The art of creating an illusion is normally assigned to magicians or to illusionists of small and big stages around the world when they cut their assistants in half or have white doves emerge from their hats.
After watching sufficient debunking videos on social media, it is clear that their performances are not unexplainable magic guided by supernatural forces which do not follow the laws of physics. Instead, the observed tricks are the result of hard work, hours and hours of practice, and a great amount of knowledge of human attention span and attention direction.
Of course, manual skills are required and a nifty usage of small pieces of technology which are not obvious to the eyes of the observer. But at the end of the day even magicians and illusionists cannot escape the laws of physics which is not a bad thing to know.
In aesthetic medicine something similar can be achieved and its foundations are based on the deep understanding of human facial recognition.
Since a couple of years, an injection technique has emerged from China which can slim the face by adding volume behind the ear, resulting in the clinical effect of lateralizing the auricle. The health care provider injects soft tissue filler material into the supraperiosteal plane of the mastoid process directly behind the auricle, which then pushes the auricle away from the bone achieving the opposite effect of an otoplasty; an otoplasty is the surgical removal of auricular cartilage to re-align and re-shape the position of the auricle following auricular deformities or auricular mispositioning.
This injection-related outcome is using the rheologic characteristics of the injected soft tissue filler as a wedge to re-position the ear toward a more lateralized position.
Now, most of you might ask: Why would someone want their ears to be more lateralized and look like Dumbo the elephant (nothing against this tiny, cute little elephant - who, by the way, traumatized my entire childhood when he was separated from his mother)? Meanwhile, others spend money to have their ears aligned in order to avoid scrutiny from others, especially since children at a young age often fall victim to bullying because of their ear position.
This was a question that our research group also asked and as all of you know the only way to answer such a question is to conduct a clinical investigative study to find out what the clinical merit of such an injection technique is.
Here is what was done: 30 Chinese patients (29 females, 1 male) were evaluated based on their 2D frontal full-face images after they were injected with 4 cc of high G-prime product behind each auricle resulting in the total administration of 8 cc per patient.
The clinical result of this injection procedure was the bilateral lateralization of their auricles. The 2D frontal images were taken before the treatment and approximately 3 months later (2.73 (2.0) months) resulting in a total of 60 images for the entire study sample. These 60 images were randomized to the sequence of when they were taken and sent out to 14 independent international reviewers without any additional information about the patients.
These reviewers were experts of aesthetic procedures with at least 7 years of experience of which nine were plastic surgeons, three were dermatologists, one was a general surgeon, and one was a radiologist. None of the expert reviewers knew which image was the before or after treatment image but were tasked to rate various criteria like facial attractiveness, facial unattractiveness, the age of the patient, and various facial regional scores, based solely on the images provided.
The results surprised all of us because they were not expected but confirmed why this injection technique is so popular in Asian countries. The 14 blinded reviewers stated that after the auricles were lateralized the faces were more attractive, less unattractive, and appeared to be in their 20s and not in their 30s (= the real age of the patients was on average 37.70 (9.4) years).
All evaluated regional facial aesthetic scores improved but reached statistical significance (= scientific measure of true change) only for the improvement of the nasolabial fold but not for scores like facial shape, facial fullness, temporal volume, midfacial volume, or jawline contouring.
In other words, the overall perception of the face improved on scientifically measurable level after the treatment but not the facial regional scores. And this is interesting because the expert reviewers did not know which image was the before and which image was the after the treatment image.
These results make sense when understanding that human facial perception is a two-stage approach: First, we are analyzing the facial outline and only in a second step are we looking at details. Lateralizing the auricles improved the overall perception of facial attractiveness and the perceived age of the study subjects but did not really influence the perception of small regional changes like the temple, the midface, or the jawline even though the severity of the nasolabial fold received a substantially improved rating. Therefore, the performed injection technique did exactly what it should: it changed the perception of the facial outline.
But how does lateralizing the auricle do that?
By lateralizing the auricles, the face appears in relation to the outline slimmer and narrower because facial perception does not work with absolute numbers but works instead with proportions. Imagine that your facial outline is a circle which surrounds the head, the ears, and the neck and within that circle there is another circle with represents the face itself and includes the forehead, the cheeks, the jawline and the chin: outer circle vs. inner circle.
If the ears are more lateralized the outer circle appears larger and the distance to the inner circle increases. This increase in distance between these 2 circles creates the illusion that the inner circle is smaller. This results clinically in the observed changes of the face even though the face was not treated (only the postauricular region was injected). By changing the facial outline (= outer circle), the inner circle appears in relationship smaller; and this is very much desired in Asian communities which by default have wider and fuller faces; and this is what the expert reviewers confirmed in their blinded rating.
The criticism of this injection technique is justified and should be mentioned here.
The conducted study was a verification study to find out if this injection technique has any measurable effect or if the results are pure illusion and the effect of a magic trick. This study was not intended to promote this technique nor to animate injectors to try this technique in their patients.
However, the results have revealed that this post-auricular injection technique has a scientifically reproducible effect which is based on human facial perception and ultimately follows the laws of physics and science. Understanding how we perceive faces is important in that it can support our clinical decision making and can guide us to discover new and safer ways of how we can support aesthetic patients and address their needs.
This research study was published in the August 2025 edition of the Aesthetic Plastic Surgery Journal under the following doi: 10.1007/s00266-025-05154-7
Reference link: https://link.springer.com/article/10.1007/s00266-025-05154-7
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