and use any preoperative, intraoperative, or postoperative
photos of myself for purposes of record, research, education, and medical publication, as well as
assisting others in making their surgical decisions. Any of these uses may be eliminated from
this form.
I further understand that no form of compensation shall become payable to me for the use of these
photographs.
I hereby release
and its agents from any and all claims and demands arising out of or in conjunction with the use of
these photographs.
Signature
Date
Print Name
I hereby certify that I am a parent or the person legally responsible as the guardian of the above
patient, a minor person, and that I also hereby provide authorization and grant the releases described
above in this document.
Parent/Legal Guardian Signature
Date
Print Name

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Chapter 5  Photographic Essentials in Aesthetic Surgery
PLASTIC SURGERY PHOTOGRAPHY CONSENT
Page 2 of 2
Please initial in the spaces below:
I consent to being photographed and/or videotaped before, during, and after treatment.
These images will become part of my permanent medical record.
I give my permission for these images to also be used for:
Educational purposes
Scientific publications
Other publications
Demonstration to other prospective patients
Internet
I give my permission for photos of my:
Face
Body
Breasts
to be used on:
Your preferred website
Other website:
Patient Signature
Date
Print Name
Witness

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Part I  Fundamentals
The advent of digital imaging and morphing software that can mimic postoperative
results introduces new legal issues. Although we do not know of any lawsuits re-
garding the implied “guarantee” of an altered digital image, certainly the risk of this
happening is real. If imaging is used as part of patient consultation, it is imperative
to ensure that the patient understands that digital imaging only represents a “possi-
ble” outcome and is not a guarantee. Any altered images shown or given to a patient
should include this statement: “THIS COMPUTER IMAGE CONSTITUTES A SIM-
ULATION AND IS NOT A GUARANTEE OF YOUR RESULT” or a similar phrase,
in capital letters on the photograph. Images of any sort that are given to patients
should be authenticated with a time-date stamp or signature to ensure image legiti-
macy and to minimize the possibility of a patient tampering with images.
Concluding Thoughts
To practice plastic surgery is also to practice photography. As we strive to improve
our skills as surgeons, we should also aspire to be good clinical photographers and
apply standard techniques to the taking of photographs. We must exercise care to
maintain patients’ privacy and rights and to use photography to educate our patients,
our colleagues, our trainees, and ourselves.
Common Errors in Clinical Photography
 Zoom or wide-angle lenses should not be used at the limit of their range.
 For facial oblique views, the entire body should be turned, not just the head, so the
neck contour is not distorted.
 Distracting backgrounds and dirty operative fields interfere with clear patient photog-
raphy.
 The pincushion effect of closeup photography and short focal lengths should be
avoided.
 Low-number aperture settings with shallow depths of field should not be used.
 Altered photographs should not be submitted for publication or presentation unless
they are explicitly labeled as such.
 When consulting with patients and using morphing software, the surgeon should be
conservative, taking care not to alter images beyond his or her surgical capabilities.

Clinical Caveats
 A comfortable, private area should be provided for all clinical photos with a ded-
icated imaging system.
 All image data should be backed up on a regular basis.
 It is essential to obtain patient consent for taking photos and using them for edu-
cational purposes.
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Chapter 5  Photographic Essentials in Aesthetic Surgery
Annotated Bibliography
Chavez AE, Dagum P, Koch RJ, et al. Legal issues of computer imaging in plastic surgery: a
primer. Plast Reconstr Surg 100:1601-1608, 1997.
This article includes a brief review of the law regarding clinical digital photography.
The lead author is a graduate of the Stanford Law School. The authors state that to date
no cases regarding computer imaging exist in federal or state case law. Sound recom-
mendations are made to reduce legal susceptibility when using digital photography.
Galdino GM, Vogel JE, Vander Kolk CA. Standardizing digital photography: it’s not all in
the eye of the beholder. Plast Reconstr Surg 108:1334-1344, 2001.
These authors have written multiple publications on clinical photography. This article
compares clinical photos taken with different digital cameras with different resolutions.
Sound guidelines regarding the standards of clinical photography are reviewed.
Milburn K. Digital Photography Bible. Chicago: IDG Books, 2000.
This is a comprehensive guide to digital photography that reviews the needs of a digi-
tal studio. It covers digital cameras, scanners, and image processing. This is an excel-
lent resource for the serious amateur or professional photographer. The section on pro-
cessing and editing digital photographs is extensive.
Photographic Standards in Plastic Surgery. Plastic Surgery Educational Foundation Clinical
Photography Committee.
This pamphlet is a quick guide to the standards of patient positioning and camera settings
in clinical photography. It is a must-read for anyone learning the standards of plastic
surgery photography and handy to keep in a studio.
URL:
Digital Photography Review is an independent resource providing news, reviews, and
information about digital photography and digital imaging. The reviews and compar-
isons are very thorough and informative and should be considered a must to consult be-
fore purchasing a digital camera. The site also has an informative section about general
and digital photography.

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BUSINESS BASICS
PART II

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The Practice:
Models, Management, and Marketing

FOAD NAHAI, GUSTAVO A. COLON, WENDY LEWIS,
MARIE CZENKO KUECHEL, ANDREW R. BERGER
CHAPTER 6

The Environment
FOAD NAHAI
In today’s competitive environment, practicing good medicine is only one of the tal-
ents that a successful aesthetic surgeon must possess. Business, financial, and mar-
keting acumen, communication and organizational skills, office planning and deco-
rating expertise, website and social media marketing knowledge, and myriad other
skills or information may be required for a practice to not only run smoothly and
effectively, but also to be a successful financial endeavor. These are not things we
learned in medical school or during residency. With the rapidly changing face of med-
icine, we have to take a far more active role in understanding and directing the busi-
ness and planning aspects of our practices, in addition to the purely medical and sur-
gical aspects of providing our patients with the finest care possible.
This chapter and the three that follow cover a spectrum of issues and basic decisions
associated with running an aesthetic surgery practice and offer solutions that have
worked in the real world. The topics addressed range from decisions about the ba-
sic practice model (whether an academic or a private practice), management issues,
patient relations, financial and budgetary considerations, communication skills,
staffing and services, marketing and practice enhancement, online tools for practice
enhancement, and legal considerations.
