Photographic protocol for image acquisition in craniofacial microsomia.

METHODOLOGY Open Access
Photographic protocol for image acquisition in
craniofacial microsomia
Carrie L Heike1,2*, Laura P Stueckle1, Erik T Stuhaug1, Luiz A Pimenta4,6, Amelia F Drake4,5, Daniela Vivaldi4,6,
Kathleen CY Sie1,3 and Craig B Birgfeld1,3
Abstract
Craniofacial microsomia (CFM) is a congenital condition associated with orbital, mandibular, ear, nerve, and soft
tissue anomalies. We present a standardized, two-dimensional, digital photographic protocol designed to capture
the common craniofacial features associated with CFM.
Keywords: Craniofacial microsomia, craniofacial features, digital photograph, protocol, standardize
Introduction
Craniofacial microsomia (CFM) is a congenital condition
characterized by underdevelopment of the facial struc-
tures, typically involving the ear and mandible [1,2].
More specifically, the craniofacial malformations asso-
ciated with this condition can include: orbital anomalies
in size and position, mandibular hypoplasia, ear malfor-
mations (microtia), facial nerve palsy, and facial soft tis-
sue deficiency; all of which can be classified using the
OMENS classification system [3,4]. CFM often involves
one side of the face, though the condition can be bilat-
eral. Individuals with CFM can also have dental, cardiac,
renal, and cervical anomalies [1,2]. Phenotypic variability
among individuals with CFM is wide, and clinicians dis-
agree about the minimal diagnostic criteria for CFM
[5-7]. For the purposes of this article, we consider CFM
to include criteria listed in Table 1.
CFM has an estimated prevalence of 1:5,600 to
1:26,550 live births [8,9] and represents one of the most
common conditions treated at craniofacial centers; yet,
little is known about the etiology of CFM and few out-
come studies are available. Multicenter studies are
required to include large numbers of individuals with
this condition. In order to ensure accurate phenotypic
characterization of study participants recruited from
multiple centers, we must develop methods to ensure
high quality, standardized phenotypic data on children
with CFM.
Photographs can facilitate standardized phenotypic
assessment of craniofacial morphology [10]. Several
photographic protocols exist for assessment of craniofa-
cial surgical outcomes [11-13], including cleft lip repair
[14-16]. To our knowledge, a published image acquisi-
tion protocol intended to capture the unique craniofa-
cial features associated with CFM does not exist.
In this paper we present a standardized, two-dimen-
sional, digital photographic protocol designed to capture
the common craniofacial features associated with CFM.
Methods
We developed a multicenter consortium entitled the
“Facial Asymmetry Collaborative for Interdisciplinary
Assessment and Learning (FACIAL)” to facilitate
research on the etiology and clinical outcomes in CFM
(NIDCR RC1 DE020270). Members of the craniofacial
centers at four academic hospitals developed a digital
photographic protocol to enable classification of the
common craniofacial features coded in the phenotypic
assessment tool for CFM (PAT-CFM)[17], which is
based on the OMENS rating scale [3,4]. We developed
an initial series of images based on prior craniofacial
protocols in the literature. Team members participated
in an iterative process of evaluation and modification
the photographic protocol to optimize the ease of image
acquisition and the quality of the resulting data. We sys-
tematically evaluated the quality of images obtained in
the photo protocol in a series of 50 individuals ages 2-
21 years with CFM (manuscript under review) and
further refined the protocol. We developed a detailed
* Correspondence: carrie.heike@seattlechildrens.org
1Children’s Craniofacial Center, Seattle Children’s Hospital, Seattle, WA, USA
Full list of author information is available at the end of the article
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HEAD & FACE MEDICINE
© 2011 Heike et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
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set of instructions regarding the imaging environment
and equipment, preparation of the subject, descriptions
of the facial features of interest, instructions for each
view, and suggestions for evaluation of the photographs.
We summarized the protocol in sufficient detail to
enable clinicians and researchers at multiple sites to
replicate the protocol, and include a series of images
and checklists to facilitate ease of use. We describe
these procedures in detail below.
