The straight truth: measuring observer attention to the crooked nose

Anatomical variants of acne differ in their impact on social perception

BACKGROUND

Acne negatively affects quality of life, however quality-of-life scores poorly correlate with disease severity scores. Previous research demonstrated existence of facial areas in which skin lesions have greater impact on gaze patterns. Therefore, we hypothesized that anatomical variants of acne may be perceived differently.

OBJECTIVES

The aim was to investigate effect of anatomical variants of acne on natural gaze patterns and resulting impact on social perception of acne patients.

METHODS

We tracked eye movements of participants viewing neutral and emotional faces with acne. Images were rated for acne-related visual disturbance, and emotional faces were rated for valence intensity. Respondents of an online survey were asked to rate their perception of pictured individuals' personality traits.

RESULTS

All faces with acne were perceived as less attractive and received poorer personality judgements with mid-facial acne presenting smallest deviation from healthy faces. T-zone and mixed acne exhibited the least significant difference in respondents gaze behaviour pattern from each other. In addition, there was no significant difference in respondents' grading of acne visual disturbance or ratings for attractiveness, success and trustworthiness. U-zone adult female acne was rated as the most visually disturbing and received the lowest scores for attractiveness. Happy faces with adult female acne were rated as less happy compared to other acne variants and clear-skin faces.

CONCLUSIONS

Anatomic variants of acne have a distinct impact on gaze patterns and social perception. Adult female acne has the strongest negative effect on recognition of positive emotions in affected individuals, attractiveness ratings and forming social impressions. If perioral acne lesions are absent, frontal lesions determine impact of acne on social perception irrespective of the presence of mid-facial lesions. This perceptive hierarchy should be taken into consideration while deciding treatment goals in acne patients, prioritizing achieving remission in perioral and frontal area.

Evaluation of Facial Asymmetry in Patients with Crooked Nose

BACKGROUND

This study aims to explore the correlation between facial asymmetry and a crooked nose using objective methodologies.

METHODS

The cohort of 57 patients who underwent septorhinoplasty surgery for aesthetic reasons between 2019 and 2022. Patients were categorized based on the type of nasal axis deviation. The analysis involved reviewing patients' photographs and cone beam computed tomography images. We identified various anatomical landmarks and compared measurements across the groups.

RESULTS

Among the study population, 21 (36.8%) exhibited Type-I (linear) and 15 (26.3%) demonstrated Type-C nasal axis deviation, while no deviation was detected in 21 (36.8%) patients. Upon evaluating the upper face area, significant differences were found in the glabella-lateral orbit (G-LO) and rhinion-lateral orbit (Rh-LO) parameters (p = 0.002 and p < 0.001, respectively). A statistically significant difference was discovered in all three parameters between the three groups in the middle face area [glabella-zygion (G-Zy) p = 0.04, rhinion-zygion (Rh-Zy) P < 0.001, anterior nasal spine-zygion (ANS-Zy) p < 0.001)]. Further, a statistically significant difference was noted in the soft tissue parameters gonion (Go) and LO (p = 0.008 and P = 0.005, respectively).

CONCLUSION

Patients with crooked noses, in particular, exhibit asymmetries in the upper and middle faces. The glabella in the upper face and the anterior nasal spine in the middle face are stable points, and the fact that the parameters derived from these two reference points are significant, when considered in conjunction with other significant parameters, strongly supports the aforementioned statement.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Determining Asymmetry Thresholds in Anophthalmia/Microphthalmia Using a Three-dimensional Animated Model

PURPOSE

Congenital microphthalmia and anophthalmia are rare development disorders with underdevelopment of the orbital region, resulting in asymmetry of the face. No clear guidelines exist to determine when these deviations are acceptable.

METHODS

The face of a healthy 6-year-old child was three-dimensionally scanned. On this scan, we modeled various incremental degrees of facial asymmetries using three-dimensional modeling software. We modeled for smaller palpebral fissures, sunken eyes, and downward displacement of the eye. We also tested whether adjusting the vertical palpebral fissure height in relation to the horizontal palpebral fissure width affected perception. A total of 22 videos were created in which the model turned the head horizontally and vertically. We created a questionnaire asking raters how acceptable the face is, on a linear scale from 0 to 10.

RESULTS

Results showed a correlation between the degree of asymmetry and the acceptability score of the raters. Enophthalmos of ≥6 mm, palpebral fissure width ≤79% compared with the other eye, and 2 mm or more downward displacement of the eye resulted in a significant different acceptability score. The desire for correction was strongly increased when these thresholds were exceeded. Adjusting the vertical palpebral fissure height to the horizontal palpebral fissure width resulted in a worse acceptability score.

CONCLUSION

A unilateral sunken eye (enophthalmos) of 6 mm or more, asymmetric horizontal palpebral fissure length of ≤79%, and a lower position of one eye of more than 2 mm resulted in unacceptable judgment. These data can be used to evaluate treatment outcome in children treated for congenital microphthalmia and anophthalmia.

Neck scar perception after neck dissection in HPV-associated oropharyngeal squamous cell carcinoma

IMPORTANCE

While there has been an increased understanding of the impact of visible neck scars in some patients with certain diseases, this has not yet been explored in the HPV+ OPSCC population.

OBJECTIVE

To understand patients' perception of their scar and the impact on their quality of life (QOL) at least 6 months after neck dissection (ND) for HPV+ oropharyngeal squamous cell carcinoma (OPSCC).

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective case-control study, patients who underwent primary transoral robotic surgery (TORS) and ND for HPV+ OPSCC between 2016 and 2021 at a single tertiary care center were identified. Data analysis was performed in January 2022.