The Practice Model
There are a number of highly successful aesthetic surgeons flourishing in a variety
of practice models, so it is clear that there is no one formula for success. It cannot
be stated categorically that an aesthetic practice does not belong in a university set-
ting or that the only way to have control is to be in a solo practice. Having said this,
each of these practice models—university setting, private practice, group or solo prac-
tice—will affect the surgeon and the patient. The surgeon’s working environment,
control of everyday decisions, financial independence, and schedule flexibility are a
direct reflection of the practice model. Similarly, and perhaps of greater importance,
the practice model will also have a profound impact on the patient’s experience.
Many renowned university programs attract patients from all over the world because
of their reputation, the prestige of the institution, and the well-founded assumption
that only the finest of physicians would be on staff. Equally, there are outstanding
physicians in private practice whose rise to prominence has not occurred under the
umbrella of a prestigious institution but through outstanding perfor mance. This is
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true in all areas of medicine, including aesthetic surgery. Many patients will place their
trust in plastic surgeons on staff at the academic centers merely because these sur-
geons are at that center. In the private setting it is the surgeon’s reputation and stand-
ing in the medical community, rather than institutional affiliation, that is important.
Traditionally in plastic surgery, it was common for young plastic surgeons, whether
in private practice or academics, to start with a combined reconstructive and aes-
thetic practice, far more reconstructive than aesthetic, with much emergency work
and cases referred or handed down by senior colleagues. As the young surgeon be-
came established, the practice would grow in one direction or another and over the
years, those of us with a special interest in aesthetic surgery would slowly build our
aesthetic practices so that eventually we could limit our practice to aesthetic surgery,
passing on to junior partners and colleagues the nonaesthetic part of our practices.
This model worked well for many of us who currently enjoy a sizable aesthetic sur-
gery practice. However, this model may not work as well today, because we now
practice in a very competitive environment with competition not only from our plas-
tic surgery colleagues, but also from other core physicians and surgeons, those who
are not surgical specialists, and even individuals who are not medical practitioners.
The young plastic surgeon entering practice today who wants to focus on aesthetic
surgery has to plan a specific course to attain those goals. Times have changed and
one can no longer start a practice, cover the entire field, and expect one day to have
built sufficient volume of aesthetic surgery patients to shift focus in that direction.
The good news is that even though the field is highly competitive, demand for aes-
thetic procedures continues to grow. With this continued growth and the explosion
of information via the Internet, a patient seeking aesthetic enhancements will be far
better informed, more focused, and more demanding.
Each of us will have to weigh our options so we can choose the practice model that
will afford us the opportunity to build and maintain an aesthetic practice in an en-
vironment in which both patients and the surgeon are satisfied.
Reflections on My Experience
Having practiced aesthetic surgery for a number of years in a university setting and
now in a private group practice, I have spent many hours ruminating about these
practice models and their potential impact on the total patient experience, the prac-
tice environment, and the surgeon’s flexibility, professional fulfillment, and career
satisfaction.
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Early in my career, patients chose me for their aesthetic surgery because of my po-
sition in a prestigious academic institution, with referrals from within the clinic as
well as from outside physicians. There is no question that such referrals composed
the initial building blocks of my aesthetic practice. Over the years, the focus of re-
ferrals shifted from physician referrals to word-of-mouth referrals based on patient
satisfaction. Today most of my patients are self-referred or come because of recom-
mendations from friends or family, and because I now have a recognized name within
the community. Although I still see physician-referred patients, even from prestigious
academic centers, these constitute a small portion of my current practice.
As my aesthetic practice began to grow, it became obvious to me that my patients
were selecting a surgeon who they felt would, in all likelihood, deliver the results
they were looking for. However, I also came to realize that a good result was only
part of the equation; it was the total experience that mattered most. By total expe-
rience I mean the patient’s encounters with all aspects of the practice: the medical
and nonmedical staff, the physical and human environment, the ambiance, and per-
sonal interactions. In today’s competitive environment, the total experience may be
just as important to some as the quality of the result.
Leaving the university for private practice had a significant impact on me personally
and on the experience that I could offer to my patients. When I was at the univer-
sity, new aesthetic patients were processed with all other new patients, often by clerks
with little if any knowledge of aesthetic surgery and no personal interest in the patient
or my practice. Following the initial processing, patients would proceed to a wait-
ing room that was shared with our reconstructive patients and, for a while, with
neurosurgical patients. Such an environment was not conducive to providing patients
with a feeling of privacy, warmth, or nurturing. By contrast, in a private group prac-
tice focused on aesthetic surgery, those factors that adversely affected the patient’s
experience in the university setting have now been eliminated. Patients benefit from
an environment in which everyone is focused on their particular needs. I think that
all of these changes are a direct result of the degree of control that my partners and
I have over the environment within our practice and the training of our staff.
In the more personal environment of a private group practice, the patient is more
likely to build a relationship that goes beyond the surgeon and extends to the staff
as well. This improved relationship has been reinforced for me on numerous occa-
sions by my long-time patients who followed me from the university into private
practice. They have been very complimentary about the change, specifically men-
tioning that they prefer this smaller, more personal and private environment.
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The change in my practice setting has also had a profound impact on me. I now have
full control over every aspect of my practice, including finances, office hours, and
operating room access, to name but a few.
It is encouraging to note that as cosmetic medicine and aesthetic surgery have become
more competitive, with patients now expecting more personal attention, forward-
looking universities have developed cosmetic medicine/aesthetic surgery centers to
provide the same patient experiences that are available in the community. This is a
good strategy, because it makes the university-based aesthetic surgeon competitive, in-
creases revenue, and may well contribute to retention of faculty.
