Imaging in Aesthetic Medicine: The Making of Good First and Last(ing) Impressions

As the sayings go: “You never get a second chance to make a first impression” and, “A picture is worth 1,000 words.” In an industry based on outward appearance, where patient satisfaction is the indicator of success, the role of imaging cannot be understated or underestimated. Yet so many aesthetic physicians and practices fail on what should be an all-important “one-inch putt” when they do not follow basics for good before-and-after (B&A) photos, or try to oversell patients using flashy tools without knowing the how, what and why.

Imaging is all about accurately capturing what can and cannot be seen and analyzing it, or framing it, in a useful manner. To the practitioner, this information can be revealing; to the patient, enlightening; to your staff, sensational and educational.

Putting Your Images to Work

Erica Crawford, president at Influx Marketing (Los Angeles, Calif.), has guided physicians around the U.S. on how to put their best image, and images, to work for them. “For social media and practice websites, we collect data on what is most visited and most viewed. The single most visited and viewed page is the gallery, across the board,” she reported.

“Patients might run into your work on social media or use a search engine to find your website, she continued. “They will check reviews and examine your credentials, but they seek out pictures. You will be judged by the quality of your images and the results they demonstrate. Diversity of procedures, as well as ethnicity within your portfolio, are important because you want patients to identify with what they see. It is key to the decision-making process.”

While using social media to display your work can really help boost your practice, great caution must be taken, Ms. Crawford warned. “First, HIPAA regulations must be followed, and some photos such as those of genitalia cannot be posted, obviously,” she explained.

“Outside of B&As, there is no effective way to discuss some of the subject matter,” Ms. Crawford continued. The clothing worn, or lack thereof, may get one into trouble. “Most of the time you will not be fully banned but perhaps temporarily, which you still want to avoid. The nuances are evolving constantly, and these are the biggest pitfall I have come across, so do your homework if you go there. I have seen things get banned and had no idea why.” It is also important to consider labels and comments you post with pictures. “Being body positive and avoiding controversy is more important now than ever. Err on the side of caution.”

The Power of Non-Verbal Communication

Imaging is a visual communications tool. Justin Cohen, MD, a facial plastic surgeon at Cohen Clinic for Plastic Surgery in McLean, Va., uses image morphing for any procedure that will change the face. “Using our photos with a special medical morphing program, we do a digital simulation at the consultation,” he shared. “I always stress that these are digital approximations and not a guarantee. This ensures that my patient and I are on the same page.”

If a request is something that the practitioner believes would be unrealistic or not aesthetically appropriate, patients can be counseled accordingly. “I have had patients come in looking for revision procedures who were absolutely gorgeous, and my thinking was that the time, money and recovery period may not be worth the slight improvements,” Dr. Cohen shared.

Good imaging also reveals just how profound the result actually is. With decades of experience, Bruce Katz, MD, a dermatologist and director of JUVA Skin & Laser Center (New York, N.Y.), is no stranger to imaging technology for both clinical and research purposes. “We were early users of 3D imaging for clinical trials. One can do things with 3D imaging that you cannot with 2D. Everything has its place, but the paradigm is changing,” he noted.

Some technologies allow you to focus on the eyes, for example. “With an eyelid treatment the result may be clinically obvious but a subtler overall effect,” Dr. Katz continued. “With precise imaging of the periocular region we can highlight improvements.”

There is also perception drift. “People tend to forget what their facial or body contours used to look like,” Dr. Katz indicated. “Good imaging allows you to remind them so they can see and enjoy the result that was achieved.”

According to Steven Pearlman, MD, director of Pearlman Plastic Surgery (New York City, N.Y.), who has been using 2D and now 3D imaging for more than three decades, it is always about the patient. “I am not trying to sell, but to educate. If I do great work and take consistent pictures my work will speak for itself,” he rationalized.

“Morphing technology helps me explain what needs to be done in a way the patient can see and better understand,” Dr. Pearlman expanded. “For example, if the patient wants the nasal hump flattened and that is all they want to talk about, they may not understand that a few other, minor things also need correction to make it work. They may also think they want one thing, but my experience tells me something a bit different. I can show them what I mean and how everything works together for the final outcome, which they would probably not understand fully enough from a verbal description. It also helps me spot patients who may have unrealistic expectations.”

Grant Hamilton, III, MD, a facial plastic and reconstructive surgeon in Rochester, Minn., also relies on imaging for his rhinoplasty work at the Mayo Clinic. “We cannot expect patients to have the vocabulary to discuss concerns precisely. For example, if they want a smaller nose, what do they mean – shorter, narrower, less projected, or all of the above?” he explained. “Also, their conceptualization of what they will look like and what is reasonable to expect often needs clarification. This simplifies the consult, and it gives us visible proof of the outcome, which we can readily compare with baseline. In the great majority of cases, people are happy and do not require revision, which is very important when you consider that patient satisfaction with the outcome is the true measure of success with aesthetic rhinoplasty.”

