People asks for cosmetic surgery because conference video displays, inter alia, one’s emotions in real-time, which may cause a person to notice expression lines and wrinkles which they do not see in the mirror

Zooming into Cosmetic Procedures During the COVID-19 Pandemic: The Provider’s Perspective. Shauna M. Rice et al. International Journal of Women's Dermatology, January 12 2021. https://doi.org/10.1016/j.ijwd.2021.01.012

Abstract: The COVID-19 pandemic has seen a massive shift towards virtual living, with video-conferencing now a primary means of communication for both work and social events. Individuals are finding themselves staring at their own video reflection often for hours a day, scrutinizing a distorted image on screen and developing a negative self-perception. This survey study of over 100 board-certified dermatologists across the country elucidates a new problem of “Zoom Dysmorphia” where patients are seeking cosmetic procedures in order to improve their distorted appearance on video-conferencing calls.

Discussion:

Despite the COVID-19 pandemic limiting in-person office visits and stalling many elective procedures, dermatology cosmetic consults are on the rise relative to pre-pandemic times. With people now spending record amounts of time on virtual platforms seeing their virtual image, they are becoming more critical of their features and inquiring about cosmetic improvements. In this survey study of over 100 board certified dermatologists from across the country, over 50% indicated a relative rise in cosmetic consultations within their practices despite the state of the pandemic (Figure 1). Even more notable is that 86% of respondents report their patients are referencing video-conferencing as a reason for their new cosmetic concerns (Figure 2). Other studies have noted similar results, with one recent survey of the general public showing that of those who previously did not have an interest in facial cosmetic treatments, 40% now plan to pursue treatments based on concerns from their video-conferencing appearance alone (Cristel et al, 2020).

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According to surveyed dermatologists, neuromodulating agents such as Botox and Dysport, filler injections, and laser treatments were noted as the most frequently requested cosmetic procedures reaching their offices. In a time where more invasive aesthetic surgical procedures are restricted for concern of unnecessary virus spread, higher interest in minimally invasive procedures is expected. Patients appear to be the most concerned with regions from the neck up, most notably the forehead/glabella, eyes, neck, and hair. Specific concerns include upper face wrinkles, circles/bags under the eyes, dark spots, and neck sagging (Figure 3). Concerns below the neck were much less frequently reported, with body contouring and cellulite treatments noted to be on the rise by less than 10% of surveyed dermatologists. Interestingly, an analysis of Google search trends during the COVID-19 pandemic showed an increase in search terms such as “acne” and “hair loss” (Kutlu, 2020). Authors of that analysis attributed the search trend to the association of acne and hair loss with anxiety and depression, psychological conditions weighing heavily on many quarantined individuals. Numerous other factors may also play a role, such as mask-occlusion causing acne mechanica as well as the association of telogen effluvium with COVID-19 infection (add citation). Our results show the trend may also be due to the fact that people are now becoming more aware of their appearance, scrutinizing their features from the neck up as they see their video reflection daily.

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Of concern to providers is that patients are requesting more procedures as a result of increased video-conferencing, which has been shown in the literature to reflect a distorted facial appearance. This is causing concern for aspects of appearance that may not truly require correction or to the extent that the patient fears. Of even greater concern is the mental health aspect that is uncovered in this study, that 82.7% of surveyed providers report their patients feeling more displeased with their appearance now than ever before (Figure 4). The psychological response to the COVID-19 pandemic has been understandably negative, but why are patients so unhappy particularly with their appearance on Zoom? Studies have shown that those with higher levels of engagement on social media have higher levels of body dissatisfaction and depression (Shome et al., 2020, Woods and Scott, 2016). For example, one study showed that when instructed to upload photos to social media, most participants noted a decrease in self-confidence and an increase in desire to undergo cosmetic surgery (Shome et al,2020). Although Zoom may not be considered social media, it does necessitate that people expose themselves in a virtual manner for which many are unaccustomed. Zoom adds an additional level of complexity by displaying one’s emotions in real-time, leading us to watch ourselves speak and react to others, which may cause a person to notice expression lines and wrinkles which they are not used to seeing while looking in the mirror. Additionally, one’s reflection is displayed side by side to other members of the call, allowing for easy comparison and self-judgment.

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The distorting effects of webcams could also contribute to the observed trend in cosmetic consults, as patients remain unaware of how cameras can distort and degrade video quality and inaccurately represent one’s true appearance. For instance, camera angle and focal distance make a difference in the image that appears on screen. A 2018 study found that a portrait taken from 12 inches away increases perceived nose size by about 30% when compared to an image taken at 5 feet (Ward et al, 2018). With webcams often recording at shorter focal lengths, the result is an overall more rounded face, wider set eyes, broader nose, taller forehead and disappearing ears obscured by cheeks (Trebicky et al, 2016). Moreover, video calls condense life into a 2D image, leading a graded shadow along a curved surface such as the nose to appear as a flat, darkened area instead (Lu and Bartlett, 2016). This illusion may exacerbate the appearance of facial dark spots and bring unnecessary concern to users.

Combining these elements with the current trends in cosmetic consults, it is apparent that Zoom, although a useful and necessary tool for maintaining productivity during quarantine, has introduced individuals to an unfamiliar virtual environment. This increased self-exposure and distorted image on screen may be causing patients to develop thoughts of BDD, with a tendency to be preoccupied with a real or imagined physical defects and causing functional impairment. These patients often seek cosmetic procedures to improve their perceived appearance, yet are rarely satisfied with the results, ending up in a cycle of self-dissatisfaction. Approximately 9-14% of patients in general dermatology clinics have a diagnosis of BDD, and within the cosmetic surgery setting, the prevalence is thought to be even higher (Vashi, 2016). With anxiety disorders on the rise due to factors related to the pandemic, BDD is an important consideration in patient evaluations. Elucidating the limitations of webcams and examining the trends of this new virtual world, we can better serve our patients by screening for such dysmorphic thoughts and connecting patients with appropriate counseling. Prior to the pandemic, patients presented to their aesthetic physicians hoping to look more like their filtered Snapchat selfies; we have now entered an era in which people are forced to confront a distorted and often unflattering rendition of themselves for hours a day on Zoom, distorted reflection, promoting the phenomenon of “Zoom Dysmorphia.”