Psychosocial impact of craniofacial deformities before and after reconstructive surgery

Genetic Aspects and Immune Responses in Covid-19: Important Organ Involvement

In the last two decades, the world has experienced outbreaks of three major coronaviruses with high morbidity and mortality rates. The most recent of these started in the form of an unusual viral pneumonia in Wuhan, China, and now the world is facing a serious pandemic. This new disease has been called COVID-19 and is caused by the SARS-CoV-2 virus. Understanding the specific genetic and phenotypic structure of SARS-CoV-2 in COVID-19 pathogenesis is vital in finding appropriate drugs and vaccines. With this in mind, this review sheds light on the virology, genetics, immune-responses, and mechanism of action of this virus.

Perceptions of Quality of Life among Face Transplant Recipients: A Qualitative Content Analysis

The aim of facial transplantation (FT) was to enhance quality of life (QoL) for individuals living with severe facial disfigurement. Yet QoL has proved challenging to assess, as the field lacks a unified approach for incorporating FT recipients’ perspectives into meaningful QoL measures. In this study, we review FT recipients’ self-reported QoL through a qualitative analysis of publicly available posttransplant interviews to identify the aspects of QoL they report as meaningful.

Long-Term Effect of Multiple Operations on Psychosocial Function in Teenage Cleft Lip and Palate Patients

BACKGROUND

Cleft lip and palate patients undergo a significant number of interventions during their childhood and adolescence. Although the intention of such interventions is to improve psychosocial functioning, there exists a paucity of data on the psychosocial outcomes of the burden of care on cleft children. In this work, the long-term effects of quantity and timing of childhood operations on teenagers with cleft lip and palate were evaluated.

METHODS

Cleft lip and palate patients (aged 14 to 17 years; n = 55) and an age-matched unaffected cohort (n = 14) prospectively enrolled from two institutions were administered the anger, anxiety, and depressive symptoms instruments from the Pediatric Patient-Reported Outcomes Measurement Information System. Total number of operations and operations stratified by age groups (0 to 7, 8 to 10, 11 to 13, and 14 to 17 years) were evaluated in relationship to instrument scores. Descriptive statistics, independent t tests, Pearson correlations, and multiple linear regression analyses were conducted.

RESULTS

No differences in overall psychosocial functioning were found between the cleft lip and palate and comparison groups. Total quantity of childhood operations did not correlate to psychosocial functioning of cleft lip and palate teenagers. However, multiple linear regression analyses demonstrated that increased number of operations in the 8- to 10-year-old age range predicted increased anxiety and depressive symptoms in teenagers (β = 0.38, p = 0.009; and β = 0.29, p = 0.03, respectively).

CONCLUSIONS

It was previously reported by the authors' group that the 8- to 10-year-old age range is an at-risk period for psychosocial distress in children with craniofacial anomalies. Their current work demonstrates that increased number of operations during this time frame may result in long-term consequences in anxiety and depression in cleft lip and palate patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Anatomical Fat Grafting for Reconstruction of Frontotemporal Contour Deformities After Neurosurgical and Craniofacial Surgical Interventions: A Symmetry Outcome Study

BACKGROUND

Fat grafting has been described as an option to repair frontotemporal contour deformities (volumetric deficiency of bone and/or soft tissues) after neurosurgical/craniofacial surgical interventions. However, technical surgical descriptions have varied, with reports describing the bolus fat injection or the classical multilayer injection, but with no detailed descriptions concerning how and where the fat should be grafted. The purpose of this study was to assess the frontotemporal symmetry outcomes after a single fat-grafting procedure for postoperative frontotemporal contour deformity reconstructions using the anatomical fat-grafting approach.

METHODS

A prospective analysis was conducted of consecutive patients (n = 106) who underwent anatomical fat grafting (Coleman's structural fat grafting technique using anatomical facial subunit and fat compartment principles) to reconstruct frontotemporal contour deformities after neurosurgical/craniofacial surgical interventions. A subjective assessment by a panel of external surgical professionals and laypersons was obtained to grade the frontotemporal symmetry. Objective ultrasound symmetry assessment was blindly performed preoperatively and at 3- and 12-month follow-up.