MAIN OUTCOMES AND MEASURES

Dermatology Life Quality Index was modified (mDLQI) to assess patients' perceptions of their scars. The primary outcome was the mean mDLQI survey score with higher scores corresponding to worse perceptions. Three questions adapted from the Self-Consciousness Scale (SCS) were also included to assess awareness of appearance. All questions were scaled on a 0-3 Likert Scale. Tweedie generalized linear model was used to understand the relationship between mDLQI score and patient- and procedure-specific factors (including the three SCS survey questions). An additional exploratory logistic regression was performed to understand the risk factors for clinically significant mDLQI score change.

RESULTS

A total of 67 patients (response rate 57 %) completed the survey with a mean mDLQI survey score of 0.84 (max 30). Although there was a statistically significant negative association between private insurance and mDLQI survey score (95 % Confidence Interval [CI]: -2.72 - -0.38), and a positive association between the SCS score and mDLQI survey score (95 % CI: 0.23-0.81) (p < 0.05), these variables were not found to be risk factors for a clinically significant difference in mDLQI on multivariable analysis.

CONCLUSION

The majority of patients felt their neck scars did not interfere with their daily lives. Patient perceptions of neck scars were consistent despite differing patient characteristics and treatment regimens.

Perception of aesthetic features after surgical treatment of craniofacial malformations by observers of the same age: An eye-tracking study

The aim of this study is to evaluate where exactly children and adolescents of the same group look when they interact with each other, and attempt to record and analyse the data recorded by eye-tracking technology.

MATERIALS AND METHODS

60 subjects participated in the study, evenly divided into three age categories of 20 each in pre-school/primary school age (5-9 years), early adolescence (10-14 years) and late adolescence/transition to adulthood (15-19 years). Age groups were matched and categorized to be used both for creating the picture series and testing. Photographs of patients with both unilateral and bilateral cleft lip and palate were used to create the series of images which consisted of a total of 15 photos, 5 of which were photos of patients with surgically treated cleft deformity and 10 control photos with healthy faces, that were presented in random order. Using the eye-tracking module, the data on "area of first view" (area of initial attention), "area with longest view" (area of sustained attention), "time until view in this area" (time of initial attention) and "frequency of view in each area" (time of sustained attention) were calculated.

RESULTS

Across all groups, there was no significant difference for the individual regions for the parameters of initial attention (area of first view), while the time until first fixation of one of the AOIs (time until view in this area) was significant for all facial regions. A predictable path of the facial scan is abandoned when secondary facial deformities are present and attention is focused more on the region of an existing deformity, which are the nose and mouth regions.

CONCLUSIONS

There are significant differences in both male and female participants' viewing of faces with and without secondary cleft deformity. While in the age group of the younger test persons it was still the mouth region that received special attention from the male viewers, this shifted in the male test persons of the middle age group to the nose region, which was fixed significantly more often and faster. In the female participants, the mouth and nose regions were each looked at for twice as long compared to the healthy faces, making both the mouth and the nose region are in the focus of observation.

Impact of Surgical Rejuvenation on Visual Processing and Character Attribution of Faces

Background

This study considers observers' reflexive responses to the rejuvenated face, and how instinctive responses relate to subjective judgment. We investigated observers' reflexive perception of faces both pre and post surgical intervention during the early stages of visual processing. Subjective character attribution for all test images was also assessed by the same observers.

Method

Forty frontal facial images of 20 patients portraying the pre- and postoperative high superficial musculoaponeurotic system facelift along with variable concomitant procedures were studied. Nineteen lookzone regions were mapped post hoc onto each image. Forty observers examined the images, whereas an eye-tracking camera recorded their eye movements. Visual fixation data were recorded and analyzed. Observers also rated each image on the basis of five elemental positive character attributes.

Results

A statistically coherent but nonsignificant (P > 0.05) trend was identified with the surgical intervention resulting in greater attention being paid to the central triangle region of the face with reduction in attention to the facial periphery. Facial rejuvenation significantly increased the subjective character ratings of all five positively valenced attributes tested. Average age estimate of the photos decreased significantly from 54 to 48.6 years (true average age of 57.4 years).

Conclusions

We provide data illustrating both reflexive and subjective responses to facial rejuvenation. Observers reported a more favorable impression of the treated faces and evaluated them as being younger than their true age. A trend was detected for increased visual fixation of the central facial region following rejuvenation. Interpretation of these findings and indication for further research is provided.

Look me in the eyes! A pre-registered eye-tracking study investigating visual attention and affective reactions to faces with a visible difference

This research aims to determine how disfigurement alters visual attention paid to faces and to examine whether such a potential modified pattern of visual attention to faces with visible difference was associated, in turn, with perceiver's stigmatizing affective reactions. A pilot study (N = 38) and a pre-registered experimental eye-tracking study (N = 89) were conducted. First, the visual explorations of faces with and without disfigurement were compared. The association of these visual explorations with affective reactions were investigated next. Findings suggest that disfigurement impacts visual attention toward faces; attention is not merely attracted to the disfigured area but it is also diverted particularly from the eye area. Disfigurement also eases disgust-related, surprise-related, anxiety-related, and, to a lesser extent, hostility-related affective states. Exploratory interaction effects between attention to the eyes and to the disfigured part of the face revealed a hybrid effect on disgust-related affect and an increase in surprise-related affect when participants fixated more upon the disfigured area and fixated less upon the eyes. Thus, perceiver's attention is captured by disfigurement and also diverted from face internal features which seems to play a role in the affective reactions elicited.

