Dey, Jacob K

Eye-tracking provides an objective measure of how observers direct visual attention to presented stimuli and has become an increasingly valuable tool in facial plastic surgery. It offers unique insight into how facial conditions and surgical interventions impact facial attention. A well-designed eye-tracking study can address patient questions about how others look at their face, identify targets for visual improvement, and objectively assess facial plastic surgery outcomes. Significant variability exists in eye-tracking study design and execution within facial plastic surgery, often producing data that are erroneous, difficult to interpret, or not generalizable to clinical practice. There are currently no guidelines for the design of eye-tracking studies in facial plastic surgery. Furthermore, the technical requirements for facial eye-tracking studies differ from those for non-facial studies. This article aims to synthesize the existing literature and authors’ experience to establish basic guidelines for designing eye-tracking studies in facial plastic surgery. We hope this guide will help investigators design high-quality eye-tracking studies to drive meaningful advances in the field of facial plastic surgery.

Background: Facial nerve injury can result in a spectrum of clinical presentations from complete facial paralysis (CFP) to facial synkinesis. Willingness to pay (WTP) and quality-adjusted life years are established metrics used to assess the societal value of treatments. Objective: To quantify the perceived value of surgery for CFP and synkinesis amongst casual observers, as measured by WTP and quality of life indices. Methods: Casual observers were shown standardized videos of faces with complete paralysis, synkinesis, and nonparalyzed controls (eight videos each). Observers were asked to imagine having each condition and to rate their quality of life and WTP for surgical repair. Results: A total of 557 observers were included (mean age 36.5 years, 59% female). Both complete paralysis and synkinesis were associated with reduced quality-adjusted life year indices (0.9 [95% confidence interval [CI] 0.87–0.93]) for synkinesis; 0.86 (95% CI: 0.83–0.89) for complete paralysis, p = 0.0011). The mean WTP was $22,791 for complete flaccid paralysis and $15,718 for synkinesis repair and increased with income. WTP per quality-adjusted-life year gained was $6,844 for complete paralysis and $6,604 for synkinesis ( p > 0.05). Conclusion: Observers perceived surgical repair of CFP and synkinesis as highly valuable and within common cost-effectiveness thresholds.

Background: Variable terminology is used in the literature to describe facial synkinesis and hypertonicity following incomplete recovery from facial paralysis and its associated medical and surgical treatments. Study Objectives: Establish a nomenclature consensus for this condition among a group of facial nerve experts. Design Type: Consensus study. Methods: Using modified Delphi methodology, an international, multidisciplinary group of facial nerve experts reviewed the terminology for the name of the clinical condition and treatments of interest. Online surveys and a virtual discussion were performed to establish consensus, defined a priori as agreement by 80% of the group. Results: Twenty-five facial nerve experts established consensus after three Delphi rounds. Consensus terminology for the condition is “facial synkinesis” with 84% agreement. Medical treatment is termed “chemodenervation” with 100% agreement. Surgical treatments including “selective facial neurectomy,” “selective facial neurotomy,” “selective facial myectomy,” and “selective facial myotomy,” were defined and reached agreement of 100%. Conclusions: This international group of facial nerve experts has recommended standardized nomenclature for the condition of facial synkinesis and its various treatments. While “facial synkinesis” reached consensus as the preferred term, some experts noted it may insufficiently describe the full clinical spectrum, which includes muscle hypertonicity, weakness, and spontaneous twitching.

Background: There is a spectrum of facial paralysis patient presentations from complete flaccid facial paralysis (CFFP) to facial aberrant reinnervation syndrome (FARS). Objective: To objectively compare how laypersons direct attention to faces with different facial paralysis subtypes using eye-tracking technology. Methods: Lay observers freely gazed at standardized videos of 24 individuals’ faces as follows: 8 with CFFP, 8 with FARS, and 8 nonparalyzed Controls performing common facial expressions. Eye-tracking measured observers’ gaze and extracted data as time in milliseconds looking at facial subsites. Mixed effects regression was used for comparative analyses. Results: A total of 85 observers completed the study. For faces at rest, measurable differences in gaze patterns were noted for CFFP faces (more attention spent on nonparalyzed hemiface), whereas FARS and Control faces showed similar symmetric gaze patterns. With dynamic movement (smiling and brow-elevation), gaze patterns for both CFFP and FARS faces became altered and asymmetrical compared with Control faces. Conclusions: Faces with CFFP and FARS are viewed differently by casual observers, which has implications for patient care and future research. While CFFP showed gaze alterations (compared with Control) in both rest and facial expression states, FARS caused gaze alterations only with facial movement.

BackgroundObjective, controlled eye‐tracking measurement of gaze patterns during layperson evaluation of facial attractiveness is currently lacking.ObjectivesTo objectively investigate (1) where on the face laypeople direct their attention when assessing attractiveness compared with a control group, and (2) whether increased fixation on certain facial regions is associated with high attractiveness ratings.MethodsLay observers viewed a cohort of 40 faces with a diverse age, sex, and racial distribution. Observers were either allowed to free‐gaze without a specific task or rate facial attractiveness for 10 seconds per face while their gaze was recorded by an eye‐tracking system.ResultsForty‐seven observers assessed facial attractiveness (mean age 35.1 years (range 21–76), 62% female) and 57 observers free‐gazed at the facial photos without a specific task (mean age 35.5 years (range 22–66), 54% female). Preliminary analysis showed that sex of both the face and observer substantially influence gaze‐attractiveness associations (p < 0.05). Mixed effects analysis suggests that when males assessed female facial attractiveness, increased fixation time at the mouth correlated most strongly with high attractiveness (p = 0.001), whereas when females assessed male faces, increased fixation at the eyes (p < 0.001) and hair (p = 0.002) were most strongly associated with high ratings of attractiveness.ConclusionsIncreased gaze at the mouth in females and eyes and hair in males is associated with significantly higher ratings of attractiveness by observers of the opposite sex. Practitioners may want to pay special attention to these areas when designing an evidence‐based aesthetic treatment plan.Level of EvidenceNA Laryngoscope, 135:1995–2002, 2025