RESULTS

There were significant (all P  <  0.05) postoperative subjective and objective frontotemporal symmetry enhancements (preoperative < postoperative) after anatomical fat grafting, with no differences (all P > 0.05) between the 3- and 12-month postoperative comparisons. Thirty-seven percent of patients required an additional fat grafting session for residual asymmetry after 12 months of follow-up.

CONCLUSIONS

Patients with frontotemporal contour deformities presented improved subjective and objective frontotemporal symmetry after an anatomical fat grafting session.

Family-centred care during midface advancement with a rigid external device: what do families need?

Midface advancement with distraction osteogenesis using the rigid external device (RED) is an effective but invasive treatment to correct the hypoplastic midface. This study draws up an inventory of the stressors, needs and coping strategies of families during this treatment, to determine the best conditions for family-centred care. Data were collected by reviewing the patients' files and administering semi-structured interviews. The data were analysed using the software program Atlas.ti and were re-analysed by an independent researcher. Parents and patients were interviewed separately. Fourteen families participated. Four patients had an absolute indication for surgery. All families were eager to have the patient's facial appearance improved. Nevertheless, despite psychological counselling, they experienced stress when confronted with the changed facial appearance. Another stressor was weight loss. Six patients were in a state of acute malnutrition and needed supplementary feeding. We conclude that the best conditions for family-centred care should be aligned to the different phases of treatment. Leading up to surgery it is important to screen families' expectations regarding aesthetic, functional and social outcomes and to assess their capacity to cope with the long treatment and effects of changed facial appearance. Peer contact and psychosocial training to increase self-esteem are tools to enhance co-operation and satisfaction. During the distraction and stabilisation phase, we advise the monitoring of nutritional intake and weight. During all phases of treatment easy accessibility to the team is recommended.

Psychological and social factors in undergoing reconstructive surgery among individuals with craniofacial conditions: an exploratory study

Objective : Reconstructive surgery to improve psychological well-being is commonly offered to children with craniofacial conditions. Few studies have explored the challenges of reconstructive surgery beyond the physical risks: poor treatment outcomes, infection, brain damage, and death. This qualitative study aims to understand the psychological and social implications such interventions can have for individuals with craniofacial conditions. Design : A total of 38 individuals between the ages of 12 and 61 with such craniofacial conditions as Sturge-Weber syndrome, Treacher Collins syndrome, Möbius syndrome, cleft lip and palate, Noonan syndrome, Crouzon syndrome, and amniotic band syndrome participated in semistructured video-recorded interviews. Participants were recruited at conferences, through study flyers, and by word of mouth. Descriptive, thematic analysis was used to identify themes related to reconstructive surgery. Results : Dominant themes included undergoing surgery to reduce stigmatization, the psychological and social implications of the interventions, outcome satisfaction, parental involvement in decision making about surgery, and recommendations for parents considering surgery for their children with craniofacial conditions. Experiences with reconstructive surgery varied, with some participants expressing surgical benefits and others, disillusionment. Conclusions : The range of participant attitudes and experiences reflect the complexity of reconstructive surgery. Pediatric health care teams involved in the care of children with craniofacial conditions play an important role in advising patients (and their parents) about existing treatment options. The psychological and social implications of reconstructive surgery should be relayed to help families weigh the risks and benefits of surgery in an informed and meaningful way.

Early, staged reconstruction in young women with severe breast asymmetry

STUDY OBJECTIVE

To retrospectively examine a cohort of young women with severe hypoplasia or asymmetric breast development who underwent breast reconstruction with tissue expansion and to determine complication rates as well as patient satisfaction.

DESIGN

Chart review.

SETTING

The University of Michigan Hospital, a tertiary care center.

PARTICIPANTS

Women less than 25 years of age who underwent staged breast reconstruction with a tissue expander between 1998 and 2006.