Dr. Hamilton believes the surgeon should be deeply involved in, if not personally performing, any image manipulation. “While software might be remarkably capable of morphing an image to look younger or reflect changes after treatment, and an individual may be highly skilled at the work, only the surgeon knows what is surgically achievable and what it will look like,” he stated.

“As I work on image manipulation, I perform the surgery in my head, providing a step-by-step pathway for the procedure that also gives me a plan for the consult,” Dr. Hamilton described. “I am careful not to make things look perfect because everyone has little asymmetries and aesthetic perfection is unachievable. When a patient asks if maybe I can make something look a little better, I tell them that I absolutely plan to make it better in every respect but that what is shown is a reasonable expectation. If patients are overly concerned about minute differences, it may be a sign that their expectations are unreasonable.”

To Dr. Pearlman, 3D is graphically impressive and has a certain ‘wow’ factor, but for many applications, the 2D is more useful. “It is easier to accurately manipulate in a way the patient can relate to for what I do,” he expressed. “3D with measurements can give you an analysis that is ideal for research, and it can accurately match up with landmarks on a patient’s face, but I do not use it in the consult.”

In some cases, imaging technology offers software analysis and different light sources to further enlighten clinicians and clients, almost as a diagnostic tool. Different light sources can highlight problem areas, photodamage, pigment and vascularity, isolating things the naked eye may not notice for better examination and discussion. This may have value, if not clinically, then for research, Dr. Katz noted. “For some treatments analysis of hydration, for example, may hold more value for research because you are looking for empirical data and comparisons.

“Imaging is especially useful in instances where shapes and contours change, such as with acne scars, injectable fillers, cellulite, any depressed or raised areas of the skin,” Dr. Katz continued. “Technology can accurately quantify these changes to show that dimples improved 30% or 50% rather than having to rely on a simple picture. This is excellent for research but can also help inform patients and enhance their understanding of the results.”

A downside to imaging is that patients tend to have unrealistic expectations as to its capabilities. “They want to see a virtual 3D be- fore-and-after to get a perfect vision of what the new ‘me’ will look like,” said Dr. Cohen.

“Morphing programs are certainly powerful – but they may not actually reflect what is realistic in real life. It is critical that we set and maintain appropriate expectations. That is why I often rely on 2D images in an old school way because I can show measurable changes that reflect what one can do clinically. ‘Want a 7 mm implant right there? Here is how it changes your profile.’ We can then have a realistic conversation around that.”

Dr. Katz offers an app where patients, using their own phone camera, can be shown where there might be room for improvement with things like neurotoxin and fillers – with a caveat, he asserted. “We must take all reasonable measures to assure patients that anything they see on the app or in the consult is an approximation, not a guarantee.”

Medical imaging specialist and engineer Gabriel Buendía Bordera, scientific director of the Instituto de Fotomedicina (Barcelona, Spain), has worked alongside physicians performing clinical trials and testing medical devices for 15 years. According to him, a variety of imaging systems out there provide a more quantitative analysis of different skin parameter categories, but often these are more useful for research and their clinical application is less clear. “In 15 years of working with cosmetic physicians I have seen some become slightly overwhelmed with so many numbers, because it may be hard to understand their application in a way that actually helps guide treatment choices or is at all relevant to the patient. For research or to prove a device does what it says during development, these are invaluable, but often not so for the clinical setting,” he explained. “They are better for building averages, but it is important to remember that each patient is an individual. Think of pores as an example. After some treatments, once you clean and treat the skin repeatedly and time has passed, you may actually see more pores. Social media tends to suggest that everyone have perfectly poreless skin, so the individual patient may get distracted by this and not see the visible improvement.”

Product Reviews

Embodying the future of skin assessment, Sylton’s Observ^® skin analysis system was designed, engineered and manufactured in Europe, and is now also available in the U.S. via the subsidiary Sylton Inc. (Ann Arbor, Mich.). Supported by an easy-to-use app, this system generates nine high-definition pictures within seconds to provide compelling and convincing consultations with clients, which will increase client satisfaction as well as clinic profitability. Product recommendations and treatment plans can be personalized, which will complete a logical workflow during consultations. In addition, before and after pictures will show true apples-to-apples comparisons, making it easy to demonstrate results. Efficient, effective and portable – either with or without a height adjustable stand – the Observ saves essential clinic space and allows for easy sharing between treatment rooms.

According to Mr. Bordera, “the different filters and light sources employed by Observ help physicians and their patients see through the clutter to highlight facial structures and conditions in a clinically relevant way. It also has different modes to allow the user, through the software, to highlight specific clinical issues to help the patient better understand their needs.”

PEAR (Patients Enhanced and Rejuvenated) imaging systems from DermaQuip (Marietta, Ga.) combine best-in-class photography and skin analysis technology to provide aesthetic practitioners multifaceted facial and skin analyses simultaneously. Their high-resolution photography and visualization technology captures almost microscopic detail and allows examination to reveal or highlight photodamage, wrinkles, pores, oil, bacteria, and more, to enhance the patient consultation and maximize patient satisfaction and conversion rates. The family of imaging systems includes the PEAR Elite, PEAR 3D and PEAR 3D Plus, ranging in capabilities to meet needs from day spas to physician practices. As part of its service-oriented philosophy, DermaQuip has a lifetime warranty on the software – with free upgrades – and three years on the hardware for its imaging products. Also, its software-based design allows all necessary training to occur online from any location, at any time.

