Reading Before-and-After Photos: How Do Lighting, Angle, Filters and Selected Examples Mislead?

Can before-and-after photos be trusted?

Before-and-after images are taken for two different purposes. The first is the medical record: the physician photographs under the same conditions in order to follow the change objectively, and these images stay in the patient's file. The second is promotion: the image is selected, cropped and shared in order to attract attention. In the first kind the criterion is accuracy; in the second it is often impact. Knowing for which purpose an image you come across was prepared determines how far you should trust it.

This distinction has also been examined in research. In a study in which three plastic surgeons assessed 291 posts featured under facial aesthetic surgery hashtags on a social media platform, the photographic conditions were found to differ in a way that showed the image after the procedure more favourably in 282 of the posts. In the same study this bias was more marked in accounts with a high number of followers. This study concerns operations and covers posts at a particular point in time; even so, it gives an idea of how widespread the problem may be.

Another study scored 510 posts from 102 practitioner accounts on a nine-item scale; the average score was four out of nine, and about 40 per cent of the posts were rated as low quality. The criteria most often neglected were magnification, lighting, timing of the photograph and showing more than one view. Low-quality posts were seen most with nose surgery and lip filler; this was explained by the frequency of images taken immediately after the procedure and of selfies.

This does not mean that every image shared is misleading or that the person sharing it is acting in bad faith. The differences often arise from carelessness. What matters is to see an image not as proof of the result but as the starting point for questions to ask.

How do lighting, angle and distance change the result?

Lines, hollows and pores on the face are in fact made visible by shadows. This is why, when the direction of the light changes, the image changes without anything changing in the skin.

Selfies are a problem in their own right. A phone's front camera is generally wide-angle and distorts facial proportions at close range; nor can the lighting, posture and editing be controlled. The scoring study mentioned above counted selfies, filters, images taken immediately after the procedure and mismatched comparisons (for example, comparing the right side of the face with the left) as major violations unless there was an explanatory note.

What do facial expression, make-up and hair conceal?

• Facial expression: a 'before' taken while frowning or laughing cannot be compared with an 'after' taken with the face at rest. Lines formed by movement lessen anyway when the face relaxes. The reverse also happens: a slight smile lifts the cheeks and makes the midface look fuller.
• Make-up: concealer, foundation, highlighter and contouring products markedly change the perception of dark spots, dark circles and volume. Lip liner can make the lip border look wider than it is.
• Hair and accessories: hair tied back or left loose makes the oval of the face and the jawline look different; earrings, glasses and collars also draw attention elsewhere.
• Tan and skin care: skin colour or hydration that has changed in the interval affects the appearance of the skin independently of the procedure.
• Weight change: the appearance of the face and neck changes with weight gain and loss; if the interval is long, this possibility should be kept in mind.

How can you tell a filter or retouching?

Most of the time you cannot; that is the problem itself. Many phone cameras take photographs with automatic beautifying settings that smooth the skin even if the user does nothing further. Filters in social media apps flatten skin texture and can change facial proportions. And retouching done with image-editing software may leave no trace.

Even so, there are some clues: natural skin texture such as pores and fine hairs not being visible at all, blurred transitions at the hairline or the edge of the jaw, straight lines in the background being bent, the 'before' image being of markedly lower quality. The absence of these clues does not show that the image has not been edited.

A proposal paper updating the standards of photographic documentation in aesthetic medicine keeps acceptable editing narrow: matching the brightness, colour and contrast of the two images and cropping them to show the same area. The same paper recommends that retouching and shape-altering tools be strictly avoided. We have dealt with how constantly looking at filtered faces can affect the way a person perceives their own face in our article “Body Image and Aesthetic Treatments”.

Why is a photograph taken immediately after the procedure misleading?

After injections and energy-based procedures there is swelling in the tissue for a while. Straight after filler, the lips, cheeks or chin may look fuller and tighter than in their settled state because of the swelling; fine lines may seem temporarily erased. An image taken in the chair as soon as the procedure is over therefore shows not the result but the moment of the procedure. The usual course of swelling and bruising is explained in our article “Bruising and Swelling”.

The scoring scale mentioned above requires that, for a comparison, at least two weeks have passed for injection procedures and at least three months for surgery and laser procedures. Only 16 per cent of the posts examined met this timing criterion. These periods are that study's own criteria; they vary from procedure to procedure, and with some procedures the result takes longer to settle. For a general framework on how long to wait with which procedure, see our article “Timing Aesthetic Treatments before a Special Event”.

The other end of the timing matters too. With a procedure whose effect lessens over months, an image from the period when the effect is at its most marked says nothing about how long the result lasted. An 'after' image with no time stated is incomplete information.

Why do selected examples not reflect reality?

This is called selection bias. What you see on an account or a promotional page is not a random sample of all the procedures carried out; it is the results that were liked, that were allowed to be shared and that catch the eye. Average results, those that did not meet expectations, those that needed correction and those where side effects occurred do not appear in this shop window.

