Psychosocial outcomes derived from an acid burned population in Bangladesh, and comparison with Western norms

Spectrum of vitriolage in India: A retrospective data record-based study

Introduction

Vitriolage or acid attack or acid throwing is a gender-based terrible violent crime. There are many everlasting sequels of vitriolage which consist of permanent scarring of the face or body, blindness as well as socioeconomic and psychological intricacy. The sufferer of acid attack is competitor, hatred, enmity or jealousy. Vitriolage are most common in the Asian countries especially in south east Asian region followed by Europe and South America. Bangladesh, India, Pakistan, Colombia and Cambodia are the countries having the highest incidence of acid attacks. There is a sharp rise in vitriolage cases in India in the last few years as indicated by data from the National Crime Record Bureau (NCRB). Seventy per cent victims of vitriolage are women in India as indicated by the annual reports of the Acid Survivor Foundation.

Aims and Objective

The aim of the study was to report incidence of acid attacks in India, Indian states and metropolitan cities. To analyse various police and court procedure and to discuss various steps to give justice to the victim of vitriolage.

Materials and Methods

Present study is a retrospective data record-based study. Available data for the last 5 years (from 2017 to 2021) were taken from National Crime Report Bureau (NCRB). Available as per NCRB, data were analysed as per aims and objectives.

Results

The trend of incidence of acid attacks in India was decreasing in the last 5 years, that is, the incidence was 244 in the year 2017 which become 176 in the year 2021. West Bengal and Uttar Pradesh were the states having the highest number of acid attack incidence during the last 5 years. Delhi city was the top most metropolitan city having the highest acid attack incidence in the last 5 years. Police investigation of cases of acid attacks against women and cases disposed of by the police decreased in the last 5 years. The chargesheeting rate was better in metropolitan cities than overall chargesheeting in India. There was an increased trial of cases of acid attacks against women and a decrease in cases disposed of by the court during the last 5 years. Conviction rate by the court was better in India than the metropolitan cities of India during the last 5 years. Case acquitted by the court in India was 24, 9, 10, 4 and 10, and in metropolitan cities it was 2, 1, 3, 0 and 2 during year 2017, 2018, 2019, 2020 and 2021, respectively.

Conclusion

Vitriolage not only destroys physical health but also destroys mental health. Despite of strict action taken by the Indian government, vitriolage is still prevalent in India. Male dominancy and inadequate legal systems are responsible for this. Though there is a standard set by the Supreme Court for the sale of acid, it remains easily available as the guidelines are frequently violated by the preparator. Case investigation and chargesheeting should increase by the police. Trial of the case and conviction should increase by the court. Vitriolage victims must be sure of their scope to obtain education and job opportunity and societal fiction should be reviewed to support people to acknowledge why vitriolage is committed mainly against females.

A Medical-Legal and Psychological Systematic Review on Vitriolage Related to Gender-Based Violence

Attacks perpetrated using acid are a particular form of interpersonal violence, possibly one of the most heinous manifestations of Intimate Partner Violence (IPV). Acid attacks are mainly motivated by extramarital cheating, marital conflicts, women's rejection of marriage proposals, and sexual advances. As these attacks are not well understood from a psychological perspective, we conducted a systematic review, following Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, of 284 articles identified, 13 were eligible for inclusion. Three main focuses were identified: "Risk and vulnerability factors," "Consequences and implications," and "Interventions and treatments." Acid attacks seem to be more frequent in countries where social and economic development leads to greater tensions over traditional gender roles like Bangladesh, Pakistan, and India. Identified risk factors were young age, low socioeconomic status, low educational attainment, ethnicity, unemployment status of the victim, alcohol, and drug use of the perpetrator. Among the main psychosocial consequences of acid attacks, isolation and social exclusion emerged. Additionally, the paper will discuss the role of mental health consequences and specific treatments from psychological, clinical, and medical-legal points of view.

Issues and problems involving acid attacks against male victims in India

Acid attacks involve dousing a victim with a concentrated acidic or caustic fluid. The head and face are most often targeted to maximize the chances of disfigurement, as the intention is usually to cause life-long disability, pain and lack of psychological wellbeing rather than death. In India it is often regarded as a form of gender-based violence aimed predominantly at women, frequently following the rejection of a proposed sexual relationship, however, a significant subset of cases involve males. Four cases are reported to demonstrate the different reasons for such attacks in males including revenge for reporting criminal activity, intra-familial disputes and apparently random episodes. Male acid attack victims may represent an over-looked subgroup that often does not receive adequate compensation or government support to access disability services, despite this being mandated by recent legislation.

