key: cord-0018689-q3foskd9 authors: Daar, David A.; Chiodo, Michael V.; Rohrich, Rod J. title: The Zoom View: How Does Video Conferencing Affect What Our Patients See in Themselves, and How Can We Do Right by Them? date: 2021-06-09 journal: Plast Reconstr Surg DOI: 10.1097/prs.0000000000008031 sha: 25018a8516b13524cbb827dc28326b6939049d30 doc_id: 18689 cord_uid: q3foskd9 nan I t 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 selfesteem, 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 selffocused 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 AQ6 and work interaction, where video conferencing has become a necessary norm: Inq uiry 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 Constantian 6 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. The Aphorisms and Refrains of Plastic Surgery I n plastic surgery, we learn the history of developments and innovators in conjunction with fundamental techniques, but we rarely document the personality and culture of this specialty. Through refrains exclaimed in the operating room or muttered in the clinic, the language of plastic surgery is a part of what defines us, and it is as much a part of our history as innovations and techniques. Standing tall in our surgical pantheon is Dr. Robert Goldwyn, a surgeon who guided the course of plastic surgery as a scientist but also critically examined its identity and underlying motivations with his sweeping editorials. Looking to his legacy as a guide, we attempt to capture pieces of the personality of plastic surgery, and to explain their origins. First, we encounter a phrase out of the Elizabethan era. In attempting to embellish what is already good, like the excellent breast reconstruction that could benefit from minimal fat grafting, we are "gilding the lily" as we chase perfection. This Shakespearean phrase from King John (1623) decries the King's coronation as unnecessary as if, "To gild refined gold, to paint the lily" (4. 2.11-15 ). This was misquoted as "gild the lily" in the 1895 Newark Daily Advocate's scathing critique of modern hat fashion and gradually entered the lexicon we now utilize in surgical practice. 1 The phrase "belt and suspenders" has not fallen prey to misquote. First printed in the 1930 The Marin Herald, it was a summary of a traveling preacher's appeal to avoid pessimism like those men who wore both "a belt and suspenders." 2 We've taken this to describe unnecessary redundancy in the operating room or in the evaluation of a patient. While dissecting through a capsule, suddenly a band is released and the surgical field opens up. You've struck a "blow for freedom!" In 1637, John Milton, a staunch Protestant, retreated from England to the liberal philosophical circles of Italy. Meanwhile, Charles I married a Catholic princess and attempted to forcibly convert his Protestant subjects to Catholicism, ultimately fomenting a civil war. From afar, Milton decided that he could no longer stand aside, writing in 1638 that he must support his countrymen as they "Struck a blow for freedom." 3 Variably attributed to Confucius, Shakespeare, and Voltaire, "the enemy of good is perfect" has often been used as a caution against causing mishap through surgical overrevision. Most closely, our modern phrase resembles the eighteenth century philosophical musings of Voltaire's "Le mieux est l'ennemi du bien," which he in turn attributes to an unknown Italian sage. 4 Plastic and reconstructive surgery is a field of great innovation and rich history. It is important to learn the history and the icons of the field as well as the techniques that allow us to practice. Implicitly, we absorb this culture, language, and personality, but rarely are these documented. There will be new language and standard aphorisms as the field continues to develop, but at this moment, here is a piece of our history captured. American Society of Plastic Surgeons Plastic Surgery Workforce Task Force. Assessing the plastic surgery workforce: A template for the future of plastic surgery National Resident Matching Program, results and data: 2008-2020 main residency match reports How competitive is plastic surgery? An analysis of the Canadian and American residency match So you want to become a plastic surgeon? What you need to do and know to get into a plastic surgery residency Applicant and program trends, predictors of a successful match, and future directions Photoshopping the selfie: Self photo editing and photo investment are associated with body dissatisfaction in adolescent girls Self-focused attention in clinical disorders: Review and a conceptual model The selfie view: Perioperative photography in the digital age Experimental induction of selffocused attention via mirror gazing: Effects on body image, appraisals, body-focused shame, and self-esteem Prevalence of body dysmorphic disorder in plastic surgery and dermatology patients: A systematic review with meta-analysis The new criteria for body dysmorphic disorder: Who makes the diagnosis? The Little Book of Cliches Ezra Van Nuya is speaker at Rotary meeting. The Marin Herald Paradise Lost. London: Blackie and Son, Limited The authors have no financial interest to declare in relation to the content of this article. None of the authors has received funding for the research in this article. The authors have no financial interest to declare in relation to the content of this article.