Normal Gaze Patterns of the Face in Lateral View

Importance: Current efforts to quantify the attentional distraction of facial deformities have been limited to deformities that are best perceived when the face is in frontal view, and there remains a paucity of knowledge of societal perception of the face in lateral view. To date, no attempts have been made to characterize the fixation patterns of the face in lateral view. Objective: To characterize the fixation patterns and gaze patterns of the face in lateral view. Design, Setting, and Participants: This was a prospective randomized controlled trial at an academic tertiary medical center. Eighty participants (mean age 23.6 ± 1.7 years, 52.5% female) gazed freely at 11 images of faces in lateral view for 10 s each as an infrared eye-tracker recorded eye movements in real time. Main Outcomes and Measures: Recorded eye movements are superimposed on the images to visualize areas of interest (AOIs) that attract the most attention. Fixation duration targeted at each AOI is transformed into relative fixation of the entire face and neck. Hotelling's test of variance followed by post hoc t-testing assessed for the significance of fixation differences between the mouth and cheeks. Results: Participants spent an average of 6.0 (95% CI 5.8-6.2) s gazing at the face and neck areas of each image. Of this attention, 2.8 s or 49.8% (45.4-54.2%) was directed toward the eye, followed distantly by the nose (mean, 95% CI) (16.4%, 14.5-18.3%), cheek (12.0%, 11.4-14.5%), neck (4.6%, 3.8-5.4%), and mouth (4.0%, 3.4-4.6%). These differences were found to be significant by Hotelling's analysis and post hoc testing. A student's t-test also indicated observers directed significantly more attention within the eye-nose-cheek triangle [4.6 s or 79.5% (75.6-83.5)] compared with the eye-nose-mouth triangle [4.1 s or 71.2% (66.9-75.5)] (p < 0.001). Conclusions and Relevance: When perceiving novel faces in lateral view, casual observers preferentially directed attention toward the eye, nose, and cheek. These findings suggest that we draw from a slightly different collection of features to build a schema of the sagittal face, which may serve to complement the central triangle and build upon a three-dimensional model of the "normal" human face. Level of Evidence: NA.

Eye-Tracking Technology in Plastic and Reconstructive Surgery: A Systematic Review

BACKGROUND

The use of eye-tracking technology in plastic surgery has gained popularity over the past decade due to its ability to assess observers' visual preferences in an objective manner.

OBJECTIVES

The goal of this study was to provide a comprehensive review of eye-tracking studies in plastic and reconstructive surgery, which can aid in the design and conduct of high-quality eye-tracking studies.

METHODS

Through application of Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines, a comprehensive search of articles published on eye-tracking across several databases was conducted from January 1946 to January 2019. Inclusion criteria included studies evaluating the use of eye-tracking technology in the field of plastic and reconstructive surgery. The resulting publications were screened by 2 independent reviewers.

RESULTS

A total of 595 articles were identified, 23 of which met our inclusion criteria. The most common application of eye-tracking was to assess individuals with cleft lip/palate (9 studies). All 19 studies that evaluated fixation patterns among conditions vs controls reported significant differences between the 2 groups. Five out of 7 studies assessing visual data between preoperative and postoperative patients identified significant differences between the preoperative and postoperative groups, whereas 2 studies did not. Nine studies examined the relation between severity indices, attractiveness scores, or personality ratings and gaze patterns. Correlation was found in 7 out of the 9 studies.

CONCLUSIONS

This systematic review demonstrates the utility of eye-tracking technology as a quantifiable objective assessment and emerging research tool for evaluating outcomes in several domains of plastic and reconstructive surgery.

Dermal Fat Grafting to Reconstruct the Parotidectomy Defect Normalizes Facial Attention

OBJECTIVES/HYPOTHESIS

Use validated eye-tracking technology to objectively measure 1) the attentional distraction of facial contour defects after superficial and total parotidectomy and 2) changes in attentional distraction with abdominal dermal fat graft reconstruction.

METHODS

Standardized frontal and oblique facial images of 16 patients who had undergone superficial or total parotidectomy with or without fat graft reconstruction; four normal controls were obtained. One hundred casual observers were recruited to view these images, and gaze data were collected using a Tobii Pro eye-tracking system. Gaze durations for predefined facial areas of interest were analyzed using mixed-effects linear regression to test study hypotheses.

RESULTS

For frontal images, total parotidectomy increased gaze to the operated parotid area compared to the contralateral nonoperated parotid area (92 milliseconds, 95% confidence interval [CI]: 48-138 milliseconds, P < .001). Fat grafting normalized the attentional distraction, with no difference in gaze time on the operated parotid region compared to normal control faces (P = .414). For oblique images, total parotidectomy increased gaze to the operated parotid area compared to the contralateral nonoperated parotid area (658 milliseconds, 95% CI: 463-854 milliseconds, P < .001). Fat grafting normalized this attentional distraction, with no difference in gaze time on the operated parotid region compared to normal control faces (P = .504). In both views, superficial parotidectomy demonstrated no significant attentional distractions, with or without fat grafting.

CONCLUSIONS

This eye-tracking study objectively demonstrates that total parotidectomy results in a facial contour deformity that is distracting to observers, whereas superficial parotidectomy does not. For total parotidectomy, this attentional distraction can be normalized with dermal fat graft reconstruction.

LEVEL OF EVIDENCE

3b Laryngoscope, 131:E124-E131, 2021.

The Impact of Mastectomy on Women's Visual Perception of Breast Aesthetics and Symmetry: A Pilot Eye-Tracking Study

BACKGROUND

Little is known about breast cancer survivors' perception of breast attractiveness. A better understanding of this subjective concept could contribute to the improvement of patient-reported outcomes after reconstructive surgeries and facilitate the development of new methods for assessing breast reconstruction outcomes.

OBJECTIVES

The aim of this eye-tracking (ET)-based study was to verify whether mastectomy altered women's visual perception of breast aesthetics and symmetry.