Translation and psychometric validation of the Finnish version of the Patient Scar Assessment Scale for use in patients with burn scars

BACKGROUND

The aim of this study was to create a Finnish scar assessment scale by translating and evaluating the psychometric properties of the Patient Scar Assessment Scale (PSAS), a part of the Patient and Observer Scar Assessment Scale (POSAS), with burn patients to enable its use in burn care.

METHODS

The translation process followed international guidelines with forward and backward translations and cognitive debriefing with patients. Psychometric validation was performed with adult patients with burns who had been treated at the Helsinki Burn Centre between 2006 and 2017 with skin grafting following the excision of deep second- or third-degree burns. To ensure reproducibility, the PSAS was sent to the study participants twice. The correlation between the PSAS and health-related quality of life (HRQL) was also tested.

RESULTS

In total, 192 patients, of whom 71 % were male, participated in this study. The mean (SD) age of the participants was 57 (17) years. The internal consistency of the PSAS was good, Cronbach's α 0.89 (95 % CI: 0.86-0.91). The reproducibility was also good concerning all items and the total score, ICC from 0.77 to 0.89. As expected, the total PSAS score correlated negatively with HRQL.

CONCLUSION

The PSAS was successfully translated and culturally adapted into Finnish and the newly translated version has good validity and reproducibility for assessing mature burn scars.

Applying Socioecological Framework to Acid Attack Violence: An Exploration of Inhabitant Factors

This study focused on the phenomenon of acid attack violence by using the socioecological framework. It explored the personal, relational, institutional, and cultural factors that contribute toward the act of acid violence. By using the qualitative research design, 15 in-depth interviews were conducted from acid victims. Thematic analysis was used to analyze the data. The main themes under the framework of social ecology focused on certain inhabitant aspects such as prevailing poverty, forced marriages, conflicting relationships, lack of social support, the falsified religious interpretation of violence, lack of medical assistance, and poor response of law enforcement agencies. This lack of social support is extended at an institutional level as well as where rehabilitative help and response were absent. This study concluded the complexity and interdependence of all levels factors contribute to the act of acid violence. Moreover, it emphasized the need to develop a biopsychosocial approach to address the issue.

The severity of facial burns, dental caries, periodontal disease, and oral hygiene impact oral health-related quality of life of burns victims in Pakistan: a cross-sectional study

Background

A burn to the face and neck area leaves a visible scar that impacts the victims physically and psychologically. This report was aimed to examine the factors associated with oral health-related quality of life (OHRQoL) in patients with a facial burn injury.

Methods

Patients with facial burn who attended the Burn Care Centre in Islamabad, Pakistan were systematically and randomly invited to participate in this cross-sectional study. They underwent extra- and intra-oral examinations and, completed self-administered instruments in the Urdu language. The severity of disfigurement, dental caries experience (DMFT), periodontal disease (CPI) and oral hygiene (OHI-S) statuses were assessed. The validated instruments collected information relating to sociodemographic background, oral health behaviours, OHRQoL and satisfaction with appearance (SWAP). Information relating to the time of the incident, cause and severity (type, TBSA) of the burn were obtained from medical records. The OHRQoL prevalence of impact and severity measures were derived and analysed using simple and multiple, logistic and linear regression.

Results

A total of 271 patients had participated in the study. The OHIP-14 prevalence of impact was 94% with mean severity score = 37 unit (sd = 8.5). The most impacted domains were physical pain (87%), psychological disability (87%), social disability (85%) and physical discomfort (83%). The main determinants of oral health-related quality of life were poor clinical oral conditions - particularly caries, and severity deformity. Other risk factors included poor oral health behaviours, psychological distress and longer time elapsed since the incident, and sex (p < 0.05).

Conclusion

Dental caries, the severity of the facial deformity, oral health behaviour and time are associated with oral health-related quality of life of patients with facial burns. Oral health behaviour improvement can lower the risk of developing dental problems and oral health-related quality of life impact.

