The Strange, Sensitive World of Plastic Surgery Photography

Months later, the woman came back. She'd forgotten to wear the same underwear, but that was OK: Berg was more confident this time. She directed the woman's turns using colored squares she'd affixed to the wall. The woman stood with her feet just shy of a foot apart again. The fat was gone, so were the dimples. Berg uploaded the photos to her computer and used Photoshop to change the color of the woman's underwear to match the earlier photographs. She printed the picture, taped it beside the one she'd taken a month earlier, and slipped it in to a manila folder with the woman's name on it. Berg is an artist, and taking photos of people in their underwear to document their plastic surgery has been her day job for the past six years.

Dr. Sherman was impressed Berg had worked for Annie Leibowitz. Berg thought the job was intriguing and didn't mind the prospect of photographing people pre- and post-op.

"I'm super comfortable with nudity and people, I like working with people," Berg says. "I was applying to a billion jobs, but I remember thinking, 'Wow, this is different.'"

Berg is one of a few medical photographers who focus exclusively on plastic surgery. She is also one of the only in-house plastic surgery photographers in New York. Most plastic surgeons take their own before-and-after photographs or have a nurse do it; of the roughly 40 plastic surgeons informally surveyed for this article, 37 have staff take patients' photographs. The remaining send them to Don Allen studios in midtown.

"I thought it was fun, it was interesting, it was different," Pearson says. "A lot of it is [about] your personality, and this fits me really well. I've gotten a lot of compliments on how I handle people."

Indeed, interacting with patients can be one of the trickier parts of being a medical photographer. Berg admits to feeling unsure of herself at first.

"It's a little awkward because you're asking someone who's generally kind of nervous to take their clothes off and get exposed to this really bright flash," Berg says. "I had anxiety about it in the beginning. It's always a little funny to ask people to take their clothes off. It's a language I had to learn, like what's the least offensive way to ask someone."

To learn how to act around patients, Berg paid attention to what made her feel comfortable at the doctor's office--"a friendly confidence"--and tried to mimic that. She realized that giving people specific instructions--like where to put their clothes or purse--helps them feel at ease.

But some level of discomfort or embarrassment is unavoidable. People often make self-deprecating remarks or apologize to Berg that she "has to see this." Some are annoyed and want to leave the room. Other patients comment on Berg's own face or body, asking if she's had work done. Berg says this job has changed the way she looks at herself.

"I'm grateful to have had this job create a lot more self-confidence," Berg says. "It's been inspiring to see patients' relationships to their bodies. I do have body issues, but I appreciate my body more than I ever have. It's made me realize anything I do want to change about my body is insignificant."

Berg, who considers herself a feminist, is aware of the sometimes-superficial light in which her job may be cast. The patients she photographs who need their surgeries, the cancer patients or crime victims, that assuage her guilt.

"I've had trouble occasionally reconciling that I play a tiny role in helping women achieve something that it isn't fair they feel persuaded by society to do to themselves," Berg says. "But we do so much reconstructive work for crime victims and cancer patients I feel my job is much more important. Me trying to advance a feminist agenda by not photographing the portion of our patients who are strictly interested in cosmetic 'beautification' would be a pretty ineffective statement in the larger scheme. There are far more important ways to try to shape society in a better direction for women. I feel capable of [those] on just a personal level."

At Don Allen Studios, Pearson's perspective on patient interaction is more clinical, though he also recognizes the need for a light-touch.

"You just be sensitive," he says. "We've been doing this a long time. The thing that we tend to do is we're very quick, very efficient in our movements. We'll photograph a fair amount of women who've either had a mastectomy or are having a reconstruction, or they'll come to us before the mastectomy. Sometimes they'll tell us. We tend to be really careful how we treat them because you don't know what's going on with them. It's just a lot of experience."

"If you do somebody and they say afterwards, 'Well, now I'm lopsided,' you can take out the photographs and prove [they] always were lopsided," says Pearson. "I think that might be one of the larger reasons we exist--for legal purposes."

Berg also notes that occasionally a patient will present signs of body-dysmorphic disorder. In cases like this, all the office can do is refer them to a psychiatrist, but Berg's photographs become essential in proving that the distortion is in the patient's mind, and not Dr. Sherman's work. Before-and-after photos also serve as learning tools, allowing doctors to chronicle complicated procedures or explain their processes to students and colleagues. Berg's and Pearson's photos may appear in medical textbooks, research papers, and presentations.

