Four plastic surgeons give their views on the uses (and overuses) of modern digital imaging systems

Digital imaging has grown from a novelty in plastic surgery practices to a well-accepted tool. Plastic Surgery Products asked four surgeons around the United States to participate in a roundtable to discuss the advantages and limitations of electronic imaging systems.

Plastic Surgery Products: What are the key benefits of communicating with digital images? What is the single most important aspect of digital imaging in your practice?

Jonathan R. Berman, MD, FACS, is certified by the American Board of Plastic Surgery and the American Board of Otolaryngology/Head and Neck Surgery. He is a member of the American Society of Plastic Surgeons and American Society for Aesthetic Plastic Surgery. He is an active staff member of the Boca Raton (Fla) Community Hospital and the Delray Medical Center. He performs most of his aesthetic surgery in his AAAASF-accredited surgical suite in Boca Raton.

Jonathan R. Berman, MD, FACS:I’m better able to communicate to a patient what he or she could potentially look like. Just as importantly, illustrating why a procedure shouldn’t be done is crucial, and the ability to do so is a very powerful tool.

I use a mirror-type software system. It is wonderful to show slide shows of before-and-after photography and to be able to archive and retrieve with the software’s database function. It is extremely useful to retrieve a picture to show a patient, for example, where a reconstruction suture line may fall or where an incision is to be placed. It is also valuable to print up photos on the spot rather than to bring the 35-mm film to a store, get the photos developed, and put them on the chart—that was such a hassle. Now, by clicking a few buttons, I can print the photo for preoperative use—in color or black and white. I can also zoom in on or enlarge the photo as needed.

Todd G. Owsley, DDS, MD:The benefits are innumerable. Taking prints and slides was a task of awesome proportions; now it is so easy, that anyone can take a high-quality, standardized image in seconds. I have been using an imaging system for almost a decade. This and other popular systems are as easy as using Windows®. The most important purposes for digital imaging in my practice are patient records, before-and-after pictures, and marketing.

Loren S. Schechter, MD:One of the key benefits is that I can show the pictures to a patient anywhere. I don’t have to make prints; I can just bring images up on any flat-screen monitor. The ability to pull up images using searchable criteria is invaluable. I can search by ICD-9 code, by date, or by procedure. I had all that information when I took slides, but it wasn’t easy to use. The digital imaging system I use makes all of this simple and dispenses with slide storage. Some people still operate under the misconception that paper is safer. But what if there’s a flood or a fire at the office? Your paper is gone. With computer files, you have a reliable backup source. We have off-site backup, so if anything happens, we haven’t lost all our images.

Andrew Barnett, MD:If you believe that a well-educated patient is best able to participate in the therapeutic relationship, digital imaging is second to none for conveying information. Following a thorough explanation of the procedure, including risks and potential complications, imaging completes the consultation. The marketing aspect of the tool is a byproduct of your primary goal—patient education, the single most important aspect of digital imaging.

PSP: How do you integrate imaging into consultations, and how have patients responded?

Owsley: I don’t use images in every consultation, but I frequently take pictures and blow them up on a large monitor to show patients their aesthetic problems. Often, they are shocked to see themselves in a lateral view, because most patients never see themselves at that angle. The patient response is significant because they are more educated by seeing a problem as opposed to just talking about it.

Schechter:We show representative photos preoperatively and postoperatively, but I don’t do a simulation. I don’t want to set up patient expectations for things we can’t do. The representative photos are most helpful in pointing out the nature of the incisions and their placement for each procedure: breast reduction, abdominoplasty, and so on. I also like to use the images to point out asymmetries; people will notice them after the surgery, so it’s better when I point them out first.

Barnett:I use imaging selectively. I use it in almost every rhinoplasty consultation, and perhaps three-fourths of facelift and neck lift consultations. It is extremely helpful in consultations for genioplasty, less so for malar augmentation. I rarely use it in liposuction or breast consultations—it’s simply too time-consuming for these procedures, and I find that patients respond just as well to presurgery and postsurgery photographs from my collection.

I try to keep the entire imaging component of the consultation to 5–10 minutes, using it after the verbal consultation, and before showing actual preoperative and postoperative photographs. Patients re-spond well, and their excitement about the procedure builds after seeing the anticipated result.

Berman:I set up a flow protocol. Depending on what the consultation is for, digital photos are taken and the patient is imaged. For example, with a rhinoplasty patient, digital imaging is very helpful in defining what a patient wants and what is realistic—what I can deliver surgically. Often, patients think that their alar base is too wide, and I show them, with digital photographs and software, that reduction in the alar base may not be what they want and may not be necessary.

Patients love to see the photographic digital imaging and “morphing” of themselves. We take an informed consent, explaining that the digital imaging and “morphing” do not guarantee a result. In surgery, I cannot reproduce exactly what the computer imaging techniques can do. I am very conservative about my imaging, and I explain that up front to my patients. They understand and are happy to see themselves “morphed.”

