Baseline photography at the aesthetic consultation is the third leg of Dr. Jennifer Thomas-Goering's consultation structure — risk, reality, record — and it is the one most often reduced to a single frontal snapshot taken with the patient already in the treatment chair. Her standard is a defined view set plus, for the cases that need it, moving footage: "We want to record pictures. You want to record straight on, 45 degrees, 45 degrees, 90 degrees, 90 degrees. And in some instances, you'll even want the patient to do a video so you can catch their expressions with animation."
This piece is scoped deliberately to the consultation. The canonical standard for clinical photography across this program — fixed camera and focal length, distance and framing, head position, lighting, polarisation, exposure lock and the full documentation record — is Maritza Mejia's standardised clinical photography resource, and this article defers to it rather than restating it. What follows is what is specific to the consultation visit: what the baseline is for, what the animation video adds that a still cannot, how to use the images inside the consultation conversation, and how to consent and store them.
What the baseline is actually for
Four separate jobs, and injectors who think of photography as "before and afters" are only doing the fourth.
It fixes pre-existing asymmetry in the record before you are blamed for it. Nearly every face is asymmetric, almost no patient has examined their own, and a meaningful proportion will notice theirs for the first time in the two weeks after their first treatment. Without a dated baseline, that conversation is an argument between two memories, and the memory that loses is yours.
It is the instrument of the reality conversation. Thomas-Goering's reality step — "sometimes people want things that we can't deliver" — is much easier to conduct against an image than against a mirror. Patients see themselves in mirrors every day and have stopped looking. A photograph on a screen is unfamiliar enough to be looked at properly.
It is the reference for judging a complication. If a patient presents at day four with a firm, tender area, the question "was that there before?" has an answer or it does not.
It is how you and the patient assess the plan over time. The slowest-maturing part of a plan is the part most likely to be abandoned, and image comparison is what keeps a patient with a plan they cannot yet see working.
The five views
Frontal, both 45-degree obliques, both 90-degree laterals. Five images, minimum, on every patient, at every visit that includes an assessment.
The reason it is five and not one is that the endpoints live in different views. Midface and temple volume read in oblique. Jawline and submental contour read in lateral. Brow position and upper-face symmetry read frontally. A volume loss assessment conducted on a frontal photograph alone is missing most of the information it is supposed to be based on.
The consultation-specific requirement is that all five are captured before anything is discussed in terms of product. Capture first, then plan. An image set taken after you have proposed a treatment is an image set taken to justify a decision rather than to inform one.
Everything about how those five views are standardised — the fixed variables that make visit two comparable to visit one — belongs to the canonical photography resource. Adopt it once, apply it here.
The animation video
This is the part of her record standard that injectors skip, and it is the part that is specific to the consultation.
A repose photograph documents nothing about a neuromodulator. The entire treatment is aimed at dynamic activity, and dynamic activity does not exist in a still. Worse, a still of a held expression is not the same as the expression — patients hold a frown differently from the way they frown, and the recruitment pattern you are treating is what happens in the transitions.
Thomas-Goering's phrasing is exact: have the patient do a video "so you can catch their expressions with animation."
What to capture, for an upper-face neuromodulator case:
- Repose at the start and at the end, as bookends.
- Maximal frown — glabellar complex at full contraction.
- Maximal brow elevation — frontalis, watching for where the muscle actually recruits, which is frequently asymmetric and frequently not where the static lines are.
- Full smile, then a forced or maximal smile — lateral orbicularis oculi, and the interaction with the midface.
- For lower-face plans: lip pursing, a forced "eee", chin contraction, and platysmal contraction on a held grimace.
Three things fall out of that footage that a still will not give you.
Recruitment pattern. Where the muscle actually fires, and in what order, is what determines placement. The relationship between where the line appears and where the injection sites should be is not always intuitive, and it is visible in motion.
Compensation. A patient who habitually elevates one brow to hold up a heavier lid is compensating, and treating the frontalis without recognising it produces a ptosis that was latent before you arrived.
The distinction the patient needs to understand. Dynamic versus static lines is the single most useful physiological concept to convey at a consultation, and it is nearly impossible to convey verbally and trivial to convey by showing the patient the two frames side by side — here is the line when you frown, here is the line at rest. The second one is the part a neuromodulator will not fully erase in two weeks, and the patient who has seen that on their own face does not report it as a failure later.
Video is not needed on every case. It is needed on every neuromodulator case, on any case with visible asymmetry, and on any case where the patient's chief complaint is about movement rather than about shape.
Reading the baseline back to the patient
Capturing images and never showing them is a missed opportunity, because the images are the most effective expectation-setting tool in the room.
Turn the screen. Walk the five views. Name what you see, in neutral clinical language, including the findings the patient has not mentioned — "your right brow sits slightly lower than your left, and it has probably always done that" — and specifically including the ones you are not proposing to treat.
Three things happen. The patient's own asymmetry is on the record and in their awareness, which removes it from the post-treatment conversation entirely. Your assessment is visibly based on something. And the reality conversation becomes concrete: instead of "we may not be able to fully remove that line," you can point at the repose frame and say which line you mean.
Then ask her two questions against the image: what are you hoping will look different? and what result would disappoint you, even if the technique were technically correct? Asked while both of you are looking at the same five frames, the answers are far more specific than they are asked in the abstract.
Consent for images: two permissions, not one
Consent to photograph clinically and consent to publish are different permissions and belong in different boxes.
Clinical documentation is part of the medical record and is consented as part of the treatment. Say what will be captured, why, and where it will be stored.
Marketing use is optional, separate, and must be specific: which channels, whether the face will be identifiable or cropped, whether images may be altered or edited, and whether consent can be withdrawn. It must be genuinely revocable, and a patient who declines it must not experience any difference in their care. Withdrawal also has to be operationally real — if you cannot actually remove an image from a platform after the fact, say so before the patient agrees.
