S05E75 How To Spot the "Fake" Plastic Surgery Pictures

Discover the unvarnished truth behind plastic surgery before-and-after photos as we sit down with Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Lawrence Tong @yorkvilleplasticsurgery, Dr. Sam Jejurikar @samjejurikar and Dr. Sam Rhee @bergencosmetic.

They take a deep dive into the ethics of image presentation in the aesthetic surgery world. Prepare to have your eyes opened to the pressures that social media brings to the fore, and learn how your expectations might be unwittingly shaped by subtly altered imagery. Our conversation is a rare glimpse into the real story of surgical transformations, revealing the dedication required to maintain photo integrity amid today's image-focused culture.

These four plastic surgeons bring a wealth of knowledge on the limitations and variations in capturing these transformative photos. Together, they examine the delicate balance between showcasing results and safeguarding patient confidentiality. This episode promises a candid look at the intersection of aesthetics, ethics, and the pursuit of transparency in plastic surgery.

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S05E75 How To Spot the "Fake" Plastic Surgery Pictures

TRANSCRIPT

[00:00:00]

Dr. Sam Jejurikar: All right. Welcome everyone to another edition of Rhee Plastic Surgeons at a Microphone Plus One. I'm Sam Jejurikar from Dallas, Texas. And as always, I'm joined by Salvatore Pacella from La Jolla, California. Sam Rhee from Bergen County, New Jersey, and our plus one today is Dr. Larry Tong from Toronto.

Welcome, gentlemen. Today we're going to talk about an interesting topic, uh, to our viewers. We all know how important it is to, um, you know, for everyone as they're picking their plastic surgeon to Um, to analyze before and after photos, but today we're going to talk about a topic that's recently been getting more attention, which is deception and plastic surgery photos.

Before we get into the meat of the topic, I'm going to turn it over to Dr. Tong, who's going to read our usual disclaimer. Okay,

Dr. Lawrence Tong: Thanks. So, for our listeners, this show is not a substitute for professional medical advice, diagnosis, or treatment. This show [00:01:00] is for information purposes only. Treatment and results may vary based upon the circumstances, situation, and medical judgment after appropriate discussion. Always seek advice of your surgeon or other qualified health provider with any questions you may have regarding medical care.

Never disregard professional medical advice or delay seeking advice because of something on this show.

Dr. Sam Jejurikar: so, um, I'm going to just throw it out to all of you guys. Is it important when you're seeing an aesthetic surgery patient that they have photos of yours that they can look at and how have they, how they typically found you? Um, Sam Rhee, when somebody comes in and they haven't been a direct referral from one of your patients, what do they usually tell you is the reason why they'd pick you to be their surgeon?

Dr. Sam Rhee: If they have no direct contact with what? Say that again, let's

Dr. Sam Jejurikar: So let's say, let's say they're not a direct referral, like how is it that they've picked you to be their surgeon or to do a consult with you?

Dr. Sam Rhee: right. Two, two things. Usually, um, reviews, honestly, are one big way. Like they'll see a [00:02:00] review of me somewhere. Like they'll Google and look at surgeons and look at the reviews. And then the second thing, which we're actually talking about today is they'll go do the Google, find plastic surgeons, and then look at their before and after pictures.

Dr. Sam Jejurikar: Okay. So then, um, and is it normally social media where they're finding these pictures of yours? Is it on your website? Like, where are they typically finding?

Dr. Sam Rhee: So there are two, there are two major sources, social media and website, like, as you mentioned, and I am, full disclosure, probably the worst when it comes to publishing before and after photos. They're one of those things which, um, I find kind of a pain in the ass to do. I do, it does annoy me, and this is a, you know, a specific pet peeve of mine, what we're talking about today, about, about deception in before and after photos.

And so I, one of the number one things that I hear from patients is you need to post more and more and more and more and more before and after [00:03:00] photos. And, uh, that's probably one of the biggest feedback, uh, things that I get from people. Like you do good work. Why are you not

Dr. Sam Jejurikar: And Dr. Pacella, um, are there any circumstances under which you would alter a patient's photos before you published it either on social media or your website? What is, what is your, what is your thought process on that? And what's the philosophy of the American Society of Plastic Surgeons? Is that acceptable, ever?

