The carousel on the phone
A patient slides her phone across the desk to show me an aesthetic clinic's Instagram feed. The before-and-after carousels keep going. One after another, the second photo is brighter, smoother, younger-looking. "This is what I want," she says.
I look. The photographs are good, in the way that aesthetic clinic photographs have become very good. Then I tell her the part of the work she is not seeing, because she should know it before she books anywhere.
The five decisions a clinic makes before the patient sees a photograph
By the time a before-and-after image is published, somebody has already made five choices that the viewer cannot see. Each of them moves the result.
The first is lighting. The "before" photograph is often taken under direct overhead clinic light. Overhead light flattens the skin and sharpens every shadow, every pore, every uneven patch of texture. The "after" is taken in soft, diffused side light. The same face under those two light sources looks significantly different even with nothing else changed. What the viewer is seeing is photography. The medicine has not happened yet.
The second is angle. Even a few degrees of head tilt changes the apparent volume of a cheek, the projection of a jaw, the visibility of a nasolabial fold. A practised photographer can find an angle that exaggerates the problem in the before and minimises it in the after, without anyone touching the patient.
The third is the lens. A wide-angle lens distorts a face in ways that flatter or fatten depending on distance and focal length. A before and an after shot on different lenses, or even at different distances on the same lens, are not directly comparable.
The fourth is posing. Mouth relaxed against mouth held in a half-smile. Eyebrows lifted slightly to open the eyes. Posture pulled up so the jawline drops one millimetre. None of these are dishonest by themselves. They are the everyday choices a portrait photographer makes. The patient looking at the carousel rarely knows they were made.
The fifth is filter and edit. Skin smoothing, colour adjustment, contrast lift, eye brightening, subtle reshaping. Modern editing tools do these in seconds. A small, defensible amount of editing on the after image, with none on the before, produces a difference that no treatment actually delivered.
The selection bias the carousel never mentions
Even setting the photographic choices aside, there is a more fundamental problem with a before-and-after gallery. It is the patients you do not see.
A clinic running fifty patients through a treatment in a given month gets a range of results, the way any medical intervention produces a range. The middle of that range is what most patients will actually experience. The clinic publishes the top of the range, because the top of the range is what makes a good carousel.
This is the selection bias inside every cosmetic before-and-after you have ever seen. The patient looking at the photograph has been quietly shown a result at the favourable end of the distribution and led to believe it is typical. What she has been shown is the published result. The typical result sits some distance away from it.
The honest version of a result presentation would show three things side by side: the best case, the worst case, and the median case, all photographed under identical lighting, the same camera, the same lens, the same hair and makeup. Almost nobody does this, because the median case is rarely as exciting as the hero case, and the worst case may be a patient who responded poorly to a treatment that suited most others.
What this means for a patient about to book
You do not need to become a photographer to protect yourself. There is one question, asked in the consultation, that does most of the work.
"Can I see your average result for this treatment, not your hero result?"
The answer matters less than the response. A clinic that takes the question seriously, that talks honestly about the range of outcomes, that says some patients respond well and some do not and here is how we decide which is which, is a clinic that is going to be honest with you about your own face. A clinic that deflects, or insists every patient does brilliantly, has already told you something useful.
The reason this site does not publish before-and-after photographs goes beyond modesty and beyond regulation. The format does not do what patients think it does. A carousel of someone else's results is a marketing aesthetic. A sensible person chooses her doctor on different grounds entirely.
The better basis is the consultation itself, where the doctor looks at your face, listens to what you actually want, and tells you honestly what is possible. The slide on the phone is somebody else's story, edited.