METHODS

A group of 30 women after unilateral mastectomy and 30 healthy controls evaluated the aesthetics and symmetry of various types of female breasts displayed as highly standardized digital images. Gaze patterns of women from the study groups were recorded using an ET system and subjected to a comparative analysis.

RESULTS

Regardless of the study group, the longest fixation duration and the highest fixation number were found in the nipple-areola complex. This area was also the most common region of the initial fixation. Several significant between-group differences were identified; the gaze patterns of women after mastectomy were generally characterized by longer fixation times for the inframammary fold, lower pole, and upper half of the breast.

CONCLUSIONS

Mastectomy might affect women's visual perception patterns during the evaluation of breast aesthetics and symmetry. ET data might improve our understanding of breast attractiveness and constitute the basis for a new reliable method for the evaluation of outcomes of reconstructive breast surgeries.

Measuring Outcomes of Mohs Defect Reconstruction Using Eye-Tracking Technology

Importance

Objectively measuring how Mohs defect reconstruction changes casual observer attention has important implications for patients and facial plastic surgeons.

Objective

To use eye-tracking technology to objectively measure the ability of Mohs facial defect reconstruction to normalize facial attention.

Design, Setting, and Participants

This observational outcomes study was conducted at an academic tertiary referral center from January to June 2016. An eye-tracking system was used to record how 82 casual observers directed attention to photographs of 32 patients with Mohs facial defects of varying sizes and locations before and after reconstruction as well as 16 control faces with no facial defects. Statistical analysis was performed from November 2018 to January 2019.

Main Outcomes and Measures

First, the attentional distraction caused by facial defects was quantified in milliseconds of gaze time using eye tracking. Second, the eye-tracking data were analyzed using mixed-effects linear regression to assess the association of facial defect reconstruction with normalized facial attention.

Results

The 82 casual observers (63 women and 19 men; mean [SD] age, 34 [12] years) viewed control faces in a similar and consistent fashion, with most attention (65%; 95% CI, 62%-69%) directed at the central triangle, which includes the eyes, nose, and mouth. The eyes were the most visually important feature, capturing a mean of 60% (95% CI, 57%-64%) of fixation time within the central triangle and 39% (95% CI, 36%-43%) of total observer attention. The presence of Mohs defects was associated with statistically significant alterations in this pattern of normal facial attention. The larger the defect and the more centrally a defect was located, the more attentional distraction was observed, as measured by increased attention on the defect and decreased attention on the eyes, ranging from 729 (95% CI, 526-931) milliseconds for small peripheral defects to 3693 (95% CI, 3490-3896) milliseconds for large central defects. Reconstructive surgery was associated with improved gaze deviations for all faces and with normalized attention directed to the eyes for all faces except for those with large central defects.

Conclusions and Relevance

Mohs defects are associated with altered facial perception, diverting attention from valuable features such as the eyes. Reconstructive surgery was associated with normalized attentional distraction for many patients with cutaneous Mohs defects. These data are important to patients who want to know how reconstructive surgery could change the way people look at their face. The data also point to the possibility of outcomes prediction based on facial defect size and location before reconstruction. Eye tracking is a valuable research tool for outcomes assessment that lays the foundation for understanding how reconstructive surgery may change perception and normalize facial deformity.

Transoral neck surgery prevents attentional bias towards the neck compared to open neck surgery

OBJECTIVE

Measure attentional distraction of neck scars after open neck surgery compared to transoral endoscopic thyroidectomy via a vestibular approach (TOETVA) or transoral endoscopic parathyroidectomy via a vestibular approach (TOEPVA) using eye-tracking technology.

METHODS

Casual observers viewed facial images of patients who underwent open neck surgery, TOETVA/TOEPVA, or no surgery (controls). An eye-tracking monitor recorded eye fixations in real time. Multivariate Hotelling's analysis followed by post-hypothesis testing compared fixation durations for predefined regions of interest, including the eyes, nose, mouth, neck, and remaining face between open neck surgery patients, transoral neck surgery patients, and controls.

RESULTS

One hundred forty observers completed the experiment. The majority of their attention was directed towards the central triangle (eyes, nose, mouth). On multivariate analysis, distribution of attention was significantly different on the faces of those who underwent open neck surgery versus TOETVA/TOEPVA (T² = 43.66; F[32,131] = 14.5389, P < .0001). Observers attended significantly more to the neck (0.20 seconds, P < .0001; 95% CI, 0.13, 0.26 s) and less to the peripheral face (-0.24 seconds, P = .0031; 95% CI, -0.39, -0.08 s) of open neck surgery patients. In patients who followed up months after surgery, significant differences persisted (T² = 13.97; F[3451] = 4.6377, P = .0033). By contrast, fixation patterns for TOETVA/TOEPVA patients were not significantly different from controls (T² = 5.59, F[31,186] = 1.8602, P = .1345). Observer race and gender did not significantly affect attention to neck scars.

CONCLUSION

Scars following open neck surgery draw attention in casual observers. This attentional distraction is prevented in TOETVA/TOEPVA patients due to the absence of a scar, even months after surgery. Moreover, visual processing of TOETVA/TOEPVA patients' faces is similar to that of controls. These data support the effectiveness of transoral neck surgery in giving patients a cosmetic result that does not distract the attention of observers.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:1603-1608, 2020.

Association of Dorsal Reduction and Tip Rotation With Social Perception

Importance

Social perception by laypersons of people who have undergone rhinoplasty primarily for cosmetic purposes has not been fully described.

Objective

To evaluate the social perception of patients who have undergone cosmetic rhinoplasty.

