Discussion: Analysis of the Visual Perception of Female Breast Aesthetics and Symmetry: An Eye-Tracking Study.

www.PRSJournal.com 1267 I this study, the authors used eye-tracking technology to assess the gazing patterns of 100 laypersons that included 50 men and 50 women as they looked at digital images of eight different female breasts that included frontal, lateral, and oblique views.1 Each breast image was divided into several areas of interest that included the nippleareola complex, breast quadrants, neck, clavicular region, sternal region, and inframammary fold. The observers were told to assess breast aesthetics and symmetry on a scale ranging from 1 to 10. Eye-tracking technology was used for each participant; however, the true purpose of the eye tracking was not revealed until after the study was completed. The observers assessed each image for 30 seconds before going on to the next image. During this time interval, visual gaze data were accrued and included the duration of gaze and the number of times their gaze was directed at a particular area of interest. Findings included no difference in the mean duration of gaze for each image between the men and women, with a range of 21.21 to 22.08 seconds. The remainder of the 30 seconds was spent on blinking and saccadic eye movements. The authors found that, for both groups, the longest fixation duration and the highest fixation number were recorded for lower breast regions and the nipple-areola complex. I believe that this is a fascinating study for several reasons. First, it demonstrates that eye tracking can provide useful information during object analysis. Previous work has validated eye tracking based on oculomotor metrics including fixation frequency and duration, saccade variation, eye blink, and pupil diameter.2 Second, it demonstrates that men and women tend to focus on the same areas of the breast without gender disparity. It is not surprising that the nipple-areola complex had the highest gaze duration, as this is the focal point of the breast and usually the reference point for symmetry. Third, I applaud the authors for including the lay public as the principal subjects because this established a true baseline without inherent bias. Had the observers been plastic surgeons, the gaze patterns may have been different because of inherent bias as to the parameters that constitute an ideal breast. Finally, I believe that this study will be extremely useful moving forward as we try to better understand patient expectations in the preoperative setting. It is this point that I will further elaborate on. One of the most frustrating aspects of aesthetic and reconstructive breast surgery is performing an operation in which the plastic surgeon is happy with the result, but the patient is not. We all appreciate that “setting” patient expectations preoperatively is important; however, truly “understanding” patient expectations is critical. How a plastic surgeon sees the breast may be completely different than how a patient sees her breast. Having knowledge of this disparity preoperatively may serve as validation to proceed with surgery or to raise a “red flag” and prompt the plastic surgeon to reconsider the operative strategy or decline surgery altogether. Studies have demonstrated the incidence of body dysmorphic disorder in breast reconstruction patients to be 17 percent compared to 2 percent for the general population.3 If there was a mechanism with which to identify these patients more accurately, specific insights could be obtained to help ensure that expectations are understood and realistic from the patient’s and the plastic surgeon’s perspectives. Future applications for this technology could be for patients who are identified preoperatively with body dysmorphic disorder. By using eyetracking technology focused on a digital image of their own breast, the specific areas of interest could be tracked and analyzed. Knowing exactly what areas of the breast a patient is focused on