Research

Original Investigation

Effect of Protruding Ears on Visual Fixation Time

and Perception of Personality
Ralph Litschel, MD; Juleke Majoor, MD; Abel-Jan Tasman, MD

Invited Commentary page 189

IMPORTANCE Protruding ears are often thought to be a stigma, supposedly drawing attention Journal Club Slides at
and negatively influencing the perception of personality. These purported negative effects jamafacialplasticsurgery.com
that may indicate corrective aesthetic otoplasty in patients too young to provide informed
CME Quiz at
consent have not been quantified.
jamanetworkcme.com and
CME Questions page 232
OBJECTIVE To quantify attention directed toward protruding ears and its effect on the
perception of selected personality traits.

DESIGN, SETTING, AND PARTICIPANTS In this observational study conducted from August 1,
2013, to October 31, 2013, visual scan paths were recorded of 20 lay observers looking at
photographs of faces of 20 children (age range, 5-19 years) with either protruding ears or ears
morphed via computer software to appear nonprotruding. Subsequently, the observers rated
10 perceived personality traits based on the same photographs.

MAIN OUTCOMES MEASURES Visual fixation time on protruding vs nonprotruding ears was
compared and correlated with observers’ scores for personality traits.

RESULTS Fixation time on protruding ears was significantly longer compared with that for
morphed nonprotruding ears (mean [SD], 9.6% [5.6%] vs 5.8% [3.2%] of total fixation time,
P = .04). The difference between the overall personality questionnaire scores and between
individual scores for assiduousness, intelligence, and likeability was not significant for
protruding and nonprotruding ears. Faces in which the protruding auricles received the
highest percentage of visual attention scored higher than average for the overall personality
scores (mean [SD], 66.09 [4.50] vs. 55.81 [13.36]) and for assiduousness (6.64 [0.74] vs. 5.59
[1.41]), intelligence (6.78 [0.74] vs. 5.83 [1.31]), and likeability (7.29 [0.47] vs. 6.28 [1.40]).

Author Affiliations: Department of

CONCLUSIONS AND RELEVANCE Protruding ears had the potential to draw viewers’ attention
Otorhinolaryngology–Head and Neck
but did not cause a negative perception of personality traits. This study therefore does not Surgery, Cantonal Hospital, St Gallen,
provide confirmatory evidence for the stigmatizing nature of protruding ears. Switzerland.
Corresponding Author: Abel-Jan
LEVEL OF EVIDENCE 3. Tasman, MD, Department of
Otorhinolaryngology–Head and Neck
Surgery, Cantonal Hospital,
JAMA Facial Plast Surg. 2015;17(3):183-189. doi:10.1001/jamafacial.2015.0078 Rorschacher Str 95, 9007 St Gallen,
Published online March 19, 2015. Switzerland
(abel-jan.tasman@kssg.ch).

P
rotruding ears continue to be perceived as a negative
physical attribute in many cultural settings, with af-
fected children frequently being ridiculed and adoles-
cents experiencing reduced self-esteem.1 Protruding ears have
been associated with inferior cognitive performance at school,
immaturity, less favorable personality traits, diminished self-
confidence, and social avoidance.2,3 Media often select a per-
son with large, prominent, or oddly shaped ears when wish-
ing to depict an odd character or a less-intelligent individual.
Few, if any, features are believed to elicit such negative re-
sponses as prominent or overly large ears. Prominent ears have
been found to be significantly larger than normal ears.4 From
this perspective, protruding ears may be perceived as a stigma,
defined as “an attribute or characteristic that conveys a social
identity that is devalued in a particular social context,” which
includes “being the target of negative stereotypes, being re-
jected socially, being discriminated against, and being eco-
nomically disadvantaged.”5(p505) Facial stigmata, such as scars,
acne, strabismus, nasal deformities, and protruding ears are
the most common reasons for a request for surgical revision.
Persons with these facial stigmata provoke a negative reac-
tion in the observer, with facial deformities having a negative
effect on the perception of honesty, trustworthiness, and em-
ployability and, thereby, social functionality.6 The relation-
ship between visual deformities and high psychological dis-
tress was demonstrated to be close.7 Several studies have

