Cosmetic surgery or photo trickery?
By Jane Elliott
BBC News health reporter

How lighting and a change in position can change perceptions. 

"Before-and-after" shots of plastic surgery seem to fill the pages of our glossy magazines.

They seem to offer miraculous results - but are they always what they seem?

Or are they using clever tricks of the photography trade, such as using ambient lighting, changing the flash settings or even digital wizardry?

The surgeon who took these shots did so to illustrate the trickery that can be obtained from before-and-after shots.

Review

He did not manipulate the shots, but by changing the lighting used and shooting the model lying down, he managed to create the impression that her wrinkles had disappeared.

Worried that a widespread abuse of manipulated images in the media is harming patient trust, the British Association of Aesthetic Plastic Surgeons (BAAPS) is taking action and is holding its first photography course for plastic surgeons.

Magazines seem to be full of before-and-after pictures showing the apparent benefits of cosmetic treatments.

The one-day course, to be held later this month, will offer advice on data-protection issues, and explore advances in digital imaging as well as teach surgeons how to improve the accuracy of their before-and-after photographs.

Norman Waterhouse, consultant plastic surgeon and former president of BAAPS, is speaking at the event.

"Magazines seem to be full of 'before and after' pictures showing the apparent benefits of cosmetic treatments," he said.

"Surprisingly, there is currently no code of conduct in the use of photographs by plastic surgeons during pre-operative counselling and marketing.

"This event offers a valuable forum in which to review these issues."

Photography has long been an important tool for the plastic surgeon.

Half a century ago the father of British plastic surgery Sir Harold Gillies said: "The advances in plastic surgery in the past 10 years are primarily those of photography."

For the first time plastic surgeons were able to properly show the public the results of the new specialty.

Some say it is as an important a tool to them today as the X-ray is to an orthopaedic surgeon.

Techniques

But Adam Searle, consultant plastic surgeons and president of BAAPS, said surgeons must ensure they always act responsibly.

"At the BAAPS we promote the highest ethical standards in aesthetic practice, including the use of modern photography techniques," he said.

"They can be a powerful tool for documentation and research purposes and must be used responsibly."

He said photography was used for documentation purposes in the before-and-after shots, to aid patient consultations, and to show new techniques as well as for advertising and marketing.

However, despite its importance in the specialty, medics had never before received any formal teaching in photographic techniques, the medico-legal issues surrounding them or the impact of photo-manipulation.

Manipulate

Plastic surgeon and lecturer Charles Nduka, who is based at Imperial College and St Mary's Hospital in London, explained that advances in technology had made it much easier to manipulate the images.

With the advent of digital photography and desktop publishing software it is very easy, even for the novice, to manipulate images

Charles Nduka,
Plastic surgeon

"Before the widespread availability of digital imaging, photographs had to be re-touched manually," he said.
"This was a specialised technique that required a great deal of time and expertise.
"With the advent of digital photography and desktop publishing software it is very easy, even for the novice, to manipulate images.

"There is widespread use of manipulated images in the media [magazines] and also on the internet.

"Undoubtedly photography is a vital tool for the plastic surgeon.

"The main uses can be considered under the categories of documentation as part of the medical record, evaluation of the benefits or otherwise of interventions, and as an aid to doctor-patient communication.

"However, in the absence of specific guidance on its appropriate uses and potential for abuse, patient trust may be harmed."

He added that photography was a tool to aid communication and should not be misused.

"If that means of communication is degraded by misuse then it reduces trust and harms the doctor-patient relationship."

Nicolas Miedzianowski-Sinclair, whose company Surface Imaging International provides 3D and 2D images, said its images showed people as they are, but said it would be easy for photographers to manipulate an image.

"If you take a picture right up close it will show wrinkles," he said.

"If you take it further back it will be less focussed so might give the impression that the wrinkles have gone away."