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December 5, 2023

Inside Plastic Surgery’s Epidemic of Shady Before-and-After Photography

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Surgeons get real about the rise in misleading post-op pictures — and reveal how to spot fakery.

Originally posted in Allure by Jolene Edgar


Over the past six months, I’ve been receiving provocative DMs from a famous plastic surgeon. Most mornings, I open my phone to find images of perky breasts and taut tummies, straight noses, sharp jawlines, and the occasional rear end of enviable proportions, all surgically manufactured. The doctor sends each photo with an uncensored critique — not only of the work that’s been done, but how it is portrayed — and a clear aim: to expose the subterfuge that is rampant among aesthetics accounts on social media. It’s as if he’s building a case, with Instagram as his richest source of discovery.

Much of what this surgeon shares are unreliable before-and-after images, engineered to elevate the results they’re promoting. “Beware the surgeon who isn’t fastidious enough to take consistent photos,” he warns. “It shows they are lazy, not careful, or intending to manipulate you.” The tactics run the gamut, he points out, from sneakily irregular poses (“He compares standing to supine?!”) to more egregious offenses, like presenting intraoperative “on-the-table” shots as actual outcomes when, in fact, real results take months to develop (“That’s not an ‘after!’ It’s a ‘during.’ It is during the first minute of the healing process”).

These concerns are valid — and backed by data. In a study published in Plastic and Reconstructive Surgery Global Open in 2022, researchers reviewed and graded more than 2,000 before-and-after images of facial cosmetic procedures posted to Instagram by aesthetic medicine practitioners, and “showed that the average before and after is medium-to-poor quality, with as many as 40% being potentially deceptive,” says lead author Danny Soares, MD, a board-certified facial plastic surgeon in Fruitland Park, Florida.

The most misleading photos are those taken moments after treatment, before tissues have begun to mend, settle, and scar, and selfies snapped by patients — “often with favorable lighting, makeup, angulation, and filters,” notes Dr. Soares, that providers commonly post without acknowledging said embellishments and their sway over results.

New additions to the category of “after” enhancements are semaglutide (a.k.a. Ozempic) and other GLP-1 drugs known to have a slimming effect. Steven Teitelbaum, MD, a board-certified plastic surgeon in Santa Monica, California, recently alerted me to the burgeoning trend of tummy tuck and liposuction patients “looking better than expected” after surgery due to substantial weight loss. “This has always happened to some extent — breast reduction patients often lose weight [post-op] and improve their bodies on their own — but we are seeing much more of it,” he says. And the doctors posting images of these metamorphoses rarely point out the influence of Ozempic on the surgical result. Says Umbareen Mahmood, MD, a board-certified plastic surgeon in New York City, “To me, this is as deceitful as photoshopping.”

Ideally, clinical photos are taken in a room designed for that purpose, always with the same camera, on the same settings. Patients are carefully posed at a prescribed distance from the lens and captured from multiple angles. Backdrops (solid, matte) and lighting (bright, balanced) are identical. Nothing distracts from the transformation that is being documented — not hair, makeup, clothing, or jewelry. “Nonsurgical treatments should adhere to the same established standards that exist for surgical procedures,” says Dr. Soares.

Plastic surgeons in training learn the fundamental elements of clinical photography and the importance of uniformity, so deviations from textbook norms can hardly be excused as ignorance or accidental. Also, interestingly, the trickery isn’t limited to a select subset of doctors: “It spans all different surgeons, from the best I’ve ever seen operate to people who are brand-new and probably still trying to figure out their lighting setup,” says Elizabeth Chance, MD, a board-certified facial plastic surgeon in Charlottesville, Virginia.

What’s behind the sharp uptick in illusory images? Many attribute it to the unrelenting nature of social media and the 24/7 pressure to produce grabby content. “With Instagram, there’s this immediate need to feed the beast,” says Troy Pittman, MD, a board-certified plastic surgeon with practices in Washington, DC, and New York City. “That’s why we get so many on-tables. It’s like, ‘This will be cool to show right now, today.’” Plus, for the public, he continues, “there’s something really salacious about the operating room,” so these photos tend to get likes. Because such images disregard the healing phase and its impact on remodeled tissues, however, they are not legitimate afters.

“No one puts on-table results on their website,” Dr. Pittman says. In those galleries, “there’s almost an expectation of standardization.” The same goes for the portfolio-style photo books in doctors’ offices, which are still surprisingly useful in this digital age. Many folks don’t want their results plastered on a surgeon’s social media or website, but they will allow doctors to show their pictures to prospective patients during in-person consultations.

Office websites may be more trustworthy than social feeds, but most of the doctors I interview say they update them infrequently — once every nine months, in Dr. Pittman’s case — because it’s a cumbersome task that involves paying a web specialist. For better or worse, it seems “Instagram has become the new website,” says Jason Roostaeian, MD, a board-certified plastic surgeon in Los Angeles.

