Impact of Medical Photography on Plastic Surgery in Brazil

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A 19th-century invention, photography today is often looked at as a way for people to take perfect pictures (blemish free) and serve as a memory of your life. However, photography has had a bigger impact than taking selfies (self-portraits) on a smartphone. What is often overlooked within photography is that it opened so many doors for the medical field, specifically with plastic surgery. The invention of photography allows surgeons the ability to see the success of the performance of their plastic surgery on patients by taking photos before and after the procedures.

Moreover, many countries see extreme numbers of plastic surgery among citizens every year, but this is especially true in Brazil. Brazil is the second leading country in terms of plastic surgery, right behind the United States. According to the data collected by the International Society of Aesthetic Plastic Surgery (ISAPS) in 2018, Brazil had 2,267,405 procedures (ISAPS 2018, 16). On the other hand, Brazil is the leader in terms of total surgical procedures, which include breast augmentation, liposuction, and breast lifts. This dataset differentiates between surgical and non-surgical plastic procedures. Non-surgical procedures include hair removal, non-surgical fat reduction, and hyaluronic acid (ISAPS 2018, 16). The number of total surgical procedures in Brazil from the same dataset is 1,498,327 procedures (ISAPS 2018, 16).

Despite the expansive research on medical photography and the intersectionality of plastic surgery and gender roles, there is a lack of literature that brings all three of these together. More specifically, it may be beneficial to look at medical photography through the lens of gender expectations in terms of plastic surgery. Prior to delving into the advantages and disadvantages of medical photography, it is important to explain the history and development of medical photography and the current plastic surgery situation in Brazil.

Long before the invention of photographic images and drawings have been developed to represent life. Fabian Michangeli outlines this historical evolution of photography in his article Imagining the unimaginable: Medical imaging in the realm of photography. As mentioned in the introduction, photography is a 19th-century invention and it was quickly developed to be used in medical campaigns across the world, but especially in Latin America (Michelangeli 2018, 44). Medical photography opened up the possibility for telemedicine, which is holding a doctor visit via technological means, such as video calling or chatting through WhatsApp and surgical procedures may be conducted by robots (Michelangeli 2018, 44). This is beneficial to those who are in remote areas and may not have access to doctors: those who are in remote villages may have access to doctors: “In some cases, telemedicine is the only means of health care provision in remote areas in developing countries. There have been successful projects in Africa (SAHEL, SATMED) and Latin America, especially Venezuela (Michelangeli 2018, 44).” It is fascinating to understand to some extent the expansion of medical photography in the field, but it is also important to understand the techniques for medical photography.

Growing up in a family of photographers, I have always been drawn to taking pictures and find this expansion of photography to the medical field interesting as most people want pictures to be perfect and hide all your faults. Prior to this course, it never crossed my mind the importance of medical photography in a highly globalized world. With medical photography it is the complete opposite, surgeons want to see the flaws to show the improvement/accuracy of the results pre- and post-operation (Hagan 2008, 188). However, there are standards that must be followed with medical photography, which Kevin Hagan outlines in his article called Clinical Photography for the Plastic Surgery Practica – The Basics, which is helps the non-photographer wrap their head around what is necessary and expected when taking medical photographs.

The first important principle of medical photography to follow in terms of plastic surgery is consistent lighting: “The use of different types of lighting for pre-and post-operative photographs is unacceptable and is often a deceptive technique that is deliberately used to enhance the surgical result” (Hagan 2008, 189). Another part of the protocol is that the position must be exactly the same (Hagan 2008, 189) and that clothing should be minimal and not distracting (Hagan 2008, 189). Hagan also emphasizes that the background color must be exact for the photographs (2008, 189). Last but not least, Hagan explains that all images should have “the same magnification or size” and the photo should be taken from the same distance (Hagan 2008, 189). All these images are shown below with descriptions for a visual of what Hagan explains and are taken directly from the source.

Moreover, to test what the reader learned in terms of the procedures for clinical photography, Hagan provides an image for the reader to dictate how this medical photographer did not follow protocol as seen in figure 1 below.

Based on this reading, the mistakes made in photography A are that the clothes are distracting, the lighting is off, and the position and the distance are not the same when compared with photography B. Overall, it is important to have a basic understanding of the protocol for medical photography for research purposes even if you have no prior knowledge of professional photography.

In Alexander Edmonds’ book: Pretty Modern: Beauty, Sex, and Plastic Surgery, he does not discuss the importance of clinical photography with plastic surgery in Brazil. Having this very basic understanding is important to forming the connection between expectations of beauty through plastic surgery and medical photography. He does present the medical practice of Brazil and the demand for plastic surgery through an ethnographic study that is more qualitative in nature. What is most striking and important is his testimonies from those who either want plastic surgery or have received it from all social classes. One of the testimonies that struck me the most is from a female presented at the opening of Edmonds’ book: Ester. She is a female of the lower class working as a maid in the favelas (slums), who wants to save up her money to get breast implants (Edmonds 2010, 3). Just like Ester, many women who want plastic surgery in Brazil due so to raise their social status and get better-paying jobs (Edmonds, 2010). But, some also do it to feel good about their body as the media has created an ideal image of women in Brazil and that plástica is necessary to lead a good life (Edmonds 2010).