Dr. Salvatore Pacella: No, it's never acceptable. Um, I think, you know, it's, it's an ethical standard to be as, um, transparent in your photographs as much as you can. Um, things like, you know, um, doing erasing shadows, erasing scars, you know, that's clearly an ethical violation and ethically suspect and I believe our societies would agree with me on that.

However, I think there are certain things you can't necessarily [00:04:00] control in standardization of So, for example, I've been to your facility, Dr. Jejurikar, in Dallas, and you have a very standardized way of taking photographs, right? Because you have the infrastructure to do that. You have all patients come into the same photographic studio to do this, okay?

In my office, you know, we don't, we don't have that kind of resource. So we have, um. We have a black background in each exam room where we take photographs and the lighting is not exactly the same in every single room. Um, I try to control for that a little bit with a ring flash, um, but you know, even if you look at my photos, some of the photographs, um, the lighting in the photographs is different just by Ambiently being in a different room and so, you know, I think that's something that the surgeon can't necessarily control for many times, but, you know, I, I said when I'm looking over [00:05:00] photographs with patients in my office or on my website, I say, you know, the, this is clearly, you know, different lighting.

However, you know, look at the scar line, look at this jawline, you know, you can't necessarily hide that with different lighting, you know, so I think it's a, it's a challenge. For

Dr. Sam Jejurikar: Um, Dr. Tong, so you're really a specialist. You're really well known for your facial aesthetic procedures. Um, how do you balance, um, the desire, you know, to show before and after pictures with the ability to, uh, maintain patient confidentiality? Because I have to imagine you have patients who want you to show pictures of themselves or want to show, like, do you ever modify pictures in a way to hide their identity?

Dr. Lawrence Tong: So that's a, that's a great question. So for our viewers and listeners, um, you should understand that, um, we are not, um, [00:06:00] as surgeons just able to publish any of your photos without your consent. So, it's very important, um, to obtain consent whenever we're even thinking about putting any of these photos anywhere.

So that's a given, I know that, um, Sam, Sam and Sal, you guys all do that, um, but just for the listeners, that's, you know, that's, um, that's something that is, uh, is a must. But beyond that, when we ask patients, uh, if we can use their photos, sometimes they will say. No, I'm not comfortable with that, um, because of, you know, whatever reason.

Sometimes it's because if we're doing like a, uh, photo of their, of their breast augmentation, they'll have a tattoo. So sometimes we will offer to, uh, Photoshop out the tattoo. And I think that if it's not, um, you know, on the breast, I think that's perfectly acceptable. On the face. Sometimes we'll, uh, put black [00:07:00] squares on the eyes, but when I do that, I will always tell the patient, um, you know, thank you, we will do a mock up of it, basically I, we will, um, show them what would be published and then they, they have to sign off on it before, um, before we would put it out there.

So yes, sometimes we do make alterations, but that is, um, based on the patient's, uh, desires and also, and approval as well.

Dr. Sam Jejurikar: Pacella, you put your hand up.

Dr. Salvatore Pacella: I figured visually it's easier than the audio. Um, so, um, so question for, uh, for the others. Um, so I know of surgeons that are very engaged with social media. Whenever they take a photograph, even a preoperative photograph before the surgery, they have a large, a long release form saying that they can use this.

Um, how do you guys do this? So, in my practice, [00:08:00] you know, we have a consent form for photography, clearly, for their medical record. But we also have a specific consent for publishing on the web or social media. So, I, I will decide ahead of time, I will decide after the result is in. Whether or not I want to use somebody's photographs, and then I'll ask them specifically, secondarily, do you guys get a blanket consent for every single patient to publish?

Or do you do it specifically individually? Oh, we should publish this person's photograph. They have a great result.

Dr. Sam Rhee: I have a blanket and it's very explicit about being able to be published or used with, you know, and there's a caveat about, you know, as Larry said, to not publish anything that's specifically identifiable to that patient. And it's very clear when patients. register that all of these things are there. And I do have some patients that [00:09:00] will say, well, I, this is okay, but maybe this is not okay, like specific situations.

And we'll include that into the consent. But other than that, most patients really don't have a huge problem. I think it is an issue in terms of facial procedures where patients are personally identifiable in in those pictures. And that's where I go specifically to patients and will ask additionally, are you okay with this?