Design, Setting, and Participants

Preoperative images of 4 patients with dorsal hump and tip ptosis were selected using the Delphi method. Computer simulations of dorsal hump reduction and tip rotation, alone or in combination, were performed. Using the Qualtrics internet-based survey platform, laypersons blinded to the purpose of the study viewed randomized original and simulated images and estimated the age, approachability, perceived success, overall health, intelligence, and rated their attractiveness on a visual analog scale from 0 to 100.

Main Outcomes and Measures

Comparison of responses (mean [SD] score) for each of the 3 types of simulated image against the original image employing a pairwise comparison of means (Dunnett test).

Results

After excluding 27 (4%) invalid responses, a total of 813 respondents (593 women and 220 men) were included in the study. The mean (SD) age was 44.6 (16.2) years. A total of 628 (77%) respondents were white and the observed highest level of education was a bachelor's degree (193 [24%]) or having attended college but without a diploma (194 [24%]). A significant age reduction (31 [10] years; 95% CI, -2.5 to 0; P = .04) and an increase in approachability (64 [22]; 95% CI, 0.7-5.8; P = .009), attractiveness (60 [22]; 95% CI, 4.0-9.4; P < .001), and health (70 [19]; 95% CI, 0.7-5.2; P = .006) for the simulation involving hump reduction was observed. When combined simulation of dorsum and tip rotation were tested, only significant increases in attractiveness (60 [23]; 95% CI, 3.6-9.0; P < .001) and health (69 [19]; 95% CI, 0.1-4.6; P = .03) were seen. No significant association was found for any of the responses when the tip alone was rotated. The Wilks λ varied slightly below 1.0 showing significant P values (P < .05) for all variance and covariance (respondent particulars).

Conclusions and Relevance

Though rhinoplasty procedures for nasal cosmesis involving both the nasal dorsum and tip were perceived to make a person more attractive and healthier, these results suggest that manipulation of the dorsum is more strongly associated with perception of the nose.

Level of Evidence

NA.

Assessment of the Influence of "Other-Race Effect" on Visual Attention and Perception of Attractiveness Before and After Rhinoplasty

IMPORTANCE

The "other-race effect" describes the phenomenon in which individuals demonstrate greatest recognition ability among faces of their own race. Thus, in our multicultural world, it follows that race influences social interactions. However, the association of race with perception of plastic surgery outcomes has not been studied.

OBJECTIVE

To objectively measure how the other-race effect influences perception of white and Latin American patients undergoing rhinoplasty by using eye-tracking technology and survey methodology.

DESIGN, SETTING, AND PARTICIPANTS

In the first part of the study, 134 participants viewed 32 paired facial images of white and Latin American patients, either prerhinoplasty or postrhinoplasty, on an eye-tracking system that recorded observer scan paths. In the second part of this study, the same patient images were individually graded by a separate group of 134 participants for degree of racial identification and perceived attractiveness.

MAIN OUTCOMES AND MEASURES

The primary outcome was to measure the influence of patient and observer race on perception of rhinoplasty outcomes. For the eye-tracking part, planned hypothesis testing was conducted using an analysis of variance to compare patient race, rhinoplasty status, and attractiveness with respect to visual fixation time.

RESULTS

Of the 134 eye-tracking participants, 68 (51%) were women and the mean (SD) age was 26.4 (7.7) years; of the 134 graders, 64 (48%) were women and the mean (SD) age was 25.0 (6.9) years. Rhinoplasty did not affect racial identity scores among either same-race or other-race evaluators. Visual fixation times for white faces were significantly increased compared with Latin American faces among all casual observer groups (white observers mean change, -20.14 milliseconds; 95% CI, -29.65 to -10.62 milliseconds; P < .001; Asian observers mean change, -39.04 milliseconds; 95% CI, -48.95 to -29.15 milliseconds; P < .001; and African American observers mean change, -20.73 milliseconds; 95% CI, -37.78 to -3.69 milliseconds; P < .02), with the exception of Latin American observers (mean change, -7.8 milliseconds; 95% CI, -29.15 to 14.39 milliseconds; P < .51). With respect to attractiveness, white graders reported a significant postrhinoplasty increase across both races (white patients mean change, 8.07 points; 95% CI, 5.01-11.12 points; P < .001; and Latin American patients mean change, 3.69 points; 95% CI, 0.87-6.49 points; P = .01), whereas Latin American graders only observed a significant attractiveness increase in their own race (Latin American patients mean change, 10.50 points; 95% CI, 1.70-19.32 points; P = .02). Neither perceived attractiveness nor rhinoplasty status influenced fixation times.

CONCLUSIONS AND RELEVANCE

Both patient and observer race influence visual attention and perception of attractiveness before and after rhinoplasty. These findings underscore the importance of counseling patients that the influence of rhinoplasty, as perceived by the casual observer, may vary by race or ethnicity of the observer group.

LEVEL OF EVIDENCE

NA.

Objectively Measuring Observer Attention in Severe Thyroid-Associated Orbitopathy: A 3D Study

OBJECTIVE

Measure the attentional distraction of facial deformity related to severe thyroid-associated orbitopathy using three-dimensional (3D) images and eye-tracking technology.

METHODS

Observers recruited at an academic tertiary referral center viewed 3D facial images of patients with severe thyroid-associated orbitopathy (TAO) and controls without TAO. An infrared eye-tracking monitor recorded their eye movements and fixations in real time. Multivariate Hotelling's analysis, followed by planned posthypothesis testing, was used to compare fixation durations for predefined regions of interest, including the eyes, nose, mouth, central triangle, and remaining face without the central triangle between severe TAO patients and controls.