The images throughout Brazilian magazines present plastic surgery in a positive light through overly edited photographs, whereas medical photography emphasizes the importance of showing the accuracy of the operations so that the surgeons and patients may see the improvement or mistakes made during the operations. Edmonds does include some of these before and after operation photos, but they are not fully accurate due to the differences and it seems that the surgeons may be purposefully making them look different to show the patient that improvements were made. This is based on my own perceptions (see the example to the left). For example, in the first set of images, the position of the woman is not the same and in the second set of images, she is standing with a proper posture where she is not in the first image. Although it is not clear if these are medical photographs directly from surgeons if the surgeons and doctors do not present accurate results, why should the media be expected to do the same? It is a constant cycle of how can the medical field (in terms of plastic surgery) help the economy, and how can the doctors/media present it in a way that will make people attracted to using their life funds on plastic surgery. Edmonds 2010, 140.

Moreover, what is also rewarding about his book is the very detailed descriptions of the experiences at the hospitals, as he turns it into a narrative to humanize the lives and feelings of these people. Plastic surgery is so increasingly popular in Brazil that the public hospitals often witness extreme overcrowding as Edmonds shows in this photograph to the right (Edmonds 2010, 182). (Edmonds 2010, 182).

Moving away from the current plastic surgery situation in Brazil toward the advantages and disadvantages of medical photography, Edmonds describes the Foucault concept of the medical gaze within Brazilian plastic surgery procedures:

“While there is more privacy in private clinics, in public hospitals patients are asked to disrobe in front of a lecture room while surgeons discuss bodily flaws and the merits of particular techniques. Dr. Paulo worried about an undignified vulgarization of his craft. He complained of a seventy-five-year-old patient, “short and fat” who asked if a facetime would make her look like a photo of a beautiful eighteen-year-old girl in a wedding dress. Exasperated, he said: “If I operate on a woman who is old and ugly, she is going to continue old and ugly, with her skin stretched (Edmonds 2010, 199).”

As Edmonds describes, male surgeons in public hospitals will often line up the potential patients and determine who can be operated on by having them remove their clothes and analyzing if they fit the expectations of the plastic surgeon and if the operation would be successful (Edmonds 2010, 199). It is not clear whether these doctors have a protocol to follow, but this instance of lining up the patients and the surgeons analyzing them removes the humanistic aspects of the individual and solely focuses on the body/whether the body is good enough to receive plastic surgery. This is exactly what Michael Foucault discusses in Birth of the Clinic: “He describes the medical gaze as superior, revealing knowledge that is somehow encoded into the visible body, claiming the ultimate knowledge and power over the body gazed upon (Zittlau 2013, 546).” Therefore, the invention of photography has allowed for the development of the medical gaze through a camera lens, and now the whole world is able to partake in the medical gaze. In turn, this leads to the unethical practices of medical photography.

a. Consent – causes psychological distress (Creighton, 71)

Benefits of Medical Photography?

a. Surgical team briefing (Omran, 1)
b. Communication (Omran, 1)
c. Better Monitoring (Omran, 1)
d. Assess outcomes (Omran, 1)

As developed thoroughly above, there are clear unethical issues associated with medical photography within plastic surgery and also advantages such as better communication and monitoring (Omran YEAR, 1). However, there is something crucial not accounted for in the literature: Only two of the articles I found while researching discuss the connection of gender or assigned sex with medical photography. Erin O’Connor’s article titled Pictures of Health: Medical Photography and the Emergence of Anorexia Nervosa emphasizes how medical photography recreates expected gender roles, especially of women:

“By identifying both sickness and health with a particular look, the photography of anorexia enabled a series of assumptions about what a woman should be – or at least what she should be like – to mediate the diagnosis and treatment of self-starvation (O’Connor 1995, 543).”

This relates back to the earlier discussion of the presentation of plastic surgery in magazines as a way to reinforce the roles of women and the ethical issue of the medical gaze and also as a way of placing women back into the place of the caretaker and as the pleasure object for the man as this medical gaze decenters the individual and focuses on the body, rather than the personality of the person receiving the gaze.

On the other hand, the authors of Medical Photography: Ethics, Consent, and the Intersex Patient bring in the role of those born with variations in genitals or other sexual characteristics. Those in medicine often want to take medical photographs of something that is not normal and that they fixed. It is the equivalent of a trophy for playing sports, this is a moment of pride for those doctors. However, taking into account of consent and the dehumanizing of the individual discussed earlier, these doctors do not take into account how publishing instead of protecting these images affect the patient and hurts the doctor-patient relationship (Creighton et al. 2001, 69). This testimony presented in this article explains the feelings of one intersex patient:

“They made be naked in a room and take pictures of me and they took pieces of my skin and left two marks one on each arm and nobody said to me why they were doing it. Those marks are still there, and I look at them and I think “Why did they do that?” You know, why did they make me stand in a room and have pictures taken with no clothes on and humiliate me like without saying anything to me? Why. What was wrong with me? A 53-year-old CAIS patient (Creighton et al. 2001, 69).”

