How to read a before and after photograph

The first question is when, not how it looks

A rhinoplasty result is not an event, it is a slow settling. Three dimensional photographic measurement puts most of the resolution in the first few months and the rest over a much longer tail, with the shape generally accepted as final at around twelve to eighteen months. The American Society of Plastic Surgeons says the same plainly: the final result takes a year or more to appear. So the honest label on a photograph is a date, and its absence is worth noticing. Four photographs of one patient can each be true and tell you four different things.

• At the end of the operation. The bone and cartilage are where the surgeon put them and nothing else has happened. Swelling follows surgery rather than precedes it.
• At one week. The splint comes off and the nose is near its most swollen. Almost nobody looks like their result here.
• At three months. Most swelling has gone and the shape is recognisable. The tip is still thicker than it will be.
• At a year or more. The photograph that answers the question people are actually asking, and the one least often published, because the patient has to come back for it.

Two photographs are only a comparison if they were taken the same way

The Institute of Medical Illustrators, the professional body for clinical photography in the United Kingdom, publishes a national guideline for rhinoplasty and septorhinoplasty photography. It exists because the useful comparison is a controlled one: a fixed set of standard views and a defined head position, so that the only thing differing between two frames is the nose. A photograph ignoring such a standard is not necessarily dishonest. It is simply not evidence of what it appears to be evidence of. Four variables do most of the damage, and all four are visible if you look.

• Distance and lens. A nose photographed close up looks larger and more projected than the same nose from further away. If the two frames are cropped differently, some of the change is the camera.
• Head position. Tilting the chin up shortens the nose and shows more nostril; tilting it down lengthens it and hides the tip. A few degrees is enough to change a profile.
• Lighting. A hump is a shadow before it is a shape. Move the light and a dorsum can gain or lose definition without anybody touching it.
• Expression and make up. Smiling pulls the tip down, and contouring does a softened version of the operation in minutes.

Two things no photograph can tell you

Whether the patient can breathe. The airway is inside the nose and the outside carries no reliable information about it. A nose can look better and work worse, and one operated on for a blockage can look almost unchanged and be a complete success. If breathing is your question, a gallery is the wrong instrument and what is measured instead is the page you want.

How often that outcome happens. A published pair is one patient, whose starting anatomy, skin thickness and reason for operating you know nothing about. It carries no denominator, so it cannot tell you whether it is typical, and a page of them still cannot.

What a pair of photographs is genuinely good for

All of that warns against reading them as proof, not against looking at them. Used properly they answer a real question, which is not "is this surgeon good" but "do I recognise what this surgeon is aiming at".

• Direction, not magnitude. A surgeon whose noses all end up small and turned up is telling you about their taste, whatever the swelling is doing.
• Starting points like yours. Thick skin and thin skin behave differently, and one case resembling your anatomy tells you more than a gallery of the opposite.
• Something to point at. Being told plainly why your nose will not do that beats any gallery.

Our own galleries sit on the doctors' pages, each carrying that caveat. Between those photographs and a settled nose is what recovery actually looks like.