Layperson Bias and Empathy Influence Visual Attention Toward Patients with Hemifacial Microsomia: A Prospective Eye-tracking Study

Abstract

INTRODUCTION: Facial attractiveness influences our perceptions of others, with beautiful faces reaping societal rewards and anomalous faces encountering penalties. Previous work with functional magnetic resonance imaging (fMRI) has demonstrate implication of certain neuroanatomic structures in visual pathways when viewing others with facial anomalies. For example, laypersons with high levels of implicit bias toward those with facial anomalies demonstrated increased amygdala reactivity. This study aimed to characterize associations between visual attention patterns and implicit biases (attitudes toward groups of people without conscious awareness), explicit biases (attitudes toward groups of people with conscious awareness), and social dispositions toward people with facial anomalies. METHODS: Participants completed an implicit bias association test (IAT), an explicit bias questionnaire (EBQ), and several social disposition tests (e.g. empathic concern and perspective taking) prior to viewing publicly available images of pre- and postoperative patients with hemifacial microsomia (HFM). Eye-tracking was used to register visual fixations. Four areas of interest (AOIs) were defined on each face: cheek and ear, forehead and orbit, mandible and chin, and nose and lips. Linear mixed effects models (LMEMs) in R Studio tested whether locations of participant fixations were affected by surgical correction of HFM and influenced by IAT, EBQ, or social disposition scores. RESULTS: Sixty participants (38 women) were prospectively enrolled. LMEMs revealed participants with higher IAT scores fixated significantly less on the cheek and ear region preoperatively compared to postoperatively (β = 0.115, SE = 0.040, z = 2.855, p = 0.004). Participants with higher scores on empathic concern fixated more on the forehead and orbit preoperatively compared to postoperatively (β = -0.107, SE = 0.053, z = -2.007, p = 0.045) and participants with higher scores in perspective taking fixated more on the nose and lips (β = -0.085, SE = 0.038, z = -2.215, p = 0.027) preoperatively compared to postoperatively. EBQ scores and other social disposition scores did not significantly influence visual fixations in any AOIs based on better fit to the null models. CONCLUSION: Levels of biases, empathic concern, and other social dispositions may influence visual attention toward people with facial anomalies. Those with higher levels of implicit bias may avoid looking at anomalous anatomy, while those with higher levels of empathic concern and perspective taking do not show similar avoidance behaviors. These findings may have neural underpinnings with amygdala reactivity modulating visual activity in response to facial anomalies. This study has implications for the experience of patients with craniofacial anomalies and for characterizing neurologic mechanisms of the ‘beauty-is-good’ and ‘anomalous-is-bad’ biases.