Plastic Surgery Research Council

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Objective Outcomes in Upper Blepharoplasty: An Eyetracking Study
Amjed Abu-ghname, MD1, Thanapoom Boonipat, MD1, Ali Charaffadine, MD1, Kevin Fleming, PhD2, Mitchell , Stotland, MD3, Uldis Bite, MD1.
1Mayo Clinic, Rochester, MN, USA, 2Norwich University, Northfield, VT, USA, 3Sidra Medical, Doha, Qatar.

Purpose:
Visual markers that lead to differential perception of patients before and after upper blepharoplasty were explored. By examining the early stages of visual processing that occur when an observer encounters images of affected individuals, we intended to reveal the focus of impression formation, thereby helping surgeons and their patients pinpoint the facial features that are most salient to viewers.
Methods:
Eighty images for 13 patients who underwent upper blepharoplasty, with and without lower blepharoplasty and browlifts, were collected. Photographs were obtained before and after surgical correction (>3 months postop). Twenty lookzone regions were mapped onto each facial image, reflecting the aesthetic units of the face.
Eighty observers examined the images while an infrared eye-tracking camera continuously recorded their eye movements. The observers were then asked to rate the image for character attributes (Attractiveness, Trustworthiness, Sociability, Healthy, and Capability, 1-7 scale). Factorial ANOVA and student t-test analysis was performed to determine significance of differences between groups.
Outcomes measured were the total number of eye fixations within different lookzone regions. Eyetracking data of pre- and post-operative images were analyzed and compared.
Results:
Thirteen Blepharoplasty patients were identified.
(i) The surgical intervention was found to increase observers' attention to the upper lid and periorbital area, and to decrease attention to the forehead, lower lid, and mid-cheek areas, Figure 1.

(ii) The surgical intervention was found to significantly increase the character ratings for all five attributes compared to pre-operative controls: Sociable 3.66 to 4.01, Trustworthy 3.91 to 4.24, Attractive 3.39 to 3.75, Healthy 4.26 to 4.66, Capable 4.27 to 4.56; (p<0.05) except for Attractive (p=0.059).
(iii) For those pre-operative images of brow and upper lid ptosis that resulted in clinical lid asymmetry, observers' attention was overwhelming drawn to the area of disproportion, Figure 2.

(iv) Our eye tracking methodology clearly reflects a trend towards normalization of gaze attention following surgical intervention. This finding was associated with the improvement in character assessment of the images in the post-op cohort of images, Figure 3.

Conclusion:
We provide data illustrating a novel and objective technique to evaluate the effect of reconstructive intervention for the upper lid and/or the brow. This information may be used to inform patients about how these areas of facial difference are perceived, and the potential effect
that surgical intervention may have on others' perception of them. This work may assist patients and their surgeons to more meaningfully focus their surgical decision-making priorities.


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