The relationship between psychosocial distress and oral health status in patients with facial burns and mediation by oral health behaviour

BACKGROUND

There is limited discussion on the influence of psychosocial factors on the oral health of patients with a facial burn injury. This report investigated the relationship between oral health and psychosocial distress in patients with facial burns and the role of oral health behaviour in mediating the relationship.

METHODS

The data were part of a cross-sectional study that had systematically and randomly selected patients with > 10% total burn surface area from a burn centre in Pakistan. The oral health status (DMFT, CPI, OHI-S) and severity of facial disfigurement were assessed. Validated instruments in the Urdu language were self-administered and information relating to oral health behaviour (brushing and dental visits), oral health-related quality of life (OHIP-14), satisfaction with appearance, self-esteem, anxiety and depression, resilience, and social support were collected. The statistical analyses included simple linear regression, Pearson correlation, t-test, and ANOVA. Mediation analysis was carried out to examine the indirect effect by oral health behaviour.

RESULTS

From a total of 271 participants, the majority had moderate to severe facial disfigurement (89%), low self-esteem (74.5%), and moderate to high levels of social support (95%). The level of satisfaction with appearance was low, whereas anxiety and depression were high. Disfigurement and satisfaction with appearance were associated with lower self-esteem and social support (p < 0.05). Greater severity of disfigurement, higher levels of anxiety and dissatisfaction with appearance, and lower levels of self-esteem and social support were associated with greater DMFT and OHIP-14 scores, worse periodontal and oral hygiene conditions, and less frequent tooth brushing and dental visits (p < 0.05). The main barriers to oral healthcare utilization were psychological and social issues (p < 0.05). The indirect effect by oral health behaviour was not significant for anxiety but was significant for disfigurement, satisfaction with appearance, self-esteem, and social support.

CONCLUSION

There is an association between the psychosocial factors and oral health of patients with facial burns through a direct effect and mediation by oral health behaviour.

A randomized controlled trial of a forgiveness intervention program with female acid attack survivors in Pakistan

Despite the traumatic effects of acid violence on its victims, treatment options are very limited. The present study was aimed at examining the efficacy of a forgiveness intervention with female survivors of acid attack violence in Pakistan. Female acid attack victims in Pakistan were randomized to either a forgiveness group (n = 8) or a treatment-as-usual (TAU; n = 8) control group. The forgiveness group received twice-a-week forgiveness sessions for 4 months, whereas the TAU group either received typical psychological treatment sessions for acid attack victims or no treatment. All participants were assessed on their levels of forgiveness, anger, anxiety, depression, and hope four times prior to the 4-month intervention period, twice after the intervention period, and once at the 1-year follow-up. Posttreatment, the forgiveness intervention group showed greater improvement in hope, anger, anxiety, and depression when compared with the TAU group. Upon further examinations, both groups improved on forgiveness from pretreatment to posttreatment, but the forgiveness group had a higher baseline. From pretreatment to the 12-month follow-up, the forgiveness group, when compared with the TAU group, showed greater improvement in all areas except for depression. This is the first study that examined the effects of a forgiveness intervention for acid attack victims in Pakistan. Results showing the improvement posttreatment as well as over a 1-year period posttreatment are encouraging.

Length of hospital stay and mortality associated with burns from assault: a retrospective study with inverse probability weighting analysis

Background

Burns resulting from assaults account for considerable morbidity and mortality among patients with burn injuries around the world. However, it is still unclear whether unfavorable clinical outcomes are associated primarily with the severity of the injuries. To elucidate the direct relationship between burns resulting from assaults and mortality and/or length of hospital stays, we performed this study with the hypothesis that burns from assault would be independently associated with fewer hospital-free days than would burns from other causes, regardless of the severity of burn injuries.

Methods

We conducted a retrospective cohort study, using a city-wide burn registry (1996-2017) accounting for 14 burn centers in Tokyo, Japan. Patients who arrived within 24 hours after injury were included, and those with self-inflicted burn injuries were excluded. Patients were divided into two groups according to mechanism of burns (assault vs. accident), and the number of hospital-free days until day 30 after injury (a composite of in-hospital death and hospital length of stay) was compared between the groups. To estimate the probability that an injury would be classified as an assault, we calculated propensity scores, using multivariate logistic regression analyses adjusted for known outcome predictors. We also performed an inverse probability weighting (IPW) analysis to compare adjusted numbers of hospital-free days.

