If you've ever removed red eye from a digital photo, you know how much fun imaging software can be. With practice - and the help of a program such as Photoshop - you can even take your ex-boyfriend right out of the picture! Which has to make one wonder - are before-and-after photos the real deal?

Toronto plastic surgeon Dr. Mitchell Brown explains that it's not difficult to manipulate pictures digitally. While conducting research on the variables affecting nipple symmetry, he said he took one photo of a breast. "Using my imaging software, I was able to come up with almost forty realistic variations of the same breast by changing the size, shape, colour and placement."

There are several ways to protect the integrity of an image - by embedding a digital watermark, storing the image with WORM (Write Once Read Many) software, or incorporating an icon attesting its authenticity. Even with these deterrents, it's easy to alter a photo. For this reason, Brown says such organizations as the American Society of Aesthetic Plastic Surgery expect their members to adhere to a code of ethics: in other words, they shouldn't alter before-and-after photos to make results look better than they really are.

Dr. Michael Kreidstein, another Toronto-area plastic surgeon, says that The College of Physicians & Surgeons of Ontario doesn't support the use of before-and-after photos in advertising. "Photos are so powerful, we respond without thinking," he says. "Ideally, an ad should carry the disclaimer: 'This is an example of the surgeon's work, but it is not necessarily representative.'"

Often, a problem with photos is the surgeon's failure to disclose all the procedures a patient has had. "A practitioner might be illustrating how well a particular cream works, but deliberately leave out the fact the patient has also had a facelift," says Kreidstein. "Marks, wrinkles and lines and blemishes can easily be removed by imaging software too."

Lighting can affect pictures, too. "In a before photo of acne, pockmarks can be accentuated by lighting the patient from above," he says. "Then, by changing the light source to the front in the after photo, results will look more impressive because the shadows are less defined."

Brown says that the angle from which a patient is photographed can also make a procedure appear to be more successful than it really is. "Photographing the body at a 45-degree angle provides the most flattering perspective, but not necessarily the most accurate one." To get a good idea of the surgery results, you should be looking at photos taken from more than one angle - so you can see all sides of the patient.

Clothing plays another major factor. "The way clothing is arranged can also give the illusion of a better result," adds Brown. "With an abdominoplasty or liposuction, undergarments should be in the same position, not pulled up or down to exaggerate the result."

Of course, what doctor wouldn't want to choose the most dramatic images to portray his work? According to Kreidstein, photo selection bias is more common than photo manipulation. "Seeing a few pictures of really good results can be comforting to patients, but they must consider whether or not they're only looking at the best results." Brown agrees. "It's only human nature to want to show your best work, but what I try and do is to show the typical results that I get nine times out of 10."

Both surgeons stress that patients shouldn't be too worried about altered photos. "I am convinced most of my colleagues are ethical," states Brown. "But it is a potential issue, and patients can educate themselves by knowing just what to look for."

What to look for in before-and-after photos:

1. Size. Both pictures should be taken from the same distance and cropped identically.
2. Angle. Pictures taken at a 45-degree angle may be more flattering.
3. Lighting. Shadows and "soft focus" lighting are common clues to deceptive photos.
4. Clothing. With body surgery, the patient should be wearing the same clothing, styled in the same way. Posture should be identical - slumping exaggerates any body problems.
5. Makeup. If a patient is wearing makeup in the after photo, they should be wearing makeup in the before picture, too.

Finally, ask to see many, many photos. The more you see, the better idea you'll have of average results, and what's too good to be true.