Look At Me!

The rise and rise of the selfie phenomenon has turned aesthetics consumer behaviour on its head – at the same time as cosmetic medical and aesthetics professional are seeing an increase in clients and patients exhibiting body image issues.

The cult of dissecting other people’s appearance feature by feature (and one’s own) – whether it be celebs in the spotlight or on a day-to-day level on social media platforms – has been tabbed by some experts as contributing to the rise in the psychological condition known as Body Dysmoprhic Disorder. However, this is a subject of debate.

Either way, you as a salon, spa or clinic professional can play a pivotal role in helping clients/patients deal with these issues – and perhaps deter them from pursuing unnecessary or extreme solutions to perceived problems with their appearance.

It is a tragic consequence of BDD that it can drive people to destructive behaviours, thoughts of suicide, or to the act itself.

The condition is a preoccupation with an imagined defect in appearance, or excessive concern over a slight physical anomaly.

It is characterised by time-consuming behaviours such as mirror- gazing, comparing one’s appearance with the appearance of others, excessive camouflaging to hide the “defect”, skin picking and seeking reassurance.

Studies have suggested that patients with BDD pay more attention to facial appearance in others, and have a tendency to misinterpret the neutral facial expressions of others in a negative way.

Although there are many similarities between the BDD and Obsessive Compulsive Disorder (OCD) – which often co-exist – differences have been identified.

In his 2015 talk at Cosmetex  – How People See Themselves: How Media Drive the Aesthetic Patient World – Dr David Castle, Chair of Psychiatry at St Vincent’s Health and the University of Melbourne, discussed the relentless pursuit of a perfect body image.

With no gender, nationality or age group seemingly immune to media’s impact on perception of self, Dr Castle highlighted not only the growing number of cases of BDD but that, more than ever, the industry needed to be equipped to deal with them.

“How we make and manufacture beauty, how we talk about appearance is important,” he said. “The images we are subjected to daily have very likely been doctored through programs like Photoshop and this is increasingly intimidating for young people who, despite being technology-savvy, are in an ‘editing haze’.

“We thrive off a culture of celebrity worship and a yet there exists a counter-culture that picks on their very body faults. We have then, on the whole, culturally become uncomfortable with the age we have earned, the self, yet this continued connection of image and happiness persists.”

Dr Castle cited TV shows such as the erstwhile Extreme Makeover that distort our notion of inner and outer beauty, where appearance has the power to dictate personality traits and an assumed way of living. A powerful combination that could be headed right through your salon, spa or clinic door.

“Rates of body dissatisfaction are on the rise in both men and women,” he said. “We need to be careful and aware of the expectation of clients. And just as practitioners are equipped to say yes to client procedures, they also have the power to say no.”

It of course takes a specially qualified and experienced medico to formally diagnose and treat BDD, but aesthetics and wellbeing professionals who treat clients on a regular basis to enhance their appearance (and thus self-esteem) may be the first to recognise a client has a problem that is way more than skin deep.

As such professionals, who see clients at often their most vulnerable, you are in a unique position to recognise the difference between someone who is just very conscious of maintaining their appearance and a person unhealthily obsessed with it in negative, even delusional ways. Ergo, is vulnerable to desperate measures to cure or camouflage their perceived problem(s).

Unfortunately these measures rarely satisfy a BDD sufferer and, indeed, may make things worse.

Speaking on behalf of the Cosmetic Physicians College of Australasia (CPCA), leading Brisbane cosmetic practitioner Dr Mary Dingley says: “The Australian cosmetic industry is growing at an unprecedented rate. At the same time, social media plays a growing role in our lives and how we interact with others.

“Forms of bullying online, such as body shaming, negatively impact one’s view of one’s own face and body and in some cases can lead to an individual experiencing low self-esteem, which is directly related to body dysmorphic tendencies.

“While social media may not cause body dysmorphic disorder directly, it can be an environmental trigger in those genetically predisposed to the disorder (i.e. those with a relative who suffers with BDD or OCD) or patients who have had a previous diagnosis of depression or anxiety).

