Beware of Enhanced Photographs

For better or for worse, the Internet has become the primary source of medical information for many people. Virtually all plastic surgeons today have websites, which allow potential patients to locate surgeons in their area or elsewhere, and investigate those who do specialized surgery. However, you should be careful when viewing websites (or print ads, for that matter) that contain before and after photographs. While photographs are essential to show the results of surgery, they present several challenges. Digital photos can be easily retouched by anyone with access to Adobe Photoshop^® software. Removal of a distracting background may be deemed acceptable, however, touching up or improving a neckline or waistline is misleading.

Makeup and hair present another problem. It is not uncommon to find photos where the patient is wearing makeup in the "after" photo, but not in the "before." It may simply be that the patient was unwilling to remove her makeup or put her hair back in the post-op photos, but it can also be quite deceiving. Because of the dramatic difference makeup and hairstyles can make, it may be impossible to tell whether the attractive result was from cosmetics or from the actual surgery itself.

Other false photographic representations -- deliberate or not -- can result from patient positioning and lighting. For many years photos showing results of necklifts were frequently helped by positioning patients so they would look younger. A simple tilt of the head can make a big difference in the apparent tone of the neck skin. By the same token, a forehead lift can be simulated by having the patient raise their eyebrows.

Lighting can also be used to play up or play down a patient's features. Women have long known that good lighting can make them look younger. Lighting the patient from the side or above can emphasize shadows and wrinkles, while strong frontal lighting or even subtle lighting from below can help hide signs of aging. Diffused lighting can also soften the look of aging skin.

An unfortunately too common lighting trick can be observed in use on a number of "infomercials" for anti-aging products and rejuvenation procedures. If you look carefully at the before and after photographs, you will notice that the size of the white highlights in the eyes of the "patients" changes dramatically when the "after" images are shown. Illuminating the face with a broader light source smoothes out the texture of the skin - regardless of what the product or procedure may or may not be doing to the skin. You may also notice that the white highlights in the eyes move from the top to the center or even to the bottom of the eyes. There is one particularly offensive sequence in which an additional very large white highlight appears across the bottom of the eyes in the supposed "after" photograph.

These are common -- and often obvious -- tricks used when making "after" photographs. The key with medical photography is to look for consistency in lighting and patient positioning between the before and after photos. The changes you see should only be brought about by the surgical procedure. Because it can happen even in the best of circumstances, an occasional mismatched set of photos is not necessarily cause for alarm. Especially in the case of long-term follow-up photographs, the camera, lights, and studio probably will have changed over the years.

You should be aware of these subtle patterns of inconsistency to judge photographs correctly. Regrettably, it is impossible to decipher the validity of photos in a magazine ad or on a web page, since there is no monitoring group to establish criteria for integrity. You have to use your own judgment. There are even some websites featuring patient photos that are not actually patients of that particular surgeon. Be sure to read the fine print!