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 Research Original Investigation
analyzed the psychological effect of microtia in children.8,9 Pa-
tients with larger deformities were found to cope better with
the negative feelings of others (mostly pity and aversion) prob-
ably owing to adaptation, unlike those with less-pronounced
cosmetic deformities, who may be continuously uncertain
about their ears potentially becoming subject to ridicule.10 Chil-
dren pay more attention than do adults to small differences
in appearance between themselves and others.1 Measuring the
effect of corrective otoplasty using tests, such as the Child Be-
havior Checklist, the State-Trait Anxiety Inventory for Chil-
dren, and the Children’s Depression Inventory, revealed im-
provements in almost all the assessed items after the
procedure.10,11 Happiness and self-confidence increased, so-
cial experience improved, and bullying was reduced. Oto-
plasty was also found to potentially significantly increase pa-
tients’ health-related quality of life and lead to a high rate of
patient satisfaction.12,13 It is estimated that roughly 10% of the
population bears some type of facial deformity, with protrud-
ing ears having an incidence of 5%.14 Surprisingly, given the
high prevalence and psychological effect of facial deformi-
ties, data on the visual perception of faces with deformities are
sparse.15,16
To our knowledge, no attempt at quantifying the
attention-drawing potential of protruding ears has been pub-
lished. Also, the effect of auricular deformities on the per-
ception of personality traits has not been reported. The aim
of this study was therefore to quantify the visual attention of
naive observers directed to protruding ears and to measure
the effect of protruding ears on the perception of personality
traits. Our first hypothesis was that protruding ears unknow-
ingly cause the observer to give them more visual attention
compared with nonprotruding ears; our second hypothesis
was that personality traits of faces with protruding ears are
judged less favorably.
Methods
This observational study was conducted at the Department of
Otorhinolaryngology–Head and Neck Surgery of Cantonal Hos-
pital, St Gallen, Switzerland. Written informed consent for the
use of patients’ photographs was obtained from patients or
their legal guardians and ethical approval was granted by the
local Ethics Committee of the Canton St Gallen. The study con-
sisted of 2 parts, reflecting both hypotheses.
Visual Attention for Protruding and Nonprotruding Ears
In the first part, visual attention to the auricles was quanti-
fied with an eye-tracking device. A sample of 20 preopera-
tive photographs of patients (14 male and 6 female; age
range, 5-19 years) who had requested an otoplasty and 20
photographs of the simulated desired outcome of the proce-
dure was selected from the database of the Department of
Otorhinolaryngology–Head and Neck Surgery of Cantonal
Hospital. All en face patient photographs were taken under
standardized conditions (distance, lighting, background, and
resolution). The degree of overall ear protrusion and sym-
metry of protrusion was heterogeneous among the patients,
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Protruding Ears
reflecting the variability found in the consecutive sample.
Outcome simulations were created as part of the routine ini-
tial consultation using Adobe Photoshop Elements (Adobe
Systems) as described elsewhere. 17 Simulations of the
intended outcome of otoplasty were used instead of the
actual postoperative outcome to eliminate inevitable con-
founders in postoperative photographs, such as facial
expression or changed hair color, hairstyle, or clothing
(Figure 1). The 20 preoperative photographs and the 20
simulated outcome photographs were divided into 2 series
of 20 photographs each, containing either the preoperative
or the simulated outcome photograph. These sets were pro-
cessed for eye tracking by cropping, centering, and correct-
ing scales (resolution of 1024 × 1024 pixels) of the patient
images and by adding calibration images and relaxing photo-
graphs of pleasant landscapes between the patient photo-
graphs in a file (PowerPoint, Microsoft Office Professional
2010) for presentation. Presentation times of the faces and
landscapes were 10 and 3 seconds, respectively.
Twenty participants were recruited from the outpatient
clinic at the Department of Otorhinolaryngology–Head and
Neck Surgery of Cantonal Hospital. Participants were pa-
tients in good health presenting for a routine follow-up, as well
as persons who were accompanying patients. All participants
