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Before and After Photos Can Be Deceiving

This weekend I was channel surfing and saw an ad pitching a plastic surgery procedure that was being promoted by a national marketing agency. You’ve probably seen the ads, but if not, you’ve probably seen similar ones touting a procedure or some new skin cream with fantastic claims like “better than Botox” or “look ten years younger in ten minutes”. They always show before and after photos, and they’re usually quite impressive. Or are they? I am going to discuss how to look at before and after photos with a critical eye, so you can make a more informed evaluation of any set of comparison photos, whether at your plastic surgeon’s office, online, on television, or in a magazine.

Although the possibility of fraud exists, such as photographing the smoothing effect of a cream when in fact the patient actually had Botox, I’m not going to discuss that. Why bother doing that when people can be just as easily fooled with impressive looking photos without resorting to such blatant fraud?

I’ll just discuss “before” and “after” photos – the principles are the same whether the photos in question are depicting surgical results, or the results of a non-surgical procedure or skin care treatment.

Clinical photography (or at least, honest clinical photography) differs from other forms of photography in that we are simply trying to document a person, or an anatomical area, and not necessarily flatter or portray that person as something he or she is not. It is a medical record. Unlike an endocrinologist who may document the changes of a patient’s blood glucose over time by measuring it, in plastic surgery we don’t typically have such objective ways of documentation.

The way we can get as objective as possible with our clinical photographs is to standardize the technique. This is so that the “after” photographs do not differ from the “before” photographs, except to reveal the changes from the procedure. This is easier said than done, for many reasons, and it invites manipulation. Here are some of the things clinicians need to consider when taking photos, along with questions and clues for you to consider when looking at photos…

Camera and lens: The same camera with the same focal length lens should be used. Is the nose as compared to the ears the same in both frontal photos? A “big” nose could mean a wider angle, shorter focal length lens was used, which distorts the face by enlarging features closer to the camera. This can also change the skin texture, a consideration when looking at photos of an acne patient for example. A focal length of 90-110 mm for the face is usually best, but many clinicians use zoom lenses with variable focal lengths, making matching before and after techniques difficult.

Lighting: Clinicians and photographers can argue about the best way to light a patient, with strobes, backlights, and fills, but the main issue is consistency between before and after photos. Is the patient lit straight from the camera? This can wash out wrinkles, and make an “after” photo look better, if compared to a “before” photo that was lit more from the side. Side lighting causes wrinkles to cast shadows, making them look deeper. Look at the pupils: there will usually be reflections that tell you where the light(s) came from. Lighting is tough – I have rejected many sets of photos from my photobooks and website because the lighting between the before and after photos was too different.

Position: This one is commonly abused, particularly when I see photos on television or in magazines. Look at the chin projection and position in relation to the neck, and also see if the patient is turning the head slightly. This can make a dramatic difference in a profile view – taking “years” off someone’s face. The goal of the honest clinical photographer is to try and keep the camera at the patient’s level, have them gaze straight ahead, and repeat this with the “after” photo.

Subject expression: Do you ever notice how often the patient looks sullen in the “before” photos, and cheery in the “after” photo? This alone makes the patient look better and younger. The photographer needs to try and direct the patient to minimize facial expression.

Hair and makeup: Ideally, the patient would come in the day of the “before” photos and the day of the “after” photos wearing the same clothes and jewelry, the same makeup, and with the same hair style and color. Obviously this is one aspect of clinical facial photography that is difficult to completely control. With breast and body photography, we often have a problem with patients who are pale in the “before” photo, but tanned in the “after” photo!

Photographer: Few clinicians have a dedicated photographer. Where I trained in New York, many surgeons sent their patients to a nearby professional photography studio where their photographs were taken under very strict and professional conditions. I am still impressed when I see these black and white photos in textbooks. Photos taken by an unbiased professional photographer is desirable, but logistically and financially unrealistic for most patients. Most offices are lucky to have a single person, usually a nurse or physician assistant, taking the photos.

Choice of subject: The photos being shown are likely to be the best ones they’ve got. If the procedure has been done “tens of thousands of times” as I heard in one commercial recently, you can be sure that the photos won’t be of someone with an average result. Now add some of the changes I’ve noted between the before and after photos, and you’ve got an impressive set of photos!

In summary, taking good clinical photos is a skill and an art unto itself, and we as plastic surgeons (and our staff) are not exactly professional photographers. However, we do need to try and keep before and after photos as consistent as possible. It is disturbing when I see bogus before and after photos in the media. It is just as maddening when I see them presented by my colleagues at meetings or published in peer-reviewed professional journals.

Douglas J. Mackenzie, M.D., F.A.C.S.

Santa Barbara, CA

Douglas J. Mackenzie, MD

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