“Seeing a doctor who is aware of dysmorphism, rather than a technician who is paid according to how many people they can see in a day, means that more care is taken over whether the treatment is really in the patient’s best interest.

“The facial features that tend to be of most concern to people who want to look better in photos generally depends on their age bracket.

“The CPCA’s annual survey consistently shows that it is the visible effects of ageing that is of most concern to people. More people now worry about looking ‘old’ (54 percent) and over 80 percent of those surveyed believe it is acceptable to use such treatments to address premature ageing – a 10 percent increase over the last three years.

“The younger generation may like their lips and cheeks enhanced for social media selfies but it is important to realise that this is not suitable for everyone and enhancements should only be undertaken if this improves facial proportions rather than distorting facial features.

“In terms of Australian men, recent research has revealed more than one third are worried about looking old, with the top ageing concerns thinning hair and wrinkles.

“The CPCA believes that patients of any age should have a medical assessment before any procedure and it should be assessed whether they are psychologically suitable for treatment.

“If a cosmetic physician suspects that a patient is suffering from body dysmorphia they can then refer them to a psychiatrist or psychologist for specialist assessment.

“This may minimise, but does not remove, the risk of the patient doctor shopping. It is a difficult and delicate situation and relies upon excellent communication and development of rapport with the patient.

“It also relies upon the medical profession following high ethical standards and being educated as to the signs and symptoms of BDD.

“According to the Medical Board of Australia’s Good Medical Practice: A Code of Conduct for Doctors in Australia, an important part of the doctor-patient relationship is effective communication, regardless of a patient’s perceived vulnerability, and includes:

  • Listening to patients, asking for and respecting their views about their health, and responding to their concerns and preferences.
  • Encouraging patients to tell you about their condition and how they are currently managing it, including any alternative or complementary therapies they are using.
  • Informing patients of the nature of, and need for, all aspects of their clinical management, including examination and investigations, and giving them adequate opportunity to question or refuse intervention and treatment.
  • Discussing with patients their condition and the available management options, including their potential benefit and harm.
  • Endeavouring to confirm that your patient understands what you have said.
  • Ensuring that patients are informed of the material risks associated with any part of the proposed management plan.”

Sydney liposculpture surgeon Dr Meaghan Heckenberg, a spokesperson for the Australasian College of Cosmetic Surgeons (ACCS), says the influence of social media has created much higher patient expectations.

“We have become much bigger consumers [of aesthetics] than when I was young.

“When I went to my school formal back in the early 80s, I put a bit of mascara and eyeliner on and a bit of lip gloss and that was it!

“Nowadays makeup artists and hairstylists are employed and the strive for perfection is much greater.

“I just watched a one-minute video on Instagram featuring Victoria Beckham. Six people were credited at the end of it and there were 18 takes edited to blend together, to look like it was a continuous story.

“She looked perfect in every three-second take. It looked effortless – but I know it is not. Look at how many people were required to make Victoria Beckham look perfect for a 60 second video!

“When I do neck liposculpture consultations, the common mantra from patients is how much they hate their necks in photographs.

“Everyone is a photographer these days so there are more and more photographs of ourselves.

“We even pose differently in photographs to get the best image of ourselves and we are more conscious of our negative features. Before we used to just smile at the camera. Nowadays the pose has to be perfected to get the best looking image of ourselves.

“The Kardashian phenomenon has influenced us in this respect for sure.”

Dr Heckenberg says necks and profiles are the features her patients are most concerned about in the context of selfies. Then, achieving a more even-toned complexion, re-establishing cheek definition and fullness [with dermal fillers], and reducing creases between the eyebrows and around the eyes.

“The smile also plays an important role in the selfie and the advances in cosmetic dentistry mean whiter, straighter teeth are highly accessible these days,” she says.

“It’s a fantastic era and these treatments have contributed to increased self-esteem.”

Among the strangest requests Dr Heckenberg has had from a patient was from a 20-year-old who presented for inner thigh liposculpture.