Results

Of 7419 patients in the registry with burn injuries during the study period, 5119 patients were included in this study. Of these, 113 (2.2%) were injured as a result of assault; they had significantly fewer hospital-free days than did those with burns caused by accident (18 [27] vs. 24 [20] days; coefficient = [Formula: see text]3.4 [[Formula: see text]5.5 to [Formula: see text]1.3] days; p = 0.001). IPW analyses similarly revealed the independent association between assault burn injury and fewer hospital-free days (adjusted coefficient = [Formula: see text]0.6 [[Formula: see text]1.0 to [Formula: see text]0.1] days; p = 0.009).

Conclusions

Burn from assault was independently associated with fewer hospital-free days, regardless of the severity of burn injuries. The pathophysiological mechanism underlying the relationship should be further studied in a prospective observational study.

Corrosive attacks in the UK - Psychosocial perspectives and decontamination strategies

Acid attacks, or vitriolage, are defined as violent assaults involving the deliberate throwing of an acid or similarly corrosive substance with the intention to "maim, disfigure, torture or kill" [1]. The Acid Survivors Trust International suggest a prevalence of 1500 attacks reported worldwide per annum, although this is likely to be an underestimate by 40% [2]. The UK is thought to have one of the highest of rates of recorded corrosive attacks, with an increase from 228 attacks in 2012 to 601 in 2016. Most were reported by the London Metropolitan police force followed by Northumbria, Cambridgeshire, Hertfordshire, Greater Manchester and Humberside [[2]]. The chemical agents involved include acids, alkalis, oxidising and reducing agents, alkylating and chelating agents and solvents. They cause injury by producing a chemical interaction which can lead to extensive tissue destruction and extreme pain. Herein, we present a review on the changing epidemiology of corrosive attacks in the UK and currently employed management strategies.

Bringing research to the bedside: Knowledge translation in the mental health care of burns patients

Advances in surgical techniques and wound management have improved outcomes for burn patients; however, the psychological impacts on burn survivors have had less attention. There is a higher rate of mental health disorders amongst burns victims, with those with pre-existing mental health conditions likely to have worse outcomes. To implement effective burns care and rehabilitation, knowledge and understanding of mental health issues is required. This position paper discusses the extent to which clinicians currently translate knowledge around mental health and burns into practice to identify enables and inhibitors. Successful knowledge translation requires dissemination and accessibility of information with the capacity and readiness for change. Clinicians and researchers need to identify how translating research to practice can meet the needs of burn survivors. There is a gap in the utilization of evidence concerning mental health and the needs of burns survivors, and we need to understand what we know as compared to what we do. Clinicians are well placed to determine how and why knowledge does not necessarily translate to practice and how they can better accommodate the needs of burn survivors.

Acute chemical skin injuries in the United States: a review

The objective was to perform a thorough review of published and other available data to elucidate the extent of chemical skin injuries in the US. Chemical skin injuries differ significantly from skin lesions produced by other injury mechanisms, so this review was restricted to the former. Retrieval of relevant published data was performed in PubMed and Google. Other data were retrieved from the American College of Surgeons National Trauma Databank, American Burn Association National Burn Repository, US Department of Labor Bureau of Labor Statistics, websites of all 50 US States Departments of Health, and the National Poison Data System of the American Association of Poison Control Centers. Two areas of significance in disfiguring skin burn injuries and particularly of chemical skin injuries, psychosocial issues and the associated financial burden, have been briefly reviewed. Because of the paucity of published data, international as well as US data have been included. A brief description of an active flushing fluid as an alternative to potable water, Diphoterine^® solution, has also been included. Chemical skin injuries generally comprise approximately 2-5% of all skin burns, but sometimes higher percentages have been reported. Data analysis shows that while there are various sources regarding the epidemiology of chemical skin injuries, the total annual number cannot be determined because there is no centralized US national reporting mechanism. Literature and clinical experience demonstrate the importance of chemical skin injuries in USA. Dermal exposures to chemicals can result in mortality and morbidity. Chemical skin injuries can be avoided or ameliorated and preventive advanced measures should be taken to reduce or ameliorate them.

