Proof Or Deception: Exposing the Truth About Before & After Images in Plastic Surgery

Park Avenue Plastic Surgery Class Episode 1

I am excited to announce that I’ve launched a podcast “Park Avenue Plastic Surgery Class”.  Together with my co-host, Doreen Wu, we will explore controversies and breaking issues in plastic surgery.

I have been deeply involved in technology development in plastic surgery and aesthetic medicine for more than 25 years.  Given all the options, it is overwhelming for plastic surgeons to understand where new technologies fit.  This task is even more difficult for non-plastic surgeons.  I wanted to share my perspective with the public about the increasingly crowded and confusing arena of plastic surgery options.  As always, I strive to provide a realist perspective and debunk some myths.

Before and after images were photographs in the old days, and are now digital images shown on a computer screen, tablet or cell phone.   Taken by the plastic surgeon to help with evaluation during consulting for precise diagnosis, for planning procedures and treatments, and to assess outcomes (final results) when taken months after healing is complete, they are an essential part of plastic surgery.  They are also used for marketing purposes on websites, social media, advertising and elsewhere by physicians, and manufacturers of aesthetic technologies.  Images also give us the chance to see how we look to the outside world –not an inverted image as we view ourselves in mirrors.  They often s how us features that we miss in person or when viewing a mirror.

There are few good ways to quantify aesthetic changes and even these often correlate poorly with clinically significant visual changes.  Images are our best way, albeit an imperfect one, for documenting changes.  Before and after images are used in product development and regulatory approval to validate aesthetic technologies like laser and injectable treatments.  In addition to safety data and any quantitative or biological measurements, an obvious visible improvement in appearance on images is essential to insure the value of a new aesthetic technology.

Can we count on images to tell us the truth?  When taking images months apart, before and say 6 months after surgery or a series of treatments, it is almost impossible to take matching images.  Conditions are typically tightly controlled by taking pictures in the same room, with the same lighting, posing and camera settings but small differences in any of these, tan skin in one image but not the other 6 months later, small difference in clothing, muscle tone, positioning can all make big changes to how the images look completely independent of what changed as a result of the medical treatment or surgery.

Some newer technologies help us by matching images digitally using anatomic landmarks or providing three dimensional imaging.  The digital world also hurts us in some ways, making it very easy to retouch or modify images in ways that are not easy to see with the naked eye.  A lot of times this can be detected in a computer lab by analyzing the digital record but this is not an option when looking at websites or social media online.

Given human nature, selection of which images to show, naturally mitigates towards showing the biggest changes or sifting through dozens or hundreds of before and after images to find the one result that is really striking.  Brighter lighting washes out details like wrinkles and skin blemishes.  Sometimes you can tell by looking at the background which may be lighter in the after image.    Raising the arms reduces visible fat contour and skin redundancy in body sites.  These things can be present in images accidently or can be intentionally staged to unfairly represent the results.  Ideally, arms should be shown in before and after body images to verify similar positioning.

Be skeptical when looking at images for these kinds of deceptive differences.  Also, the person seen in a small image on a computer or cell phone display may not really relate to your body size, shape, age, etc.  You can obtain some very limited guidance about what you think looks better compared to another images to refine your aesthetic viewpoint but such images are really not good for decision making about specific procedures or implants, for example.

Important takeaways:

  • Before and after images are our best tool for assessing results in plastic surgery and aesthetic medicine treatments
  • Online images don’t tell much about what result you might get as an individual
  • If it looks too good to be true, or perfect, it’s probably not real.
  • Look for a change to show on multiple images from different angles –if it is only evident on one image, it may not be real.

More coming soon.  Subscribe to avoid missing any episodes at Apple, Spotify, Stitcher or wherever you listen to podcasts.


Doreen Wu (00:01):
I am excited to welcome you to our first episode of the Park Avenue Plastic Surgery Class. I’m your cohost Doreen Wu. And I’m here with Dr. Lawrence Bass Park Avenue Plastic Surgeon, educator, and technology innovator. Together, in every episode, we will explore various controversies and breaking issues in the world of plastic surgery. The title of this first episode is “Proof or Deception: Exposing the Truth About Before and After Photos in Plastic Surgery.” But before we get to that, Dr. Bass, can you explain a little about how this podcast got started and what your inspiration was behind it?

Dr. Lawrence Bass (00:40):
Sure. Doreen, for more than 25 years, I’ve been deeply involved in technology development in plastic surgery and aesthetic medicine. And I’ve been teaching and practicing surgeons and resident physicians, how to integrate new technologies into their practices. There are so many options today compared to even a decade ago that it can be overwhelming. I wanted to share some of the same information with the public to help navigate these increasingly crowded waters.