Or if they have something distinctive about. their body or something that, you know, a tattoo or something, for instance, that is very identifiable. I will also go to a patient just to be sure that they're comfortable with that. But most of the time, um, our consent is very clear about that upfront. And if a patient has an issue with it, then a patient will mention it at the time that they read.

through this. It's not like we're hiding it. It's actually pretty. It's not like, you know, one of those things that you just sign at the bottom, [00:10:00] you know, I accept it. It's like, it's, it's very, very, very clear.

Dr. Sam Jejurikar: Same, same in our practice. It's a blanket consent that they'll do before we do any sort of procedure on them, but it's really clearly stated in there that if they choose not to sign it, it won't impact their care even in the slightest. I'd say it's 50 50 whether or not people actually sign up my practice.

There's a lot of people that don't want to have their stuff floating out there on social media or on the web, and that's fine. I totally respect that. Much like Larry, if it's a tattoo, I, we, and that's kind of where I was going. We routinely remove those on social media before we post it. Social media, and I think you guys would agree with this, has totally changed the way that we practice plastic surgery.

And then it used to be that I would, I would, you know, sort of pick my. My, my like best of everything and put them on my website. Social media requires you to just keep like putting tons and tons and tons and tons of new material out there. Um, you have to, you have to obscure genitalia, you [00:11:00] have to obscure nipples.

Um, I think it's, it's good to get rid of tattoos for patients. The problem though is though, is with all of these filters that are in these programs that are out there, um, you'll see. Patients coming in with other surgeons work where if it's a body shot, they may have made the waist smaller. They may have made the hips bigger.

Um, they may have totally obscured the scars or they'll bring in their wish picks and every, I mean, you guys know people in your own life who, every picture they. Posted themselves, which is frequent on social media, has some sort of filter on it where they look nothing like they actually do in real life as well.

And so it's tough because we're in the before and after game where we're trying to make sure we give people an accurate representation of what we are going to look like, but patients wish picks are based off of distorted images of reality.

Dr. Sam Rhee: That is the biggest issue. And I, I would say two things. One is there is deception in before and afters where it's clearly. Unethically edited, like you [00:12:00] mentioned, like it looks like the before the after picture was shot through a Snapchat filter where it's so fake and so obviously not real and like you said, I've had patients who showed me before and after pictures of.

Of other, um, surgeons. And I can only say, I know this surgeon looks like they achieved like a miracle of God results on this, uh, figure that looks sort of like your figure before. But that after is nothing based in reality whatsoever. I'm sorry. And they take it for gospel. They just believe that if they see it on social media, this is, this is real.

And that's something that, um. I wrestle with. The second thing, though, is, is that I have engaged in what you might call deception and plastic surgery in, in our, in my before and after photos. For example, I have been guilty of shooting on table results [00:13:00] for, for patients, right? And we know that the on table result is not necessarily what you will see.

Later, and I do that for social media, you know, or I, you know, and we see, and other plastic surgeons do this all the time. You see it in the White Journal, our, our main research journal in plastic surgery, people who have facelifts or other, um, uh, work. And I can tell you like 10 plastic surgeons where the before they have no makeup, they look like crap, like they just woke up.

And then their after pic, like their hair is done, the lighting looks amazing, like they colored their hair. And they look fantastic. And, and we all know the plastic surgeons do that. So, I mean, honestly, I do it, but only because like a lot of my before pics for stuff like that is shot just before a procedure per se.

And so they don't have makeup and they are not. Sort of looking great. And then when they come in on their post ops, they're made up really nicely. And, and, you know, they look good. [00:14:00] And so either on purpose or inadvertently, I'm, I am creating deceptive before and after pictures just because of that.

Dr. Salvatore Pacella: Sam, do you. Do you use oil in your po? Do you use oil in your postoperative on table picks or just in your personal life? Um, in , in, in bodybuilding, or do you use both?

Dr. Sam Jejurikar: I can, uh, I can honestly say I've never, I've never used, I've never used oil in my post operative photos, but I may have used a spray bottle of alcohol to give it that shiny appearance. But you know, it's one of those things where it's the same thing where, you know, um, it's like an Instagram filter to make your lips, lips look like they have lipstick on them that women use.

It's like, it's

Dr. Salvatore Pacella: Notice he didn't answer the question Notice, he didn't answer the question.