With high resolution 3D technology and multiple light sources, the IMAGE Pro^® SUNlite and Hybrid Systems from Emage Medical (Charlotte, N.C.) can reveal sun damage, sebum and porphyrins, hydration, skin pigment, vascularity, inflammation, and much more. Other analysis tools include skin age, skin texture and symmetry. A retractable hood creates an isolated environment for facial photography using normal, cross-polarized, parallel polarized and ultraviolet light. This incorporated light technology also automatically sanitizes the camera between patients, killing more than 99% of pathogens including COVID-19. Software integrates smart image recognition to automatically match up current and previous facial images. The result is consistent, reproducible facial photography and skin analysis designed to inform patients and increase satisfaction. These devices even produce a QR code patients can use to access and view their analysis results from their mobile devices. Both are also extremely portable with a 21.5 inch x 15 inch x 16.5 inch footprint, each weighing less than 25 pounds.

For David J. Goldberg, MD, JD, a dermatologist and director of cosmetic dermatology and clinical research at Schweiger Dermatology Group (New York City , N.Y.), the “SUNlite system has improved patient satisfaction considerably, because I can overcome virtually any patient’s uncertainty with visual evidence,” he stated. “It easily replaces doubt with satisfaction, and once even resulted in an apology from a skeptical patient.”

With more than 20 years of 3D imaging solutions in skin photography, Quantificare SA (Biot, France) is a giant in the industry. Its Research & Development (R&D) department works closely with physicians, integrating feedback and ensuring their 3D photography systems are always adapted to evolving practitioner needs. The Company’s full range of 3D LifeViz® systems allows you to digitize consultations and communicate more effectively with patients through 3D images. Portable and compact by design, each of the cameras achieves remarkable results for face, body and breast.

Heralding a new era for 3D aesthetic photography, the wireless LifeViz® Pro series integrates artificial intelligence to streamline the consultation workload and save precious staff time. Using the latest hybrid camera, automatic detection, classification of image sets, and automatic wireless image transfer, the results are superior image quality making it a gold standard in 3D photography.

“Our LifeViz Mini system has been a tremendous addition to our armamentarium,” said Gregory Chernoff, MD, a facial plastic and reconstructive surgeon in Santa Rosa, Calif. “It provides a useful tool for evaluation improvements and changes in surgical, nonsurgical and research applications. We can demonstrate 3D changes in volume on the face or body; measure improvement in wrinkles, vascularity, pigment and more on the skin; or reveal changes not easily noticed in a simple 2D photo as I have in peer-reviewed research papers. It helps us manage patient expectations and validate incremental improvement.”

Incorporating Imaging Systems into the Practice

According to Ms. Crawford, practice managers are always concerned about money and office space, so two key ingredients to choosing imaging systems are the cost and the footprint. “Will return on investment be adequately rapid, and do you have the room to accommodate everything? For B&A photos, this should be a priority because the usefulness of a dedicated photography space is wide-ranging, and the cost is relatively marginal when you consider how much treatment devices cost and what good photography means to the practice,” she noted. “Even a small practice can find a large closet to fit two people, a good camera, and whatever lighting and background makes it work.” Using a corner of a room, while not ideal, is also certainly workable for smaller practices and medspas. “Also consider that a new practice needs to focus on patient acquisition. Quality imaging is important, but also scalable.”

And from a practice management perspective: “You got them in the door with B&As, but now you can analyze their skin or show views that the patient could never see otherwise,” Ms. Crawford continued. “Regardless of the technology, it is the provider’s job to present the best and most accurate vision of what is possible for that patient. Hair restoration is a surprisingly good example when you consider that 360° imaging allows patients to see what is difficult to visualize at home in a mirror, which is why hair restoration pros have this technology. It excites but also educates, which is important because expectations management is key to patient satisfaction.” It is also important to guide patients because they don’t usually know exactly what they want. They need guidance about what could use correction, how it might be done, and what they can realistically expect. “This can increase add-on sales but also prevent them from over-committing to things they don’t need.”

What’s Next?

In every industry technology continues to improve, and at times we are confronted with a truly disruptive emergence, but in the case of imaging in aesthetic medicine experts agree there is a lot of work to be done to better harness what is already possible. “I think we can expect to see more capability to work with the images we capture and have these at our fingertips, as well as to gather more quantitative data,” Dr. Katz noted.

Indeed, imaging will continue to be an increasingly crucial tool for the aesthetic practice as technology evolves. “In my experience, practices that have the best imaging technology have higher conversion rates and better patient satisfaction,” Ms. Crawford mentioned. “The ability to visualize outcomes and present them in different situations is vital to good aesthetic medical practice. A friend of mine thought she might need a little neurotoxin, maybe some fillers; through good visualization, skilled work, and visual proof of the result, she is a lifetime patient of that practice. It does make all the difference.”