“She showed me a picture of a pole dancer with the `thigh gap’ she desired. It always concerns me when people bring pictures of other people or celebrities they want to look like. It’s a lot of pressure on a practitioner.

“However, I discussed her expectations and we discussed that the photograph may have been digitally altered. We all know photographs are digitally altered or enhanced in the glossy magazines and often Instagram.

“She understood. Anyway, I was able to deliver what she wanted. In fact, her expectations were exceeded. Phew!!!”

SPA+CLINIC asked Dr Heckenberg what she does when a patient consults her for procedures and she sees they are body dysmorphic, or have significant issues.

“Difficult question. The nurse in our practice and I discuss this problem often,” she says. “We don’t want to do work on people that makes them a caricature of themselves, which is what happens if you accentuate a particular body part so it becomes disproportionate to the rest.

“Think about how newspaper artists draw politicians … their worst features are always exaggerated to make them look hideous. Then we laugh about them.

“We don’t want people to laugh about our patients. We want others to think how fabulous they look!

“No cosmetic practitioner wants that sort of patient to be their walking advertising billboard and be representative of his/her work. That’s embarrassing and a surety that you won’t be referred work.

“I am hopeful and confident that most cosmetic practitioners in Australia are ethical and want the best for their patients.

“How to stop patients who suffer a psychological problem from going to someone else who may give them what they think they need may be extremely difficult indeed. Hopefully the red flag signs are identified early on.

“The obvious cases are easy to identify. However, I have done liposculpture on a few patients who suffer depression and I did not identify that at the time.

“Unfortunately, there are some people who will never be happy, no matter what you do and even if the cosmetic results are very good. This is something that is harder to identify and is often a problem that is identified in retrospect, unfortunately.”

My suggestions to other practitioners:-
Be honest with people with a gentle touch. A smiling face, good sense of humour always lightens the atmosphere. Eye contact is important because people feel they can trust you if you establish eye contact. A gentle touch on the shoulder is another form of doctor / patient connection and establishment of trust. Then most patients will be honest and feel comfortable with you. It’s all about trust so patients don’t feel like they are being judged. Normalise their reactions. We all have insecurities as we are all only human. Absolutely nobody is perfect irrespective of what we are visually fed with social media or any type of media for that matter.


The way you communicate with clients/patients who have body image issues is all-important – what you DON’T say as much as you DO.

Well-intentioned but carelessly expressed advice or opinions can make a client even more self-conscious about their appearance – perhaps to even fixate on new “problems” – escalating anxiety and depression.

So it is important for staff of salons, spas and clinics – from the front line at the front desk and apprentices to the most senior of therapists, managers and owners – to learn how to artfully and discreetly suggest what products and treatments might help a client, while similarly dissuading them from things they might want, but actually don’t need.

This, all the while being careful not to crush their already delicate self-esteem, or feed irrational fears or delusional insecurities.

The focus of a therapist needs to be on helping clients to understand how to update or improve their “look”, downplay any weaknesses with correcting skills and highlight their best features. But all done in a way that boosts their self-esteem, not crush it. Language is key.

According to Julie Hyne, salon image/etiquette expert, business coach and founder of Business4Beauty, if a therapist senses a client has “issues” that are beyond the expertise of their business, they should consider referring the client on to someone who can help.

“This situation calls for the salon, spa or clinic owner to have an extended network of people she or he can refer clients to,” says Julie. “It’s a customer service element to be able to know when you are out of your depth and to provide a personal referral to another professional without expecting anything in return except a well and happy client. “If it is done in a confidential way and with the utmost integrity and sincerity, so that the client feels she or he or is being `heard’. “Acknowledging that you have listened and `heard’ and suggesting that another professional’s view would be worth investigating is a very valuable service you are providing.”

Leading Sydney cosmetic physician Dr Naomi McCullum says that when a patient comes to her obsessing about certain aspects of their appearance, wanting her to “fix” it, but actually can’t see their “issue”, “I am always very straight up, but at the same time, gentle with them.