As surgeons, we are in control when we are in the operating room. There isn’t one
of us who has not been frustrated by events in and out of the operating room that
are beyond our control. In the university setting and in some group practices, there is
a hierarchical structure. In solo practice there is no such structure, and this is prob-
ably a mixed blessing. The surgeon is in full command, but also has to individually
deal with all contingencies. In the university, although I enjoyed a close personal re-
lationship with my partners within the section of plastic surgery, the hierarchy went
from my section chief to the department chair, to the dean of the medical school, to
the vice president for medical affairs, and ultimately to the university president. Each
of these individuals likely had more control over my finances and practice environ-
ment than I did. Each had his own opinions and priorities as to what was best for
the university, the medical school, the department of surgery, and even the section
of plastic surgery. These views often did not coincide with my priorities and did not
place the pampering and nurturing of my aesthetic patients first.
I would be remiss if I did not acknowledge that despite my lack of control over the
university environment, for many years I was able to flourish and develop as a sur-
geon within it and to provide excellent medical care to all of my patients. Further-
more, there is no question that as a young surgeon starting out, this environment
provided me with an excellent opportunity for building a practice, and my colleagues
and partners were highly supportive of my activities and growth.
As the focus of my practice shifted from reconstructive to aesthetic, from patients
who needed and benefited tremendously from a first-class tertiary referral center to
those who sought a more private, personal setting, I realized that at the university
I was not in a position to change my environment or theirs. This is in clear contrast
to my current private group practice setting, where my partners and I can make any
change in our environment rapidly and efficiently.
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One of the most rewarding aspects of my career has been the opportunity to work
side-by-side with some of the brightest young minds in our specialty. Of course,
I am referring to the many residents I have had the privilege of training and work-
ing with who have become leaders in our field. Over the years, only one or two of
my reconstructive patients have ever inquired who would be doing their operation.
The same cannot be said of my aesthetic patients, who even to this day in private
practice will ask me who will operate on them. The answer then and now is that I do
all my own operations and make all the decisions, but I will have an assistant. The
question of resident involvement in performing aesthetic surgery is not new; the de-
bate will continue, and I do not have the answers. There is no question that we are
responsible for training the next generation of aesthetic surgeons, but we also have a
responsibility to our patients and their privacy. Even though we currently have a fel-
low and a resident whom we teach in our practice, this is a far cry from the univer-
sity setting, with numerous residents not only in plastic surgery but in anesthesia
and other specialties, not to mention the medical students our patients are exposed
to. The presence of such trainees is sometimes of concern to our patients. I have
learned that a discussion of the role of trainees and their involvement in patient
care—specifically their role, if any, in the operating room—is essential to gain pa-
tient confidence and to provide the peace of mind that the surgeon he or she has se-
lected will in fact perform the procedure. I will always inform my patients and seek
their permission to have anyone other than our full-time office-based surgicenter
staff present in the operating room.
We are very fortunate in our group practice to have our own in-house American As-
sociation for Accreditation of Ambulatory Surgery Facilities (AAAASF)–approved,
state-inspected surgical facility. Although there are pros and cons to owning such
centers, the greatest advantage, again, is control—control over when I start to oper -
ate, when I finish, how many cases a day I schedule, and which days of the week
I operate. I had no such control at the university, other than blocked time. This flexi -
bility, in my opinion, far outweighs any of the disadvantages of owning a surgicenter.
A few words about group versus solo practice: I have never been in a solo practice;
I have always been in a group, at one time with as many as six partners. There is no
question that in a group, control is shared. One partner is the administrator who
deals with the day-to-day problems and headaches and makes most of the decisions;
major decisions are made by the group. This may vary from practice to practice. In
solo practice the surgeon/proprietor has full control but also has the full weight of
all decision-making and financial burdens.
In a group practice, we consult each other concerning patient management, and it
is most reassuring to be able to call your partner to consult about a problem. In solo
practice, although colleagues may be only a phone call away, it is not the same.
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Another issue is coverage. We gladly take calls for each other and take care of each
other’s patients in an emergency. This allows us schedule flexibility and the oppor-
tunity to travel and time for professional activities, knowing that our partners will
provide excellent care to our patients during our absence.
Business and Financial Strategies
Although many of us would prefer to focus our attention on the surgical and patient
care aspects of practice and leave the business and finance to someone else, that is
not realistic in today’s health care environment. To run a successful practice, a sur-
geon must have a basic understanding of the business aspects of day-to-day opera-
tions and a budget and plan for reaching the goals to drive the practice. Although it
is essential to have expert accounting and other business advisors to run the num-
bers and execute strategic and financial plans, the surgeon needs a working knowl-
edge of these matters to ensure that the practice runs profitably and effectively and
that he or she understands the business aspects of daily operations. (See Chapter 7
for detailed information on financial planning.)
Managing the Office
Delineation of Responsibilities
Tempting as it might be for the surgeon to run his or her own office, it is money
well spent to hire an office manager. A well-qualified office manager is an asset in
either a solo or group practice. Although a solo practice may “get away” with the
surgeon managing it all, it is more difficult and far less practical to try to do this in
a group practice.
The practice manager is responsible for the day-to-day running of the practice, in-
cluding collection and posting of fees, managing the staff, and other duties and must
be empowered by you to do so.
In our practice, my assistant/patient coordinator meets with all new patients and is
responsible for scheduling them. They will contact her for any changes in schedule
and related questions. The office manager and administrative partner are responsi-
ble for hiring and firing and other personnel matters.
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Relationships With Staff
We are all busy, and the last thing any of us needs is more meetings. However, an es-
sential element in the success of any endeavor is communication. Although individ-
uals within the practice communicate with each other daily, it is essential that the
entire practice and smaller groups within the practice meet on a regular basis. In our
practice, we regularly schedule the following meetings and have found them to be a
most effective means of communication.
 Doctors’ meetings, which include the partners and the office manager, the
anesthesiologists, and the manager of the surgicenter
 Staff meetings, including all doctors and the entire staff
 Administrative meetings, including all secretaries, administrative assistants,
receptionists, and the office manager
 Nurses’ meetings, which include nurses, operating room staff, and the office
manager
It is very important for the staff, especially any newcomers, to be familiar with your
practice philosophy. We make all of our staff aware that our practice philosophy is
to provide the best and safest medical care to our patients in a warm, friendly, caring
environment. The patient’s privacy is of utmost importance, and all staff members
are aware that they may not discuss any of the patients outside the office environ-
ment. We emphasize the role that each of them plays in the maintenance of such an
environment. We have monthly staff meetings with an agenda covering various top-
ics ranging from employee benefits to compliments from patients, expansion plans,
and other matters. We have found that these monthly meetings where all staff and
doctors are present are essential to maintaining a close working relationship with
our staff. This nurtures a sense of teamwork and emphasizes the important role they
play in the success of the practice.
