BACKGROUND: Photographic standards issued by the Plastic Surgery Educational Foundation ensure accurate comparisons between preoperative and postoperative imaging. These standards, however, do not properly display the circumferential body ptosis seen in massive weight loss (MWL) patients. Photographic standardization for massive weight loss patients is needed for patient consultation, surgical planning, and accurate analysis and comparison of postoperative results. PATIENTS AND METHODS: A 10-year review of the photographic standards used for MWL patients at the University of California Davis Medical Center were reviewed and compared to current photographic standards in plastic surgery and clinical photo documentation seen in the literature for body contouring after MWL. Evaluation of arm position in obscuring the evaluation of circumferential ptosis in the upper and lower body was performed. RESULTS: Current photographic standards in plastic surgery do not capture the circumferential ptosis often seen in MWL patients, and there are no consistent modifications or standards recommended for MWL patients. Arm position was noted to affect shadowing and obstruction as well as distortion of circumferential excess. During the first 5 years reviewed, initial consultations included 8 images captured at 45-degree increments with the arms abducted to 90 degrees to document the circumferential excess from shoulders to the knees (Total Body, Fig. 1). They also included 8 images focused on the lower body (Fig. 2) and 8 images focused on the upper body. This required a total of 24 images captured per consultation. During the latter 5 years reviewed, the 8 Total Body images continued to be captured whereas the 16 images focusing on the upper and lower body have been discarded and replaced with 10 images (Fig. 3), captured from shoulders to knees at 45-degree increments with arms positioned behind the back (5) and in the lap (5) for a total of 18 images captured per consultation. CONCLUSION: Currently there are no photographic standards for MWL patients that accurately capture their circumferential ptosis. All arm positions affect the evaluation of the circumferential excess to some degree, thus any choice of arm position represents a compromise between visibility and distortion of anatomy. Having considered these issues, we recommend the use of 360-degree clinical photo documentation obtained at 45-degree increments with arms abducted to 90 degrees to capture the total body. We have discarded focused upper and lower body images as these are visible in the Total Body images, thus decreasing patient fatigue and discomfort from excessive pictures. As techniques in post-bariatric body contouring have improved, we now routinely compare our results to non-post-bariatric body contouring patients and thus have added more standard arm positioning to facilitate these comparisons.