RESULTS

One hundred sixteen observers (mean age 26.4 years, 51% female) successfully completed the eye-tracking experiment. The majority of their attention was directed toward the central triangle (eyes, nose, mouth). On multivariate analysis, there were significant differences in the distribution of attention between control and severe TAO faces (T²  = 49.37; F(5,922) = 9.8314, P < 0.0001). On planned posthypothesis testing, observers attended significantly more to the eyes (0.77 seconds, P < 0.0001, 95% confidence interval [CI], 0.51, 1.03 seconds) and less to the nose (-0.42 seconds, P < 0.0001, 95% CI, -0.23, -0.62 seconds) in severe TAO patients. There was no significant difference in time spent on the mouth, the total time spent on the central triangle, or time spent in the remaining face between the two groups.

CONCLUSION

Severe TAO distracted observer attention toward the eyes compared to control patients. These data lend insight into how TAO may alter observers' perceptions of these patients. Future studies should investigate how these changes in observer gaze patterns may reflect the social perception of TAO patients.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:1250-1254, 2019.

Association of Rhinoplasty With Perceived Attractiveness, Success, and Overall Health

IMPORTANCE

To date, the impact of rhinoplasty surgery on social perceptions has not been quantified.

OBJECTIVE

To measure the association of rhinoplasty with observer-graded perceived attractiveness, success, and overall health.

DESIGN, SETTING, AND PARTICIPANTS

In a web-based survey, blinded casual observers viewed independent images of 13 unique patient faces before or after rhinoplasty. Delphi method was used to select standardized patient images, confirming appropriate patient candidacy and overall surgical effect. Observers rated the attractiveness, perceived success, and perceived overall health for each patient image. Facial perception questions were answered on a visual analog scale from 0 to 100, where higher scores corresponded to more positive responses. A multivariate mixed-effects regression model was used to determine the effect of rhinoplasty while accounting for observer biases. To further characterize the effect of rhinoplasty, estimated ordinal rank change was calculated for each domain.

MAIN OUTCOMES AND MEASURES

The primary objective was to measure the effect of rhinoplasty on observer-graded perceived attractiveness, success, and overall health.

RESULTS

A total of 473 observers (mean age, 29 years [range, 18-73 years]; 305 [70.8%] were female) successfully completed the survey. On multivariate regression, patients after rhinoplasty were rated as significantly more attractive (rhinoplasty effect, 6.26; 95% CI, 5.10-7.41), more successful (rhinoplasty effect, 3.24; 95% CI, 2.32-4.17), and overall healthier (rhinoplasty effect, 3.78; 95% CI, 2.79-4.81). The ordinal rank change for an average individual's perceived attractiveness, success, and overall health was a positive shift of 14, 9, and 10 out of 100 rank positions, respectively.

CONCLUSIONS AND RELEVANCE

As perceived by casual observers, rhinoplasty surgery was associatedwith perceptions that in patients appeared significantly more attractive, more successful, and healthier. These results suggest patients undergoing rhinoplasty may derive a multifaceted benefit when partaking in social interactions. Furthermore, these results facilitate improved patient discussions aiming to provide more precise surgical expectations with an understanding that these results represent optimal outcomes.

LEVEL OF EVIDENCE

NA.

Implications of Facial Asymmetry in Rhinoplasty

Many rhinoplasty patients present with a chief complaint of nasal deviation and are unaware of any inherent facial asymmetries; however, recognizing and discussing the interrelation between the deviated nose and facial asymmetry is an important consideration in surgical planning. The objective of this study was to evaluate whether a surgeon's subjective assessment of facial analysis in the setting of nasal deviation correlates with objective anthropometric measurements. In addition, this study sought to further quantify the frequency of facial asymmetry associated with nasal deviation to highlight important anatomical trends for the rhinoplasty surgeon. Finally, this study presents the senior author's (R.J.R.) method of addressing a deviated nose on an asymmetric face. In this study, the authors demonstrated that nasal deviation is closely related to facial asymmetry. Furthermore, the authors demonstrated that objective facial analysis closely correlates to anthropometric facial measurements. In addition, the wide side of the face correlates to the short side of the face and the nose tends to deviate away from the wide side of the face. During surgical correction of the deviated nose in the setting of facial asymmetry, the surgeon's goal should be to obtain nasal symmetry and center the nose on a line between the mid glabella and the mid Cupid's bow. This may reduce the perception of a facial asymmetry, leading to increased patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, IV.

Objective method for evaluating orthodontic treatment from the lay perspective: An eye-tracking study

INTRODUCTION

Currently, few methods are available to measure orthodontic treatment need and treatment outcome from the lay perspective. The objective of this study was to explore the function of an eye-tracking method to evaluate orthodontic treatment need and treatment outcome from the lay perspective as a novel and objective way when compared with traditional assessments.

METHODS

The scanpaths of 88 laypersons observing the repose and smiling photographs of normal subjects and pretreatment and posttreatment malocclusion patients were recorded by an eye-tracking device. The total fixation time and the first fixation time on the areas of interest (eyes, nose, and mouth) for each group of faces were compared and analyzed using mixed-effects linear regression and a support vector machine. The aesthetic component of the Index of Orthodontic Treatment Need was used to categorize treatment need and outcome levels to determine the accuracy of the support vector machine in identifying these variables.

RESULTS

Significant deviations in the scanpaths of laypersons viewing pretreatment smiling faces were noted, with less fixation time (P <0.05) and later attention capture (P <0.05) on the eyes, and more fixation time (P <0.05) and earlier attention capture (P <0.05) on the mouth than for the scanpaths of laypersons viewing normal smiling subjects. The same results were obtained when comparing posttreatment smiling patients, with less fixation time (P <0.05) and later attention capture on the eyes (P <0.05), and more fixation time (P <0.05) and earlier attention capture on the mouth (P <0.05). The pretreatment repose faces exhibited an earlier attention capture on the mouth than did the normal subjects (P <0.05) and posttreatment patients (P <0.05). Linear support vector machine classification showed accuracies of 97.2% and 93.4% in distinguishing pretreatment patients from normal subjects (treatment need), and pretreatment patients from posttreatment patients (treatment outcome), respectively.

