INTRODUCTION: The rising prevalence of obesity and demand for minimally invasive treatments has led to increased adoption of endoscopic sleeve gastroplasty (ESG). As telemedicine expands in bariatrics, understanding the role of virtual follow-up care is crucial. This study aims to use propensity-matching to compare weight loss and metabolic outcomes between virtual and in-person follow-up modalities post-ESG. METHODS: Data from patients with obesity who underwent ESG at a single tertiary care center between August 2013 and November 2024 were prospectively collected and retrospectively analyzed. Eligible patients were those with a body mass index (BMI) of 30 kg/m² or greater (or > 27 kg/m² with comorbidities). All procedures were performed by a single therapeutic endoscopist using a full-thickness technique. Patients were categorized into virtual or in-person follow-up groups based on whether over 70% of their post-procedure visits were conducted virtually or in-person, respectively. To account for potential baseline differences, propensity score matching was employed. The primary outcomes assessed were the impact of follow-up method on percent total body weight loss (%TBWL) and changes in metabolic parameters at 12 and 36 months post-ESG. RESULTS: Data from 113 patients (mean age, 43.9 years; 80.5% female, BMI 36.0 kg/m²), were analyzed, and stratified by follow-up modality (in-person: n = 54, virtual: n = 59). After propensity matching, baseline differences were eliminated and both groups demonstrated improvements in ALT, HbA1c, LDL, TG, SBP, and mean %TBWL exceeding ten at all time points, with no statistically significant differences between groups at 12 or 36 months. DISCUSSION: Telemedicine is expected to remain in the management of obesity due to its convenience. This study found no significant differences in weight loss or metabolic changes between propensity-matched groups, demonstrating comparable effectiveness of virtual and in-person follow-up. Future research should refine telemedicine strategies and assess their long-term impact on weight maintenance.