Dr. Sam Jejurikar: feel like Dr. Tong, Dr. Tong wants to say something and he just can't interject his way in because we're talking so

Dr. Lawrence Tong: what I, what I was going to say is, um, for, for listeners and the viewers, um, [00:15:00] we've, we've talked about deception, but some of the things that are very common, um, I think should be mentioned. So lighting differences. So if a before has very dark lighting and then the after has, you know, very good lighting, that's going to show a better result.

The other is the angles. If the angles are not the same before and after, then they can be manipulated to look much better, um, to, to suit, uh, to suit the result. Um, other things such as, um, like Sam said, um, having, you know, makeup all done versus not makeup, um, being all done. All those things, um, can be, um, enhancing the appearance.

Uh, when somebody does a facelift. When you look at their before and after photos, the side view should have the hair behind the ear so you can see any potential scars in and around the preauricular, uh, region, areas in front of the ear, which is [00:16:00] commonly where an incision will be placed, and if that's covered, then, you know, I think that's in some ways, uh, deceptive, so, you know, um, consistency, of, of the photos and being able to show all the areas where scars might be, aside from more blatant things like filters and erasing things, are, are sort of softer types of deceptions that, uh, that can be used to make results better.

Dr. Sam Rhee: I think one of the things that are similar is on tummy tucks. Like when you hide that incision, uh, using underwear, which. I mean, I guess when you're doing Instagram, I think one of the biggest things which you mentioned is trying to cover, um, genitals and private parts and, and make it, um, you know, not, not safe for work.

Like you're, you're hiding some of the biggest issues that you would want to see in terms of a surgeon's handiwork. What does that [00:17:00] tummy tuck scar look like? And yet I constantly see all of these high waisted underwear afterpatients where you have no idea, like. What that scar looks like, and that's the sort of thing that is it wrong?

I'm not going to say it's wrong. Is it deceptive? I guess you could call it deceptive. We're all trying to show our best. I know we're all trying to put our best foot forward and we're all as surgeons trying to, To highlight what we do, but I think, and like most, most ethicists would say, there's a kind of a gray area here.

And if you see someone consistently sort of being deceptive or very deceptive or, or they show nothing but Uh, you know, things that clearly are not the same before and after, or they're showing certain, like, for example, I know a surgeon who all of the after pictures are basically the patient in real life, like they show video of them dancing around or something like that, but [00:18:00] they don't, you don't even see what they're, you know, they could be wearing a compression garment underneath.

You don't know what they really look like. All you see is this, um, really Slick social media posts, like before, you know, frumpy and, you know, not attractive. And then after they're like doing a pirouette, like in some ballroom or something. And you're like, wow, that's what I want to look like. Um, I mean, even something as simple as like sucking your gut in before and after a picture, like those all make huge differences.

Like you could, If you just ask the patient, take a deep breath in and hold it when I shoot this picture, I mean, how much of a difference are you going to see on a before and after for liposuction? Like tremendous. So these are all kinds of things that, I mean, like I said, it's a gray area. I feel like I've been on one side of it and I can't say I'm blameless, but on the other hand, I also see a lot of people who are just consistently are over at least.

A personal line that I draw in terms of what deception [00:19:00] is in before and after surgeries. Pictures.

Dr. Sam Jejurikar: so then, so then my question then for all of you guys, and we'll maybe start with Dr. Pacella and kind of. What advice would you give patients? Because we've talked about all of the different ways that we can be deceptive, yet we know people look at pictures for and afters to at least make some initial decisions as to whom they should screen to be their surgeons.

So, if you're going to talk to a friend who's trying to find a, who's going to try to find a plastic surgeon, how would you tell them to interpret photos that they're seeing? How would you have them incorporate those photos into their overall decision making process?

Dr. Salvatore Pacella: I mean, I think I would say, you know, you want to, you want to be a, um, a student of some photography, right? So, in looking at before and afters, I would suggest to patients, you know, they should be in the same position. Um, you look for things like makeup, you look like for things that cannot be hidden by shadows or light.

So, for example, [00:20:00] things like contour of the breasts, contour of the dorsum of the nose. Those are all things that cannot really be, um, say, adjusted with the lighting in the room necessarily, right? Um, I think you have to be careful if, uh, if results are exactly, um, perfect. in 100 percent of the photos. You have to look for things like scars.