Never bundle the two into a single checkbox. A bundled permission is the one that generates complaints, and it is the one that is hardest to defend. What belongs in the consent document overall is covered in what to include in botox consent forms.
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HIPAA-secure capture and storage
The operative fact is this: a facial photograph cannot be meaningfully de-identified. Full-face images are explicitly among the identifiers that make information individually identifiable, which means every clinical image you take is protected health information from the moment of capture — not from the moment it reaches the chart.
That has practical consequences that most aesthetic practices violate daily.
Capture into the record, not into a camera roll. If the image lands in a personal phone's photo gallery, it is in a consumer cloud backup, it is in a shared photo stream, it is potentially in a device someone else in the household unlocks, and it is outside every access control you have. Use an application that writes directly to the medical record or to a managed clinical image store, and disable automatic gallery saving on any device used for capture.
No personal devices without management. If staff use their own phones, the practice needs device management, an explicit policy, and a plan for what happens when that person leaves. "She had all the before-and-afters on her phone" is a common and entirely avoidable exposure.
No consumer messaging. Do not send patient images over standard SMS, personal email, or consumer messaging apps — not to a colleague for an opinion, not to the patient themselves, not for convenience.
Access control and audit. Role-based access, individual logins, no shared accounts, and an audit trail. Who has looked at which patient's images should be answerable.
Vendors and agreements. Any third party that stores or processes patient images on your behalf — imaging platform, EMR, cloud backup, practice management system — is handling PHI and the relationship needs the appropriate business associate agreement in place. Consumer photo storage products are not designed for this and generally will not sign one.
Retention and disposal. Know your retention period, apply it to images as to the rest of the record, and have a defined disposal process. Marketing images copied out of the clinical system need their own tracked location and their own deletion process when consent is withdrawn.
This is a general summary of good practice, not legal advice, and the details vary by state and by your professional board. Have your own counsel review your image policy.
When the patient refuses photography
Some will, and the refusal is often about marketing rather than about documentation — which means the first move is to separate the two permissions out loud and offer clinical-only capture.
If they still decline, you have a decision to make. Photography is not a legal precondition for treatment, but treating without a baseline means treating without the ability to evidence pre-existing findings, without a reference for assessing a complication, and without a way to demonstrate the result. Many practices set a policy that they do not treat without at least clinical documentation images, and that is a defensible position provided it is a written policy applied consistently rather than a decision improvised per patient.
Whatever you decide, document the refusal, document that the implications were explained, and document what you were able to record instead — a careful written description of pre-existing asymmetry is worth considerably more than nothing.
What changes on Monday morning
Capture the five views before you discuss product, not after.
Add animation video to every neuromodulator consultation. It costs thirty seconds and it is the only record of the thing you are actually treating.
Turn the screen and walk the patient through the baseline, naming pre-existing asymmetry out loud. This is the highest-value two minutes in the consultation.
Split your photography consent into two boxes today if it is currently one.
Check where your images are actually landing. If the answer involves anybody's personal camera roll, fix that this week.
Structured assessment, documentation and consultation technique are taught alongside injection technique in Empire Medical Training's Complete Botox Training.
The consultation record standard described here reflects Dr. Jennifer Thomas-Goering's clinical practice as taught in Empire Medical Training's hands-on curriculum. The privacy and storage section is a general summary of good practice, is not legal advice, and is not a substitute for training or for your own counsel's review of your image policy.
About the author. Dr. Jennifer Thomas-Goering, DO, MBA, is a board-certified anesthesiologist, a clinical lead instructor and executive committee member at Empire Medical Training, and the founder of an aesthetics practice in Ann Arbor, Michigan.
Frequently Asked Questions
Which photographs should be taken at an injectable consultation?
Five views as a minimum — frontal, both 45-degree obliques and both 90-degree laterals — captured before any product is discussed. Different endpoints live in different views: midface and temple volume read obliquely, jawline and submental contour read laterally, brow position and upper-face symmetry read frontally.
Why record animation video at a neurotoxin consultation?
Because a repose still documents nothing about the thing being treated. Video captures recruitment pattern, compensatory movement such as habitual brow elevation over a heavier lid, and the difference between the dynamic line and the static line — the last of which is the expectation patients most often misunderstand and later report as a failure.
Does photography consent cover using images for marketing?
No, and it should never be bundled. Clinical documentation consent is part of the treatment record; marketing consent is separate, optional, specific about channels and alteration, and genuinely revocable. A patient who declines marketing use must experience no difference in their care.
Are clinical photographs protected health information?
Yes. A full-face image is among the identifiers that make health information individually identifiable, and facial photographs cannot be meaningfully de-identified. They are protected from the moment of capture, which means the camera roll, consumer messaging and unmanaged personal devices are all exposures, not conveniences.
What if a patient refuses to be photographed?
Separate the two permissions first — the refusal is often about marketing rather than documentation. If they still decline, decide by written policy rather than case by case, document the refusal and that the implications were explained, and record a careful written description of pre-existing asymmetry as a partial substitute.
Disclaimer
This article reflects the clinical opinions and experience of Dr. Jennifer Thomas-Goering, DO, MBA, an independent faculty member contributing to Empire Medical Training's curriculum. The views expressed are the author's own and do not necessarily represent those of Empire Medical Training.
It is professional education, not medical advice, and is no substitute for hands-on training or independent clinical judgment. Licensed clinicians remain responsible for their own patient selection, technique and outcomes, for verifying current product labelling, and for practising within their scope and applicable law. Empire Medical Training accepts no liability for reliance on this content.