PSP: How do you use images for risk management or patient screening?

Schechter:Using digital imaging for risk management is probably more of an issue for the nonelective cases we do. When I get called into the emergency room, I don’t have control over the patient’s preoperative condition. My physician’s assistant carries the digital camera with her, so we can document the patient’s condition prior to surgery.

Barnett: It’s easiest to answer this by describing a typical consultation. I start a rhinoplasty consultation with an examination of the patient and decide in my own mind what type of result I can obtain. It’s essential that the surgeon visualize a realistic result so that later in the consultation, the imaged result matches. It’s too easy to be caught up with the patient’s request for “just a bit more off the tip, and just a little bit smaller, Doctor . . .”

After the examination, I explain the procedure in detail as part of the informed consent. Then, I take a photo of the patient and upload it to the imaging software. I double the image and begin to manipulate one of the images into my anticipated final result. Frequently, patients will say that they were hoping for more, and if I think that the result that I can realistically obtain will make for a disappointed patient, I will tell the patient that he or she needs to understand the limitations of the procedure. Remember, it’s a lot easier to deal with a disappointed patient before surgery than after surgery!

I draw lines indicating the location of the nasal bones and the upper and lower cartilages. In a different color, I indicate where the reduction will be and where I will make the incision. I generally show only profile views, but on occasion I also modify the frontal view. I finish up with actual preoperative and postoperative photos.

I do not provide copies of the digital image, and I always provide a verbal disclaimer that the image I’ve provided is in no way a guarantee of the final result, because many factors can come into play to determine the final result. I document in my chart that I’ve given a verbal disclaimer. I will also have some patients sign a written disclaimer.

Digital imaging is an excellent tool for screening patients when it is used honestly. Surgeons who are just beginning their careers and have not yet had the experience to be able to predictably anticipate the final result need to be extremely careful in using digital imaging. It’s easy to sell a patient on surgery with digital imaging, but you must be careful to deliver what you promise.

Plastic surgery is all about managing expectations. No patient will ever complain that you’ve given him or her more than you promised, but delivering less than promised may give you the opportunity to demonstrate your digital imaging skills to a jury.

Berman:As for risk management, there can never be too many photographs taken. Because it costs no more to take 40 versus 10 photographs, and hard-drive space is measured in gigabytes, the cost per image is ridiculously small. Taking a large number of photos has saved me a great deal of trouble many, many times.

Todd G. Owsley, DDS, MD, is in private practice in Greensboro, NC. He is board-certified in oral, maxillofacial, and cosmetic surgery. He is a graduate of the University of North Carolina, Chapel Hill, School of Medicine and the University of Missouri, Kansas City, School of Dentistry. He maintains full hospital privileges at the Moses Cone Hospital System in Greensboro, NC. He was recently chosen as a board examiner for the American Board of Cosmetic Surgery. He also instructs residents as a clinical assistant professor at the University of North Carolina.

Owsley: Digital images are important in risk management for several reasons. On many occasions, I have had a patient comment about something that he or she feels is a result of surgery, and when I pull out the digital preoperative photos and show that this problem existed before surgery, the misconception is corrected. In addition, I examine my digital images of patients the night before surgery to plot my course and identify problematic areas. Then, I discuss this with them immediately before the surgery.

PSP: What were the unexpected bonuses involved with digital imaging?

Barnett:I did expect—and was rewarded with—an increased conversion rate with digital imaging, but there were two unexpected bonuses. Once you are facile with the technology, you will find that you can convey the critical information to your patient rapidly, shortening the consultation and saving you time. The other bonus was the ability to screen out those patients whose expectations are unrealistic, and who will be overly demanding.

Berman:With imaging or anything else you take on, the more you do, the more comfortable you are with the technology. The more breast augmentations you perform, the better and quicker you can do the operation. Your complication and revision rates drop, and the results improve. The learning curve in digital imaging is not that steep, but there is a learning curve.

The more facile you become with digital imaging and computerization, the more in control you will be. They certainly help for designing advertisements, marketing plans, and Web sites. The major point is to embrace the new technology, use it, become familiar with it, and it will become your friend and not your enemy. It will become your greatest ally!

Owsley:Before-and-after images have become very popular, and patients request copies to show friends and relatives. This serves as free and unexpected marketing.

Loren S. Schechter, MD, is certified by the American Board of Plastic Surgery. He is a member of the American Society of Plastic Surgeons, the American College of Surgeons, the American Society of Reconstructive Microsurgery, and the American Society of Maxillofacial Surgery. He is in private practice in Morton Grove, Ill, and serves as division director of plastic surgery at Lutheran General Hospital in Park Ridge, Ill, St Francis Hospital in Evanston, Ill, and Rush North Shore Medical Center in Skokie, Ill.