CONCLUSIONS

The eye-tracking device was able to objectively quantify the effect of malocclusion on facial perception and the impact of orthodontic treatment on malocclusion from the lay perspective. The support vector machine for classification of selected features achieved high accuracy of judging treatment need and treatment outcome. This approach may represent a new method for objectively evaluating orthodontic treatment need and treatment outcome from the perspective of laypersons.

Emotional responses to disfigured faces and Disgust Sensitivity: An eye-tracking study

Facial disfigurement attracts attention and evokes negative emotion, but evidence is lacking for a link between these two reactions. The present experiment ( n = 29) investigated emotional and attentional reactions to photographs of people with disfigured faces. An eye-tracker was used to measure fixation on internal expressive features and on the forehead. Disfigurement to the internal expressive features invoked a stronger emotional reaction than disfigurement to the forehead. Attention in the area of disfigurement was associated with negative emotion (embarrassment, sympathy, disgust, repulsion) as well as surprise. Attention to the disfigurement, and negative emotion, was related to the trait of Disgust Sensitivity.

Frequency and Characteristics of Facial Asymmetry in Patients With Deviated Noses

IMPORTANCE

Facial asymmetry is frequently detected in patients who are seeking rhinoplasty for a deviated nose, and its presence often leads to failure to create a straight-looking nose.

OBJECTIVE

To analyze the frequency and characteristics of facial asymmetry in patients with a deviated nose and to identify representative parameters to describe types and severity of facial asymmetry.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective review of at a tertiary referral center of preoperative photographs of 152 patients who underwent rhinoplasty for a deviated nose between January 2008 and December 2012. The incidence of facial asymmetry in these patients was compared with the incidence in 60 control patients undergoing septoplasty without external nose deviation.

INTERVENTIONS

Using frontal photographs, the presence of facial asymmetry and the types of deviated nose were noted and measured by 2 observers.

MAIN OUTCOMES AND MEASURES

Facial asymmetry was categorized into 4 types depending on which subunit of the face was affected, and deviated nose shapes were classified into 5 types. Anthropometric measurements were also performed.

RESULTS

Facial asymmetry was more common in patients with a deviated nose (84 of 152 [55%]) than in controls (19 of 60 [32%]) (P = .04). Mixed-type facial asymmetry was the most common type in the patient group. Among the anthropometric measurement parameters, the distance between the midpoint of the interpupil line to the most prominent malar point, lateral canthal angle, lateral alar angle, lip margin angle, and tilted chin angle were significantly different between the patient group and the control group (P < .05 for all comparisons). There was no difference in the incidence of asymmetry with respect to deviation type.

CONCLUSIONS AND RELEVANCE

Facial asymmetry was more common in patients with a deviated nose than in control patients, and mixed-type facial asymmetry was the asymmetry most often associated with deviated nose. This study suggests that deviated nose may be a developmental defect caused by a discrepancy in the growth of facial bony skeleton between the 2 sides of the face. The objective anthropometric measurements developed in this study could be useful for making appropriate preoperative facial assessments.

LEVEL OF EVIDENCE

NA.

Nasal Septal Deviations: A Systematic Review of Classification Systems

Objective. To systematically review the international literature for internal nasal septal deviation classification systems and summarize them for clinical and research purposes. Data Sources. Four databases (including PubMed/MEDLINE) were systematically searched through December 16, 2015. Methods. Systematic review, adhering to PRISMA. Results. After removal of duplicates, this study screened 952 articles for relevance. A final comprehensive review of 50 articles identified that 15 of these articles met the eligibility criteria. The classification systems defined in these articles included C-shaped, S-shaped, reverse C-shaped, and reverse S-shaped descriptions of the septal deviation in both the cephalocaudal and anteroposterior dimensions. Additional studies reported use of computed tomography and categorized deviation based on predefined locations. Three studies graded the severity of septal deviations based on the amount of deflection. The systems defined in the literature also included an evaluation of nasal septal spurs and perforations. Conclusion. This systematic review ascertained that the majority of the currently published classification systems for internal nasal septal deviations can be summarized by C-shaped or reverse C-shaped, as well as S-shaped or reverse S-shaped deviations in the anteroposterior and cephalocaudal dimensions. For imaging studies, predefined points have been defined along the septum. Common terminology can facilitate future research.

Facial reanimation surgery restores affect display

OBJECTIVE

Assess the ability of facial reanimation surgery to restore affect display in patients with severe facial paralysis.

STUDY DESIGN

Survey of healthy observers' perception of change in facial visage from preoperative to postoperative state.

SETTING

Academic tertiary referral center.

MAIN OUTCOME MEASURES

Observer graded affect display.

METHODS

Ninety naive observers completed a survey with pictures of paralyzed faces, smiling and in repose, before and after surgery, as well as normal comparison faces. Observers characterized affect display of each face coded in primary affects from the Derogatis Affects Balance Scale. Results were analyzed with latent class analysis and regression using a three-class model.

RESULTS

Preoperatively, paralyzed faces in repose were most likely to be considered negative (56.0%), then neutral (41.3%) and positive (2.7%). In this same cohort of patients in repose, reanimation surgery restored affect display to normal levels: decreasing negative classification (18.9%) and increasing neutral (53.4%) and positive (27.7%) classification. Hypothesis testing revealed no statistically significant differences in the mean classification probabilities for postoperative faces in repose versus normal faces in repose. The same analysis was performed for smiling faces, which showed marked improvement with reanimation surgery: decreasing negative (45.6%-11.7%) and increasing positive (26.2%-60.0%) classification. Despite this improvement, there were statistically significant differences in classification of postoperative smiling faces versus normal smiling faces.

