In my experience, dermatologists and plastic surgeons are almost too honest. You go in for your mole check and leave worried about your jowls. You ask for some Botox in your forehead and somehow get sold on lip injections. But, I figure, they're trained to have a hypercritical eye that comes from a medical perspective. (Not quite the same as when your grandma grabs your love handles at Thanksgiving and notes how "well-fed" you are.) Which is why I assumed that the before-and-after photos in medical offices would also be held to the most critical standards.
But after coming across some photos on a doctor's Instagram account that made me question the authenticity of the results, and after talking with other pros in the beauty industry who were also skeptical of too-good-to-be-true transformations, I reached out to board-certified dermatologist Robert Anolik, MD, and plastic surgeon Sachin Shridharani, MD, to ask: Should patients blindly trust before-and-afters?
According to Dr. Anolik, maybe not. And part of that comes down to the work of the camera — not necessarily the dermatologist. "You really need wonderful photography to know what you’re accomplishing. There are lots of ways to create standardization, and there are also lots of things that really fool the viewer," he says. Because he participates in many clinical trials (and both docs agree those before-and-afters are legit), Dr. Anolik has a dedicated room for photography. It's windowless, has cameras that ensure proper lighting and facial position, and mats on the floor that make sure patients are standing in exactly the same spot. "It's extraordinarily expensive," he says.
When doctors and nurses use iPhones, iPads, and handheld cameras (common in the age of Snapchat surgeons), take shots in different rooms with different lighting, and don't give any instructions to the patient on positioning, it's possible that in photos taken a minute apart, one could show a cosmetic improvement versus the other, even though they did nothing, says Dr. Anolik. He has an acronym he employs when reviewing photos in medical journals, social media, and magazine features: LAMPS. It stands for lighting, angles, makeup, position, and shadowing.
First up, lighting. "If you have lighting that’s prominent on the side as opposed to lighting that’s central, you’re going to see more shadowing," says Dr. Anolik. "Take that fold from the nose to the mouth. If you put the light in front of the person, you’ll see very little of that fold, but with lighting from the side, you’ll see a lot of it. And if the lighting is brighter one time, you’re going to see more lines."
Angles are just as important. If someone is getting Kybella, an injection that dissolves the fat bed under the chin, and the chin is positioned just a teeny bit higher in the after photo than the before, the result will appear more dramatic.
Perhaps the easiest things for a potential patient to look for in a doctor's photo catalogue are makeup, hair, lash extensions, and jewelry. There should be no makeup, no earrings or necklaces ("Jewelry is a big distractor," says Dr. Anolik), and the hair should stay the same — down, as a ponytail can lift the face — in both the "pre" and "post" pics. A very poor example of before-and-after snaps? The ones Chelsea Handler shared of her profractional laser treatment, which laughed in the face of every letter in LAMPS.
While Dr. Anolik acknowledges that some dermatologists and surgeons might be trying to fool people into coming in — or being just plain lazy — he acknowledges that the photos are very difficult to make perfect. "I'll admit that on busy days when we're running around, we can't stop everything and move the patient [to the photography room] unless it's a clinical-trial patient. I do everything I can in the exam room, but it's not going to be on the same level as clinical trials," he says.
But don't put this all on the derms; the patients are also driving the issue. "Because of the nature of filters on Snapchat and all the different things we can tweak on our own, like getting rid of blemishes, or shaving a nasal hump down, patients now have an idea of what they think they should look like," says Dr. Shridharani. "They come in with an [edited] photo, saying, 'I need to look like this.'"
Unfortunately, some doctors take the bait and end up airbrushing or blurring the patients' after photo a little to closer match their expectations, which have been skewed thanks to social media. "It's deceptive and misleading, but it definitely happens...because the realistic expectation of what things should look like has changed so much," says Dr. Shridharani. (And friends or influencers who are posting their progress might be editing their photos as well.)
However, there is an exception, he says, when it comes to photoshopping: "Sometimes a patient says they'd love to be in the before-and-after, however, they have a tattoo that really tells people who they are. Blurring or removing a tattoo to protect patient confidentiality is one thing; fading out a scar or making a result look better than it is is a major ethical issue."