You have to look for things like subtle contour deformities. Um, and then I would be very, um, I would be very suspect of standardized before photos in the exam room and then post operative photos sitting in a hot tub. You know, I mean, it's just, it's not that, it's not apples to oranges.

Dr. Sam Jejurikar: Dr. Tong,

Dr. Lawrence Tong: Yeah, I agree with those things. Like I said before, make sure the lighting is the same. One thing that is often used is the magnification of the photo for body procedures like if you're doing liposuction. You will see that the [00:21:00] after photo is cropped in a way that makes the entire body look slightly smaller.

So, you know, you, you want to try to look at landmarks and make sure they're the same size, like if, if you look at, um, maybe somebody's liposuction of, of the neck and it looks way better. Take a look at, uh, the side view, look at their ears, make sure they're the same size because if they're not, then maybe some manipulation has gone on.

Look at the, um, like, salages and the, the quality of the photo. If, if the photo afterwards looks like super Professional and really glossy and everything looks very smooth, then you know, you might suspect there's been a filter put on. And like I said before, make sure, you know, the hair, if it's a facial procedure, is out of the way.

Make sure the clothing is out of the way. That might be, um, um, blocking, uh, potential scars. So angle, lighting, size of the photo, and the potential for, you know, covering up of scars, I think are all important things, basic things to be [00:22:00] aware of.

Dr. Sam Jejurikar: Dr. Rhee,

Dr. Sam Rhee: I think you should take, I think I would tell patients, listen, you don't have to be an expert on detecting fakery because there's just too many ways surgeons can, can fool people. So I would say take All of the before and afters use them as a data point. Like, sure. Look at them. If there's something that doesn't sit right with you, like, wow, they all look perfect as Sal said, like, God, everyone looks like amazing.

Or if you're like, Oh, like, yeah, these kind of look hinky. The before and afters, like you can sort it. Like if you, if there's a gut feeling about something not really authentic or right about the before and afters, that can be a telltale sign, but. Even then, like, listen, I, I can be fooled, and I've been doing this for a long time, like, I would say, just take it as a grain of salt.

Don't ever, like, go with someone as a surgeon, just because their before and afters were awesome. [00:23:00] Like, use that as one piece of data, like, but look at everything else. How, you know, how is a surgeon communicating with you? You know, what are their reviews like? What is their office like? Have you, you know, have you talked to anyone else who's had work done by this surgeon?

It's totally, I think one of the best of things that patients have done, which surprised me that more patients don't, is like, can I talk to someone who's had work done by you? Like, that would be amazing. Like, I, I love when. Surgeon, you know, when patients do that, like I feel like there's way more information that you can get about a surgeon than just a before and after.

Like, yes, they can be helpful. Yes. It's really easy because you don't have to do anything. You can just click on your phone. You don't have to do any real investigative work or, or, or thinking just to do that. But that's probably, if you're only going to use before and afters, you're probably not, you're shorting yourself and you, you might get it.[00:24:00]

Dr. Sam Jejurikar: I think that's all great advice. I think Dr. Pacella and Tong have told us how to look for photos that look that are more real, but Dr. Rhee is totally right in the sense that photos are just one piece of the puzzle. The more you can find out about a surgeon, the more you can find out about their office, their interaction with other patients, the better off you're going to be.

Well, before we sign off, do any of you gentlemen have anything else to add? Anything that you think that we need to touch on, or do you think we're good to call it?

Dr. Sam Rhee: That was the best tip ever, is to like, put a nice glossy sheen with the alcohol on the post ops. If there's one thing I learned from this podcast

Dr. Sam Jejurikar: that's just the immediate post op. That's just the immediate post op. That's all.

Dr. Lawrence Tong: Ha ha ha ha ha ha.

Dr. Sam Jejurikar: all right. And I think Dr. Pacella just said something, but luckily his audio is lagging and I have no idea what it was. So, um, oh, he's

Dr. Salvatore Pacella: No, no, no, no, no. Yeah. [00:25:00] Sorry. My dog was barking, so I muted myself. Um, so do you know what the second rule of CrossFit is? No, no, no. Um, the second rule of CrossFit, always use oil while doing CrossFit.

Dr. Sam Jejurikar: Exactly. All right, gentlemen. It's a pleasure as always. Until next time.