CONCLUSION

Facial reanimation surgery was associated with normalized affect display for faces in repose and improved affect display for smiling faces. These results provide evidence that facial reanimation improves the facial expression of emotion. Further assessment in additional contexts will help better characterize the ability of facial reanimation to mitigate the psychosocial burden associated with facial paralysis.

Detection and perceptual impact of side-to-side facial movement asymmetry

IMPORTANCE

In this study, we examined whether specific facial movements have different time-delay detection thresholds, and to what extent such side-to-side facial movement asymmetry affects subjective ratings of movement naturalness. Ratings of dynamic asymmetry in experimentally manipulated video recordings demonstrate that there are different side-to-side time-delay thresholds for distinct regions of the face, with a strong inverse correlation between naturalness rating and the length-of-time delay. These findings will be helpful for counseling patients with unilateral facial paralysis and guide the design of neural interfaces for facial reanimation.

OBJECTIVE

To determine the detection threshold of side-to-side facial movement timing asymmetry and measure its effect on perceived movement naturalness.

DESIGN, SETTING, AND PARTICIPANTS

Videos of 5 symmetrical facial movements (eye blink, rapid eyebrow raising, slow eyebrow raising, smiling, and lip depression) were edited to introduce 6 levels of side-to-side timing asymmetry, ranging from 33 to 267 milliseconds. Participants (N = 58) viewed video clips through an online survey service, indicating whether they noticed side-to-side asymmetry and judging movement naturalness on a 5-point scale.

RESULTS

There was a significant difference among facial movements in asymmetry detection threshold. There was a strong correlation between naturalness ratings and amount of delay across movements (R = 0.823), with greater asymmetry being judged as progressively less natural. Blink was judged as less natural at 33, 67, 100, and 133 milliseconds of side-to-side delay compared with all other movements (P < .005).

CONCLUSIONS AND RELEVANCE

Side-to-side asymmetry in blink timing is detected sooner and viewed as less natural compared with asymmetry of the eyebrow and lips. At 100 milliseconds of delay, nearly all movements are detected as asymmetric, although blink is judged as the least natural. These findings will help set timing goals for facial pacing technologies treating unilateral paralysis.

LEVEL OF EVIDENCE

NA.

Seeing is believing: objectively evaluating the impact of facial reanimation surgery on social perception

OBJECTIVES/HYPOTHESIS

Objectively measure the ability of facial reanimation surgery to normalize the appearance of facial paralysis using eye-tracking technology.

STUDY DESIGN

Prospective randomized controlled experiment.

METHODS

An eye-tracker system was used to record the eye-movement patterns, called scanpaths, of 86 naïve observers gazing at pictures of paralyzed faces (House-Brackmann IV-VI), smiling and in repose; before and after facial reanimation surgery; as well as normal, nonparalyzed faces. Observers gazed at each face for 10 seconds. Fixation durations for all predefined facial areas of interest were analyzed using mixed-effects linear regression.

RESULTS

Observers spent the majority of time (6.6 of 10 seconds) gazing in the central triangle region (eyes, nose, and mouth) of normal faces and paralyzed faces. There were significant deviations in fixation within the central triangle of paralyzed faces as compared to normal faces. Total fixation on the eyes remained conserved. However, total nose fixation decreased and mouth fixation increased on paralyzed faces. Facial reanimation surgery normalized many of the hemifacial gaze asymmetries caused by unilateral facial paralysis, and restored a normal distribution of gaze between the functional and paralyzed sides of the face and mouth.

CONCLUSION

There were objective differences in the way observers directed their attention to facial features when viewing normal and paralyzed faces. After facial reanimation surgery, the attentional distraction caused by facial feature irregularities was reduced. These findings are important additions to the emerging body of objective evidence indicating the effectiveness of reanimation surgery; they also suggest opportunities to optimize reconstruction.

LEVEL OF EVIDENCE

N/A.

Impact of crooked nose rhinoplasty on observer perceptions of attractiveness

OBJECTIVES/HYPOTHESIS

To evaluate the impact of a crooked nose on observer perceptions of facial asymmetry and attractiveness and the ability of rhinoplasty to minimize it. We hypothesized that the presence of a crooked nose would penalize symmetry and attractiveness ratings as compared to normal faces. We further hypothesized that straightening rhinoplasty would restore symmetry and improve attractiveness.

STUDY DESIGN

Randomized controlled experiment.

METHODS

A group of 39 naïve observers viewed pictures of patients with crooked noses before and after straightening rhinoplasty, and normal patients. Observers rated the overall asymmetry and attractiveness, and the asymmetry of facial subunits using a survey with a rating scale of 1 to 10 for each category.

RESULTS

For asymmetry, patient group (preoperative, postoperative, normal) was statistically significant by multivariate analysis of the variance. Post-analysis of variance showed significant differences in asymmetry scores for overall, nose subunit, and mouth subunit. Pairwise testing then showed significantly different overall asymmetry scores between normal and preoperative (P < .001), and preoperative and postoperative (P < .001), but not between normal and postoperative (P = .215) groups. Mixed linear regression analysis showed that decreasing nasal asymmetry by 1 point increases attractiveness by 0.18 points or 0.082 attractiveness standard deviations (P < .001).

CONCLUSIONS

Faces with crooked noses were rated less symmetrical overall and less symmetrical at the nose and mouth subunits as compared to normal and postoperative faces. Straightening rhinoplasty diminished overall facial asymmetry and subunit asymmetry scores. Decreasing nasal asymmetry led to significant improvements in facial attractiveness. These data provide objective evidence supporting the idea that a straightening rhinoplasty can improve attractiveness.