MAIN OUTCOME MEASURES

Complication rate and patient satisfaction.

RESULTS

The mean age of patients undergoing the procedure was 18.1 years (range 14-25 years). Of 10 patients with recorded tobacco use, 8 (80%) were noted to be nonsmokers. One of 14 patients (7.1%) was found to have a minor complication (cellulitis), and 2 of 14 (14.2%) were found to have major complications. Of the 13 patients who had at least 6 weeks of follow-up after completion of their reconstruction, 10 were subjectively documented as pleased with the result, 2 records made no mention of patient satisfaction, and 1 patient had concerns regarding her results.

CONCLUSION

Our study shows promising results for the use of tissue expanders in young women with significant breast asymmetry or unilateral/bilateral micromastia. The very important issues of short-term and long-term satisfaction and outcomes needs further study before advocating an early approach to teens with breast deformities.

Hemifacial microsomia: from gestation to childhood

Hemifacial microsomia (HFM) is a variable, complex malformation involving asymmetric hypoplasia of the face and ear. Little is known about the risk factors for or consequences of HFM. In this study, we describe 3 studies that have been or are currently being conducted to further our understanding of this malformation. The first completed study examined whether HFM risk is related to maternal exposures that may affect blood flow. In that case-control study, interview data from 230 mothers of children in the case group and 678 mothers of children in the control group suggested that maternal use of vasoactive medications in the first trimester, particularly in combination with cigarette smoking, was associated with increased risks of HFM. The second study is currently underway, in which we are evaluating whether HFM risk is related to genetic variation in pathways associated with vasculogenesis and hemostasis, using DNA collected in the first study. The third ongoing study observes children with HFM to identify psychosocial, cognitive, dental, and medical sequelae. When the children from the original case-control study are 6 or 7 years of age, mothers and teachers complete self-administered questionnaires that cover a wide range of psychosocial development domains. Preliminary analyses of 115 case and 314 control children suggest that children with HFM may have worse teacher-reported academic performance and possibly higher levels of internalizing behavior problems than control children. When data on the full study sample are available, further analyses will determine whether the preliminary findings remain and if they vary by HFM phenotype, parenting style, or indicators of social risk.

Patient expectations in facial transplantation

Meeting patients' expectations is essential for successful outcomes in reconstructive surgery. In the case of new procedures like facial transplantation that carry with them many unknowns and real, or potential, risk of toxic side effects this becomes especially important. In this study we assessed patient expectations in facial transplantation by surveying individuals with facial disfigurement (n = 34), reconstructive surgeons (n = 45), and controls from the general population (n = 148). Questions focused on quality of life improvement, esthetic and functional outcomes. Student t test was used to compare means of the 3 study groups. All groups projected low quality of life for nontreated disfigured persons, controls responding the most negatively (M = 1.91), followed by disfigured persons (M = 2.91; t = 2.14, P <or= 0.03) and plastic surgeons (M = 2.71; t = 2.10, P <or= 0.04). Regarding face transplantations' ability to improve a disfigured persons' quality of life, the disfigured group reported the highest score (M = 8.12) followed by controls (M = 6.99; t = 2.744, P < 0.007) and plastic surgeons (M = 6.57; t = 3,72, P <or= 0.0001). Regarding the importance of esthetic outcomes, controls (M = 6.63) and disfigured persons (M = 6.15) responded similarly whereas plastic surgeons expected the least (M = 4.84; t = 4.13, P < 0.0001, and 2.74, P <or= 0.008). Regarding functional outcomes, disfigured individuals (M = 7.55) and controls (M = 7.36; NS) placed significantly more importance on expressive functionality than plastic surgeons (M = 6.11; t = 2.66, P <or= 0.009, t = 2.79, P < 0.007). We observed a significant difference between disfigured persons and reconstructive surgeons regarding their expectations for face transplantation. When consulting potential face transplantation patients, surgeons should maintain open communication to assure that their expectations are closely aligned with the realities of the procedure.