Doreen Wu (01:17):
That’s really interesting. And the title of this podcast is Park Avenue Plastic Surgery Class. What exactly does that mean? And can you give us some insight into why the name of this podcast is what it is?

Dr. Lawrence Bass (01:31):
Well, there are a lot of valuable lessons about how plastic surgery is practiced on Park Avenue in New York City, without a doubt. It’s one of the great pinnacles of the art of aesthetic plastic surgery worldwide. It’s a unique location where there are many, many plastic surgeons and other aesthetic providers of all types. Nearly everyone is extremely well trained and excellent at what they do. So it’s a place where you really have to stay state of the art in order to survive. And in order to have a successful career separate from that, there are many aspects of the Park Avenue approach that are distinctive and valuable. I’m hoping to share some of that perspective with our listeners, with the goal of helping them to understand plastic surgery better. I I’d like to teach about an approach to plastic surgery that helps you achieve your beauty goals rather than simply listing a bunch of facts and details about individual procedures or individual technologies or treatments in general Park Avenue Plastic Surgery patients tend to be smart consumerist and really, really knowledgeable. I intend this podcast to provide a real perspective about plastic surgery, debunk a few myths and clear up some of the confusion associated with the really high level of noise with plastic surgery in the 21st century.

Doreen Wu (03:13):
That’s awesome. I’m always very anxious to hear trusted information from credible sources and to learn more about all of the amazing new things that are available to boost and refine one’s appearance. I know I’m looking forward to learning a lot going forward. Now let’s shift gears and turn to our topic for this episode before and after images. Can you tell me a little about what they are and why they’re so important in plastic surgery?

Dr. Lawrence Bass (03:40):
Well, before and after images are taken by plastic surgeons and in the old days, we’d call these photographs. But now they’re digital and electronic. So we take images of any area that’s going to be treated before we get started. This is actually an important part of the consultation, even before we’re ready to do a treatment. I always see some things about patient’s features on an image that I didn’t see during the in person examination, the before images help, therefore with precise diagnosis and with planning the treatment. It’s also a way for patients to see features that they may not have picked up when looking at themselves in the mirror. And of course, it’s, it’s more the way the world sees you in an image where a mirror image is exactly that it’s a reversed image, not the way the world sees you. So that’s an important part of consultation. Since appearance changes, can’t be well quantified with a number like if you take someone’s temperature, you get a number and you can tell whether a number on a different day is higher or lower. You can’t do that with appearance. It’s too subjective. So the best way we have to document the appearance and anything that change before or after treatment is using photographs or images, we can’t really rely on our memory because we try to think back the way it used to look. But you really can’t again, quantitate where things changed.

Dr. Lawrence Bass (05:25):
A lot of cosmetic technologies are validated in some objective way, like a measurement in skin elasticity or production of new collagen when we do skin biopsies. And those are important, but only when they’re matched with or when they correlate with a change in the image, because the whole reason we’re doing these treatments is to change how people look. And if we can’t see a change, the fact that there’s a change on some objective measure, like a skin biopsy is, is not that significant.

Doreen Wu (06:02):
That all sounds great. So from my understanding of what we just talked about before and after images are kind of a way to document patient’s progress, um, as they get different treatments and kind of monitor that in a very definitive way. So what’s the catch. Should I always believe what I see in these before and after images?

Dr. Lawrence Bass (06:23):
Well, you know, as I just said that we’re dependent on the images. We have to have them. There’s no way for us to function at the level we currently do in plastic surgery without them. But everything depends on the quality of the pictures. It’s immensely difficult, even for experienced photographers to take matching pictures, months apart, you know, you meet a patient, you take before pictures, you do a treatment, then you have to wait months to see once things have healed and are stable. What does the result look like? And you have to take that picture exactly the same way that you took the picture three months before or six months before. That’s really tough to do in, in my office. I have a photo studio room and that has a standard background and fixed lighting. And a lot of work goes into positioning the patient to be exactly the same.

Dr. Lawrence Bass (07:20):
And we use fixed exposure settings, still any little difference in rotation if the patient tilts their head, any of these little changes will really change what shows in the pictures. So that points out why it’s so hard to take reproducible pictures, even when you’re trying very hard to do exactly that there are some technological changes that are helping us with this three dimensional imaging and computer algorithms that match landmarks on the patient’s face or on the patient’s body part, help align images that are taken at different times. So they’re better matched up. So there are some ways we’re starting to get better at this.

Doreen Wu (08:04):
Those are all really interesting points that I never really considered before. Based on our discussion so far, does that mean that all of the flaws in before and after images result from small mistakes in how the images were taken, what do you think?

