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Before and After

I never wanted a new nose until I saw a better one on Instagram

Exploring the viral culture of before-and-after photos and the dangerous effects they can have on us

Photographic evidence has long been the gold standard for cosmetic surgeons. In an era of live streaming and celebrity surgeons, the ubiquitous before-and-after photo is getting a facelift. Elite cosmetic surgery practices that once trafficked in discretion—with private backdoor entrances to shield A-list clients from paparazzi—are taking cues from the generation of radical transparency. In recent years, Instagram has become the launch pad for a new generation of plastic surgeons who’ve built empires by using the platform to share their work – from before-and-after photos to videos on the operating table. The quality of elective cosmetic surgery was once based on its ability to go undetected. So when did the preoccupation with incognito surgery fade away in favour of what feels like the digital equivalent of shouting it from a rooftop?

It’s fair to say that the iconography of cosmetic enhancement has become part of our social media lexicon. In a recent press release, the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) states that, “unlike prior generations who often kept their tweaks on the low, Millennials are coming of age in a time where facial plastic surgery is normalised – even deemed mainstream by some in an era of ‘resting rich face’, selfies and Snapchat.” In the organization’s 2018 survey, members reported a 24 percent increase in cosmetic surgery or injectables in patients under 30 since 2013 (58% in 2013 to 72% in 2018). Millennial patients also bring the added benefit of free advertising.

Dr. Johnson C. Lee, a Beverly Hills-based, board-certified plastic surgeon echoes the AAFPRS’s findings. He describes his younger patients as “more amenable to having their photos [posted]. Especially the ones who find me on social media—they request that I post their before-and-afters. Or they request for me use stories to share their intra-operative posts so friends can keep tabs on them throughout their surgery.”

Before-and-after images are an important aspect of shopping for a surgeon. So what makes a before-and-after particularly sharable? Board-certified plastic surgeon, Dr. Malcolm Z. Roth (current Trustee and Former President of the American Society of Plastic Surgeons) who doesn’t use Instagram to promote his practice in the same way as Dr Lee, but who often observes patients sharing their own images, says it comes down to an issue of style as well as the type of patient you want to attract. He has at times used deidentified (faces cropped, eyes blurred, etc.) before-and-afters in his office, but only with the patient’s written consent. Meanwhile, Dr. Lee opts for dramatic, yet realistic results in the before-and-after photos he posts on Instagram, where he says 50-60 per cent of his patients find him. Adding social media to the doctor-patient relationship introduces a whole host of ethical concerns, many of which revolve around the issue of consent to share patient before-and-afters. Dr. Lee is careful to make sure his patients sign specific consent forms to have their photos shared on social media.

Instagram is evidently a double-edged sword for plastic surgeons looking to build or expand their practice. On the one hand, it benefits from a culture of patients who—in addition to paying for their procedures—are willing, if not excited to participate in an unregulated grassroots ad campaign. On the flipside, social media has a tendency to magnify the industry’s long-standing issues with ethics and standardisation of photography. “Not only is it easy to Photoshop,” says Dr. Roth, “but there are also little tricks you can do to make your results look better than they really are.” He mentions the use of superficial tweaks like make-up, hairstyle, lighting, or even just the angle of the face. Some of Instagram's biggest surgeons are guilty of sharing before-and-after posts that make little effort to convey actual surgical results. These posts sell a lifestyle more so than a surgery. On the other side of the coin are the surgeons who’ve adopted a before-and-immediately after approach. The result is grizzly, but not unfairly so. After all, elective as it may be, cosmetic surgery is surgery nonetheless. It’s fair, you might even say, responsible, to provide potential patients with the less-than-glamorous visuals as a reminder of how serious these procedures really are.

Whether it’s before-and-afters or before-and-immediately afters, shared by surgeons or shared by satisfied patients, more people than ever are sharing their before-and-after photos. But what effect are these photos having on the rest of us? Is constant exposure to facial transformations contributing to a heightened sense of body dysmorphia? The authors of a 2018 study published in the American Medical Association’s Journal of Ethics caution that, “social media now allows consumers to compare themselves to a much wider, if not global, set of peers that might further exacerbate their anxiety regarding their appearance.” When I stumbled upon this meme, I instantly saw myself in the “before” picture. My nose isn’t particularly drastic—neither was hers—but still, could it be holding me back from my true potential?

At what point do other people’s before-and-after photos become the Rorschach test onto which we project our own perceived flaws? Shari Foos, a Licensed Marriage and Family Therapist, adjunct professor, and scholar of Narrative Medicine, considers before-and-after imagery to be part of what she calls the ‘Cult of Culture,’ the mass onslaught of social media, advertising, institutions, banks, etc. “It’s what assures all of us that we're ugly, fat, not cool, no-good no-talent impostors. So, of course, you get evoked when you see that kind of a picture and think: ‘Wow, my life could be better.’”  But when it comes to surgical enhancements, she’s cautious. “Because on some level,” she says, “you don’t want your physicality to lead.”

With Instagram, plastic surgeons can extend the reach of their practice, interested consumers can shop around for doctors, and satisfied patients can proudly show off their results. So what about sponsored posts and influencer marketing? Dr. Roth tells me that as far as he knows, it’s not illegal. “However, it’s absolutely a violation of the American Society of Plastic Surgeons’ Code of Ethics,” he says, and could result in sanctions or even loss of board certification. But that only applies to board-certified plastic surgeons, who aren’t the only ones posting before-and-after photos on Instagram. Technically speaking, any doctor with a medical licence can perform a cosmetic surgery, with or without the specialty training required for board certification in plastic surgery. Also on that list: medi-spas providing injectables like Botox and filler, where sponsored posts are quickly becoming the norm.

For cosmetic surgeons, the business of Instagram shows no signs of slowing down. Anyone with a smartphone can scroll through before-and-after photos. Given the influx of users trying to cash in on the #plastic_surgery rat race, if these images haven’t caught up with you yet, it’s only a matter of time before they infiltrate your explore page. When that day does come, proceed with caution. “Buyer beware,” warns Dr. Roth, who advises consumers to do their homework when looking for surgeons on social media.

For a casual Instagram user with some latent nose paranoia (me), seeing the before-and-after pictures of the girl whose nose job changed everyone else’s life brings up simultaneous feelings of familiarity and betrayal. It’s unsettling to be confronted by someone who looks like me (but doesn’t want to) alongside the new and improved version of us both.

The Instagram before-and-after can be an empowering resource for the person actively seeking to go under the knife. But if—like me—your nose wasn’t a problem until you saw a better one, then therein lies the issue. A person’s openness to share the work they’ve had done feels like a positive step toward a more transparent beauty culture. But when it comes to the omnipresence of before-and-afters on Instagram, I worry that by co-opting this trend for promotional purposes, cosmetic service providers may be doing more harm than good. As Shari Foos stresses, no one is immune to the Cult of Culture. If we aren’t careful, these images can tear us down just to build us back up (and charge us for it). Next time you find yourself scrolling through pictures of noses, jawlines, and butts, think of them as advertisements—whoever posted them certainly does.