What is reality? Determining if a before and after is too good to be true

There have been ways to manipulate photography for as long as there has been photography. Yet, manipulating photographs has evolved from double exposure and bleaching to computer enhancements and digital alterations. Modern technology has given us filters, Photoshop and now AI-generated images, blurring the lines between fact and fiction to the point where many people can no longer tell the difference between real and fake.

As it gets harder to differentiate between real photos, manipulated photos and AI-generated images, how do you know what reality is? Can you trust before and after pictures to accurately assess what a plastic surgery result will look like? Do photos reflect the true skill and artistry of a plastic surgeon? Is giving your surgeon an AI or Photoshopped image of your ideal aesthetic result setting you up for disappointment?

Sometimes, advancements in technology raise more questions than answers. Before your plastic surgery appointment, ask yourself, "What is reality?"

Is there a before and after problem?

The answer to whether or not there's a before and after problem in plastic surgery isn't as straightforward as one might hope.

"Reality in plastic surgery is a tough one," Karen Horton, MD, MSc, FACS.

It is not just before and after photographs that patients have to worry about when it comes to plastic surgery and obtaining a realistic aesthetic result.

"Some patients come in showing their surgeon a photo of themselves with filter effects, which are not possible in reality," said Dr. Horton. "Others Photoshop in or out the contours they are seeking, which also are unlikely to be achievable in a plastic surgeon's hands. Setting realistic expectations is key to ensuring patients are getting what they are paying for and avoiding unhappy patients with consequent negative reviews and/or threats of lawsuits."

She even notices the "touch-up trend" on herself.

"On social media, many images are touched up with filters, major editing and the like," said Dr. Horton. "Even photos of me in magazines are touched up! If the difference is striking, I sometimes disclose in a side-by-side image the original and the edited image so that viewers can see my skin flaws, fly-away hairs or imperfect makeup in the live photo versus the professionally touched-up final shot."

Even before the arrival of Photoshop and filters, individuals used photography "tricks" to enhance the look of before and after photos.

"A more sophisticated consumer already knows about Photoshop and filters," said Roy Kim, MD. "So, if a 'before' photo has bad skin tone, bad lighting, a weird or bad pose, the patient is wearing a clinical patient gown and the patient looks unhappy and then the 'after' photo has better skin tone, the patient is wearing makeup, the patient is wearing nice clothing, the patient is smiling that is easier to detect."

Real or fake: Determining when photographs are too good to be true

So, what steps can a patient take to differentiate between reality and fantasy? With such striking technological advancements, how can a patient tell the difference between a genuine photograph, a realistic result and something that only exists online?

"I do not think this is a big issue yet because what AI can generate looks slightly unrealistic, and I do not think plastic surgeons routinely post fake content," said Dr. Kim.

Yet, he also notes that we may only be less than a year away from being unable to tell the difference between an AI-generated image and a real before and after photograph.

AI photos currently may still contain imperfections and oddities that a discerning human eye can pick up on, but Dr. Horton already sees the effects of artificial intelligence in the doctor-patient space.

"I'm beginning to think it is an issue," said Dr. Horton. "I personally don't use AI in my practice, but I know others are. I've been invited to use AI to record patient conversations, but I have serious concerns about patient confidentiality, data breaches and the potential for limiting what is being said if they know they are being recorded. The doctor-patient relationship is intimate and personal and should be kept private, not transcribed by a computer, with a record of the conversation saved on a computer server."

She recommended patients think critically and look for consistency when viewing at images.

"When looking at before and after images on a surgeon's website or their social media, you must have a discerning eye," said Dr. Horton. "First, the photo should be a standard medical view with standardized lighting and camera angles. Look for images that defy gravity, such as an earring that is not hanging. Consistency in surgical results is also something to look for. If there are zero scars, but the image says the patient is only a few weeks or months postoperative, that is not normal. Incisions are often visible for a year or two before they fade."

Dr. Kim also said consistency is the key to before and after images.

"For consumers, I would look for consistency in before and after images," said Dr. Kim. "For example, my clinical photos always have the same poses, angles, lighting, background, and camera. I think it's pretty clear that the photos are real. I do not post a grumpy patient with no makeup as the 'before,' and a happy patient with makeup, great filters, great clothing, great lighting, doing a professional photoshoot on the beach as my 'after.'"

Technology is the cause behind these issues, but it may also be the solution.

"For the near future, I think that photos can use 'blockchain' technology to ensure that the photo is original, that the metadata is real and that documents any alteration," said Dr. Kim. "If every image on a website has a little watermark or metadata tag ensuring it has not been altered, sort of a "seal of approval", that would help consumers know that the photos are authentic and real and not altered."

Technology can be intimidating. How do you know what you are seeing is real? How do you know a person is writing this and not a bot? (Spoiler: It's not.) There are nuances and imperfections. The future is here, reshaping how we see ourselves and the world around us. Understanding technology and its limits can help you spot fakes. It can also put you in a better position to achieve a realistic plastic surgery result with no filters needed.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.