(18 male and 2 female; mean age, 44.7 years [range, 21-75 years])
had normal, symmetric eye movements as a prerequisite for
eye tracking. The participants were informed that they would
be asked questions about the personality of the persons whose
faces they were about to see on a screen after the having seen
the photographs. Participants provided written informed con-
sent that their eye movements would be recorded but they were
not informed of the purpose of the study.
An eye tracker is a device used, especially in psychologi-
cal research, to record eye movements (visual scan path) of a
study participant and measures the duration of the fixation in
specific regions of interest. This technique enables investiga-
tion of the spontaneous, initial visual assessment of a face. A
visual scan path is composed of a sequence of fixations and
saccades.12,18 Fixations contain a continuous series of gaze
points on a segment of the visual field with a predefined du-
ration that is set at 200 milliseconds.18
The visual scan paths (Figure 2) were recorded using a To-
bii X120 eye tracker (Tobii Technology AB) linked to a host com-
puter and a second monitor with a 19-inch diagonal display fac-
ing the seated participant. For the calibration of the eye tracker
and presentation of the photographs, Tobii Studio Software,
version 2.0.6 (Tobii Technology AB), was used, in which par-
ticipants had to follow a red dot on the screen.
In each group, there were 200 eye-tracker measurements
and a total of 400 measurements. The power analysis was based
on the data published by Ishii et al14 (mean [SD] fixation time
of the defect region of 1630 [1177] milliseconds). A total of 137
viewed photographs per group or 247 photographs in total were
required to detect a difference of 400 milliseconds with 80%
power and a significance level of P < .05. These calculated num-
bers of photographs were increased from 137 and 247 to 200
and 400, respectively, to improve power of the study and be-
cause of anticipated withdrawals.
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 Protruding Ears
Figure 1. Preoperative and Simulated Postoperative Photographs of Patients With Protruding Ears
A B
C D
E F
Personality Ratings for Faces With Protruding
and Nonprotruding Ears
For the assessment of perceived personality traits, a question-
naire was delivered that included pairs of antipodes on 10 per-
sonality traits (sociable–withdrawn, content–discontent, as-
siduous–lazy, intelligent–unintelligent, creative–uninspired,
friendly–unfriendly, successful–unsuccessful, exciting–
boring, accessible–inaccessible, and honest–dishonest). These
items were extracted from the Neuroticism-Extraversion-
Openness Personality Inventory and are said to represent the
5 broad dimensions of traits that are used to describe human
personality: neuroticism, extraversion, openness, agreeable-
ness, and conscientiousness.19 We added 4 more traits in ac-
cordance with previously published research: successful-
ness, boringness, accessibility, and honesty.20 Each trait was
displayed on a visual analog scale from 0 to 10, with 0 indi-
cating the lowest and 10 the highest positive score. These per-
sonality traits were rated by all participants immediately af-
ter they had completed the eye-tracking part of the study with
the image they had seen on the screen printed on the ques-
tionnaire for recognition. Eye tracking and rating of person-
ality traits required between 25 and 35 minutes and was moni-
tored by one of us (J.M.).
Statistical Analysis
The auricles were selected as the area of interest in Tobii Stu-
dio and the fixation time of both pinnae was calculated as the
percentage of total fixation time (Figure 3). The difference be-
tween relative fixation times for protruding and nonprotrud-
ing ears was analyzed by the average fixation time for each
patient with protruding and nonprotruding ears with a non-
parametric paired sample test (Wilcoxon signed rank test). The
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Original Investigation Research
A-F, Selection of the photographs of
6 of 20 patients who were included
in the study. The preoperative images
are on the left, the simulated
intended outcome of an otoplasty on
the right. These are the patients who
are referred to in Figure 5,
representing the orange, green, and
blue squares.
fixation time of both pinnae was also correlated with the sum
score of the questionnaire, as well as with the scores for indi-
vidual questions regarding likeability, intelligence, and as-
siduousness.
Results
Visual Attention for Protruding
and Nonprotruding Ears
