key: cord-0867965-l3922dx1 authors: Gülbitti, Haydar Aslan; Waziri, Sohrab; van der Lei, Berend title: From Some-tox to More-tox during the COVID-19 Pandemic date: 2021-09-07 journal: Plast Reconstr Surg DOI: 10.1097/prs.0000000000008366 sha: d115a35a7cd4ac6b2883d572b0027a7719ecc746 doc_id: 867965 cord_uid: l3922dx1 nan S ince the coronavirus disease of 2019 pandemic, in our clinic, there is an increasing number of patients (especially businesswomen) seeking help for rejuvenation of the periorbital area, despite recurrent lockdowns and closing of the (aesthetic) clinics. As has been demonstrated by several studies in the past, "beauty is around the eyes of the beheld": the periorbital area is one of the foremost areas we look at when gazing at a person. [1] [2] [3] An aesthetically pleasing face is characterized by a relatively low eyebrow position, a high lid-cheek junction, and smooth skin around the eyes. Aging results in drooping of the upper eyelids, crow feet's, deepened frown lines. and a lower lid-cheek junction. Different studies have shown the (negative) effects of periorbital aging on the perception of emotions. 1, 4 In particular, a low eyebrow position in combination with a low lid-cheek junction is associated with negative emotions such as fatigue. All these aforementioned emotions have become even more prominent because of mouth mask wearing since the start of the COVID-19 pandemic. Now, during the COVID-19 pandemic, the periorbital area has probably become an even more important area we look at: the observer and the beholder now mostly only see the periorbital area because often the perioral area is covered by a mouth mask. So now (during the COVID-19 pandemic), the perception of beauty of an individual is thus mainly focused and determined by this anatomical area and might explain the increased demand for periorbital rejuvenation treatments (botulinum toxin, fillers, eyelid surgery, eyebrow lifts) as experienced in our and in many other clinics. Except for many negative effects and an initial drop in the number of aesthetic procedures, the COVID-19 pandemic has had also a positive effect on our aesthetic practice: patients are now more aware of their periorbital appearance. invites and ranking applicants have not significantly changed with COVID-19. Four of the top five important factors for extending interview invites in our survey results were identical to that of the 2018 National Residency Matching program director survey results, except for a higher emphasis on grades in required clerkships compared to Alpha Omega Alpha Honor Medical Society membership (Fig. 1 ). 3 Similarly, the top five factors for ranking interviewees as reported by program directors in our study were unchanged from the 2018 survey. 3 Overall, program directors and applicants were in concordance on several aspects of changes in the application process, including an understanding that students without home programs would have difficulty obtaining clinical experience and letters of recommendation from plastic and reconstructive surgery physicians. However, applicants expected a greater shift in the match process compared to program directors, who anticipated a relatively unchanged application cycle or weighting system compared to previous years. Although students expected increased interview invitations and home student selections as a response to reduced away rotations, program directors did not share the same sentiment. Direct messaging and transparency on the part of programs is imperative in dispelling other differences in perception between programs and applicants. Now equipped with data, we believe we must consider our role in this alarming trend. Medical ethics can be divided into four pillars: patient autonomy (the patient's right to medical care decisions), beneficence (actions that promote the patient's well-being), nonmaleficence (do no harm), and justice (balancing the interests of the patient and physician). 5 Viewing these pillars in a plastic surgeon-to-patient context, it is clear how challenges can arise. First, we believe that posting patient identifying information does not act in the beneficence of the patient. Surgeons risk little whereas patients risk having their likeness publicly available in perpetuity. Regarding nonmaleficence, few surgeons can be up to date with evolving social media terms and policies, resulting in challenging, and often inadequate, informed consent and assurance that posts will not cause harm. Finally, patient information was always meant to be protected from the public-a mutual expectation among all of our medical and surgical colleagues. When plastic surgeons post patient identifying information on their social media accounts, they risk causing harm to their patients, themselves, and our specialty. As such, we would like to present three key recommendations: 1. All patient images posted on social media should be censored for anonymity, including identifiable facial features, tattoos, and other unique cutaneous landmarks. images can be saved, downloaded, and manipulated even after the post has been deleted. 3. We strongly encourage internal governance to prevent inadvertent harming of patients, surgeons, and our field. Finally, we would like to ask that this conversation not end here, but rather be the start of a dialogue to spark future change. Our hope is for a reevaluation of the American Society of Plastic Surgeons Code of Ethics, which does not currently address the posting of patient identifying information on a member's social media accounts. A strong effort toward protection of patient information will benefit our patients and uphold the professionalism of our storied specialty. S ocial media have had incredible growth throughout our country in just the past decade. In fact, in the past 5 years, the industry has boasted an unprecedented 25 percent year-over-year growth, which is only projected to continue. 1 This growth has undeniably impacted medicine, and more specifically our field of plastic surgery. A 2018 study showed that over 60 percent of all plastic surgeons had active professional social media accounts. 2 Although social media can provide patients with educational content, many within our field have outlined concerns with its unprofessional use. Unfortunately, violation of patient rights, Health Insurance Portability and Accountability Act compliance, inappropriate operating room behavior, and incomplete consent have all been reported. 3, 4 In a recent Plastic and Reconstructive Surgery publication analyzing plastic surgery social media content, Mullens et al. highlighted a troublesome statistic: 13 percent of all Instagram posts containing the hashtag "#PlasticSurgery" displayed patient identifying information. These identifying posts were also far more popular, with 20 percent of them achieving a status of "trending" because of high user engagement. 4 Association of American Medical Colleges. Important guidance for medical students on clinical rotations during the coronavirus (COVID-19) outbreak Away rotations and matching in integrated plastic surgery residency: Applicant and program director perspectives Results of the 2018 NRMP program director survey The orbital oval balance principle: A morphometric clinical analysis Eye fixations when viewing faces Eyes as the center of focus in the visual examination of human faces The influence of forehead, brow, and periorbital aesthetics on perceived expression in the youthful face The authors have no financial interest to declare in relation to the content of this article. The authors have no financial interest to declare in relation to the content of this article. No funding was received for this work.