Schechter: There are quite a few bonuses. The biggest one is probably the ease of archiving and accessibility of the archives. They’re dated, titled, and coded, and they’re readily searchable using a variety of parameters. With slides, you had to handle the film and slides, label them manually, and find somewhere to store them. That’s expensive real estate.

Digital imaging is much more cost-efficient. You take the photos, you can delete the ones you don’t like immediately, and, of course, you don’t waste money on film and developing for those bad shots. The setup is basically the same; I still have a dedicated photo room. I use a high-end camera with interchangeable lenses in the office and a less expensive camera in the operating room.

PSP: What are the most important considerations in selecting an imaging system?

Berman:It is now 12 years since I purchased my digital imaging system. There are less expensive systems than the one I currently use. After all, I have used this system for a very long time. Ease of operation? Almost all systems are easy to use these days. Which platform, Macintosh® or Windows? Most software is available in the Windows environment, but Mac is much easier to use. Technical support is a must, but what kind and what quality? Can you reach them 365/24/7? What works best for you? Can they troubleshoot for you and with you? Can they log into your system from the Internet? Tech support is very key.

Is the software easy to use? Is it CAD-like, Photoshop®-like, or Paint-like? Do you want all the “bells and whistles”? You need to be able to do what you want to do, but it has to be quick, easy, and reproducible. There is nothing more frustrating than having a live patient fidgeting in the exam chair while you spend 20 minutes to create the “ideal morph” of the patient. The patient will tire, you will fatigue, your stress level will go up, and you will lose the patient. The software must be quick to load and quick to work with.

Archiving is a must: Date stamping and tagging the images with not only the name of the patient, but the procedure and diagnosis, is helpful for the time you need to give a presentation on your Mohs surgical reconstruction of facial defects. You can be as elaborate as you want to be on the data-entry level, but it should be straightforward, easy, and not tedious to get the information in for that picture. The upload from the digital camera to the computer should be quick and easy as well. Nothing is more frustrating than waiting for the reader to read a JPEG file and load the picture onto the disk. Worse yet, the reader may not read the compact flash card.

If you are reasonably computer literate, the learning curve for imaging software is shorter and less steep. But don’t be afraid to call tech support and pay a little if you have questions. You will learn a lot. Most of what you will learn is by trial and error, not from a book, but often the manual is helpful. The nice thing about Apple® computers is their discussion and support Web site. The subculture of Mac users is remarkable. There is probably one Mac for every 200 PCs, yet this Mac group is loyal and helpful to one another.

In the end, computer imaging is a must. Today, you cannot act like an ostrich with its head buried in the sand about computers and plastic surgery, or about computer imaging and plastic surgery. Whether you morph your patients or not, archiving digital photographs into a database is a must. The slide-viewing box, 35-mm slide projector, and screen are “gone with the wind.”

Owsley:There are many choices available today. I like the system I’m using because of its affordability and portability. I think the single most important factor in selecting a system is customer support and simplicity of use. Your staff should be able to use it with minimal training.

Schechter:When I incorporated digital imaging into my practice 5 years ago, I did it as an overall software package. The important thing is to have a modular system, in the sense that it has scheduling, imaging, billing, accounting, and charting systems. I want to prevent things like dual entry. I want things streamlined to minimize keystrokes. With my system, we can update patient information in one system and know that the information has been documented everywhere.

Andrew Barnett, MD, has been in private practice in San Francisco since 1985. He is certified by the American Board of Plastic Surgery, and is an active member of the American Society of Plastic Surgeons, the American Society for Aesthetic Plastic Surgery, the California Medical Association, and multiple specialty societies. He is chief of plastic surgery at St Francis Memorial Hospital, and has staff privileges at St Francis, California Pacific Medical Center, and San Ramon Regional Medical Center. He has offices in San Francisco and Walnut Creek.

Barnett:The five most important considerations in choosing an imaging system are the specific capabilities of the software, ease of use, nonproprietary image format, vendor support, and price. A feature-laden program may be overly cumbersome to use, and too slow to efficiently integrate into your practice. When considering imaging software, forget about archiving features. These are separate functions, and there are many inexpensive archiving systems that are better than the systems integrated with digital imaging programs written for plastic surgeons.

Some systems use proprietary (nonstandard) image formats, making the systems difficult to integrate with other software—this is not a good thing! If the system you are considering is difficult to use and has a high support fee, think twice about purchasing the software. Cost is self-explanatory, but keep in mind that many of the programs out there were developed more than 10 years ago, in the ice age of digital photography, and they have maintained a cost structure that should have disappeared with the dinosaurs. Caveat emptor! PSP

Acknowledgment: Holly Fisk, a Santa Ana, Calif-based freelance writer, organized and conducted this roundtable.