Some doctors view the eschewing of formal photos as a reaction to the nudity restrictions imposed by social media platforms. “Instagram uses AI to scan content and constantly flags before and afters of breast and body procedures for going against community guidelines,” Dr. Mahmood explains. Patient selfies, on the other hand, “tend to trigger less flags.”

Melinda Haws, MD, a plastic surgeon in Nashville and president of The Aesthetic Society, agrees that social media is subverting age-old photography standards. “Doctors who are posting traditional, medical-quality before and afters tend to get more dings for inappropriate content and get shadow-banned or thrown into Instagram jail,” she tells me. “Somebody who posts a selfie that a patient sent them is not.”

After years of helping clients navigate platform restraints and violations, Joseph Jericho, who manages the social media accounts of several high-profile plastic surgeons, sees limitations only getting stricter and predicts a sea change of sorts: “Soon, you won’t be able to view any before-and-after photos on IG,” he asserts. “They’ll be website-exclusive.”

In the meantime, some surgeons are attempting to avoid repercussions by creating separate accounts solely for before and afters, or B&As. “It’s the best thing I’ve ever done on Instagram,” says Dr. Pittman. He links his before-and-after handle in the bio of his main page, offering it up as “a business card for people who want to see my work.” Because this option exists more for serious patients seeking surgery than casual scrollers, it doesn’t matter if IG limits visibility. Relegating results to their own grid also spares his regular followers from “seeing boobs first thing in the morning,” he says jokingly.

Further driving the rise in selfies as after images is the escalating number of patients who travel to have work done. “Ninety percent of my patients fly in and out for surgery,” says Dr. Chance. But not all of these patients can make it back for annual follow-up visits, she adds, so “I’m having to rely on the images they send me.” She does her best to guide patients through various iterations to get the right lighting, expressions, and angles, but admits that it’s hardly a seamless solution.

Competition within the field — among purveyors of surgical and noninvasive treatments — may also be contributing to the proliferation of unorthodox B&As. In a study published in the Aesthetic Surgery Journal in 2021, investigators searched hashtags for popular facial cosmetic surgeries, amassing over three million Instagram before-and-after images. They then analyzed the top posts for discrepancies in lighting, facial expression, makeup, head position, backdrop, and other key factors, finding some form of “visual enhancement of the postoperative result” in a majority of the posts. Investigators also noted a higher degree of photography bias among accounts with more followers, suggesting that “photographic misrepresentation is rewarded by greater user engagement.”

According to Dr. Soares, that logic holds. “Social media tends to amplify and disseminate content that has entertainment value,” he explains. “And as dramatic before-and-after comparisons elicit a greater response from viewers, poor-quality photos tend to spread much faster.”

This is troubling, given that studies repeatedly rank B&As as a highly influential factor in the selection of a plastic surgeon. For prospective patients, adds Dr. Teitelbaum, “they are one of the most important ways of judging the experience, aesthetics, and talent of a plastic surgeon.”

On social media, however, patients see only a skewed sample of a doctor’s work: the highlight reel. Few surgeons show complications, disgruntled patients, or even average results. And routinely, those exemplary outcomes are being manipulated to sell more procedures and get more clicks. As a result, plastic surgeons are confronting members of a new generation of patients who have internalized countless images of (apparent) perfection, patients who now have their own towering expectations that can’t always be safely met with a scalpel.

“Even the most amazing [result] is judged differently when put up against nonstandard before and afters,” says Dr. Chance. “How is anyone supposed to compete with this type of marketing?”

Given the ubiquity of B&As online, it’s easy to forget that they weren’t originally conceived as promotional materials. “You don’t take the before and after so you have something to show on Instagram,” Dr. Teitelbaum says. “You take the before and after for the patient’s medical record and because it’s part of being a conscientious surgeon.”

These pictures have long served an educational purpose. “When photography was introduced into the field of plastic surgery in the 1890s,” Dr. Soares explains, “it offered a great tool for surgeons to learn from each other’s outcomes. Patient photographs were quickly adopted to document and study results.”

These images enable doctors to gauge the immediate changes they’ve made while also tracking results over time to see how changes evolve as the body heals, as swelling subsides, as tissues shift, as scars mature. “The only way we can monitor and assess these things is with standardized photos,” says Dr. Roostaeian. “Anything short of that is nonsense.”

Meticulous surgeons still use B&As to scrutinize their outcomes and fine-tune techniques. Dr. Teitelbaum tells me that, occasionally, when preparing a lecture for a medical conference, he’ll pull dozens of patient photos and analyze how his work has held up over the years. “Each time, I glean something to improve my results,” he says. The process may inspire him to finesse the curve of an incision line, say, or tweak the dimensions of a breast or the placement of a belly button. “Unless photos are unsympathetically taken and displayed,” he notes, “neither the patient nor an observer of the photographs will know what was accomplished.”

