The value of “before and after” photos in orthognathic surgery.

Patients seeking orthognathic surgery seek both functional and cosmetic goals. Some are primarily motivated by functional objectives but in my 20 years of doing orthognathic surgery, the vast majority of are motivated by the expected cosmetic outcomes. This is not surprising given that malocclusion has never been proven to be detrimental to physical health. Chewing may be less efficient, speaking may be hampered by poor enunciation of certain words due the to the physical deformities, but these are usually compensated by the patient’s adaptation to them over time as these dentofacial deformities developed over time and not overnight. As such, most patients who come for consultations usually ask to see some before and after photos of cases that I did before. How important are such photos?

The fact that most patients ask to see such photos shows that it is fairly important. These photos serve as proof of experience. They give reassurance to the patient that the surgeon has done similar cases before. This is a very crude measurement of the ability of the surgeon but an important first cut for a patient to filter out his or her list of potential surgeons to choose from.

Before and after photos also provide an inkling to the aesthetic sense of the surgeon. While there are objective and measureable results that can be assessed for functional success, cosmetic objectives are subjective. Sometimes, a surgery judged by the surgeon as aesthetically successful may not be deemed as such by the patient. This is because differences in aesthetic sense do vary significantly among individuals. I usually liken this to choosing an architect or interior designer. There are countless variations in design and they are all aesthetic, as least to some people. The choice of an architect or designer hinges on whether there is a meeting of the minds of both the professional and the house owner.

While there are similarities in the process of how people choose their architect and surgeon, there are also lots of differences. Surgeons, unlike architects, never have the opportunity to start off on a clean slate. Unlike houses that can be demolished and rebuilt, a human face cannot. Some facial features cannot be changed without excessive risk to the function of attached organs such as the eyes. Surgical results are also dynamic. Bone and soft tissues do not remain the way they are over time. From the time the surgery finishes, subtle changes to the face will continue and will be superimposed by the changes that come with aging.

While cosmetic jaw surgery is an art, it is also governed by strict scientific principles. So long as the surgeon is able to elicit sufficient information from the patient and understand the needs and desires, it is possible to come up with a surgical plan to develop the results that the patient is looking for. Ultimately, it is still more science than art.

In Singapore, the use of “before and after” photos in publicity material is prohibited by the Ministry Of Health. That is why there are no websites in Singapore of Singapore registered healthcare providers showing such photos. The rationale is that such photos encourage consumption of medically unnecessarily procedures, thereby driving up healthcare cost. The other concern is the authenticity and/or reproducibility of such surgeries. If exceptional results are displayed, potential patients may be misled into thinking that those are typical results. Personally, I do not agree with this but this rule has been introduced for a few years now and it seems like it will be here to stay.

Fortunately, before and after photos can be shown to patients privately during a consultation. Once a patient-doctor relationship is already established, the use of such photos for patient education is allowed. The downside of this is that potential patients have no way of assessing a surgeon’s work before paying for a consultation. Some may end up choosing a surgeon who has not done or does not do the kind of procedure that the patient needs and will need to be referred to someone else. This applies not just to orthognathic surgery but to many other types of surgery as well.

If I were seeking cosmetic surgery myself, one of the things that I would ask of the surgeon is some before and after photos of similar cases. It would save a lot of time and money if that information is freely available on their clinic website. Although there are many other factors to consider in choosing a surgeon, “before and after” photos rank as one of the most important to me.