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It’s natural to scroll down your Instagram feed and question reality. Are her legs really that long? Is his skin actually that poreless? Can a waist possibly be that small? Usually, when we do though, we’re looking at bikini influencers—not medical pages. But maybe we shouldn’t be so quick to take before and afters at face value either.
Whether with photo-editing apps or clever camera tricks, some doctors have made a habit of manipulating these photos to make a patient’s results seem more impressive than they might actually be, and it’s not always easy to spot the deception.
“People are not very observant,” says Dr. Val Lambros, a Newport Beach, California, plastic surgeon who explains that most viewers get so caught up in looking for the result they’re told is there that they become oblivious to everything else. According to Dr. Lambros and many other industry leaders, there are a handful of red flags patients should check for every time they analyze the before and after.
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Blinded by the light
When American poet James Russell Lowell wrote, “Light is the symbol of truth,” he likely didn’t have surgical photos in mind; but his words ring true in this realm nonetheless. “There are a lot of patients who come to my office and say, ‘Look at this person and their results,’ and I always respond, ‘Well, check out the lighting. Do you notice how the lighting is completely different in the before versus the after?’” says Dr. Daniel Barrett, a plastic surgeon in Beverly Hills, California. “Remember when you’d hold a flashlight to your chin as a kid and appear scary? It’s the same kind of thing. The lighting can make you look like a devil, or it can make you look fantastic—and that’s the number-one thing I think 90% of before and after shots that have been messed with are guilty of.”
Dr. Barrett says that often, doctors will take before pictures using overhead lighting and after pictures using flash. “If your lighting is different and your shadows disappear, it might not be Photoshop, but it is selective lighting control.” He notes that features like wrinkles, acne and scarring can be visible and even accentuated with overhead lighting but will disappear when flash or straight-on lighting is utilized.
Lighting doesn’t always have to be altered with the camera itself though; it can happen in the post-production process. Here, doctors can apply filters and adjust the brightness, contrast and exposure of after photos to give the appearance of optimal results. This sort of manipulation typically occurs in before and after imagery of skin treatments, injectables and even some body treatments. It ultimately doesn’t matter which lighting style a doctor opts for, Dr. Barrett says, but they must ensure that it’s consistent in both photos.
“The lesson to be learned is not to try to look for results, but to first try to look for the light, because the light is usually what’s been changed,” Dr. Lambros adds. “If something looks so phenomenally good that you can’t believe it, it probably isn’t true. You have to look at how the photo was taken—where the light is coming from and how it’s acting with the skin—and when you start looking a little bit critically like that, the world opens up and you start noticing all sorts of stuff that you didn’t before.”
Play all the angles
The naked eye also often fails to detect inconsistencies in the angles of a person in before and after pics. “Angles matter,” says New York City plastic surgeon Dr. Norman Rowe. “A lot of the time, we’ll take our head-on view, our worm’s eye view from below, our bird’s-eye view from above, our ¾ view, and the shadows and lighting will change the appearance of results.” Intentionally or not, he says, doctors tend to choose the after photo that shows the best results, even if the angle from which it’s taken differs from that of the before.
Dr. Jason Emer, a dermatologic surgeon in West Hollywood, California, regularly spots this practice, especially in before and after photos of filler. “A friend sent me a photo the other day—it was a jawline and chin—and he asked if I could do this with filler. It was a before and after at a 90-degree angle, and literally, the neck [sagging] was completely gone in the second image,” he says. “There was no way that filler along the jawline lifted the neck that much. That was either manipulated with photo editing and angling or the person had a different procedure entirely. It was just so unrealistic for what filler could actually do.”
He says that the positioning of the patient needs to be exactly the same when taking before and afters at 45- and 90-degree angles; if the nose is turned slightly more in one direction or the chin is pointing up slightly, that can make the neck and jawline look more contoured.
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Assume the position
Manipulation can happen even when photos are taken from the exact same angle. The camera might remain a constant, but the positioning of the patient can change, sometimes unbeknownst to the doctor, causing the before and after photos to differ slightly. “When you’re taking somebody’s picture, they will try to help you, whether it’s conscious or subconscious,” notes Dr. Lambros. “For instance, in a lot of the photos where this occurs, the patients will stick their neck up or smile. In general, it’s hard to get perfect, but you can get pretty good. The photos just need to line up in the same way.” He encourages viewers to look specifically at creases, which, at least in after photos of the face and neck, will soften or disappear if the patient’s positioning has changed.
Dr. Lambros points out that a patient’s expression can also have a significant impact on the appearance of results, and he often quotes fellow plastic surgeon Dr. Thomas Biggs: “The smallest smile is better than the best midface lift.” “I’ve actually heard some plastic surgeons claim, ‘Well, of course she’s smiling. She’s so happy that she can’t stop smiling!’” Dr. Lambros says with a chuckle. “But if someone is smiling broadly in the post-op picture, you haven’t learned anything except that they’re smiling, because the smile distorts the face image.”
Positioning can play a large role in before and after photos of body procedures too. “Doctors will often post standing-up images before the surgery and lying down images immediately after, so you don’t notice the sagging as much or the looseness of the skin,” says Dr. Emer. “Obviously, you want a before and an after that are of the same positioning.”