From the patient’s point of view, before-and-after photos are vital to managing expectations. They’re “meant to express what can be done, accurately and truthfully,” says Dr. Chance. Over the past year, she’s met with nearly a dozen facelift patients who were disappointed with what she describes as “stunning work” performed by other surgeons. “Because their faces aren’t glossy and lineless, like what they saw in those after pictures, they’re not happy,” she says. Fraudulent photographs “led them down a primrose path,” fostering false hope — and, in some cases, fueling a desire for additional surgery.

B&As have become such a cultural touchstone, they’re starting to replace celebrity snaps as patients’ preferred type of “inspo pic,” says Dr. Mahmood. She used to have to tell people that the famous waistline or jawline they were aiming to emulate was Facetuned. Now, when patients bring in doctored pictures from other practices, demanding the same unreal outcome, she schools them in fake B&As.

To sidestep this scenario, some physicians ask patients to construct vision boards using only standardized photos from their own websites. Keep in mind, these pictures are purely inspirational and meant to convey personal tastes; the featured results can’t be ordered like items from a catalog. Says Dr. Pittman, “We set patients up for disappointment if we just go, ‘Yeah, yeah, you’ll look just like all the before and afters.’”

Furthermore, by promoting unattainable goals, bogus B&As are reinforcing already absurd beauty standards, breeding feelings of dejection, poor body image, and low self-esteem. Dr. Soares, in his aforementioned study, links the boom in deceptive photos to the growing incidence of mental health issues in adolescents and young adults who regularly use social media.

With questionable B&As all over social media, plastic surgeons are urging people to be hypercritical of results they see online and to stay attuned to these common photography tricks:

Lighting, backdrop, and focal length (the distance between a camera lens and its subject) should be unchanged from one image to the next.

The lighting should be the same intensity — the “pre” photo should not be darker than the “post” — and come from the same direction. Straight-on lighting tends to be most realistic, but Dr. Chance frequently sees after faces lit from below. This can alter “the perspective and shadowing of the face,” she says, essentially airbrushing out lines, folds, and hollows, making the skin look flawless when it hasn’t improved relative to the before image.

The same can be said for overly bright lighting. Certain lighting changes can be detected in the subject’s eyes. If the iris looks lighter in the after image, “then there was more power coming from the light source,” Jericho says. Likewise, if the pupils are wider in the before image, that’s usually due to dimmer lighting. “You can even spot differences in the reflection of the flash or light source in the pupil,” he points out. (These reflections, or highlights, are called catchlights; without them, the eyes look dull.) “If the light covers more of the pupil in the after, you most likely know the light was brighter and is therefore affecting the appearance of the smoothness and color of the skin.” Using a ring light to “glow up” the after (but not the before) is a common form of fakery.

Body-contouring specialists warn of lighting strategies used in the operating room in on-the-table shots to highlight abdominal muscles, accentuate curves, and “strategically place shadows on areas like the umbilicus [belly button], which is one thing every potential abdominoplasty patient is most concerned about,” says Dr. Mahmood.

Black-and-white B&As are also suspect. Not only are they intrinsically more flattering, they conveniently minimize fresh surgical scars by blanching their color.

If doctors finagle focal length, taking the pre-op picture up closer, the before nose looks “bigger and a bit more fish lens” and the result seems “way more dramatic,” says Dr. Roostaeian. Sometimes an unscrupulous surgeon will take the before-and-after photos from different distances and then crop the photos to make them appear the same size, which makes this cheat more difficult to discern.

Be suspicious of shifting facial expressions and body parts. In neck- and facelift B&As, you often see the patient’s chin pulled down and back in the before, but jutting up and out in the after. This elongates the neck and jawline and overstates the power of surgery.

In body-contouring photos, someone may be sitting in the before picture but standing in the after, which exaggerates the procedure’s flattening effect. Some surgeons will even take an after photo with a patient flat on their back, then rotate the images vertically, so it looks like the person is standing when they’re actually lying down.

Pay attention to arm position too. One of the oldest tricks in the book is having liposuction patients raise their arms up over the head in the after picture, even though the arms are down at their sides in the before. Says Dr. Pittman, “Everyone looks thinner with their arms up in the air.”

Facial expressions can dramatically alter the appearance of results. Even without surgery, smiling can lift the cheeks and minimize jowls, notes Dr. Chance, so people should wear neutral expressions in B&As. This can be tricky, since satisfied patients may feel inclined to express joy in their afters and surgeons often encourage it. In a facelift before photo, you might notice that the patient looks “a little bit mournful,” Dr. Chance says, due to the downward direction of the mouth and jowls. But following a facelift, “some people look happy even without smiling,” she adds. In short, you can better ascertain the true effects of a lift — the cheek elevation, lessening of folds around the mouth, smoothing of the jawline — with the face at rest.

