The Dangers of Deceptive Photography in Medical Aesthetics

Take a scroll through social media and our image-driven society is front and centre; celebrities and influencers proliferate a relentless desire and pursuit of beauty and anti-ageing goals, flaunting transformations that seem too transformative - magic almost. And therein, lies a problem, perception becomes out of whack with reality, and it’s not just the glitterati at fault. An array of before and after photographs are the stock in trade of every medical aesthetic, plastic surgery, or beauty business, but on closer inspection, can you trust that the showcased ‘results’ are truly genuine?

Much of the ‘photography’ we see prevalent on Instagram highlights an unsettling trend for deceptive photography – that which has been subtly edited or manipulated to misrepresent the results of the cosmetic procedure being marketed.

In a 2021 study to systematically assess facial cosmetic surgery before and after photography bias on Instagram, Vaca et al concluded, “Photographic misrepresentation, with photography conditions biased towards enhancing the appearance of the postoperative result, is pervasive on Instagram...and raises significant concerns.”[i]

The modern technology we hold in our hands daily can easily sharpen, smooth, or apply filters to images to enhance, alter, or add features that were not there – you don’t need to attend an evening class in Photoshop these days. In reality, and this is the scary part, you may not even realise that your benign actions when photographing your patients using smart camera devices may contribute to the distortion and misrepresentation of your before and after images.

Dating back to the 1970s, many clinical publications discussed issues related to non-standardised photography in the plastic surgery sector. “Clinical photographs should always be taken with the same camera lens, lens setting, lighting, film, and patient position to ensure reproducibility and to enable valid pre- and postoperative comparisons”, explained DiBernardo et al in 1998.[ii]

More recently, in 2004, Sommer and Mendelsohn tested the hypothesis that certain patient manoeuvres would alter the appearance of the submental area, jawline, and melo-labial groove. Naive judges were given photographs of subjects’ faces photographed in neutral, neck flexion/extension, and head protrusion/retrusion positions and found that small changes in patient positioning during photo-documentation for facial plastic surgical procedures can cause dramatic changes in the appearance of certain parameters, thus distorting preoperative and postoperative photographic comparison.[iii]

This is not a new conversation, but published studies within the last five years have warned of the disconcerting trend for sharing non-credible before and after photographs on social media platforms where they are viewed by a broader and perhaps more vulnerable audience. A 2019 survey to understand how the public seeks out plastic surgeons found that those considering surgical or non-invasive procedures are three times more likely to choose social media platforms as the most influential online method in selecting a surgeon and are five times more likely to follow a plastic surgeon on social media.[iv] The duty of care to show trusted, genuine, and validated images is clear.

What are deceptive photography techniques, and how can you spot them?

Many common ‘tricks’ are employed to illicit better photographic results. It has been shown that you can create a perceived improvement between a before and after photograph even when no treatment has been performed, as presented by Lambros at the 2017 Summit in Aesthetics.

Being aware of deceptive photographic techniques will encourage you to be mindful in your own practice and arm you to scrutinise the authenticity of cosmetic procedure results shared on social media, including in discussions with patients who may attend a consultation with armfuls of saved images viewed on social media or their own filtered selfies. The increasing popularity of selfie-taking, applying filters, and photo-editing has led to the psychological phenomenon of ‘Snapchat Dysmorphia’, where patients present with filtered selfies to illustrate their desired result from cosmetic intervention.[v]

Well-known authenticity advocate and cosmetic doctor Dr Steven Harris gave an insightful top tip when sharing his observations on deceptive photography. When evaluating before and after photographs, you should pay close attention to the tip of the nose; changes in head position can be detected by observing the nostrils, and they can indicate whether the angle has been altered to enhance the appearance of the lips or chin.

Deciphering where the deception or photographic bias lies can be an inexact science, making it difficult to report erroneous content. A qualitative evaluation of outcomes photography on Instagram by Soares et all in 2022 sought to introduce the Standards for the Evaluation of Photographs in Aesthetics (SEPIA) scoring system and grading scale.