“I always try to make them aware that I am on their side. With patients who don’t have BDD but just focus on the wrong things too much, I will try to give them a more realistic perspective about their appearance. Sometimes that is all it takes to stop them worrying about it.

“However, if I think that the patient needs to see a psychiatrist/ psychologist, I will discuss this with them.

“In my practice, it is all about knowing whether our clinic can make patients happy. With BDD patients it is unlikely that they will be satisfied.

“From our first point of contact – i.e. from when my staff answer the first enquiry via email or phone – we are actually interviewing the person to see whether we are willing to accept them as a patient.

“I always take the long term view in business. There is nothing in it for us to take on patients who are not going to be happy; it is just a headache.

The short term dollars that can be made out of treating patients who won’t be happy I would consider as wasting time, compared with spending our time giving our quality service to, and developing relationships with clients who will be satisfied.

“To gain long term trust, and to maintain an excellent reputation, a practitioner always needs to do what is in the best interest of the patient.”

Dr McCullum agrees that the “bedside manner” is all-important in the consultation and treatment processes, whether you are dermal therapist or doctor.

“I get upset when I hear about cosmetic practitioners selling their services through fear or humiliation,” she says.

“There are practitioners in the industry who are well known for this. It is just unnecessary and cruel. Beauty achievers love cosmetic treatments, and they are going to want the services anyway, without this behaviour.

“I have a patient who is 29, gorgeous and sensitive. She went to a surgeon recently for a consultation. When she had undressed his opening comment was `Well, clearly you’ve had a baby’.

“She was devastated and said that she thought to herself `What is wrong with me – do I need breast work, tummy work, vagina work ..?’

“Cosmetic doctors have to take it really seriously, this position we have. We need to be very aware of the impact that our words can have.”


Selfies have been around as long as photography itself. But the practice — and the buzzword — only became mainstream after recent improvements in smartphone camera design and the rising popularity of image hosting sites such as Instagram, Snapchat and What’sApp.

Today, over a million selfies are taken each day, with the average person taking three per day. It’s no wonder consumers are increasingly looking for products that can deliver flawless, luminous, photo-ready skin and makeup — a trend that beauty and personal care companies should take a closer look at.

Brands are releasing products with cameras in mind, and the term “HD [high definition] makeup” spiked in 2015, according to Google Trends. How can we define the category?

“Selfie beauty … is the whole preoccupation of consumers about their image, about their needs and how they’re perceived in the outer world and specifically in social media,” says Irina Barbalova, global head of beauty and personal care research for Euromonitor, a leading global independent provider of strategic market research. “It’s not just about anti-ageing now and wrinkles, but skin perfection.”

This research confirms the experience of Laurie McFee, an account manager for beauty and personal care at Hallstar (that creates ester chemistry solutions for beauty and personal care sectors): “BB/CC/EE creams and light foundation coverages are growing in popularity in Western countries, which follows this trend of having flawless skin.

“Having dewy skin to achieve the perfect selfie, without looking like you’re wearing the excessive makeup of traditional powder foundations, is still trending. We’re seeing several applications that can deliver this effect, such as primers, CC creams, bronzers, setting sprays, contour makeup, highlighters and concealers.”

While many beauty and personal care trends are seasonal or shortlived, selfie beauty products may have more longevity because they’re tied to a longer-term trend toward personalisation and a more natural lifestyle and look.

The days of heavy foundation and smoky eyes are being replaced with a more natural but glowing look that highlights individual beauty. This barefaced look aligns with increasing consumer demand for lighter, more natural products and lends itself to photographic lighting and the spontaneous look of the selfie — even when those moments are highly staged.

“High-definition makeup and illuminating lotion-like formulas are easy to apply and veil imperfections, eliminating the need for thick, matte finish makeup,” says makeup artist and stylist Michelle Simpson. “These products reflect light and create a soft, healthy glow … we need to celebrate [clients’] natural features and this is a movement toward that.”