Training and Telephone Protocols
The first contact any new patient has with your office is through the telephone or
your website. Contacts through the website are necessarily impersonal. Your tele-
phone operator or receptionist is often the very first direct contact the patient will
have with your office. The receptionist will make the first impression on your prospec-
tive new patient. It is important that calls be answered in a timely fashion by some-
one with a pleasant voice announcing the name of your practice, followed by the
telephone operator’s name and the question, “How may I help you?” The recep-
tionist should avoid picking up the phone, announcing the name of the practice, and
immediately asking the patient to hold. The one thing more annoying than this is an
automated telephone answering system by which the patient is invited to respond to
a number of options. We are in a service industry; our patients expect the best and
there is no substitute for a kind, warm human being on the phone rather than an
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impersonal machine that takes the caller through multiple options, then a selection
must be made immediately or the call disconnects. Although such automated sys-
tems are promoted to save money, in the long run it is a far better investment to have
a knowledgeable, well-spoken receptionist answer the telephone. The cost savings
may not be real if patients hang up or are left with a poor first impression of your
office and do not schedule a consultation based on this initial encounter.
The training of the telephone operator and receptionist is very important. This is
usually the responsibility of the office manager, or outside consultants can be brought
in to train the staff in customer service. Remember that you and your partners set
the tone of the practice. Your staff will see how you interact with your patients, and
it will affect their interactions.
Dress Code
Professional demeanor and dress are essential. Your practice should have a dress code
policy. Patients expect a certain standard from their physicians and staff. A well-
dressed, well-groomed staff reflect favorably on the practice. Extremes of fashion
should not be worn; an outfit that looks spectacular as evening wear is not appro-
priate in the reception area. The dress code will obviously vary from practice to prac-
tice, depending on your practice philosophy and the patient mix. All staff should
wear tags indicating their names and job titles/positions, and nurses and physician
assistants should wear lab coats and name tags identifying them.
Office Design and Flow
The office should be arranged in such a way that the patient arrives, checks in, sits in
the waiting room, is brought back to the examination or treatment rooms, and from
there can go to video imaging, scheduling, and eventually check out, pay, and make
another appointment, all without having to retrace and retrack.
If possible, space and expense permitting, the ideal is to have two separate waiting
rooms so that immediate postoperative patients with facial dressings and those re-
covering from peels or resurfacing do not share the same waiting room with new pa-
tients. The immediate postoperative patient needs privacy and is better served by
seating in a small private waiting room where he or she is the only occupant. Like-
wise, it is best not to expose new patients to this view of an immediate postopera-
tive patient before you have had a chance to discuss the procedure and the process
of recovery involved.
The second, more private waiting room is also useful for patients who would prefer
not to be in a “public” waiting room. This may include individuals with celebrity
status and others who desire a greater degree of privacy.
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Advertising and Practice Promotion
When I started in practice, advertising by physicians was unheard of. All of that
changed in the 1980s when the Federal Trade Commission (FTC) allowed advertis-
ing by physicians. As the late Dr. Michael Lewin put it in 1983, “There was an out-
pouring of originality, misrepresentation, and sleaze.” In the quarter-century since
then, very little has changed; we continue to see false and misleading advertising, not
just by physicians but by some manufacturers as well.
Despite these drawbacks, which reflect human shortcomings, advertising is a fact of
life for physicians and is here to stay. In addition, the advent of the Internet and the
new social media, such as blogs, LinkedIn, Facebook, and Twitter, have taken elec-
tronic connections to the next level and forced surgeons to embrace this new para-
digm. Physician advertising is poorly regulated. The most stringent guidelines are
those set out by professional societies which hold their members to very high stan-
dards in their advertising and web presence. A few states have passed laws that af-
fect physician advertising. Two excellent examples are the California law that requires
physicians who claim “board certification” in their advertising to mention the par-
ticular board and the Florida law, Truth in Medical Education (TIME), which re-
quires that providers indicate—orally, in writing, or on their name tag—whether
they are physicians, physician assistants, or nurses.
Community Outreach
My late partner, John Bostwick III, was a true master of marketing through com-
munity outreach. As a man of enormous charm and intelligence, he always under-
stood, even when he was new to practice, that one of the best ways to attract pa-
tients is to become involved and to make yourself available as a speaker and educator,
as a source of information for possible referring surgeons, as an advisor to support
groups, and as a local authority. John always made time for these activities, no mat-
ter how busy he was. When one of the general surgeons at Emory University Hos-
pital had a patient who wanted to speak with a plastic surgeon, he could always
count on John. He made himself available as an advisor for local breast cancer and
breast reconstruction support groups and was always ready to speak on a variety of
topics, aesthetic or reconstructive, when a public forum was being held. These con-
tacts were a ready source of referral, both from the patients who encountered him
and from the surgeons and other physicians who funneled their plastic surgery re-
ferrals to him.
He also recognized the value of reaching out to referring surgeons, sending them au-
tographed copies of his books and patient education materials to share with patients,
and making sure that he maintained regular, collegial contacts with possible refer-
ring physicians in town. This served him well.
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Internal Strategies for Practice Promotion
GUSTAVO A. COLON
If internal promotional programs are in place and effectively used to deputize pa-
tients, friends, relatives, and other physicians to refer to your practice, the cost of
promotion to bring in new patients to the practice can be significantly diminished.
At the same time, groups outside your immediate practice circle can be approached
using cost-effective marketing tools other than mass-media advertising.