The magic of makeup
As any good Kardashian devotee knows, a well-placed contour can drastically transform the face, but it can also deceive. That’s why it’s of crucial importance that makeup, preferably the lack thereof, remain consistent in both before and after photos. “If you look at some before photos, the person is washed out and their wrinkles and/or acne are far more visible, and then the after will look vibrant and refreshed because the patient has makeup on,” says Dr. Rowe. “In my own office, I make sure that all before and afters are taken in the same way, so if someone comes in with makeup on, I have them take it off so the after photo will match the before.”
“In real life, it’s hard to get people’s makeup off them, so some of that is just unavoidable,” adds Dr. Lambros. “But if it’s full-face makeup with cover-up and lipstick and eyelashes, that’s not going to make for a convincing piece of data.” That’s not to say that any before and after series in which the patient is wearing makeup should be discounted entirely, but it can definitely be a red flag. Always try to find photos of subjects who are barefaced.
Makeup and other products can be applied to the body to enhance results as well. “The other thing I find people doing lately in the afters, to make the results seem more dramatic than they are, is greasing up the body,” says Dr. Emer. “They’re watering or greasing the bodies right after surgery and they’re rubbing all the contours and muscles, so [they look] more defined.” He urges viewers to click on the tagged patient, where applicable, and look at their results in the context of “real” life. “If you follow the patient later, you can see that they lose a lot of that shaping,” Dr. Emer explains.
The editing process
“It gets a bit trickier when doctors actually use Photoshop,” says Dr. Barrett. “Picking up on this can be really hard, but if you look at a before and after and the after photo looks like something out of an Instagram or Snapchat filter, where it’s just shining and glimmering and without any blemishes, the lighting might be the same, but it might have been airbrushed.” Often, if the airbrushing is done by someone skilled, he notes, you won’t be able to tell—but if a cheap app, like Facetune, is used, there can be telltale signs.
Dr. Emer is a fan of the Instagram account @celebface, which finds and publishes cases of photo editing, specifically among celebrities. As an avid follower, he’s picked up a few tricks to detect manipulation, like always looking at the background for swirls or movement in the colors and shapes. Any blurriness or haziness in the skin can be a big red flag too. “The skin always has pores, but if it’s hazy or bright, there’s probably a filter that’s been put on it or someone has used some sort of cover-up tool,” Dr. Emer says. “You’ll also see some people who will post a live Instagram stream to show that the patient is happy, but they’re putting on the raccoon filter, which makes the eyes elongated and the jawline more shaped. The person looks a lot better, and that’s not representative of reality.”
It’s understandably challenging to spot photo editing most of the time, especially with the popularity of so many filters and editing apps in today’s day and age. “You really can’t tell if it’s a solid background or someone is really skilled at photoshop, but if there’s a fence or something with a grid, look at the background in the photo to see if that’s pinched in or distorted. That’s just some cheap editing that you can catch from a mile away,” says Dr. Barrett. “And in general, with real results, you’re always going to see little things, like pores and scars. So, if you don’t see any of that or something seems too good to be true, it probably is.”
Cheap tricks
A wise lesson in life and medical aesthetics: always read the fine print. “When patients look at a doctor’s website, they should make sure that the photos on there are actually of the doctor’s patients,” advises Dr. Rowe. “Sometimes, there’s a little disclaimer that says, ‘These photos don’t necessarily represent his patients.’ They are paid models, or they’re purchased photographs.”
It’s also important to keep in mind that the photos you see on a doctor’s website or Instagram page, when they do in fact belong to him or her, are always showcasing the very best results. “Most doctors don’t put up their worst results, but I guarantee you that everyone has results that they probably would not put up on the internet,” Dr. Rowe says. “The results you’re looking at are the best, and they’re not guaranteed. If a doctor says that those are their results all the time, they’re lying. No matter how good you are or how good you think you are, it’s just impossible to get great results 100% of the time.”
Dr. Emer adds that it’s a good idea to look for after photos that were taken days or weeks after the procedure, as opposed to right after surgery. At his practice, patients are asked to take at-home photos and are given a special selfie light and set of instructions to ensure consistency. “The reality is, the best results for a consumer are going to be a video of the patient a week later, because the immediate is always more swollen and can be manipulated.” And be wary of influencers who get discounted services in exchange for social coverage: “I know a lot of influencers who get free treatments from other doctors and then come to me to have [something] fixed, but they have to say that it was a good job because they got it for free. Consumers should be really careful about believing these influencers or celebrities getting treatments, because they may be doing it just because they’re getting it for free.”
At the end of the day, doctors get away with photo manipulation because there is no one to police the arena. “It’s advertising and trying to get more people to come in based on the pictures, and money is going to win out over honesty most of the time,” Dr. Lambros says. But he acknowledges that even with the most sincere intentions, it’s difficult to put up completely honest, identical photographs: “I think in general, most people aren’t trying to mislead; they just naturally pick out the pictures that look the best—even if they’re not as well-matched. Some people, quite simply, are just lousy photographers.”
