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It doesn't need to use all the keywords because Google does crawl the entire page.
In the example you created, you could use something like "Pictures before and after the surgery".
If there is more content than just the pictures, maybe even take the word "pictures" out of the title.
What kind of benefit in the SERP do you think that you can see by using Pictures before and after the surgery as the title tag instead of Pictures after the surgery?
You might pick up two different search queries, [Pictures before the surgery] and [Pictures after the surgery]/
Could the fact that many of the internal links contain related keywords in them