“Smizing”: COVID-19 Is Giving Us Crow’s Feet

The COVID-19 pandemic has caused substantial morbidity and mortality on a global scale. A commonly accepted preventive measure includes wearing face masks while in public or while interacting with others. Consequently, many local and state regulations have mandated the use of facial coverings to protect others and ourselves from COVID-19. In our attempts to return to some form of normalcy in the workplace and in public, we may find that wearing a mask interferes with our ability to portray emotions. Interestingly, a recent study examining perceived facial attractiveness demonstrated that the attractiveness of “average” and “unattractive” faces increased when wearing a mask.¹ Conversely, smile intensity has been associated with attractiveness and trustworthiness.² Because facial coverings impair our ability to convey emotional cues with our mouths, we find ourselves relying on periocular expression. This so-called smiling with your eyes, or smizing, is also known as a Duchenne smile. It was first described by Duchenne de Boulogne, a 19th century neurologist and father of electrotherapy, whose namesake lives on most notably due to his work with myopathies.³ His classic description depicts a photograph of an elderly man with a toothless grin and pronounced crow’s feet.

Lateral canthal rhytides (LCRs), also known as crow’s feet, are deep to fine lines that extend laterally from the lateral canthi and can add to the aging facial appearance. Sun exposure, smoking, genetics, aging, and overactivity of the orbicularis oculi muscle, as may be seen with exaggerated periocular smiling, all play a role in the formation of lateral canthal rhytides. A number of treatment modalities are available for those concerned with keeping a more youthful appearance. Skin peels, laser resurfacing, microneedling, radiofrequency ablation, botulinum injection, and blepharoplasty are among some of the interventions available to plastic surgeons.⁴ In addition, preventative measures (including skin moisturizer, retinol, and sunscreen creams) can be used. Today, there is an interest in minimally invasive management of facial rhytides and an ever-increasing awareness of prevention, as our aging population attempts to preserve a youthful appearance.

There remain many unknowns in this rapidly evolving global crisis, including a clear timeline of resolution or dissemination of an effective vaccine. However, social distancing and mask-wearing are likely to be a part of our lives for at least the near future, and potentially for years to come. The widespread nature and lengthy timeline of the pandemic paired with our desire to express facial emotions may exacerbate the development of lateral canthal rhytides on a global scale. In fact, some surgeons have already noted an increase in upper facial cosmetic procedures.⁵ Whether this leads to an extensive increase in those seeking cosmetic procedures remains to be seen. LCR exacerbation and the desire to improve upon them may be a secondary effect of widespread mask use. Studies examining trends in facial cosmetic surgery over the next few years would be beneficial. Yet, amidst the loss and severe disruption of life for so many, display of positive emotion is needed more than ever, and development of facial wrinkles may be of little or no concern.