Dr. Lawrence Bass (08:20):
Well, you know, it’s all about human nature. So most folks are trying to take really good pictures and match things up the best they can, but for marketing purposes or promotion purposes, some folks who are less careful and less concerned about being careful can take pictures that make things look better than they really are. And that’s a classic lecture that every plastic surgeon is seen at one plastic surgery meeting or another where somebody shows pictures of laser peels and lifts and all kinds of great treatments that look like really good before and afters. And at the end of the lecture, the presenter says all these pictures were taken on the same day, just with different photographic technique. So it’s important to be very critical when looking at pictures, unfortunately, unless you have a computer laboratory it’s very hard to detect some pictures that have been modified. But there’s some things that an experienced observer can figure out looking at the pictures. But the folks that are actually retouching images, which is overtly fraudulent is very hard to detect unless you take the digital image and start deconstructing it in a computer lab.

Doreen Wu (09:48):
So I guess it’s really important to interpret these images with a grain of salt and not take them at face value because in some cases it might really be too good to be true. Now that makes me wonder, given that there’s so many before and after images available on the internet and on social media, in your opinion, is looking at these images a useful way for someone to start procedure planning and assist in their decision making process.

Dr. Lawrence Bass (10:17):
Well, that’s a good question. And the real answer is yes and no. You know, looking at a bunch of images is very good at starting your thinking and starting your deliberation about what you’re looking for. What’s going to suit your needs and look good on you. But that’s kind of where it ends because looking at a thumbnail on your cell phone, on Instagram, or looking at a website on your computer at a small image, doesn’t tell you a lot about how well that patient’s appearance relates to your medical condition and your skin type and your appearance. That person could be five feet tall or six feet tall. They could be underweight or overweight, darker skin, lighter skin, younger, older, maybe they had pregnancies breastfeeding. Maybe they didn’t, it’s hard to match all of the different factors. There’s so many factors that go into this.

Dr. Lawrence Bass (11:23):
So, and then you’re looking at a teeny weeny little image and you don’t get the big picture perspective. So it’s a good starting place to know what you think looks good, but I’ve had people come in the office and say, I saw this breast implant on this mosaic of 50 breast implant images. And this is the implant I want. And that’s bad decision making because the person there could have started as an A cup or a C cup might be the same or different from the patient sitting in front of me. And you again, don’t know all those other factors, the, the general body size and shape factors, age factors, and so on. So that’s why it’s, it’s good to start, but it’s not a decision point kind of activity.

Doreen Wu (12:16):
Exactly. That makes a lot of sense. So Dr. Bass, now that we have shed some light on the good, the bad, and the ugly of before and after images in plastic surgery, what do you think are the most important takeaways for our listeners to remember about these images?

Dr. Lawrence Bass (12:34):
So there, there are a few things that I always try to keep in mind. I mean, as I said at the beginning, before and after images are our best tool to see what happened after a treatment. So we need them and we’re always going to be relying on them for the foreseeable future. Uh, online images are entertaining, but they don’t tell us a lot about what kind of result an individual surgeon can produce or an individual patient will achieve. It’s impossible for us to tell how well the patient in the photograph on the internet matches your individual circumstances. And there are some sites now that are trying to add more demographic information. They’ll tell you the patient’s height and weight and their age, but there are just too many relevant factors to really know if they’re a good match for your appearance. And when you’re looking at those internet images, remember if it looks too good to be true, it probably is plastic surgery, procedures, and treatments can do amazing things, but if the result looks perfect, it’s probably not real. If you use a critical eye, when you’re looking at images, whether they’re online or you’re own before and afters, that will really help you figure out how meaningful the results are. Since so many little factors can change how the, the appearances on the image, if you only see a nice result in one image, that’s not that persuasive, that it’s real, but if you see it on multiple different angles or views, then that means it’s probably a real result.

Doreen Wu (14:19):
Well, I know I’ll have a more critical eye looking at these images in the future. There’s actually a lot more to before and afters than I thought. Thank you for all of your insights, Dr. Bass, and we look forward to seeing you at the next episode.

Speaker 3 (14:33):
Thank you for joining us in this episode of the Park Avenue Plastic Surgery Class podcast with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. The commentary in this podcast represents opinion. This podcast does not present medical advice, but rather information about plastic surgery that does not necessarily relate to the specific conditions of any individual patient. No doctor-patient relationship is established by listening to or participating in this podcast, consult your physician to advise you about your individual healthcare. If you enjoyed this episode, please share it with your friends and be sure to subscribe to our podcast on Apple Podcasts, Google, Spotify, Stitcher, or wherever you listen to podcasts.

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