Social Media, Facelift Surgery, and the Problem with Before and After Photos
I had a patient recently who joined Instagram solely to do background searching on facial surgery. Like her, I’m sure you will have encountered the familiar format of before and after dramatic transformations (with no make-up first image and heavy make-up for the second) and a surgeon’s handle in the caption. Before and after photos have become the cosmetic surgery marketing tool on social media, and they are shaping how patients evaluate surgeons and set expectations before they come to a consultation.
We see arrangements between cosmetic surgeons and social media influencers, in which free or discounted procedures are exchanged for promotional posts and mentions to the influencer’s following. Both trends raise serious ethical questions. The NZ Medical Council guidelines are very clear that doctors should not offer discounts or deals to patients offering reviews.
The Photography Problem
The most fundamental issue with before and after photos as they appear on social media is that they are almost never equivalent images. A genuine comparison requires identical conditions: the same camera, the same focal length, the same lighting, the same distance from the subject, the same angle, the same expression, and same level of make-up.
I see many posts where the before photograph is taken in flat, unflattering lighting that emphasises shadows under the eyes, accentuates jowling, and drains colour from the face. The after photograph is taken with flattering lighting, softer focus, and careful positioning usually taken from above the head looking down. The patient may be wearing makeup in the after photo and none in the before. The head tilt may differ by a few degrees — enough to entirely change the apparent definition of the jawline.
These are not subtle differences. They are differences that can make a moderate surgical result appear transformative, or make an ordinary before photograph look far worse than the patient’s everyday appearance. Patients comparing themselves to these images are not comparing like with like.
I was quoted on precisely this issue in the Sunday Star-Times in June 2019, in a piece by journalist Anuja Nadkarni titled “Drawing the Line”, which examined the ethical questions raised by deals between cosmetic surgeons and social media influencers. The article reported that I did not support the trend of plastic surgeons working with influencers to promote their practices by offering free procedures, and that I believed free procedures created an unhealthy relationship between the doctor and the patient, converting it to a doctor/client dynamic.
As I said at the time: “With social media, plastic surgeons need to be careful that people are correctly assessed for surgery to make sure what they are asking for is realistic and they are aware of the risks.”
That concern sits at the heart of why I do not use Instagram as a vehicle for surgical marketing. The issue is not social media itself — it is the way the platform incentivises a particular kind of relationship between surgeon and patient that is, in my view, incompatible with the standards of care this work demands.
The Influencer Deal Problem
As noted before the NZMC is very clear about arrangements between doctors and influencers. Despite this The Sunday Star-Times piece focused specifically on a practice that was becoming increasingly common in 2019 and has only grown since: surgeons offering free procedures to influencers in exchange for promotional content. The Australian Society of Plastic Surgeons chairman at the time, Dr Richard Theile, rebuked surgeons he saw as damaging the profession’s reputation by treating patients as commodities to be exploited.
My position then and now is straightforward: free procedures create an unhealthy relationship between the doctor and the patient, converting what should be a clinical relationship into a commercial one. When a patient receives a free procedure in exchange for promotion, the dynamic is distorted from the outset. The influencer has an incentive to present a positive outcome regardless of reality. The surgeon has an incentive to perform a procedure that photographs well rather than one that is genuinely appropriate for the patient. And the followers watching have no way of knowing that what they are seeing is a paid arrangement rather than an authentic patient experience.
There is also a patient safety dimension. A surgeon who is regularly approached by influencers looking for free procedures — as I am — must apply exactly the same assessment criteria as for any other patient. Body dysmorphic disorder affects a meaningful proportion of people who seek cosmetic surgery, and the pressures of presenting a certain appearance on social media are a known risk factor. Turning away patients who are not appropriate candidates is not a commercial decision — it is a clinical one. That judgement is much harder to make clearly when a commercial arrangement is already in place.
Selection Bias
Beyond the technical photography issues, there is a deeper problem: the photographs that appear on Instagram are not a representative sample of outcomes. They are the best outcomes — selected by the surgeon, with consent obtained from patients whose results are most compelling.
This is not dishonesty in the conventional sense. Every surgeon uses their best work talks at professional meetings. But it means the patient scrolling through a feed of exceptional results has no way of knowing what proportion of cases produced that outcome, what the full range of results looks like, or whether their own anatomy and history would place them in the same category as the cases shown.
Surgical outcomes are not uniform. They depend on the patient’s skin quality, underlying anatomy, healing biology, age, smoking history, and a dozen other factors that no photograph reveals. A result that looks extraordinary on one patient may be entirely unreachable for another, not because of any failure of technique, but because the starting points are different.
What Patients Should Look For Instead
If before and after photographs on Instagram are an unreliable guide to surgical quality, what should patients be looking for?
Verifiable credentials. FRACS in Plastic and Reconstructive Surgery is a matter of public record. The Royal Australasian College of Surgeons maintains a searchable register. This is checkable in a way that Instagram results are not.
Genuine before and afters in consultation. Reputable surgeons maintain a library of patient photographs that can be shown during a consultation — with appropriate consent — in the controlled setting of a clinical review. These images can be examined properly, questions can be asked, and the surgeon can explain the specific similarities and differences between those cases and your own situation.
Word of mouth and referrals. The most reliable signal of surgical quality remains the experience of patients who have been through the process. GP referrals, referrals from former patients, and recommendations from other healthcare professionals carry weight that no social media profile can match.
The consultation itself. How a surgeon listens, explains, and responds to your questions tells you more about the care you will receive than any photograph. A surgeon who takes time, gives honest assessments, and does not pressure you toward a decision is one worth trusting.
A Note on Patient Privacy
There is one further dimension to this issue that I consider important. Facial surgery is deeply personal. Patients come to me in a position of significant vulnerability — sharing concerns about their appearance, their ageing, and often aspects of their identity that they have rarely discussed with anyone. The trust involved in that relationship is something I take seriously.
Sharing a patient’s face — even with consent — on a public social media platform, where it can be screenshot, shared, commented upon, and circulated indefinitely, is a use of that trust that I am not comfortable with. Consent obtained in the context of a clinical relationship is not always freely given, and the permanence of content once it exists online is something patients cannot fully anticipate at the time of signing a form.
My practice is to share results in consultation, with patients who have given specific consent for clinical use, in a setting where that sharing serves a genuine educational purpose for another patient considering a similar procedure.
Social media is a powerful tool for reaching people who might benefit from surgery they are otherwise unaware of or uncertain about. Used responsibly — with educational content, honest information, and respect for patient privacy — it has a legitimate place in how surgeons communicate with the public.
But the before and after photograph arms race that has developed on Instagram is not that. It is marketing dressed as evidence, and patients deserve to understand the difference.
If you would like to discuss facial surgery and see examples of outcomes relevant to your situation in a proper clinical context, I invite you to book a consultation.