It has become increasingly evident over the past several years that the popularity of social media and online culture has found people scrutinizing their image in different and more deliberate ways than the previous generation did. The birth of the “selfie,” in addition to the liberal use of photographic filters to enhance and even change a person’s image on screen or in photographs, highlights the significance of this phenomenon.
Just as the coronavirus disease of 2019 pandemic has altered and continues to alter nearly every aspect of our daily lives, one major adjustment is the rapid rise in use of video conferencing (e.g., Zoom; Zoom Video Communications, San Jose, Calif.) for communication. While video calls have existed for some time, the inability to work together in an office or socialize in communal settings has cemented the video conference or virtual hangout in American life for the foreseeable future. Not to mention, the time spent on social media has invariably increased since quarantine and social restrictions were set in place in the United States.
We have learned from the rising popularity of social media and the “selfie era” that the plastic surgery patient consultation is changing. Plastic surgeons have seen a steady increase in interest in invasive and noninvasive facial enhancement, especially among younger patients. Oftentimes these images are displaying unrealistic expectations due to adjustments from a filter or even a facial enhancement application such as FaceTune (Lightricks, Jerusalem, Israel). A number of studies have investigated the popularity of the selfie view and the psychosocial impact of selfie taking. Many studies have correlated higher body dissatisfaction, lower self-esteem, and decreased life satisfaction with frequent selfie viewing. For example, McLean et al.1 found that regular selfie taking among teenage women was associated with higher body dissatisfaction and overvaluation of body shape.
More recently, numerous articles and blog posts have been published online regarding “how to look good on Zoom.” While the in-person interaction typically involves being seen from head-to-toe, the aesthetic focus has shifted attention heavily to facial images on video calls. In lockstep with this pattern, anecdotally, we have seen an increase in the number of patients coming to our aesthetic offices specifically to address facial aesthetic concerns. Patients working primarily at home via video conference calls have admitted to noticing more distinctly the facial features they find least appealing and that they have become increasingly self-conscious of these particular “problem areas.”
Video conference calls include a panel of varying size displaying what the computer or telephone camera sees, which is, in most cases, when sitting at a desk, the person’s face, up close and personal. As meetings or calls can last anywhere from minutes to hours, this inevitably creates a mirror effect as participants stare at themselves for an extended period of time.
The act of “mirror gazing” has been shown to be directly linked to selective self-focused attention, which is a preoccupation with thoughts, feelings, images, or appraisals about one’s own physical appearance.2 This self-focused attention tends to be negative and causes selective fixation on specific attributes of features considered to be minor flaws, magnifying their intensity. Also of relevance is the angle at which the video conference image is being captured. Eggerstedt et al.3 analyzed selfie photographs posted on individuals’ social media among three cohorts: female influencers, amateur females, and amateur males. These investigators found a tendency for these groups to capture selfies from an angle higher than eye level with an angle of rotation off midline. Though anecdotal, comparing this to the video conference angle of below eye level and midline, we think this “unfavorable” angle of capture is also contributing to increased perceived flaws.
In a recent study by Barnier and Collison,4 patients were subject to 5 minutes of mirror gazing at short-range (4-inch) or long-range (39-inch) distances. Patients engaging in short-range mirror gazing experienced significant negative effects, including body shaming, increased distress with appearance—specifically with disliked parts, as well as lower self-esteem. Further, this effect is exacerbated in patients with body dysmorphic disorder and may contribute to its development.
It is well known in plastic surgery that the cosmetic patient has a significantly higher likelihood of being diagnosed with body dysmorphic disorder, with a prevalence of 15 percent in this population.5 Therefore, in this current pandemic, in which we are experiencing the rise of video conferencing, video calls, and virtual hangouts, there is potential risk that a larger number of patients who present to an aesthetic plastic surgery clinic may be suffering from body dysmorphic disorder, or are experiencing similar effects due to the selective self-focused attention caused by Zoom mirror gazing.
Here are some considerations to help us navigate this unique, drastic change in the landscape of social and work interaction, where video conferencing has become a necessary norm:
- Inquiry regarding the patient’s occupation and the use of video conferencing to communicate should be performed during the initial evaluation. Patients engaging in high-volume video conferencing require further analysis as to its effect on their perceived cosmetic deformity.
- Surgeons and office staff should key into potential signs and symptoms of body dysmorphic disorder, especially the patient’s body image both on and off camera.
- Patients should be counseled as to the effects of mirror gazing behavior, which can be exacerbated by video conferencing. Concordant expectations between surgeon and patient should include a discussion of how the patient’s result may be represented on a video conference screen.
As Constantian6 presciently wrote in an editorial in the Journal in 2013, “Cosmetic diagnoses are always in context.” Quarantine away from the workplace seems to be providing patients with ample time for recovery from aesthetic surgical procedures, both operative and nonoperative. Also, frequent use of video conferencing and virtual hangouts may further increase interest in facial aesthetic procedures. Nevertheless, several aspects of Zoom mirror gazing may highlight dissatisfaction with perceived flaws in appearance. Thus, we must consider this new context of quarantine, lack of in-person social interaction, and the rise of Zoom culture to affect how we evaluate and ultimately care for our cosmetic surgery patients.
Dr. Rohrich receives instrument royalties from Eriem Surgical, Inc., and book royalties from Thieme Medical Publishing, is a clinical and research study expert for Allergan, Inc., Galderma, and MTF Biologics and a medical monitor for Merz North America, and owns Medical Seminars of Texas, LLC. No funding was received for this article. The other authors have no financial interest to declare in relation to the content of this work.
1. McLean SA, Paxton SJ, Wertheim EH, Masters J. Photoshopping the selfie: Self photo editing and photo investment are associated with body dissatisfaction in adolescent girls. Int J Eat Disord. 2015;48:1132–1140.
2. Ingram RE. Self-focused attention in clinical disorders: Review and a conceptual model. Psychol Bull. 1990;107:156–176.
3. Eggerstedt M, Schumacher J, Urban MJ, Smith RM, Revenaugh PC. The selfie view: Perioperative photography in the digital age. Aesthetic Plast Surg. 2020;44:1066–1070.
4. Barnier EM, Collison J. Experimental induction of self-focused attention via mirror gazing: Effects on body image, appraisals, body-focused shame, and self-esteem. Body Image. 2019;30:150–158.
5. Ribeiro RVE. Prevalence of body dysmorphic disorder in plastic surgery and dermatology patients: A systematic review with meta-analysis. Aesthetic Plast Surg. 2017;41:964–970.
6. Constantian MB. The new criteria for body dysmorphic disorder: Who makes the diagnosis? Plast Reconstr Surg. 2013;132:1759–1762.
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