The Imaging Environment and Equipment
We have included several recommendations for the ima-
ging environment, and these are illustrated in Figure 1
and summarized in Table 2.
Location and configuration of equipment
We recommend acquiring images in a space with mini-
mum area dimensions of 3 meters by 1.2 meters (10 feet
by 4 feet). Place the participant approximately 1 meter
(3 feet) in front of the background. The camera should
be 1.2 meters to 1.5 meters (4 to 5 feet) in front of the
participant (Figure 1). Posting stickers, posters, or toys
on the walls can cue the participant where to look dur-
ing certain image acquisitions.
Background
We recommend using a blue background to optimize
contrast for individuals with various skin tones [13].
The collapsible mat illustrated in Figure 1 works well as
a portable background. The background mat should be
placed against a wall so that it completely covers any
structures directly behind the seated subject.
Lighting
Optimal images depend on adequate lighting, and stu-
dio-style lighting setups have been well-described [13].
For this portable protocol, we use the following three
lighting sources: (1) ambient light (2) built-in camera
flash and (3) a remote flash on a monopod (Figure 1).
The ambient light in clinic or office settings is usually
Table 1 Inclusion criteria for craniofacial microsomia
(CFM).
At least ONE of the following:
 Microtia
 Anotia
 Facial asymmetry AND Preauricular tag(s)
 Facial asymmetry AND Facial tag(s)
 Facial asymmetry AND Epibulbar dermoid
 Facial asymmetry AND Macrostomia (i.e., lateral cleft)
 Preauricular tag AND epibulbar dermoid
 Preauricular tag AND macrostomia
 Facial Tag AND epibulbar dermoid
Figure 1 Example of possible configurations for the image environment. Photo of the recommended set up (A) and illustrations of a set
up with the monopod flash behind the participant (B) and to the side of the participant (C). (1) Blue background, (2) flash reflection on the
background, (3) monopod flash, (4) participant seat, (5) camera.
Table 2 Imaging environment, equipment, and
participant preparation checklist
 Select a space with sufficient room and lighting
 Lighting sources include: (1) ambient, (2) camera flash, and (3) extra
flash
 Ensure blue background adequately covers space behind the
participant
 Select seating that is appropriate for the participant
 Reposition any scalp hair that obscures the ears, face, and neck
 Ask the participant to remove all jewelry from the face and ears
 Work with the participant to achieve the desired facial expression
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adequate and may include fluorescent or incandescent
lights with or without natural light. The extra flashes
incorporated into this protocol minimize the reliance of
the ambient light, which is only important for assisting
with automatic focus. The built-in camera flash should
be set to “on” or “forced” so it will trigger during all
image sessions. The monopod flash is used to eliminate
shadows, and ideally should be placed behind the parti-
cipant on a flash stand and triggered remotely. Light
from the flash should not fall on the participant. There
are two options for the position of the monopod flash.
The optimal location is approximately 0.6 meters (2
feet) behind the participant. The flash should be posi-
tioned as low as possible and angled upward, pointing at
the background just below the plane of the subject’s
head. The flash should remain hidden from the photo-
grapher’s view by the participant’s head, and should not
appear in the picture. If the physical space does not
allow for this, place the flash 0.6 meters (2 feet) to the
left or right of the participant on the opposite side of
the camera’s flash (Figure 1). The flash should be
arranged on the flash stand so it approximates the parti-
cipant’s head height. The flash should be both angled
and pointed at the spot on the background directly
behind the participant’s head.
Camera settings
Though this protocol can be performed with a digital
SLR camera, our protocol can be completed using a
digital point and shoot minimum six megapixel camera.
It is optimal to have a lens that falls between 60 mm
and 105 mm. Cameras should be checked at the begin-
ning of each photo acquisition session to ensure that
the correct time and date are set, and that the settings
comply with the study protocol. The camera should be
in a mode that allows the operator to select the highest
resolution setting and set the flash to “on” or “forced.”