The best internal marketing tool is a well-trained staff. As mentioned previously, the
staff person who answers your phone makes the first impression with prospective
patients. As obvious as this seems, I have noticed that many physicians seem unaware
of how their phone is being answered. Patients should feel that from the very first
phone call their needs are your most important concern. They should also perceive
that your appointment schedule and other aspects of your office management are
handled in a highly efficient manner.
It is vital that all staff members who deal directly with patients be consistent in their
approach; they should be adequately prepared through a comprehensive staff train-
ing program. The staff should always express your philosophy, plans, and proce-
dures—not their own personal ideas.
The next step in creating a positive impression is the initial office visit. Office decor
should be comfortable and appealing and consistent with the practice. Ostentation
should be avoided, since it could have a negative psychological effect on patients,
who might automatically assume they cannot afford your services. The flow of pa-
tients in and out of the office should be smooth, with prospective patients separated
from current patients if at all possible. Finally, ample parking should be available in
close proximity to the office.
Every surgeon occasionally has a patient who wants to argue about fees or voice
other complaints; as minor as these disagreements may be, they surely would be dis-
concerting to new patients and should always be discussed in a private setting. Pa-
tients want their physician’s office to be well organized and efficiently run for psy-
chological reasons as well as practical ones. If the office is chaotic, patients may
conclude that the surgeon’s operating room is similarly haphazard.
Small touches are important. Every patient who visits our office receives a thank-
you note, mailed out the next day. We also make a point of sending thank-you’s to
referring patients and physicians. It is also important to keep in touch with past pa-
tients, even if it is only a once-a-year mailing of a newsletter, practice brochure, or
patient questionnaire. People appreciate receiving information on new techniques
in aesthetic surgery or being updated on changes within your practice. If you send
out any kind of literature, invest the time and money to produce an attractive and
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professional-looking piece. A poorly designed newsletter or brochure will not achieve
positive results for the practice. Tracking patients through a computer system should
make periodic mailings a relatively easy task.
Monthly, potential new surgical patients should be tracked against new patients seen
in consultation. At least once or twice a year, this ratio should be compiled and
checked. If the ratio is less than 50% of new patients who actually schedule for sur-
gery, try to find out what is happening to the rest of your prospects. Consult your
records for clues. This review is likely to suggest changes you might make in your
practice management and your personal style and/or your staff’s approach to pa-
tients. Personal public relations should be used rather than advertising to boost your
image in the community. This will keep the promotional costs down. Offer seminars
on aesthetic surgery or plan an open house in the office. The staff should be ade-
quately prepared for these kinds of professional or social interactions in or outside
the office, especially if you have an office surgicenter.
In any patient contact, it is important to maintain a warm, personal manner. The
patient should be shown through eye contact and a brief touch that he or she has
your respect. Include in your notes personal information the patient mentions, such
as a new job, an upcoming vacation, the wedding of a son or a daughter, and so on.
Then the next time you see the patient, you can inquire about the vacation to Ber -
muda or how the new job is going. The patient will be amazed at your memory, and
such inquiries will help convey your genuine interest in the patient. It is that kind of
friendly professionalism that earns trust and shows that you are a caring physician.
Your patients are your most receptive audience; keep them happy and informed and
focus on providing a rewarding patient experience. A professional, ethical reputa-
tion is essential; this should be reflected in your every interaction with patients, staff,
and others. It has been demonstrated that a happy patient, on average, will tell three
or four other prospective patients about you, but an unhappy patient will spread the
bad news to 20 or more potential patients.
Patient Relations
The Role of the Physician
WENDY LEWIS
Patients need to feel that they can bond with the surgeon and have confidence that
he or she can address relevant concerns and provide needed services. Because there are
so many choices today among practitioners, likability is often the determining factor
when patients choose you over your competitors. They want to feel a connection
with their plastic surgeon. When training, expertise, reputation, results, and costs are
equivalent, intuition and personal impressions will factor into their final decision.
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Building trust with patients is critical to the success of an aesthetic practice. You can
instill confidence through the words you choose, your tone of voice, body language,
eye contact, and facial expressions. Patients want to feel special and unrushed, as if
they are the only patient you have. They want and expect your full attention during
every visit. As mentioned previously, your ability to remember small details about
each patient will help to establish a strong bond. Whenever possible, it is important
to speak in specific terms that relate to each patient, rather than in general terms
that are less personal. This more personal approach shows that you have taken an
interest in the patient, and that he or she is not just a number in your practice.
Well-informed patients can be a challenge. On the one hand, if they are knowledge-
able about procedures, have done their research, are serious about proceeding, and
are essentially prequalified, they can reduce your consultation time significantly. On
the other hand, some patients think they are well informed but have actually received
incorrect or misleading information from unreliable sources. These patients may
pride themselves on being well informed, so it is wise to acknowledge their efforts.
In this situation, your job and that of your staff becomes more difficult, because you
will have to reeducate them. When a patient comes to a consultation with a thick file
of printouts from websites, articles from magazines, and a legal pad of notes and
questions, it is helpful to inquire about the sources of this research to get a sense of
the quality of the information on which the patient is relying. Even if you disagree
with something a patient says, you should avoid contradicting the patient; instead,
diplomatically point out another way of approaching the subject without making
the patient feel stupid.
Steps for Building Rapport With Patients
 Smile warmly when greeting the patient and use his or her name.
 Shake hands as you meet, and establish eye contact.
 Seat yourself on the same level as the patient.
 Do not allow interruptions during the consultation.
 Inquire what the patient’s particular concerns are.
 Listen carefully, without interrupting or contradicting.
 Don’t fidget; remain focused on the patient.
 Jot down notes as reminders of personal details.
 Let your responses reflect that you are actively listening; repeat the patient’s words
back for confirmation and mutual understanding.
 Ask open-ended questions to stimulate further communication.
 Do not appear rushed or eager to conclude the meeting.

Communicating
To relate to potential new patients, you need to understand how to effectively com-
municate with them. When people visit an aesthetic surgeon, they are often uncom-
fortable and unable to communicate freely. You may find yourself having to coax in-
formation out of a prospective patient. You may have to ask questions in more than
one way to extract the real responses you need to determine the best treatment plan.
Probing further may allow you to gain insights into who the patient is and his or her
motivations.
