Where Do We Look? Assessing Gaze Patterns in Cosmetic Facelift Surgery with Eye Tracking Technology

Purpose: Aesthetics plays a central role in determining success in plastic and reconstructive surgery, particularly following cosmetic surgery. As such, understanding perceptions of favorable aesthetics following cosmetic procedures is critical to ensure patient satisfaction. Eye-tracking technology offers an unbiased way to evaluate attention and understand how viewers direct their focus in patients who undergo such procedures.

Methods: Thirty-six subjects with plastic surgery experience ranging from layperson to attending plastic surgeon were shown 15 sets of photos before and after patients underwent an elective facelift procedure. They were instructed to examine and evaluate the overall aesthetic quality on a 1-to-10 Likert scale, while eye-tracking equipment from Tobii Technology was used to track their gaze and analyze the distribution of attention during the viewing task. Ten areas of interest (AOIs) were pre-defined for analysis: eyes (2), cheeks (2), chin (2), neck (2), nose, and mouth. The primary metrics evaluated were the fixation duration, fixation location, fixation count, and time to first fixation.

Results: Post-operative images showed an average Likert score improvement of 0.51±0.26 points, with the greatest inter-group difference seen in attending cosmetic plastic surgeons (1.36±0.22; p<0.05). Plastic surgery residents demonstrated the longest time to first fixation (0.64±0.35 seconds), while laypersons demonstrated the shortest time to first fixation (0.21±0.16 seconds); attending cosmetic plastic surgeons’ times were intermediate (0.32±0.26 seconds). The nose was the most common location of first fixation for all subjects (31% of all first fixations) and was also the most viewed area (16±3% of all fixations), while AOIs relevant to facelift procedures (cheeks, chin, and neck) received 19±4% of all fixations in both pre-operative and post-operative images. Experienced surgeons spent less time in non-relevant AOIs (30±11% for attending cosmetic surgeons and 37±10% for attending non-cosmetic plastic surgeons) compared to subjects with less experience (50±15% for laypersons and 48±11% for medical students)

Conclusions: Eye tracking provides an objective way to evaluate viewers’ attention and correlate gaze data metrics with clinical aesthetic outcomes. This study suggests that viewers with greater experience in cosmetic surgery tend to focus more quickly on areas of interest relevant to facelifts, such as the cheeks, chin, and neck and have a more evenly distributed gaze pattern across the entire face. Conversely, layperson assessments of aesthetic outcomes may largely be driven by the first facial feature that catches their attention, which most frequently tends to be the nose. Given the emphasis on visual aesthetics in cosmetic plastic surgery, our results suggest that visual gaze can be a useful adjunct in educating patients undergoing facelift procedures on the potential range of aesthetic outcomes.