Narrative: The Fear of Disfigurement in Cancer Patients

Fear of disfigurement affects patients with cancer, in whom the disease or its treatment leaves them permanently marked. Contrary to our thought, disfigurement is equally distressing to male patients, and it causes severe dislocation in their lives. We describe two cases in which disfigurement caused tremendous change in our patients; these cases underline the need for psychotherapy in patients suffering from cancer.

The patient-body relationship and the "lived experience" of a facial burn injury: a phenomenological inquiry of early psychosocial adjustment

Background

Throughout development and into adulthood, a person’s face is the central focus for interpersonal communication, providing an important insight into one’s identity, age, sociocultural background, and emotional state. The face facilitates important social, including nonverbal, communication. Therefore, sustaining a severe burn, and in particular a facial burn, is a devastating and traumatizing injury. Burn survivors may encounter unique psychosocial problems and experience higher rates of psychosocial maladjustment, although there may be a number of potentially mediating factors.

Objectives

The purpose of this phenomenological study was to examine the early recovery experience of patients with a facial burn. In particular, this study focused on how the injury impacted on the participants’ relationship with their own body and the challenges of early psychosocial adjustment within the first 4 months of sustaining the injury.

Methods

In 2011, six adult participants encompassing two females and four males ranging from 29 to 55 years of age with superficial to deep dermal facial burns (with background burns of 0.8%–55% total body surface area) were recruited from a severe burn injury unit in Australia for participation in a Burns Modified Adult Attachment Interview. Narrative data were analyzed thematically and informed by Colaizzi’s method of data analysis.

Results

Three overarching themes emerged: relationship to self/other, coping, and meaning-making. Themes identified related to how the experience affected the participants’ sense of relationship with their own bodies and with others, as well as other challenges of early psychosocial adjustment. All participants indicated that they had experienced some early changes in their relationship with their body following their burn injury.

Conclusion

These findings highlight the struggle burn survivors experienced with postburn adjustment, but expressed altruism and optimism around their recovery. Past trauma was observed to be a significant finding in this sample. Understanding the “lived experience” supports the way clinical and family systems can foster positive adjustment and coping. Consequently, multidisciplinary burn teams and health care professionals need to understand the principles of trauma-informed care and translate these into practice in the treatment of this group of patients.

Assaults from corrosive substances and medico legal considerations in a large regional burn centre in the United Kingdom: calls for increased vigilance and enforced legislation

Burn injuries from corrosive substances have been recognised as a common method of assault in low and middle income countries (LMICs) motivated by various factors. Such injuries often leave survivors with severely debilitating physical and psychological injuries and scars. The number of reported cases of acid assaults within the United Kingdom (UK) appears to be on the rise. As one of the largest regional burn centres in the UK, we have reviewed our experience of chemical burns from assault. This study aims to: (1) review the demographics, incidence and patient outcomes; (2) evaluate the long-term psychosocial support provided; and (3) review current criminal litigation proceedings and preventative legislations in the UK specific to assault by corrosive substances. A 15-year retrospective review of 21 burn injuries from assault with corrosive substances presenting to a regional burn unit was conducted. Victims were mostly young men; male perpetrators were more common. The most common motive cited was assault. The most common anatomical region affected was the face and neck. The number of victims who pursue litigation is disproportionately lower than the number of total cases at presentation. In an effort to better understand the legal considerations surrounding such assaults, we also collaborated with lawyers experienced in this particular field. We hope that our work will help educate healthcare professionals regarding the legal assistance and existing laws available to protect these patients.

Acid violence in Cambodia: the human, medical and surgical implications

INTRODUCTION

Acid violence is the deliberate use of acid to attack another human being. Such attacks leave a terrible human, medical and surgical legacy. This study, from one of the largest cohorts of acid attack victims to date, provides insights into Cambodia's unique demographics of such attacks, as well as the human cost and necessary surgical interventions.

METHODS

A retrospective cohort consisting of all patients presenting to the Children's Surgical Centre, Phnom Penh with acid burns from 1 January 2000 to 1 January 2013 was identified and information retrieved from their hospital records.

RESULTS

254 patients were identified. Males and females were almost equally likely to be victims of an acid attack (48.4% and 51.6% respectively). There was no significant association between victim and assailant gender (p=0.475). The face (78.0%), neck (51.5%) and chest (49.0%) were the most frequently affected body areas. The median total surface body area affected by acid burns was 7.0%. The mortality rate from acid assault was 2.0%. Patients required an average of 2.0 operations, ranging from 0 to 18.