A clinical study of 31 individuals with midline facial defects with hypertelorism and a guideline for follow-up

In order to contribute to clinical delineation of midline facial defects with hypertelorism (MFDH) and to etiologic diagnosis of the isolated form, 31 patients with MFDH unaffected by known syndromic associations were evaluated. Group A included patients personally examined by the authors, while Group B included those previously evaluated by other geneticists. Among the 14 patients from Group A, there were 7 with distinct pictures of multiple congenital anomalies. In Group B, 5 of the 17 patients also exhibited a distinct pattern of defects. Among isolated MFDH, there was association with anomalies of the skull and facial bones (13/14), otorhinologic (11/16), central nervous system (9/16), and ocular (6/7), and audiologic (3/16); 1/3 of the cases had a relevant gestational intercurrences. Isolated FNM may have involvement of environmental components in some cases; the possibility of a syndromic picture should be extensive investigated. Follow-up of such patients must include the examinations herein performed.

On the ethics of facial transplantation research

Transplantation continues to push the frontiers of medicine into domains that summon forth troublesome ethical questions. Looming on the frontier today is human facial transplantation. We develop criteria that, we maintain, must be satisfied in order to ethically undertake this as-yet-untried transplant procedure. We draw on the criteria advanced by Dr. Francis Moore in the late 1980s for introducing innovative procedures in transplant surgery. In addition to these we also insist that human face transplantation must meet all the ethical requirements usually applied to health care research. We summarize the achievements of transplant surgery to date, focusing in particular on the safety and efficacy of immunosuppressive medications. We also emphasize the importance of risk/benefit assessments that take into account the physical, aesthetic, psychological, and social dimensions of facial disfiguration, reconstruction, and transplantation. Finally, we maintain that the time has come to move facial transplantation research into the clinical phase.

Management of nonsyndromic craniosynostosis

In approximately 1 in 1000 live births in the United States, an infant has some variant of a facial, skeletal, or craniofacial deformity. If cleft lip and palate deformities are included, the incidence is greater. Timing of the surgical management of these patients has been advocated from the first few weeks after birth until well into the second decade. Many of these patients require multiple, staged procedures that involve movements of the bone and soft tissue from the intracranial and extracranial approaches. The surgical approach to most of these congenital deformities was radically changed by techniques introduced to the United States by Paul Tessier of France in 1967. From his imaginative intracranial and extracranial approaches, numerous advances have been made that facilitate the care of most of these children. More recently, additional advances in pediatric anesthesia and biodegradable plating systems have improved the management of these complex craniomaxillofacial deformities.

After plastic surgery: adolescent-reported appearance ratings and appearance-related burdens in patient and general population groups

The aim of this study was to determine the effects of appearance-related surgery on psychosocial functioning during adolescence. To this end, changes in bodily attitudes and appearance-related burdens in adolescents undergoing corrective (for aesthetic deformities) and reconstructive (for congenital or acquired deformities) surgery were compared with those in a general population sample.A group of 184 adolescent plastic surgery patients (corrective, n = 100; reconstructive, n = 84), and a comparison group of 83 adolescents at random selected from three municipalities (corrective, n = 67; reconstructive, n = 16), aged 12 to 22 years, were studied at two time points with a 6-month interval. The plastic surgical patients were studied presurgically and postsurgically. Using fully structured telephone interviews and postal questionnaires, adolescents' ratings of their appearance, bodily satisfaction and attitudes, and appearance-related burdens were obtained. All patients reported a significant decrease in burdens after surgery compared with the comparison group, indicating a much more prominent improvement in the patient sample compared with the developmental changes that may be expected to occur in adolescence. The corrective patient group reported least burdens after the operation. More specifically, the "breasts" group benefited most from the operation, indicating that breast corrections are rewarding interventions. The findings of this study imply that adolescents can be regarded as good candidates for plastic surgery. They gain bodily satisfaction, and they are relieved of many appearance-related burdens. Physical, social, and psychological burdens related to appearance satisfaction improve considerably in both corrective and reconstructive adolescent patients.