Data of all 20 observers on 20 patient photographs were ame-
nable for analysis of 400 eye-tracking data sets. Four ques-
tionnaires had to be excluded owing to missing data.
Mean (SD) fixation time of both auricles was 9.6% (5.6%)
of total fixation time for protruding ears and 5.8% (3.2%) for
nonprotruding ears (Figure 4). This difference was signifi-
cant (P = .04).
Personality Ratings for Faces With Protruding
and Nonprotruding Ears
Sixteen of the 20 observers returned the questionnaire fully
completed, including 10 visual analog score personality trait
ratings for each patient image, totaling 200 individual rat-
ings by each of the 16 observers, for a sum of 3200 individual
ratings.
A significant correlation between the sum of the person-
ality questionnaire scores for faces with protruding and non-
protruding ears was found (Pearson correlation; R, 0.73,
P < .001). The difference between the sum of the personality
questionnaire scores for faces with protruding and nonpro-
truding ears was not significant (mean [SD], 55.8 [1.37] vs 53.6
[1.25], P = .31).
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 Research Original Investigation
Figure 2. Eye-Tracker Recordings
A B
C D
As for the sum of all personality traits, the difference be-
tween the mean (SD) scores for assiduousness, intelligence, and
likeability did not differ significantly depending on protru-
sion or deformity of the ears (5.59 [14.5] vs 5.24 [1.43], P = .22;
5.83 [1.34] vs 5.53 [1.42], P = .41; and 6.28 [1.44] vs 6.20 [1.26],
P = .83, respectively). A significant positive correlation be-
tween the scores for faces with protruding and nonprotrud-
ing ears was found for likeability (R, 0.75, P < .001).
Both the quartile of the 5 faces for which the protruding
auricles received most visual attention (patients 2, 3, 4, 5, and
6, respectively; orange and green squares in Figure 5) and the
quartile of the 5 faces with the largest difference in fixation time
between protruding and nonprotruding auricles (patients 1, 3,
4, 5, and 6, respectively; orange and blue squares in Figure 5)
scored higher than the average for overall personality scores
(mean [SD], 66.09 [4.50] vs 55.81 [13.36]) and for individual
scores on assiduousness (6.64 [0.74] vs 5.59 [1.41]), likeability
(7.29 [0.47] vs 6.28 [1.40]), and intelligence (6.78 [0.74] vs 5.83
[1.31]). In the quartile of faces for which the protruding au-
ricles received most visual attention, the sum of personality
scores and the likeability score was lower for the modified pho-
tograph without protrusion of the auricle in 4 of 5 patients (pa-
tients 3, 4, 5, and 6). The scores for assiduousness and intel-
ligence were lower for the modified images in 3 of 5 patients
(patients 3, 4, and 5).
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Protruding Ears
A and B, The upper row shows
preoperative photographs. C and D,
The lower row shows simulated
postoperative photographs. Each dot
represents a fixation time of more
than 200 milliseconds; dot size
corresponds to visual fixation time.
Connecting lines represent the visual
scan path. Fixation times are
represented as heat maps (red
represents maximum cumulative
fixation time).
Discussion
Facial stigmata catch the eye because a negative stimulus re-
ceives more visual attention than does a positive stimulus. Spi-
ders or unhappy faces, for example, are fixated on longer than
butterflies or happy faces.21-23 One contributing factor to this
phenomenon may be that an abnormality in the face is per-
ceived as new and represents a novel stimulus. According to
the novel stimulus theory, to become familiar with it, people
stare at a stigma.24 Also, unexpected facial features, such as a
crooked nose or floppy ears, may be helpful in the face recog-
nition process and therefore receive more attention.7,25
Research has shown a negative correlation between at-
tractiveness and the lesion size of a facial disfigurement but
not between attractiveness and the location of a facial
disfigurement.26 A person’s attractiveness is known to strongly
influence the perception of personality by the viewer. This phe-
nomenon is often referred to as the attractiveness halo. Indi-
viduals who are considered attractive will more likely be seen
as nice, friendly, and intelligent. As a consequence of a nega-
tive first impression, people with facial deformities will more
likely be treated harshly.27 Such a first impression can have a
distressing effect and dramatic psychosocial influence on
people with facial disfigurements. Dating agents ranked pro-
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 Protruding Ears Original Investigation Research