In other cases, the patient may not stop talking long enough for you to get your
points across. This may be from a combination of nervousness, excitement, and an-
ticipation, or a sign of a controlling personality type. In this instance, it may be best
for you to talk less and listen more. By paying careful attention to the subtle ways in
which patients express themselves, you can pick up important clues to their person-
alities, fears, and possible psychological issues; this facilitates better screening.
Most surgeons start a cosmetic consultation by asking the patient to describe what
his or her principal concern is. It is rarely going to be just one feature or area; rather,
the patient may have a laundry list of many areas needing attention—the skin, the
face, and the body. The first item mentioned usually holds particular significance.
For example, if a patient opens by tugging at the slack skin under the chin and states,
“I feel like I am beginning to show my age,” the lower face may be the major source
of concern. Therefore, if you suggest a face lift and blepharoplasty but fail to ade-
quately address the neck, the patient may be disappointed.
To streamline the consultation process, it is important to get the patient to focus on
the problem that is most pressing. It is nearly impossible to cover multiple areas suffi -
ciently in a single visit, especially if it is a first visit. If the patient comes in with a legal
pad of questions, you may suggest that the initial consultation be divided into two
sessions so there will be enough time to cover everything. The patient should be urged
to prioritize—face versus body, or eyes and nose versus breasts and liposuction—
so you can map out a long-term plan that is safe, sensible, and in line with the pa-
tient’s budget. Start with the first stage. If all goes well, the patient will return for other
pro cedures or treatments over time, and you will have built a long-term relationship.
While explaining how you would address the patient’s concerns, speak clearly, keep it
simple, and use straightforward, conversational speech. Avoid phrases that instill fear
and anxiety or confuse the patient. For example, “discomfort” is preferable to “pain,”
and “redness and bruising” will be easier to grasp than “erythema and purpura.” Pro-
vide ample opportunity for the patient to ask questions, which will allow you or your
staff to go into greater detail based on the patient’s level of understanding and quest
for specifics. When you feel that the consultation is coming to a logical conclusion, al-
ways ask if you have left anything out or if the patient needs more clarification.
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At the close of the consultation, you’ll want to reassure the patient that you have
performed many of these procedures with excellent results, and that you feel confi-
dent that you can meet the patient’s goals and expectations. Think empathy; convey
that you understand their concerns and fears, and that you look forward to seeing
them again.
Cosmetic patients expect clinical excellence. They need to know that they can expect
consistent results in your practice, especially for repeat treatments. If nonsurgical
procedures go well, patients are more likely to feel confident entrusting you with
more invasive procedures in the future.
Today’s patients will not be comfortable with being pressured into booking surgery
at the first visit. You can expect that if you are the first plastic surgeon they have con-
sulted, you will surely not be the last. The average patient today will see at least three
surgeons in consultation, and often twice that, especially if free consultations are
common in your geographic region. Beware of the patient who has seen an unrea-
sonable number of doctors; this is usually a red flag that he or she is not serious, is un-
able to make a decision, or is unstable.
The Role of the Patient Coordinator
The clinical and nonclinical staff in your practice who deliver service play a signifi-
cant role in creating the patient experience. One of the most critical roles in an aes-
thetic practice is that of the patient coordinator; he or she is the “go-to” person who
manages the consultation process with patients. A good patient coordinator can have
a profound impact on the success of a plastic surgery practice. This is the person to
whom patients turn when questions arise. Patients want to feel that they are in good
hands and in a safe and nurturing environment. The patient coordinator helps to
achieve that goal.
A highly skilled patient coordinator who has been with the practice for many years
reflects favorably on the surgeon and practice; he or she is seen as a loyal staff mem-
ber who fosters a continuity of care that is comforting to repeat patients and reas-
suring to new patients. Frequent turnover may signal to patients that the office is dis-
organized and inefficient and that the doctor is difficult to work for.
The patient coordinator serves as a vital link between the surgeon and the patient.
Patients often perceive this professional as more approachable than the surgeon and
consequently will often be more open to confiding private information and concerns.
The patient coordinator must be able to connect with patients on a personal level
and to instill trust and confidence in the surgeon and the practice. The patient co-
ordinator can promote your credentials, training, and expertise with patients much
better than you can, presenting your surgical results in the most effective manner.
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The patient coordinator is responsible for much of the handholding and personal-
ized attention to detail that is provided in a well-run aesthetic practice. Communi-
cation skills are of paramount importance. This professional should be able to han-
dle the most difficult and demanding patients with equanimity and a friendly, helpful
manner, never showing annoyance or frustration. This key staff member should be
nonthreatening to both male and female patients and mature enough, for example,
to make perimenopausal women feel at ease in disclosing their concerns about the
aging process.
In a busy aesthetic surgery practice, it is common for the patient coordinator to con-
duct a preliminary consultation with new patients before they meet with the doctor.
This professional should be adept at establishing a bond with patients during these
initial meetings that will help to guide them through the surgical process and prepare
them for what to expect during the consultation, thereby saving valuable doctor-
patient consultation time. An effective patient coordinator should also be attuned to
the nuances of conversion. A low-key approach reviewing the merits of the proce-
dure and highlighting the surgeon’s unique capabilities is usually preferable to an
overly aggressive sales pitch that can be a turn-off to many patients.
It is always preferable to assign this critical role to an individual who can make this
patient interaction his or her foremost priority. A patient coordinator who is en-
cumbered with a multitude of responsibilities cannot devote sufficient time to ap-
propriately manage potential patients. This professional’s effectiveness will be lim-
ited if he or she feels overburdened and is pulled in too many directions to give
patients the individual attention they expect. It is virtually impossible to act as a true
patient coordinator while having to answer the phone and schedule appointments
in between explaining the complexities of a face-lift procedure. Patients also find
these interruptions to be distracting and inconsiderate of their time.