Children of the Philippines: attitudes toward visible physical impairment

OBJECTIVE

This pilot study was designed to evaluate children's attitudes and understanding of physical disabilities with special reference to those with craniofacial anomalies in the Philippines. Children with and without craniofacial anomalies were studied.

DESIGN

This was a two-group correlational design with additional statistical assessment of subgroup differences. Each group was interviewed and information obtained on a standard disability preference task, attributions for playmate choice, and frequency of contact with disabilities. Parents completed a structured interview.

SETTING

Participants were 122 children recruited from Negros, Philippines.

PARTICIPANTS

Fifty-four children with craniofacial anomalies (aged 7 to 12 years) were enrolled in the study, and 68 children without any disabilities were recruited from a local school in Bacolod City, Negros, Philippines.

MAIN OUTCOME MEASURES

Participants completed a picture-ranking interview of specific physical disabilities and provided their reasons for their play choices and their contact with physical disabilities.

RESULTS

The Kendall W correlation was significant for the children with craniofacial anomalies and for those without physical disabilities. Both groups reported lower preferences for disabilities that interfere with play and social interactions. Children depicted with facial anomalies received lower preference, compared with other physical disabilities. Children with craniofacial anomalies who have experienced surgical repair reported more positive rankings for the child depicted with a facial cleft. Sex differences in disability preference were noted.

CONCLUSIONS

Children in the Philippines with and without craniofacial differences revealed similarities in preferences to children in several Western (United States) and non-Western countries. Children depicted with facial anomalies received lower preference than other visible physical differences. Children reported both positive and negative explanations for their disability play preferences. Facial differences may result in illogical and negative explanations for social avoidance among children. Similar reactions are noted in other parts of the world.

Assessing adolescents and young girls for plastic surgical intervention: pre-surgical appearance ratings and appearance-related burdens as reported by adolescents and young adults, parents and surgeons

Currently available research on psychological aspects of plastic surgery offers little basis for clinical decision making in the plastic surgeon's assessment of adolescents and young adults applying for surgery. Therefore, the research aims were to study: first, how these adolescents and young adults estimate their appearance as compared to their parents and plastic surgeons to determine the reality of their own appearance perception; second, what appearance-related burdens they experience to determine the urgency of their request for surgery; and third, the surgeons' considerations for the operation. Data were obtained from 184 plastic surgical patients aged 12-22 years (71.2% girls), 172 of their parents and 37 surgeons from 16 hospitals in The Netherlands, using appearance rating scales and to surgeons and parents, and reported substantial appearance-related suffering. There was a moderate to large overlap between the adolescent- and parent-reported burdens. In their assessment, surgeons took psychological and social impediments into consideration. In conclusion, plastic surgeons may rightfully assume that adolescents and young adults have a realistic view of their appearance and that they suffer from significant appearance-related burdens. Parents prove to be an important additional source of information.

Psychological aspects of toe to hand transfer in children. Comparison of views of children and their parents

Thirty-seven children with congenital (n = 32) or post-traumatic (n = 5) hand anomalies underwent unilateral or bilateral toe transfers. All had undergone preoperative counselling. After rehabilitation and more than 1 year after surgery, the children and their parents were reviewed by a clinical psychologist to assess the psychosocial outcome of the surgery. A high level of satisfaction was reported with regard to the surgery, in terms of function, cosmesis, donor site, psychosocial wellbeing and the reactions of others. This was true regardless of the gender of the child. However, there was a tendency for the children to be more positive in their responses than their parents.

Psychosocial adjustment in twin pairs with and without hemifacial microsomia

OBJECTIVE

To compare the psychosocial adjustment of children with and without hemifacial microsomia (HFM).

DESIGN

This cross-sectional pilot study investigated psychosocial adjustment of twin pairs in which one twin was affected with HFM and the other was unimpaired. Data were analyzed using paired t tests.

SETTING

The dental medicine clinic of a large urban children's hospital, serving a multistate area.