Additional suggested settings include: Shutter sync: first
curtain; Red Eye Correction: off; Red Eye Lamp: off;
Wide-angle: off; Digital zoom: off. Do not use wide
angle lenses as they can distort craniofacial features for
a portrait. Many cameras have the default as a wide
angle. If a camera has this default setting, the photogra-
pher should zoom in for each picture to avoid obtaining
a wide angle photo. We recommend using the grid lines
on the viewer to ensure optimal head positioning in the
Frankfort horizontal plane (see “Views” section below).
Seating options
To maximize patient safety, we recommend placing
infants and toddlers between 5 months to 3 years of age
who are able to sit with minimal support in a booster
chair [18]. To ensure adequate safety, we recommend
that an adult stay near the child during image acquisi-
tion. For children who do not tolerate this separation
from the caregiver, we recommend placing the child
sideways on the caregiver’s lap such that the blue mat
remains in the background and the caregiver is out of
the image view. Older children and adults should be
placed in a chair with a low back rest to avoid interfer-
ence of the seat back with the blue background. Ideally,
the chair will have an adjustable seat height, and flexibil-
ity to rotate the chair to obtain the optimal positions
required for image capture. Alternatively, younger chil-
dren might need to stand and rotate positions for photo
acquisition.
Preparation of the Subject
We have included several recommendations for prepar-
ing participants, and these are summarized in Table 2.
Capturing the face and ears
The hair should be pulled back to allow for an unob-
structed view of the ears. A variety of items can be used
to accomplish this, including: a wig cap, a hair tie, barr-
ettes, bobby pins, self-adhesive tape, headband, and hair
rubber bands [18]. Whenever possible, subjects should
remove glasses and jewelry from the face and ears,
along with hearing aids [18,19]. Removal of sweatshirts
with hoods, and tucking in collars and other clothing
articles around the neckline facilitates adequate capture
of the neck, mandible, and ear. Wiping the noses and
mouth areas of infants and toddlers just prior to image
capture can minimize reflection from wet surfaces that
create artifacts.
Positioning the subject
When possible, the participant should sit on a mobile
chair or an exam stool so the photographer can rotate
the participant to the correct positions required for
image capture. While adults and older children are fre-
quently comfortable and safe to sit on a seat with
wheels, younger children might need to stand and rotate
positions for photo acquisition. Infants and young chil-
dren who cannot stand should sit on a parent’s lap.
Instructions for subjects
This protocol includes images obtained while the parti-
cipant has a neutral expression, as well as during facial
animation. The rationale for the expression requested
for each view is described in Table 3.
For neutral expressions, it is often sufficient to
instruct subjects to relax their face. In addition to
obvious signs of facial tension or emotional expressions,
photographers should pay attention to the subject’s
mouth and eyes [20-22]. The subject’s mouth should be
closed during capture, with the lips gently pressed
together. The subject’s eyes should be fully open during
image acquisition to allow for adequate capture of epi-
bulbar dermoids and colobomas of the iris. A mirror
may assist participants achieve the desired position and
expression [23]. Older children can often follow instruc-
tions to keep neutral, relaxed face, with the mouth shut
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and lips gently touching [24,25]. It may also help to ask
them to swallow and relax [26,27]. Younger children
may require distraction devices to focus their attention
in the preferred direction, and care must be taken not
to elicit facial expressions (e.g., laughter or a surprised
look). Such distraction devices include bubbles, toys
with soft sounds and/or lights, or a children’s video. We
have created a template “Making Faces for the CFM
Photo Protocol” (Figure 2) to show participants the
types of facial expressions included in this protocol [16].
Facial features of interest
We developed this photographic protocol to capture the
facial features commonly affected in CFM and to allow
for the recording of these features using the OMENS
rating system. These features are briefly described
below, and summarized in Tables 3 and 4, along with
Figures 2, 3, 4, 5, 6.
Orbit
Malformations of the orbit in CFM commonly include
small size, and inferior or superior displacement. These
features are best illustrated on View A (Figure 2 and 3)
and views M and N (Figure 4).
Mandible
Mandibular asymmetry is a hallmark of CFM and is
classically attributable to malformations of the ramus.
Mandibular anomalies can be difficult to fully evaluate
on two-dimensional images. Our protocol incorporates
multiple views of the mandible to capture mandibular
hypoplasia and resulting facial asymmetry (views A-F of
Figures 2 and 3, Tables 3, 4). We’ve also included exam-
ples of common errors in image acquisition that can
lead to an inability to interpret images with regard to
the mandible (Figure 5).