Background: Facial aberrant reinnervation syndrome is characterized by aberrant facial muscle reinnervation after facial nerve injury producing facial synkinesis, hypertonicity, and muscle spasm. Objective: To systematically review the surgical treatments for facial aberrant reinnervation syndrome and assess their effectiveness as measured by patient-reported outcomes, physician-graded outcomes, or computer-automated grading systems. Methods: We conducted a systematic review using PubMed, Embase, and Cochrane CENTRAL in accordance with PRISMA guidelines. Texts reporting outcomes of any surgical treatment for facial aberrant reinnervation syndrome from 2003 to 2023 were included. Results: After screening, 25 studies with 731 patients were included. Surgical procedures included selective neurectomy (SN), selective myectomy (SM), cross-facial nerve graft, masseter nerve transfer, and gracilis muscle transfer. All surgical techniques and combinations showed significant improvement in at least one clinical outcome measure from baseline ( p < 0.05), although one study found no significant improvement. Thirty different outcome measures were used, the most common being the FaCE and eFACE scales (seven studies each). Conclusions: All surgical procedures in this review yield improved clinical outcome measures for facial aberrant reinnervation syndrome, with SN and SM being the dominant surgical treatments. Standardized outcome assessment and more nuanced patient evaluation are necessary to determine the most effective surgical treatments.

A common sequela of peripheral nerve injury is aberrant regeneration and recovery. Aberrant regeneration of injured motor nerves can affect all aspects of the nerve circuit from the motor cortex to the target muscle. A more comprehensive term for the symptoms that develop after aberrant motor neuromuscular reinnervation is aberrant reinnervation syndrome (ARS). Injury to the facial nerve followed by aberrant reinnervation results in a spectrum of symptoms that has been called many things in the literature. The authors support that this commonly encountered sequela of facial nerve injury be called facial aberrant reinnervation syndrome (FARS), a term that is more descriptive of the underlying pathophysiology and more inclusive of the clinical symptoms: facial synkinesis, facial muscle hypertonicity, and facial muscle spasm/twitching, which occur following facial nerve injury and recovery. In the following article, we present the clinical manifestations and sequelae of facial nerve injury and recovery and briefly discuss our evolving understanding of the pathophysiology and treatment of FARS.

Background: Objective measurement of where observers direct their attention to faces when searching for signs of facial plastic surgery (FPS) is currently lacking. Objective: To compare where laypersons direct their attention on facial photographs using eye-tracking software when they are asked to (1) search for signs of aesthetic facial surgery or (2) allowed to gaze without direction (free-gaze). Methods: Naïve observers either free-gazed or examined faces for signs of FPS (FPS-prompted) for 10 s per face while their gaze was recorded by an eye-tracking system. Faces had no known history or signs/stigmata of FPS and were selected from the FACES and CFD databases with a diverse demographic distribution. Gaze times in nine facial subregions were analyzed using mixed-effects linear regression. Results: In FPS-prompted observers ( n = 50, mean age 32.7 ± 11.3 years, 23/50 (46%) female), the nose, mouth, cheeks, and forehead experienced the most substantial increases ( p < 0.001) and a high percentage of overall gaze time (17.9%, 12.5%, 12.0%, 9.6%, respectively) compared to free-gazing observers [ n = 57, 35.5 ± 13.9 years, 31/57 (54%) female]. Conclusions: Observers direct attention differently on a face when searching for signs of plastic surgery with increased attention on the nose, mouth, cheeks, and forehead.

Background Septoplasty is used to correct nasal obstruction from nasal septum deviation. However, the long‐term efficacy of septoplasty is unclear, and no literature reviews have examined long‐term outcomes of septoplasty with or without turbinate modification. This systematic review aimed to evaluate the long‐term efficacy of septoplasty with or without turbinate modification in improving nasal obstruction. Data Sources PubMed, EMBASE, Cochrane CENTRAL. Methods A systematic review of the literature was conducted using the aforementioned databases. Studies reporting outcomes 12+ months after functional septoplasty with or without turbinate surgery for nasal obstruction were included. Septorhinoplasties, concurrent sinus surgery, pediatric studies, and studies where septoplasty was performed for indications other than nasal obstruction were excluded. Results After screening, 35 studies with 4,432 patients were included. Mean weighted post‐operative follow‐up time was 29.1 months (range 12–120 months). All studies reported significant improvement in subjective and objective outcomes at long‐term follow‐up compared to baseline. When comparing short‐term (<12 months) to long‐term (≥12 months) outcomes, four studies noticed that subjective outcomes worsened slightly over time, but no study found a significant change in objective outcomes over time. In addition, 23 studies reported patient satisfaction and/or improvement rates, with 75.4% (2,348/3,113) of patients expressing satisfaction/improvement at an average of 27.0 months after surgery. Conclusions Overall, septoplasty with or without turbinate modification shows significant improvement in obstructive symptoms at long‐term follow‐up per both objective and subjective measures. Whether outcomes may worsen slightly over time remains indeterminate based on mixed results in the literature. Level of Evidence N/A Laryngoscope , 134:2525–2537, 2024