The environment in which the patient coordinator works is another key considera-
tion. To perform the job effectively, the patient coordinator should have a proper of-
fice or secluded area in which to counsel patients. Whenever possible, this office
should have a door that can be closed to preserve patient privacy and create an in-
timate atmosphere in which patients can talk confidentially without fear of being
overheard. With the current emphasis on medical privacy regulations, this type of
private space should be considered mandatory. For young surgeons just starting out
in practice, it may be acceptable to have an office manager or nurse handle these re-
sponsibilities during the first few years. However, as the practice grows, it is impor-
tant to hire someone whose main function is to educate your patients, promote your
skills, and schedule procedures.
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Patient Education Tools
Before patients decide to proceed with treatment, they need confirmation that they
can relate to your practice and the quality of your work and will be happy with the
outcome. Educational tools are helpful in supporting your treatment recommenda-
tions and in assisting patients to visualize the range of results they can expect. Pa-
tients want to see examples of your results. These tools are also a valuable means of
marketing the practice and the quality outcomes it provides.
Technology offers a number of tools for improving doctor-patient communication;
these can be helpful when discussing different procedures and their associated risks,
limitations, and possible outcomes. For example, digital photo albums and Power-
Point programs can be used to showcase your clinical photographs on a continuous
loop, both on the practice website and in the waiting room. Some practices have in-
vested in touch-screen patient education centers to highlight the procedures offered.
Skin analysis systems offer another opportunity to engage patients and educate them
about their skin quality and to recommend products. Most vendors provide practice
marketing materials, including brochures, postcards, mailers, DVDs, media clips,
and even reward programs that can be effective in attracting new patients. The ad-
dition of a sleek flat-screen monitor and a DVD player in part of your reception room
can transform this area into a patient education center.
Patients have come to expect some form of computer imaging in a modern aesthetic
practice. They want to see simulated results to help them decide whether this is the
right surgeon to meet their needs. Computer imaging is an effective communication
tool during the consultation and when reviewing surgical results. It provides a basis
for defining goals and developing an appropriate treatment plan. It also helps to rein
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Potential Pitfalls in the Office
 Long lead time for consultations, treatments, or surgery
 Long waits in the reception area before patients are seen
 Delays in returning phone calls
 Excessively high fees; poor value
 Doctors or staff members who appear rushed and inattentive
 Unprofessional, inattentive, or rude staff
 Poor office management
 Reluctance to show before-and-after photographs
 Reluctance to discuss training, qualifications, and board certification
 Lack of attention to details, service, and follow-up

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in patient expectations by demonstrating what is and is not possible to achieve
through surgery and adjunctive treatments. When showing patients preoperative and
posttreatment photos, it is important to select patients of the same sex and similar
age, ethnicity, and skin type who had comparable procedures. Patients cannot be ex-
pected to imagine what their results will look like; they want the surgeon to show
them what to expect.
In the age of Internet and social networks where consumers meet online to discuss
their experiences, it has become commonplace for prospective patients to ask to
speak to other patients. If the surgeon is unwilling to have satisfied patients serve as a
reference, then staff members who have undergone treatment are a good alternative.
Signage within your practice is also important to educate patients about every pro-
cedure, treatment and product that the practice offers. A common lament among
doctors is the long-standing patient who undergoes treatment somewhere else and
proclaims, “If I had known you do that, I would have asked you about it.” One way
to avoid this missed opportunity is to regularly communicate with your patients
through email blasts and newsletters, keep the practice website up to date, display a
menu of your services in patient areas, and provide brochures on the brands featured
in your office.
Office Materials
FOAD NAHAI
Today’s patients want to be as well informed as possible. They have access to a wealth
of information online, some accurate and informative and some highly misleading.
We have the opportunity to provide our patients with balanced information con-
cerning aesthetic surgery. This is one of the best marketing devices we have. We have
three avenues open to us for disseminating this information: our website, informa-
tional brochures, and electronic media, such as DVDs and videos. On the website,
you should include a brief biography or mini–curriculum vitae of each surgeon in
the practice, a statement of your practice philosophy and mission, contact informa-
tion and address, maps and directions to the office, and images of the office, surgicen -
ter, and overnight stay rooms if you have them. You should also include a list of fre-
quently asked questions, a description of operative procedures and cosmetic
treatments offered, and a gallery of preoperative and postoperative pictures.
Although most patients have access to your website and have probably visited it more
than once before making the appointment to see you, it is worthwhile to mail a pack-
age of information about the practice to each new patient at the time that the initial
appointment is made. In our practice, this includes a folder with several inserts in-
cluding a description of the practice, a biography/mini-CV of the surgeon with whom
they have made the appointment, directions to the office, and a list of local hotels

and restaurants (see Chapter 1). In addition to the information about the practice,
an appropriate procedural information brochure is placed in the folder. The design of
the information packet should be coordinated with the look of the website. All of
this information should also be available on your website.
During the initial consultation, most patients are shown preoperative and postop-
erative images of patients who have undergone similar procedures. It is a good idea
to offer patients the opportunity to view an informative patient education video or
DVD of the procedure they are interested in. For patients who will have implants,
an additional informational booklet is provided. For patients undergoing Botox or
Restylane injections, the manufacturer’s brochure is also helpful.
An effective internal marketing approach is to have a variety of brochures about pro-
cedures available in your waiting and examining rooms. A patient who is seeing you
in consultation for a face lift may not be aware that you or others in your practice
also perform breast and body-contouring procedures.
MARKETING AND
COMMUNICATION INITIATIVES
MARIE CZENKO KUECHEL
Making a Connection
The very last thing that many aesthetic surgery providers manage in their practices
is the very first thing your patients will encounter—not your staff, services, or fees, but
your marketing and communications. Most people acquire information about aes-
thetic surgery from television, magazines, the Internet, or other people; however, this
is not always how they locate a provider. Where individuals connect with a provider
varies widely; it can be through referral by a physician, friend, or family member,
through an Internet listing, or an advertisement.
