Refocusing the Surgical Lens for Ear Reconstruction: Understanding Lay Perception of Ear Asymmetry

Objective Ear reconstruction principles center on restoring a natural-appearing ear that does not draw visual attention. However, limited objective evidence exists defining which auricular differences are most perceptible. This study evaluated layperson perception of ear asymmetries to identify characteristics that influence visual attention. Design Experimental survey study using digitally manipulated standardized facial photographs. Setting Online crowdsourcing platform. Participants Six standardized facial identities were digitally modified. A total of 550 adult participants evaluated 50 randomized stimuli. Interventions Baseline ears were digitally symmetrized, followed by unilateral modifications across graded magnitude levels of 4 auricular characteristics: contour/definition, projection, size, and vertical position, generating 138 experimental stimuli. Main Outcome Measure(s) Proportion of responses identifying the ears as an attention-drawing feature, and predictors of ear selection as attention-drawing evaluated with generalized linear mixed-effects models. Results Across experimental stimuli, ears were selected as attention-drawing in 3.8% of responses. The highest rates of ear selection occurred with +10% vertical displacement (32.1%), +15% size increase (22.9%), and −10% vertical displacement (21.5%). In mixed-effects models, increasing vertical position magnitude was significantly associated with higher odds of ear selection (odds ratio [OR]: 1.041, P = .004), followed by size magnitude (OR: 1.017, P = .018). Projection ( P = .91) and contour/definition ( P = .168) were not significant predictors of ear selection. Conclusion Ear asymmetries were infrequently identified as attention-drawing during frontal face viewing, even at larger magnitudes of deviation. Vertical position and size were the most salient. These results may inform reconstructive planning, counseling, and expectation-setting regarding how postoperative ear asymmetries are perceived.