Ear
CFM is frequently associated with various grades of
microtia with or without absence of the external auditory
meatus. We have incorporated profile (view C and E),
oblique (views B and D), and frontal view (view A) of the
ear to allow for assessment of size, shape, and position.
Views C and E allow for subsequent enlargement to cre-
ate views O and P, respectively (Figures 3 and 4).
Nerve
Facial palsies can involve any or all branches of the
facial nerve and may be unilateral or bilateral. We pro-
pose a series of images (views A, G-J, Figures 2 and 3)
designed to capture the participant in a neutral expres-
sion, and well as animation that requires function of
each branch of the facial nerve.
Soft tissue
Deficiency of the soft tissue is common in CFM. As
described for the mandible, capturing soft tissue defi-
ciency and the resultant facial asymmetry can be chal-
lenging using a two-dimensional imaging modality. For
this reason, we’ve included several views of the face to
allow for assessment of soft tissue asymmetry (views A-
F, Figures 2 and 3).
Other facial features
Individuals with CFM may have additional anomalies of
the face not included in the original OMENS system.
For this reason, we added other common features to the
CFM phenotypic assessment tool [17], including epibul-
bar dermoids, colobomas of the upper lid, ear tags, facial
tags, preauricular pits, facial pits, macrostomia, clefts of
the lip, occlusal cant, and tongue hypoplasia. The
images captured in this photographic protocol
(described below) can be used to assess for these fea-
tures. View A can be enlarged to create views M and N
for evaluation of the eyes (Figure 4). Similarly, enlarge-
ment of views C and E allows for detailed assessment of
the ears in Views O and P (Figure 4).
Views
We identified 16 image views that collectively capture the
facial features described above. Views (A-E, G-L) should
taken with the participant in the Frankfort horizontal
plane, which is achieved by ensuring the lower margins
of the orbits are on the same level as the upper margins
of the ear canals. This can be challenging for participants
with microtia and/or orbital displacement. The goal is to
obtain a full frontal view, in which the face is perpendicu-
lar to the camera. Participants should be optimally posi-
tioned on the horizontal and vertical axes to eliminate
rotation from the midline [11]. The grid lines on views
A-C, F can be used on the camera’s viewer to ensure
optimal head positioning in this plane [11].
Oblique views should be obtained in the Frankfort
horizontal position, and the participant should face
approximately 45 degrees away from the camera [11].
The photographer should attempt to align the profile of
the face with the opposite cheek, as illustrated in Views
B and D. Profile views should be obtained with the
Table 3 Common facial features affected in CFM and the
image view(s) that captures these features
Feature View
Orbit View A
Mandible Views A-F
Ear Views A- E, O, P
Nerve Views A, G-J
Soft tissue Views A-F
Other features
Occlusal cant View K
Tongue Views L-T
Epibulbar dermoid Views A, M, N
Ear tags/pits Views B-E, O, P
Facial tags/pits Views B-E, O, P
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participant facing at an angle 90 degrees away from the
photographer [11], as illustrated in Views C and E.
As previously described, views M, N, O, and P (Figure
4) can be generated by enlarging and cropping views (A,
C, and E) from Figure 3. We illustrate the views
obtained during image acquisition in Figures 2 and 3,
and demonstrate the full set of 20 images (including 4
created during image processing) used in the contact
sheet in Figures 3 and 4. We have illustrated optimal
images, as well as common factors that contribute to
suboptimal images (Figure 5). We have also included an
image acquisition checklist to be used during image
acquisition sessions for interpretation of data during
image analysis (Figure 6).
Figure 2 Making Faces for the CFM Photo Protocol. This collage illustrates optimal image acquisition for each of the views described in this
protocol. This figure can be used during image acquisition to show participants examples of the requested facial expressions. The grid lines on
views A-E can be used on the camera’s viewer to ensure optimal head positioning in the Frankfort horizontal plane. The circle overlying images
A-E represents the focal point of the image.
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