PARTICIPANTS

Participants were six twin pairs aged 9 to 15 years and their parents. Data were also collected from classroom teachers.

MAIN OUTCOME MEASURES

Outcome measures included: the Child Behavior Checklist (CBCL), the Teacher Report Form (TRF), the Coopersmith Self-Esteem Inventory (SEI), and a structured self-concept interview (the Self-Interview).

RESULTS

Children with HFM had significantly higher CBCL and TRF total behavior problem scores and lower SEI general self-esteem scores than their unimpaired twins. No differences were found in CBCL competence scores. Interview data revealed concerns among the HFM group related to appearance, negative social responses, and fear of hospital procedures. Children also reported positive aspects of coping with HFM.

CONCLUSIONS

The results of this study suggest that, similar to other craniofacial conditions, HFM is associated with an elevated risk for childhood psychosocial difficulties. Replication of specific findings with a larger sample is needed. Multicenter, collaborative studies are a crucial next step for this field.

The impact of interpersonal support on patient satisfaction with orthognathic surgery

PURPOSE

This prospective longitudinal study examined the relationship between interpersonal support and patient satisfaction with orthognathic surgery.

PATIENTS AND METHODS

Fifty-five adult patients were assessed with two questionnaires measuring the level of general social support they perceived receiving from significant others during treatment, and the level of perceived support specifically for their decision to undergo orthognathic surgery and the treatment results.

RESULTS

Availability of support and satisfaction with support from specific members of the patient's support group were found to be related to satisfaction in the early postoperative period. Support of close friends for the patient's decision to undergo surgery was found to be associated with satisfaction in the early postoperative months. Further, reactions of the patient's support group to his or her postoperative appearance was found to be highly related to satisfaction in both the early and late postoperative stages.

Treacher Collins syndrome: present concepts of the disorder and their surgical correction

Treacher Collins Syndrome is a rare bilateral congenital deformity occurring in 1 in 10,000 births. It is also known, in the European literature, as Franceschetti Syndrome, and is additionally known as mandibulofacial dysostosis. It is a syndrome with a very wide spectrum of manifestations characterized by distortions of the orbit secondary to hypoplasia of the maxilla, mandible, and, most markedly, of the zygoma. Soft tissue deformities include lower lid colobomas, laxity and dystopia of the lateral canthus, microtia, and a paucity of the muscular aponeurosis of the midface. The syndrome is frequently accompanied by significant hearing loss, early failure to thrive, chronic respiratory insufficiency, and sleep apnea. Intelligence is usually within normal limits although learning disabilities are common in early life. These major anatomical and physiological abnormalities, as well as the psychological and social stigma associated with severe facial deformity, make this syndrome one of the most challenging reconstructive problems presented to the craniofacial surgeon.

The psychiatric assessment of the patient requesting facial surgery

Recent years have witnessed an increasing demand for cosmetic or reconstructive facial surgery. This paper addresses the pre-operative psychiatric assessment of the patient requesting facial surgery. Most patients adjust well to surgery and appreciate and accept the outcome. The psychiatrist who helps to screen difficult cases needs specific skills and must understand the body image issues involved. The psychiatrist needs to evaluate the patient's motivations, expectations and understanding of the risks and implications of surgery. Potential problem patients are described, including the minimal defect patient, the patient with secondary gain from the deformity, the older patient, the patient in crisis, the polysurgical patient, the paranoid patient, the schizophrenic patient, and the male patient. Guidelines for evaluating the patient need to be applied flexibly. The psychiatrist must communicate with the surgeon to appreciate clearly the concerns the surgeon has about each patient.

Working with facially disfigured children: a challenge in prevention

This paper reviews the growing literature on the psychology of appearance and outlines prevention principles for working with facially disfigured children, based on 15 years of psychiatric consultation to a major pediatric craniofacial team.

