Moving toward objective measurement of facial deformities: exploring a third domain of social perception.

In this issue,Litschel et al1 presentnoveldataon thevisualdistraction caused by protruding ears. They used an eyetrackingdevice forobjectiveevaluationandcorrelated theeyetracking test findings with personality survey assessments. These data represent an importantadditiontoaburgeoning body of evidence on the effect of facial deformities. Until now, in facial plastic and reconstructive surgery,wehave had a relatively limited understanding of the effect of facial deformities and abnormalities on visual distraction and facial perception. Previously, we had accepted the general tenet that faces with abnormalities are less attractive and less “normal,” and that our surgical procedures restore attractiveness andnormality; however, these ideas have been based on limited objective evidence. Furthermore, we have relied primarily on the subjective perceptions of experts and the patients themselves to inform our ideas on these paradigms of attractiveness and normalcy, inadequately assessing the perceptions of casual observers. Onlyrecentlyhavewebeguntoformallyattempttomeasure theeffectof facialdeformities fromtheperspectiveofcasualobservers. The importance ofmeasuring this effect lies in part in the fact that, formanypeople, one of their greatest concerns is howtheythinkothers,particularlystrangers,areviewingthem. Inasurveyofpatientswithheadandneckcancer,patientsnoted that of greatest concern to them was how they would be perceivedbyothersonce theyhadadeformity.2 Patientswithnew facial deformities or abnormalities report changing their social habitstoavoidencounteringstrangersorevenfamilyandfriends. Furthermore,wefacialplasticandreconstructivesurgeonsperform cosmetic and reconstructive procedures intrinsically believing, alongwith thepatients, that ourprocedurewill restore amoreattractiveandnormalappearance toourpatients so they can engagemore effectively in society. Significant progress has beenmade in recent years in subjectively and/or objectively measuring the perception of the casual observer of facial deformities or abnormalities, including the “abnormality” of the aging face. In a 2013 survey study by Zimm et al,3 patients who had undergone surgical procedures for aging faces were perceived to be younger than their actual age. An objective line of investigation using eye trackinghasdevelopedbasedonthefoundationofnormal faceviewing, first described by Walker-Smith et al4 in the 1970s. Eye movements are a surrogate for attention, so, bymeasuring eye movements, one has insight into where an observer is directing attention. In their seminal work,Walker-Smith et al demonstrated that casual observers gazing on novel faces do so in a highly conserved manner, directing the majority of attention to thecentral triangle region inamannermeasurableusing objective eye tracking. Recent research has taken advantage of this foundation, using eye tracking to objectively measure how distracting facial deformities are by measuring how facial gaze patterns deviate from the normal, highly conserved pattern in the presence of deformities. Thismethod has been used to quantify the visual distraction caused by crooked noses,5 skin lesions, and facial paralysis.6 After objectively showing the extent to which the gaze of naive observers is drawn to facial deformities, survey studies have demonstrated how observers then perceive attractiveness,7 affect display,8 andwillingness to engage in conversation, based on the distraction of the deformity. Furthermore, these findings have been extended to show the effect of surgical reconstruction on these visual distractions and changes in perception.6 In their novel application, Litschel et al1 firstmeasurehow casualobserversgazeonfacesof childrenwithprotrudingears, and then measure gaze patterns after a surgical simulation, using software to morph protruding ears into normalappearing ears. They correlate the changes in eye gaze by an observer with changes in perception of the faces before and Related article page 183 Protruding Ears Original Investigation Research