The best way to manage the messages that influence your patients’ decisions is
through strategically targeted communications that make a connection that yields
the right results. Every connection you make can enhance your practice’s ability to
thrive. Making a connection requires:
 A goal that defines what you hope to accomplish by making a connection
 Effective and appropriate vehicles for delivering your message
 A call to action that motivates others to act
 A cost analysis of these communications (worth as well as expense) to maxi-
mize their value
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The most successful practices establish a connection, maintain it at every opportunity,
and communicate effectively. This is neither marketing nor advertising. Marketing
encompasses all the activities necessary to get others to accept or purchase your ser -
vices or products. Advertising is a marketing strategy—a paid message about a ser -
vice or product for sale. Many successful aesthetic practices do not advertise, but
every practice must market, persuading others to accept or buy into their services.
Marketing is essential for effectively communicating your practice’s identity, for get-
ting others interested in the services you provide, and for enabling potential clients
to connect with you. You must convey how and why you can best fulfill the patient’s
desire for appearance enhancement and extend the invitation to act on this rela-
tionship. Communication and education are part of the marketing mix and are in-
tricately intertwined: without one, the other is useless.
In an aesthetic surgery practice, education is the basis of every message. Regardless
of your audience, you need to communicate essential information about the services
you provide and your ability to provide them. The way in which a message is deliv-
ered to your intended audience represents half of its value. This can be done with
varying levels of efficiency, speed, attraction, and cost.
Although patients are usually the focus of your marketing and communication strate-
gies, it is also wise to target some of these communications to referral sources and
business-to-business resources to enhance your ability to attract new patients.
Marketing Channels
There are three general communication initiatives essential to every practice of aes-
thetic medicine: patient relations, outreach, and advertising. Even if you have the
skills to provide services and have willing patients who desire your services, your
practice will need to communicate through one of the following marketing channels:
1. Direct communication: Specific messages designed for visibility and educa-
tion, to retain current patients, to encourage service and repeat service, and
to elicit referrals. An example is the patient education or core practice mate-
rials that you put into your patients‘ hands or make available in your prac-
tice setting.
2. Outreach: Outreach entails no-cost or low-cost messages to your target pop-
ulation that provide visibility, education, and generate traffic. Examples in-
clude your practice’s website, your referral sources, social media (such as blogs,
Twitter, and Facebook), and one-to-one networking.
3. Advertising: Ads are created specifically to reach the market of individuals
interested in your services or those in a specific demographic. Ads provide vis-
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ibility and education and generate traffic, but there is a fee for their trans-
mission. (Examples include directories, magazine or newspaper ads, the
recorded message on your telephone hold system, and even articles you pay
to have placed.)
Marketing and Communication Goals
Goals must define a target and an endpoint, something that signals that you have
accomplished your goal. Look carefully at the messages and tools you use to con-
nect with your market, community, peers, patients, and staff. Goals for your mar-
keting and communications include the following:
 Visibility: Your practice must be visible to those with whom you need to com-
municate. Make certain your message is consistent with the image you want
to project.
 Announcement: Announcements should be made when there is something im-
portant to convey, such as a new location, a new staff member; different hours,
added services, new policies, or rebuttals to misinformation by the media. Don’t
announce something dated or trivial, and don’t attempt to impress your audi-
ence with something you cannot substantiate. For example, don’t claim to be
the leading provider of a cosmetic injection or to have some innovative tech-
nique with injections unless you can support this claim.
 Solicitation: The service or a product you sell is part of your business and your
success. Sharing your service menu on a website or with referring physicians
is an example of solicitation.
 Education: Every communication should educate, directly or indirectly. If you
don’t have at least one key piece of valuable information to share, remain silent.
Explaining your service menu to staff, referral sources, prospective clients, and
peers is part of this education process.
 News: News is timely, previously unreported, important information that is
of interest to others. It is not self-serving. If you have valuable news, share it.
 Novelty: A novelty is something new and fresh. If your goals for connecting
are based on novelty, be certain that you are well informed about what that
novelty can accomplish. You may be excited about a new procedure, product,
or device, but before you promote it, make certain that it holds promise for
the long term. You may wish to be known as a trendsetter, but be certain you
are backing the right trend.
 Compliance: You need to communicate to current and prospective patients
that you comply with the highest standards of care and ethics in your specialty,
whether with CME or accreditation of facilities.
 Pressure: The only appropriate pressure would relate to a clinical matter that
affects a patient’s outcome or health. Pressure to act now because of pricing
or novelty creates a false connection and will result in a failed relationship.
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 Price: Your services have a valid cost. Connecting with a potential patient on
price is valid only when you know specifically what is desired and appropri-
ate for the individual.
 Connection: You must develop marketing strategies to help you maintain your
connection to others. Connections can come in the form of an invitation, a
personal message, a reminder, or simply a communication that maintains your
visibility for your patients, referral sources, or the community.
Call to Action Essentials
In marketing strategy, a call to action is the response that your communication is in-
tended to elicit in specific groups. Much like the practitioner who does not ask for
referrals, a practitioner who does not extend a call to action is not likely to receive
a reply.
 Your audience at large: In communications that generate interest and visibil-
ity, the objective is traffic, conversion, and retention. Your call to action may
be as simple as letting people know where they can find you, or as direct as an
invitation or query about an individual’s desire for services. The call to action
must be clear, timely, and effective and must not invade privacy or violate good
judgment.
 Prospective and current patients: The best calls to action allow individuals to
act on their own time, in their own fashion, with no deadline, money, or per-
sonal pressure attached. Consumers today are savvy about what they want and
are aware of attempts to elicit a response from them. Use this to your advantage
by producing a message that is educational but also speaks to patients’ personal
desires. In this way you will create a call to action that fits your audience.
 Patients and referral sources: To generate added business, your call to action
for patients and referral sources should be direct. The purpose of your com-
munication requires that you ask for referrals, so the call to action should pro-
vide the information and motivation necessary for the referral source to act.
Ongoing patient education and outreach through newsletters, clinical updates,
and special offers must include valuable information about what you want
others to act on; the inclusion of an incentive is added motivation for the in-
dividual being referred.
There is a difference between incentive and gratitude. Quid pro quo (some-
thing for something), such as a gift or bonus for a referral, is unethical in the
realm of medical treatment, much less elective medical treatment. Gratitude,
not incentive, is essential. Gratitude acknowledges that you are aware of
an individual’s effort on your behalf and in turn, your gratitude fuels future
referrals.
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