A ruse commonly used in lower blepharoplasty and undereye filler posts: “The before photo has patients looking up, which makes the fat herniation [or eye bag] more pronounced,” says Dr. Mahmood, “and the after has them looking straight ahead or down.” When you’re comparing two pictures, make sure the gaze is consistent.

It’s not unusual, or especially scandalous, to see makeup in an after photo, but it’s not ideal either. Some surgeons look past it, recognizing that patients are sometimes reluctant to remove makeup for midday photo shoots. Dr. Soares believes doctors should note in captions if patients are wearing makeup in afters, even if it’s obvious, just to be totally transparent.

Hairstyles should be alike in B&As. In facelift photos, in particular, hair should be pulled or tucked back so as not to obscure the scars that follow the natural curves of the ear.

The angles from which a patient is photographed can vary by procedure, as some perspectives are specific to certain surgeries. Explains Dr. Teitelbaum, while the up-the-nose “worm’s-eye view” is relevant for rhinoplasty, “the bent-over view is critical with abdominal work, because it’s the best way to evaluate the degree of improvement.”

For every procedure, doctors should show multiple angles — front, lateral (both sides in profile), and three-quarter oblique views (left and right), at minimum — because each view has something to offer. With breast surgery, for instance, the straight-on shot lets you judge symmetry, Dr. Teitelbaum says, while the lateral views show if the upper and lower portions of the breast are well-balanced.

The oblique view tends to be most forgiving. “If you’re only seeing one or two angles,” advises Dr. Roostaeian, “ask the surgeon to see the others.”

Surgical afters taken prior to several months post-op can’t be interpreted as true results, due to residual swelling and tissue changes that are still occurring. In fact, says Dr. Teitelbaum, “the outcome of today’s current work won’t be known for a few years.”

Dr. Soares reiterates that, historically, plastic surgery procedures are not considered final until the one-year mark: “At most academic conferences, results less than six months may not be taken seriously.” Other doctors say outcomes are mostly stable by three or four months.

Nonsurgical treatments follow a different timeline. “For injectables, a minimum of two weeks has been the norm,” Dr. Soares says, “but most practitioners would agree that three months is still best.” Nevertheless, many ignore the two-week rule. He adds, “The majority of filler before-and-after photographs feature the immediate appearance of the patient, which misrepresents the effect of injection swelling as being part of the final outcome.”

Given that selfies are not standardized — and can be edited or filtered — we can’t compare them to clinical before pictures. Moreover, Dr. Soares explains, “selfies use a wide-angle lens that alters the subject compared to standard portrait photography with single-lens cameras.” Studies (herehere, and here) show that cameras held at a short selfie distance from the subject can stretch, magnify, and otherwise distort facial features by as much as 30%.

Selfies may hold more value as testimonials, rather than as authentic afters. They “allow us to share real moments of real people wearing their own clothes and living the life they enjoy,” says Dr. Mahmood. “The confidence they exude is palpable, and it helps others relate to them.”

But, again, patient selfies shouldn’t comprise the bulk of photos on a surgeon’s grid.

Plastic surgeons are split on the virtues of video. “People want to see video, and it’s great for the Instagram algorithm,” Dr. Roostaeian says, “but the clarity is just not as good when the image is constantly moving — you can’t see all the details.” But with a high-resolution, well-lit still photo, “any little deformity is glaring,” he says. “I mean, what can I hide? Nothing.” (He’s referring to nose jobs, primarily.)

On the other hand, only video can show how naturally (or not) a face moves after surgery. Following a lip lift, “people can look great in static photos, but odd in animation,” Dr. Teitelbaum says. (The procedure, which shortens the space between the nose and upper lip, can change the mechanics of the mouth.) So, a clip of a lip-lift patient laughing, smiling, and talking could be enormously revealing. Likewise, a facelift in motion can reveal a lopsided grin (from nerve injury), excessive tension, awkward transitions (like skin bunching) between cheeks and temples, or other telltale signs of surgery.

Before-and-after images advertise more than outcomes — they disclose a doctor’s values. “They’re how you judge the work and how you judge who’s going to be truthful with you,” Dr. Chance says.

Consistent clinical photos are the gold standard. If a doctor’s page is rife with patients’ poolside selfies, freshly sculpted noses (on still-asleep patients), and juxtapositions that are anything but apples to apples, adds Dr. Roostaeian, “I’d second-guess that surgeon’s ethics.”

Photo Credit Matthew Donaldson / Trunk Archive

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