This article also emphasizes the expected gender [image: ]roles as men are meant to be strong, not sensitive, nor have female genitalia, which causes doctors to fall back into the rabbit hole of creating expected gender roles. For example, another CAIS (Complete androgen insensitivity syndrome) patient “always thought the photo should have carried the caption of what doctors were obviously thinking when they took it i.e. ‘Have you ever seen a genetic male looking so female?’ I think the particular expression on my face speaks volumes and I was obviously traumatized by it (Creighton 2001, 69).” This is the photo of the man giving the testimony, which was also taken without consent as explained in the caption of the photograph. Overall, with only finding two articles that present expectations of gender, it is clear that the connection of gender within the context of medical photography is under-researched and it may be beneficial to better acknowledge the connection of medical photography and gender roles in the future. Creighton et al. 2001, 70.

Moreover, Alexander Edmonds in his ethnographic study of plastic surgery in Brazil does not present the intersectionality of medical photography, gender studies, and plastic surgery. This would be an interesting future research development specifically on Brazil as well because most of the literature on medical photography is very broad and not specific to one place, which tells you that this is under-researched and would add something new to the expansive literature on plastic surgery and gender roles in Brazil or elsewhere.

In conclusion, medical photography could be developed further in a gender lens to present the ethical and unethical practices of plastic surgery in Brazil. The literature presents medical photography as a modern-day term and that the overall impact on medical photography should be expanded more to specific cases, especially in Brazil and Latin America, to thoroughly explain and develop the true impact of medical photography on the expansion of plastic surgery through field research, testimonies, and expansion upon the research already published.

References

Al Omran, Yasser, Dariush Nikkhah, Herman Vercruysse, and Neil Bulstrode. ‘Medical Photography During the Plastic Surgery Team Briefing.’ Plastic and Reconstructive Surgery – Global Open 4, no. 8 (2016): E1009.
Creighton, Sarah, J. Alderson, S. Brown, and C. L. Minto. ‘Medical Photography: Ethics, Consent and the Intersex Patient.’ BJU international 89, no. 1 (2002): 67-71.
Edmonds, Alexander. Pretty Modern: Beauty, Sex, and Plastic Surgery in Brazil. Durham, NC: Duke Univ. Press, 2011.
Foucault, Michel. The Birth of the Clinic: An Archaeology of Medical Perception. New York: Vintage Books., 1994.
Friega, Murillo, Diego Ricardo Colferai, and Marcela Sampaio. “Photographic Principals of Medical Photography .” In Oncoplastic and Reconstructive Breast Surgery, Second ed., 139–42. Springer International Publishing, 2019.
Hagan, Kevin F. ‘Clinical Photography for the Plastic Surgery Practice—The Basics.’ Plastic Surgical Nursing 28, no. 4 (2008): 188-92.
International Society of Aesthetic Plastic Surgery (ISAPS). ‘ISAPS International Survey on Aesthetic/Cosmetic: Procedures Performed in 2018 (2018).
Killion, Cheryl M. ‘Understanding Cultural Aspects of Health through Photography.’ Nursing Outlook 49, no. 1 (2001): 50-54.
Michelangeli, Fabian. ‘Imaging the Unimaginable: Medical Imaging in the Realm of Photography.’ Clinics in dermatology 37, no. 1 (2019): 38-46.
O’Connor, Erin. ‘Pictures of Health: Medical Photography and the Emergence of Anorexia Nervosa.’ Journal of the History of Sexuality 5, no. 4 (1995): 535-572.
Olawoye, Olayinka. ‘Clinical Photography and Video Recordings in Plastic Surgery: Beyond Patient Autonomy and Informed Consent.’ Nigerian Journal of Plastic Surgery 14, no. 1 (2018): 15-16.
Riml, Stefan, Agnieszka T. Piontke, Lorenz Larcher, and Peter Kompatscher. ‘Widespread Disregard of Photographic Documentation Standards in Plastic Surgery: A Brief Survey.’ Plastic and Reconstructive Surgery 126, no. 5 (2010): 274e-76e.
Silva, James. ‘Photography and Science: The Utopia of Objective Image and Its Uses in the Sciences and Medicine.’ Boletim Do Museu Paraense Emílio Goeldi Ciências Humanas 9, no. 2 (2014): 343-60.
Silveira, Carlos Eduardo Goulart, Silva, Thiago Buosi, Fregnani, Josn Humberto Guerreiro Tavares, Da Costa Vieira, Renn Aloisio, Haikel, Raphael Luiz, Syrjanen, Kari, Carvalho, Andrn Lopes, and Mauad, Edmundo Carvalho. ‘Digital Photography in Skin Cancer Screening by Mobile Units in Remote Areas of Brazil.’ BMC Dermatology 14, no. 1 (2014): 19.
Zittlau, Andrea. ‘Pathologizing Bodies: Medical Portrait Photography in Nineteenth-Century America.’ Amerikastudien/American Studies (2013): 543-558.

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Impact of Medical Photography on Plastic Surgery in Brazil

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