Figure 3. Marking the Area of Interest (AOI) for Both Ears Figure 4. Visual Fixation Time for Both Ears for Protruding
vs Nonprotruding Ears

30

Nonprotruding Ears, %
20

10

AQI-R-EAR 0
AQI-L-EAR
0 10 20 30
Protruding Ears, %

Visual fixation time is reported as a percentage of total fixation time.

Figure 5. Visual Fixation Time of Both Ears vs Personality Trait Total Score

A B

The right and left ear were individually marked on the patient photographs 80 80
using the eye tracker’s Tobii Studio Software. Personality Sum Score

Personality Sum Score

truding ears as having a large negative effect more in men than
in women.28 Of all visible disfigurements, those of the face
seem to be least tolerated and most likely to provoke anxiety
and aversion. Children with protruding ears had more prob-
lems regarding self-esteem compared with children with nor-
mal ears or even facial port-wine stains.29
Experience shows that the eyes of the viewer typically fol-
low a particular scan path in a face with no obvious facial de-
formities, focusing on a central triangle, which includes the
mouth, nose, and eyes.14,30-32 Attention had been found to be
redirected to obvious facial defects at the expense of time spent
analyzing the central triangle.
Therefore, it was expected that the average visual fixa-
tion time on protruding ears would be longer than the atten-
tion directed to nonprotruding ears. Still, the difference that
was quantified in this study appeared smaller than the per-
ception of the clinical problem from the patient’s and physi-
cian’s perspective might suggest. The experimental setup and
the cutoff setting for registration of visual fixation of 200 mil-
liseconds may have reduced an effect that could be more pro-
nounced in personal encounters. The spectrum of auricular de-
formities included in this study was representative of the
patients requesting an otoplasty at a Swiss tertiary care cen-
ter. Obviously, the degree of deformity varied considerably, ex-
plaining part of the variation in attention directed toward the
ears. Only ears that protruded markedly or were conspicu-
ously deformed caught the eye, as documented for patients
2, 3, 4, 5, and 6.
If noticeable protruding ears were to be perceived by the
population at large as heralding less-favorable personality traits,
the experimental setup in this study should be expected to have
reflected this phenomenon, at least in part, through lower
scores given by the observers. Surprisingly, the opposite was
found, with the quartile of faces with the ears attracting the
60 60
40 40
20 20
0 0
0 10 20 30 0 10 20 30
Protruding Ears, % Nonprotruding Ears, %
A, Protruding ears. B, Nonprotruding ears. Visual fixation time is reported as a
percentage of total fixation time. Four orange squares and 1 green square
represent the patient quartile with the longest fixation time on both ears. Orange
squares and the blue square represent the patient quartile with the largest
differences between the fixation times of protruding and nonprotruding ears.
most attention scoring higher than the 3 quartiles with less no-
ticeable ears. These faces also yielded higher scores than their
counterpart with corrected auricles in 4 of 5 cases for the total
personality sum score and likeability score and in 3 of 5 cases
for assiduousness and intelligence scores. In light of these find-
ings, the relevance of protruding ears as a negative stigma re-
garding perceived personality traits may be considered less pro-
nounced than purported in the literature.
This study has several strengths. Use of preoperative origi-
nal and morphed postoperative images in which the degree of
protrusion and deformity was the only variable in otherwise
identical images excluded potentially attention-drawing dif-
ferences between preoperative and real postoperative photo-
graphs. In addition, lay individuals acting as observers in this
study were naive to the objective of the study and were shown
either the original or the morphed image, excluding a poten-
tial recognition of faces or noticing of a difference between 2
versions of the same face as a confounder. Finally, the degree

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 Research Original Investigation Protruding Ears

of protrusion was variable, further reducing the clues the ob-
servers may have noticed regarding the end point of the study
while scanning the faces.
Several limitations of this study require discussion. First,
observers who were initially naive regarding the end point of
the study may have noticed the high prevalence of protrud-
ing ears (50%) while viewing the faces, which may explain
relative fixation times that may exceed those reported in the
literature. Reducing the likelihood of this confounder would
have required a substantially larger sample of faces with
inconspicuous ears. A preliminary study had revealed that a
substantially larger sample would have strained the visual
attention span of observers to the point of acquiring invalid
data. It also remains unclear to what extent looking at photo-
graphs of faces on a monitor relates to visual analysis of a
face during encounters in person. The faces included dis-
played a variable degree of protrusion or deformation of the
auricle, reflecting the deformities found in a consecutive
sample of patients who requested an otoplasty in a Swiss ter-
tiary care center. The simulated degree of correction was
variable, mirroring the preoperatively agreed-upon objective
of a planned otoplasty. The shape of the modified auricle was
realistic as to the desired projection but less so for the antici-
pated relative position of the antihelical fold and helix in
some patients. This shortcoming being inherent to the
imaging method used in this study may have had an effect on
the fixation times of virtually corrected pinnae. Also, the eye-
tracking segment of the study was designed for optimum fea-
sibility, respecting the expected attention span of partici-
pants. The definition of 10 seconds’ projection time for each
face was arbitrary and an effect of this projection time cannot
be ruled out. Finally, answering 20 sets of 10 questions each
on personality was thought to be tedious by some partici-
pants and fatigue cannot be ruled out as a potential con-
founder. Still, with the sequence of the original or modified
patient image being identical in both sets, the effect of
fatigue should be expected to have been minor and evenly
distributed. Finally, the group of lay observers may be con-
sidered to be representative of the Swiss adult population.
Still, the effect of a cultural bias on the perception of protrud-
ing ears cannot be ruled out.
Conclusions
To our knowledge, this is the first study quantifying the at-
tention-drawing potential of protruding ears using an eye-
tracking device and the first report correlating this effect with
perceived personality. The confirmation of the hypothesis that
protruding ears catch the attention of observers was ex-
pected. Not finding support for the second hypothesis, that pro-
truding ears negatively affect the perception of personality
traits, was surprising. It remains unclear to what extent local
cultural factors may have influenced this outcome. These data
may be helpful for future reference and for comparison with
studies addressing other facial regions of interest.