SEPIA uses nine quality standards and considers subject positioning, facial expression, lighting, background, zoom, makeup and jewellery, multiple views, timing, and procedure-related descriptive information. The standards can be applied to full-face, close-up photographs, and those taken from different views. The creators of SEPIA raise red flags on, “…the use of selfies, isolated immediate post-procedure photographs, digital filters, and incongruent comparisons” deeming them to “represent major violations that render photograph comparisons as potentially misleading” unless social media posts include specific disclaimers to “educate the viewer on the possible distortion of the outcomes”.[vi]

• Tilting the head upward alters facial contours, making features like the lips and chin appear more prominent. Similarly, pushing the face forward and stretching the neck can reduce the appearance of jowls or a double chin in the submental area. A seated or recumbent patient will also alter appearance. Therefore, a consistent approach to the camera and patient head position should be maintained, consider using a stand or tripod for your smartphone, tablet or SLR camera. Try to keep a consistent distance, about two feet away, to prevent image distortion and keep the camera level with the patient’s face. Certain smartphone camera software uses a grid feature to align shots at eye level. This is useful for face-on photography, but ideally, you should take photographs from multiple viewpoints, e.g., frontal, three-quarters, left and right lateral profiles. Use a plain background to maintain a sharp contrast between the edges of the face and the background.
   
• How you frame a photograph also has a bearing; a close-up or zoomed-in shot can emphasise or distort certain features, making them seem larger. Although close-ups are permissible and may be preferred for privacy in online materials, similar to blanking out eyes, the viewer should be able to ascertain the impact of the procedure in the context of the whole face. Where a close-up of the upper, mid or lower face is preferable, standardisation of the zoom must be obeyed.
   
• Positioning goes hand in hand with facial expressions. Smiling can naturally enhance the lips and lift the chin, contributing to a more youthful appearance. The dynamic of smiling using elevator muscles in the lower face naturally influences structures in the mid and upper face, changing the appearance of the cheek and peri-orbital area. Keep facial expressions neutral and consistent to avoid natural enhancements that could mislead the direct outcome of treatment. Remind patients to relax and keep their faces at rest.
   
• Lighting plays a key role in photography – professional photographers use a multitude of lights and reflectors to get the best from their subjects during a photoshoot. Increased lighting reduces shadows, blanches skin imperfections, and highlights facial features; in turn, this creates a smoother appearance. Social media influencers love a ring light that can be quickly and easily tilted for the best effect, but lighting should be uniform, remaining the same for both before and after photographs to provide a true comparison.
   
• Make-up is a clear deceiver, but it may not be the patient to blame. With the popularity of lip filler treatments - arguably the most prolific images on social media – manipulation is rife with the application of lip gloss or other shiny or tinted ointments including petroleum jelly and personal lubricants to give lips a fuller look post-treatment. Piercings, jewellery and hairstyle can all influence the face in comparative photos – a tight ponytail can have a bearing on skin stretching, and hair falling on the face may obscure areas of the forehead, temples, or alongside the ear tragus. Patients should be makeup-free in pre- and post-treatment photos, keeping consistency in jewellery, facial hair for men, or hairstyles, perhaps wearing a facial headband.
   
• Timing is another anomaly. After photographs should be just that, taken some time after treatment and recovery, at a review appointment, e.g., around two weeks post cosmetic injectables. If you intend to use ‘immediately after’ images on social media, the traumatic swelling, particularly with lips, will undoubtedly misrepresent any outcome; you must add a disclaimer to the description of your post making it clear that the ‘after’ photograph is not representative of the final outcome.

Why is deceptive photography so prevalent and dangerous?

There are plenty of excuses – but ignorance certainly cannot be relied upon. Aesthetics has become a very crowded space, poorly regulated, encompassing medical and lay practitioners. The drive to secure new ‘business’, and the pressure to continually create engaging social media content to fuel what sometimes seems like a ‘revolving door’ may be to blame for the increased use of less-than-honest photography to showcase outcomes. This is neatly summarised by Vaca et al, “…accounts with a greater number of followers demonstrated significantly greater postoperative photography bias, suggesting photographic misrepresentation is rewarded by greater user engagement.”

Thanks to social media algorithms, being truthful might not get you the most followers, views, or likes, and if others are prepared to manipulate their images, it can feel like you are losing out. “…the ability for unqualified practitioners to perform procedures outside their scope of practice, exacerbated by an uneducated public and fierce competition in our present digital age, has likely further contributed to the “keeping up with the Jones’s” phenomenon to demonstrate impressive results”; a perceptive observation by Vaca et al. Healthcare professionals must maintain integrity and ethical practice and avoid getting swept up in chasing optimal digital presence. Consider this dilemma even more so if you outsource your social media management.

Of course, the real danger of deceptive photography is its impact on patients. Repeated use of social media alone has been linked with anxiety, negative body image, eating disorders, growing issues related to mental health, and a higher desire to seek cosmetic surgery. The use of edited, filtered, or unreal photography misleads and misrepresents the achievable outcomes from cosmetic interventions and will undoubtedly lead viewers to manifest unrealistic expectations and may exacerbate body dysmorphic (Snapchat dysmorphic) tendencies.[vii]