CONCLUSIONS

Acid violence in Cambodia has a complex demographic which is different to many other developing countries and requires more investigation. Tougher legislation is required to reduce the incidence of these horrific crimes.

Symptoms of posttraumatic stress, depression, and body image distress in female victims of physical and sexual assault: exploring integrated responses

While body image concerns and interpersonal violence exposure are significant issues for women, their interrelationship has rarely been explored. We examined the associations between severity of acute injuries, symptoms of posttraumatic stress disorder (PTSD), depression, and body image distress within a sample of predominantly African American victims of interpersonal violence (N = 73). Severity of body image distress was significantly associated with each outcome. Moreover, body image distress was a significant, unique predictor of depression but not PTSD severity. We recommend continued exploration of body image concerns to further integrated research on violence against women.

Defense mechanisms in congenital and acquired facial disfigurement: a clinical-empirical study

It is of clinical interest to investigate the degree to which patients with facial disfigurement use defense styles. Therefore, 59 adults born with rare facial clefts, 59 patients with facial deformities acquired at an adult age, and a reference group of 141 adults without facial disfigurements completed standardized questionnaires. There was a significant difference between the group with and the group without disfigurements on immature defense styles, with the disfigured group using the immature style more frequently. There was a trend for the nondisfigured group to use more mature defense styles. No difference between congenital and acquired groups was seen on individual types of defense style. Self-esteem had the strength to differentiate mature and immature defense styles within our disfigured groups. The association of low self-esteem and the utilization of immature defense styles suggests that professional help may tailor treatment on discussing immature defense style and problems triggering or maintaining this style.

Chemical assault and skin/eye burns: two representative cases, report from the Acid Survivors Foundation, and literature review

Chemical assault is a significant problem throughout the world, resulting in disfigurement, sometime blindness or vision impairment, and constituting a major economic burden on otherwise overwhelmed health services in developing countries. Two representative cases are presented here. One involved domestic spouse abuse with an acid and the second involved a teen-aged female assaulted with an acid, perhaps for retribution over a local judicial matter. Such atrocities have a world-wide scope, which is reviewed here. Preventive measures are the most appropriate response. However, when such chemical assaults do occur, active measures to mitigate or negate their effects deserve consideration.

Treatments for common psychiatric conditions among children and adolescents during acute rehabilitation and reintegration phases of burn injury

Advances in critical care and surgical management during the last 20 years have decreased mortality rates among children with severe burn injuries. This improved survival rate has prompted researchers to study the psychological aspects of recovering from a burn injury. Initially research focused primarily on epidemiology, prevention and descriptions of the psychological phenomenon experienced by the children and adolescents. Whereas previously interventions were often utilized during the acute phases of burn injury without knowledge of the long-term effects, more recently, priorities have shifted to include long-term treatment outcome studies. The purpose of this paper is to review and discuss the current evidence-based techniques and their efficacy in the treatment of common psychological and psychiatric conditions among children and adolescents during the three major phases of burn injury.

Psychological factors associated with response to maxillofacial injury and its treatment

PURPOSE

This study evaluated symptoms of acute stress disorder (ASD), satisfaction with appearance postsurgery, and satisfaction with care in patients with maxillofacial injury at their first postsurgical physician visit. To determine the best predictors of patients' ASD symptoms and satisfaction, data also were obtained on the patients' strategies for coping with the stress of the injury, on the patients' and doctors' interpersonal appraisals of each other, and on the doctors' participatory behavior during the visits.

PATIENTS AND METHODS

A total of 47 patients who had sustained traumatic maxillofacial injury requiring emergency medical/surgical treatment were administered self-report measures immediately before and after their first postsurgical visit 10 to 12 days after trauma exposure. Doctors completed self-report measures after the visit and evaluated the patients' severity of injury.

RESULTS

Patients experienced high levels of ASD in the short-term period after surgery. Use of emotion-focused strategies by patients to cope with stress was associated with more ASD symptoms but better satisfaction with facial appearance. The more severely injured patients were less satisfied with their appearance and were viewed by their doctors as being more interpersonally controlling during the postsurgical visit.

CONCLUSIONS

Closer attention by doctors to patients' interpersonal behavior may aid in early identification of those patients with maxillofacial injury who may experience longer-term social problems related to their altered facial appearance.