ARTICLE INFORMATION
Accepted for Publication: December 9, 2014.
Published Online: March 19, 2015.
doi:10.1001/jamafacial.2015.0078.
Author Contributions: Dr Tasman had full access
to all the data in the study and takes responsibility
for the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Litschel, Tasman.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Litschel, Tasman.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Litschel, Tasman.
Administrative, technical, or material support: All
authors.
Study supervision: Litschel, Tasman.
Conflict of Interest Disclosures: None reported.
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 Protruding Ears Original Investigation Research

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Invited Commentary

Moving Toward Objective Measurement of Facial Deformities

Exploring a Third Domain of Social Perception
Lisa E. Ishii, MD, MHS

In this issue, Litschel et al1 present novel data on the visual dis-
traction caused by protruding ears. They used an eye-
tracking device for objective evaluation and correlated the eye-
tracking test findings with personality survey assessments.
These data represent an im-
portant addition to a burgeon-
Related article page 183 ing body of evidence on the
effect of facial deformities.
Until now, in facial plastic and reconstructive surgery, we have
had a relatively limited understanding of the effect of facial
deformities and abnormalities on visual distraction and fa-
cial perception. Previously, we had accepted the general te-
net that faces with abnormalities are less attractive and less
“normal,” and that our surgical procedures restore attractive-
ness and normality; however, these ideas have been based on
limited objective evidence. Furthermore, we have relied pri-
marily on the subjective perceptions of experts and the pa-
tients themselves to inform our ideas on these paradigms of
attractiveness and normalcy, inadequately assessing the per-
ceptions of casual observers.
Only recently have we begun to formally attempt to measure
the effect of facial deformities from the perspective of casual ob-
servers. The importance of measuring this effect lies in part in
the fact that, for many people, one of their greatest concerns is
how they think others, particularly strangers, are viewing them.
In a survey of patients with head and neck cancer, patients noted
that of greatest concern to them was how they would be per-
ceived by others once they had a deformity.2 Patients with new
facial deformities or abnormalities report changing their social
habits to avoid encountering strangers or even family and friends.
Furthermore, we facial plastic and reconstructive surgeons per-
form cosmetic and reconstructive procedures intrinsically be-
lieving, along with the patients, that our procedure will restore
a more attractive and normal appearance to our patients so they
can engage more effectively in society.
Significant progress has been made in recent years in sub-
jectively and/or objectively measuring the perception of the
casual observer of facial deformities or abnormalities, includ-
ing the “abnormality” of the aging face. In a 2013 survey study
by Zimm et al,3 patients who had undergone surgical proce-
dures for aging faces were perceived to be younger than their
actual age. An objective line of investigation using eye track-
ing has developed based on the foundation of normal face view-
ing, first described by Walker-Smith et al4 in the 1970s. Eye
movements are a surrogate for attention, so, by measuring eye
movements, one has insight into where an observer is direct-
ing attention. In their seminal work, Walker-Smith et al dem-
onstrated that casual observers gazing on novel faces do so in
a highly conserved manner, directing the majority of atten-
tion to the central triangle region in a manner measurable using
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 fa-
cial gaze patterns deviate from the normal, highly conserved
pattern in the presence of deformities. This method 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 demon-
strated how observers then perceive attractiveness,7 affect
display,8 and willingness to engage in conversation, based on
the distraction of the deformity. Furthermore, these findings
have been extended to show the effect of surgical reconstruc-
tion on these visual distractions and changes in perception.6
In their novel application, Litschel et al1 first measure how
casual observers gaze on faces of children with protruding ears,
and then measure gaze patterns after a surgical simulation,
using software to morph protruding ears into normal-
appearing ears. They correlate the changes in eye gaze by an
observer with changes in perception of the faces before and

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