The Truth about Before and After Photos

I am always amazed at how much credence people put in before and after photos. These days, it’s rare that a patient will ask me to see before and after photos; since I’ve been in practice 15 years, they don’t need to see photos before scheduling surgery. When a doctor is starting out in practice, however, before and after photos are almost essential to make a prospective patient feel confident in the doctor’s skills. The only problem: many doctors know how much weight patients place on these photos, so it is too tempting not to do some very misleading things.

The first example I saw of misuse of before and after photos was about 13 or 14 years ago when a young dentist starting out in Beverly Hills invited me to lunch at the Peninsula Hotel. He brought with him a beautifully bound book of before and after photos with his name embosses in gold on the cover. The photos showed impressive results of veneers and dental implants and other cosmetic dental procedures. The only problem: I had seen the exact same book with the exact same photos at my dentist’s office in Brentwood the week before. My dentist used the book to show examples of what modern dentistry could do, but he did not claim that the patients in the book were his. At the Peninsula Hotel, I just sat and nodded and commented on the beautiful work. Obviously, I had no interest in working with such a dishonest person.

Around the same time, a patient from Orange County came to see me about laser resurfacing. The CO2 laser was new at that time and few people had much experience with it. The patient told me that she had just seen a “laser expert” in Orange County who had such extensive experience with the CO2 already that the doctor already had lots of impressive before and after photos. I told the patient that I didn’t have before and after photos yet, since we had just started doing the CO2 laser a few months before. I told her that I could show her some stock photos that were provided by the manufacturer, Coherent Laser – at least she could see some stock photos demonstrating what the laser was capable of doing. I handed her the book and, after a few pages, she stopped and looked up at me and said, “Oh my God. These are the exact same photos that the other doctor said was her work!”

Over the years, I have seen many examples of misleading before and after photos. One patient brought in her before and after photos that her previous surgeon had taken at another office. The lighting in the before photos was poor, there was extensive shadowing and the background was a yellowish-green bilious color. The after photo on the other hand, was overexposed, and the background was a brilliant royal blue. After I pointed this out to the patient, she recalls that she found it curious at the time that the doctor had two completely different rooms for the before and after photos.

Of course, the ultimate tool in 2009 is Photoshop. I can usually spot the results of Photoshopping in before and after photos, but not always. Occasionally, a patient will bring in before and after photos from a newspaper ad or from a web site that shows an obese patient in the before photo and a toned and fit patient with a six-pack in the after photo. They say, “I want that, Dr. Ryan” as they point to the six-pack. I explain that I have done hundreds of liposuction cases over 20 years and that it’s simply impossible to achieve such results with liposuction.

Bottom line: I would be skeptical if I saw dozens and dozens of spectacular before and after photos on a web site or in a surgeon’s before and after book. Of course, there are many surgeons with lots of photos of their work and they show good quality and unretouched photos as an educational tool, not as a sales tool. However, it is getting more and more difficult to distinguish between the two.