• The starting point is selected: so that the change looks striking, people with a marked complaint at the outset are featured. If your starting point is different, the result will look different too.
• The facial structure is selected: bone structure, skin thickness and age directly affect the result. The result in someone who does not resemble you does not predict your result.
• Several procedures are attributed to one: behind a change presented as 'filler only' there may be botulinum toxin, skin care, laser, weight change or even surgery. The image does not say which procedures were carried out.
• The number of sessions and the amount are not stated: a result that looks as if it was achieved in a single session may be the sum of several sessions spread over months.
• The image may have been taken from another source: a manufacturer's promotional image or another practitioner's post may have been used. You can ask whether the image is of one of the own patients of the physician you are consulting.

What does a standard medical photograph look like?

The shared idea of the standards published for medical documentation is simple: the only thing that changes between the two images should be the patient. The headings that stand out in publications on photographic documentation in aesthetic medicine are these:

• The same camera and the same settings; a fixed shooting distance.
• The camera at the same level as the face; the head position the same in every photograph.
• A plain, single-colour background.
• Diffuse lighting from both sides that does not depend on daylight and is the same in every photograph.
• No make-up or jewellery; hair tied back so as to leave the face uncovered.
• A neutral facial expression; if a procedure related to facial expression is being assessed, the same expression is also recorded separately in both sets of photographs.
• Not a single angle but images from several angles: from the front, three-quarter view and in profile.
• The same size, the same framing; in such a way that neighbouring areas are also visible.
• The date of the photograph and the time elapsed since the procedure stated.
• No editing apart from matching colour and brightness.

Reviews in this field emphasise that with the spread of smartphones and social media, adherence to these standards has slackened, and that variable lighting, angle, filters and digital editing can make results look different from what they are. If an image you come across does not meet most of these standards, the soundest course is not to draw any conclusion from it.

What you can ask yourself when looking at an image

1. Are the lighting, background and magnification the same in the two images?
2. Are the head position and facial expression the same? Is one smiling and the other serious?
3. Has the make-up, hair or skin colour changed?
4. Does the skin texture look natural, or too smooth?
5. When was the 'after' image taken? Immediately after the procedure, or weeks later?
6. Does it say which procedures were carried out, and in how many sessions?
7. Does this person resemble me in age, facial structure and starting point?
8. Is this a single example that was liked, or a series made up of different results?

Which questions should you ask the physician?

The American Academy of Dermatology advises people considering an aesthetic procedure to ask to see before-and-after images of patients on whom the physician has performed this procedure, and especially of patients similar to them in skin tone and type. Records shown during the consultation, taken under the same conditions and belonging to the physician's own patients, are more informative than the posts you see on a screen. The questions worth asking are these:

• What is the typical result at my age and from my starting point? Does the example you are showing represent the average, or a result that stands out?
• How long after the procedure was this image taken?
• In how many sessions, and over how long, was this result achieved?
• Which other procedures did this person have?
• How long did the result last; is there a record of the same person from a later period?
• How often do cases occur in which the expected level of response is not obtained, and what is done then?
• With my facial structure, what is the limit of this procedure; what does it not change?

Showing an image and saying 'I want exactly this' is an understandable request, but for the physician it is often impossible to answer: the facial structure of the person in the image, the procedures carried out and the photographic conditions are unknown. It is more useful to use the image as a tool for explaining what you like. For preparing for a first consultation, see our article “A Guide for First-Time Medical Aesthetic Patients”.

How are realistic expectations formed?

Realistic expectations come not from someone else's image but from the examination of your own face. Most medical aesthetic procedures improve appearance to some degree; they do not turn a face into a different face. The result varies from person to person and cannot be known for certain in advance. The physician setting limits for you, 'this will change, this will not, it may last about this long', is more valuable information than being shown an impressive image.

When choosing a physician and facility, we suggest you look at the safety conditions rather than at images; these are listed in our article “A 10-Point Safety Checklist for Choosing a Clinic and Physician for Medical Aesthetics”. For hasty offers that come with images, and invitations to treatments outside a healthcare facility, our article “Group Aesthetic Treatments at Home and in Hotels” may offer guidance. In adolescence and young adulthood the effect of these images can be stronger; we have dealt with this subject in our article “Medical Aesthetics for Young People”.

If you notice that you often compare your own appearance with these images, and that this upsets you or affects your daily life, talking about it with a physician or a mental health professional may be a more useful step than looking for a new procedure.

Conclusion

Before-and-after images can give you an idea; however, because of lighting, angle, facial expression, make-up, filters, the timing of the photograph and the fact that the examples are selected, they do not show how a procedure will turn out for you. Drawing no conclusion from an image that was not taken under standard conditions, and for which the time elapsed and the procedures carried out are not stated, is the safest approach. Make your decision not on the basis of a frame on a screen but on the typical result, the limits and the risks that you discuss with your physician during the consultation.