Craniosynostosis update 1987

Information on craniosynostosis in this paper updates "Craniosynostosis: Diagnosis, Evaluation, and Management" (Cohen MM Jr: New York: Raven Press, 1986). It also discusses recent developments that were included in the book but need further explanation or emphasis. Subjects discussed are: epidemiology, etiology, sutural biology, growth and development, neurological and psychosocial aspects, surgery, cloverleaf skulls, craniosynostosis syndromes, and prenatal diagnosis. Under the subject of etiology, fetal head constraint, maternal thyroid disease, calcified cephalohematoma, teratogens, and delayed suture closure and Wormian bones are considered. An updating of 15 cloverleaf skull conditions includes four monogenic disorders, two chromosomal disorders, one disruption, one iatrogenic condition, and seven syndromes of unknown cause. Newly recognized disorders with cloverleaf skull include Beare-Stevenson cutis gyratum syndrome and Say-Poznanski syndrome. Craniosynostosis syndromes and associations discussed include acrocraniofacial dysostosis, Apert syndrome, Beare-Stevenson cutis gyratum syndrome, Calabro syndrome, calvarial hyperostosis, chromosomal craniostenosis, Cole-Carpenter type osteogenesis imperfecta, Crouzon syndrome, Curry-Jones syndrome, Curry variant of Carpenter syndrome, cutis aplasia and cranial stenosis, Fontaine-Farriaux syndrome, Gomex-López-Hernández syndrome, Hersh syndrome, hyper-IgE syndrome and craniostenosis, hypomandibular faciocranial dysostosis, Marfanoid features and craniostenosis, Pfeiffer-type cardiocranial syndrome, Pfeiffer-type dolichocephalosyndactyly, and Say-Barber syndrome.

Psychosocial adjustment of 20 patients with Treacher Collins syndrome before and after reconstructive surgery

Eight males and 12 females (mean age, 12.2 years) with Treacher Collins syndrome were studied longitudinally before and after craniofacial reconstruction. The patients and the parents of the 16 patients who were children were interviewed by a psychosocial team (child psychiatrist, psychologist and social worker) 6 months before and 1, 2, 3 and 4 years after surgery. The patients' facial appearance (Hay's Rating Scale), intellectual ability (Wechsler scales), self-esteem (Piers-Harris Self-Concept Scale for Children) and adaptive functioning (DSM III) were measured. The findings indicate that while their intellectual ability was unchanged, their appearance, self-esteem and adaptive functioning improved, peaking 1 year postoperatively and levelling off at the 2- and 4-year postoperative assessments. The improvement in the patients' facial appearance seems to have a direct, positive influence, creating psychosocial and social benefits for them.

A psychiatric profile before and after reconstructive surgery in children with Apert's syndrome

Twenty-five children with Apert's syndrome, characterised by craniosynostosis and symmetrical syndactyly of hands and feet, were seen by a psychosocial team. The patients ranged in age from 1 month to 15 years. All had undergone synostosis release in the first year of life and were being assessed for craniofacial reconstructive surgery. Psychosocial adjustment was evaluated using a semistructured interview, psychometric testing. Piers-Harris Self-concept Inventory and Hay's Appearance Rating Scale administered by a team consisting of a child psychiatrist, psychologist and social worker, 6 months before surgery and 1, 2 and 4 years after surgery.

Beauty and the eye of the beholder: social consequences and personal adjustments for facial patients

Patients' pre- and postoperative self-reports were compared with reports of non-medical observers to investigate whether improved self-esteem is a direct result of increased social acceptance in maxillo- and craniofacial patients. Twenty-two children and adolescents undergoing reconstructive surgery for a variety of facial deformities were asked to rate their physical appearance on the Hay's Scale and fill out the Piers-Harris Self-Concept Scale. Their ratings were compared with scores given by a panel of lay volunteers on random presentation of pre- and postoperative photographs of the same patients. Patients rated their appearance as noticeably improved after surgery, their self-esteem rose significantly and they reported more social adeptness and acceptance at home and school. Raters observed only relatively subtle changes. Apparently, quality of life improved for the postsurgical facial patient because of increased self-esteem and confidence, which free him to overcome social barriers.