The most common use of plastic surgery photos today, however, is for PR. All doctors have a portfolio, a binder of before-and-after photos they show new patients considering a procedure. Doctors also use the photographs on their websites and in print ads.

When Don Allen studios first began, in the pre-internet era, they rather successfully cornered the market. They produced slides for doctors to use during lectures and printed images for textbooks. They took photographs in operating rooms during surgery. They provided a level of experience and confidentiality it was hard to find elsewhere. Allen went to great lengths to ensure photographs were taken, developed, and printed on site. He installed a dark room and invested in industrial printers. Photographs were delivered using a uniformed courier service or by studio staff themselves.

For almost 40 years, the studio coasted on its production of high-quality, standardized photographs. But with the rise of digital photography in the 80s, business slowed. Doctors could now easily take and print photographs themselves without leaving the office.

"Technology has taken away a lot of things," says Pearson. "We used to produce a tremendous amount of slides for presentations, but now fifth graders can put together a PowerPoint. We used to go in the ORs and photograph procedures, but now that's automated."

Another problem is the patients, whether at Don Allen or Dr. Sherman's office, have to pay for the photographs themselves.

"We used to send [patients] to Don Allen. They charged $600-$700 for medical photographs, and that included post-op views," says Dr. Sherman. "[After I hired Berg,] nobody ever went back to midtown for post-op photos, [since my office is uptown]."

"To me it's a no brainer," Dr. Sherman says. "I don't understand why everybody doesn't do this."

Standardization and consistency are two of the more important features of medical photography, and plastic surgery photography is no different. Both Pearson and Dr. Sherman recognize there's a learning curve and it takes a while to become good.

"One of the problems the doctor's offices have when they do it themselves is whoever is taking the pictures may leave and someone else comes in," Pearson says. "Now there's a new learning curve, and your consistency goes up and down."

Berg has experienced this herself.

"It was difficult to figure out how to master the craft," she says. "I was comfortable with the equipment but learning how to take really precise, consistent angles on the subjects was new for me."

Eventually, Berg did learn, and after a few weeks she was producing the high-quality, standardized work Dr. Sherman was looking for. She uses IntelliStudio, a camera mount specifically designed for plastic surgery photography and specialized editing software. Dr. Sherman describes Berg has being part of his office, as integral as an anesthesiologist or nurse.

"I think it's a beautiful and revealing moment," Berg says, in reference to post-op photographs. "It's probably the least self-conscious nude photograph that you can get."

Berg isn't the only artist who recognizes the stark, haunting nature of before-and-after pictures. New York-based photographer Ji Yeo shot a series titled "Recovery Room Beauty" in 2008 that chronicles women in South Korea recovering from plastic surgery. From 2008-2010, the New York-based, British photographer Phillip Toledano shot a series called "A New Kind of Beauty," showing people who've had "extreme' plastic surgery.

"We tend to have a generic reaction, or people do often, when they see the pictures I've taken," Toledano says. "Like, 'Oh, this is horrifying.' I think that that's unfair and, frankly, not very smart. I understand the reason why people do that, but I think it's interesting to look at the journey these people have gone on."

Toledano recounts working with plastic surgery subjects as being both educational and thought-provoking. The psychology of body image, and the way plastic surgery can affect it, is powerful. The glimpses Berg has gotten of patients' mindsets both pre- and post-op--and the effects their relationships to their bodies have had throughout their lives--have been so intense that the experience has inspired her to consider a third career in mental health or social work.

"I end up acting as a therapist of sorts with the patients," Berg says. "I think a lot about the big and small ways in which we can, as a society, and as individuals, help people feel more comfortable and more safe in their own skin."

For artists like Toledano and Berg, plastic surgery photography provides a window into a strange, intriguing, and often beautifully sad world, where self image is malleable. For the general public, the photos are jarringly magnetic; for internet browsers, they are a possibility of what can be; for patients, they are a chronicle of change; and for doctors, they are a guide, a record, and, sometimes, a trophy.

For the photographers themselves, they are business. For Berg, a photographer who straddles the creative and the medical, they are a magnifying glass.

"Sometimes I'm surprised by what I see," she says. "It is funny to have to photograph a person, to treat a subject as this clinical thing while you're having a conversation with the person. It's funny to shift back and forth, from medical photographer to just a person who's talking to another human."