Aesth. Plast. Surg. 14:249-257, 1990

Aesthetic _ Plasuc Surgery 9 1990 Springer-Verlag New York Inc.

Facial Disfigurement: Problems and Management of Social Interaction and Implications for Mental Health Frances Cooke Macgregor New York, New York, USA

Abstract. The concern of this article is with the impact of facial disfigurement on social interaction during brief encounters, the ramifications of which have the potential for psychological and social destruction. Largely ignored by those interested in the social and psychological problems and rehabilitation of the functionally impaired, such as the blind, the deaf, the amputee, the intent here is to point up the major problems associated with facial disfigurement and to explore some of the ways of dealing with them. The data on which this article is based were collected over many years and are no longer new, but this attempt to synthesize them for a particular purpose is. Key words: Facial disfigurement--Social interaction-Psychosocial problems--Rehabilitation

"It is difficult, my dear Lucius, to escape becoming the person which others believe one to be. A slave is twice enslaved; once by his chains and once again by the glances that fall upon him . . ." [29] The effect upon social interaction during brief encounters in daily life when the face of one of the participants is disfigured is a subject that deserves far more attention and systematic investigation than Support for the research on which this article is based was provided by the National Institute of Mental Health, United States Public Health Service, the Milbank Memorial Fund, the Society for the Rehabilitation of the Facially Disfigured, and the Social Rehabilitation Service, United States Department of Health, Education and Welfare. Address reprint requests to Frances Cooke Macgregor, M.A., Institute of Reconstructive Plastic Surgery, New York University, 550 First Avenue, New York, NY 10016, USA

it has received. And yet, as research has shown, for those whose faces do not c o n f o r m to the n o r m it is this very process that is a source o f unremitting stress, anxiety, and anguish, all o f which h a v e negative implications for personality functioning and mental health.

Problems of Social Interaction In-depth studies of the social and psychological problems associated with facial anomalies, b o t h congenital and acquired, c o n d u c t e d on 181 plastic surgery patients m o r e than three decades ago showed that the patients' m a j o r complaints and difficulties centered around the patterns of interaction b e t w e e n themselves and others [14-17]. I n t 9 8 7 , and m o r e than 500 patients later, we found the complaints and p r o b l e m s to be the same. While distressed each day b y the reflection in their o w n mirrors, as m u c h if not m o r e hurtful and damaging to their self-image and self-esteem is seeing their own flawed faces reflected in the reactive behavior of the nondisfigured. This is experienced m o s t often during face-to-face encounters with strangers: when traveling to work or school, shopping, entering and eating in a restaurant, walking along the street, standing in line. Attending to what m a y be m u n d a n e affairs for those whose faces are u n r e m a r k a b l e is fraught with potential hazards for those w h o look different. The need for social interchange and comingling a m o n g humans is basic and strong. But so too is the need for privacy, for preserving o n e ' s territ o r y - b o t h personal and p h y s i c a l - - f r o m the intrusion of strangers. F o r m o s t people these needs are met, but not for those who look different or h a v e

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conspicuous facial defects. The "civil inattention" [10] that is normally conferred by strangers on one another and that makes it possible to move anonymously and unhindered in public places is a right anc~ a privilege most longed for by facially disfigured people who, unable to conceal their handicaps, are vicl~ims of intrusions and invasions of privacy, against which they have little or no protection. In their efforts to go about their daily affairs they are subjected to visual and verbal assaults and a level of familiarity from strangers no otherwise dared: naked stares, startle reactions, "double-takes," whispering, remarks, furtive looks, curiosity, personal questions, advice, manifestations of pity or aversion, laughter, ridicule, and outright avoidance. Whatever form the behaviors may take, they generate feelings of shame, impotence, anger, and humiliation in their victims. The purpose of this article is to direct attention to and further explore some of the problems inherent in the interactive process that confronts the facially disfigured in the establishment of social relationships and in the maintenance of interactions--problems that are often so trying and so difficult that protective stratagems must be devised in order to survive. In so doing my specific objectives are threefold: (1) to gain more knowledge of the patterns and the processes of social interaction between the disfigured and the nondisfigured and their potential for social and psychological destruction, (2) to examine ways of reducing the roadblocks to social acceptance, (3) to help define areas for further investigation. First, however, despite its being self-evident, it is essential to make the following points in order to place the subject of this article in context. In all human relationships, it is the face that is the symbol of or synonymous with the person. Intimately connected with communication, both verbal and nonverbal, and the region where the sense of self is located, it is the focus of attention whenever people meet. Because of its social significance, any condition that distorts it and makes it ugly or unsightly to look at can take precedence over all other personal and social traits and insidiously can become the most important thing about that person. For the majority of people their days involve faceto-face encounters which, as pointed out by Goffman [9], Becker [1], and others, involve certain rituals, behaviors, and rules of social conduct,that are both learned and patterned and which people normally observe automatically and without thinking. For example, in salutations or while addressing another, proper eye conduct (in our culture) requires looking at the face of the speaker with eye contact that is neither a fixed gaze nor fleeting. With strangers or new acquaintances there are rules about keeping one's distance, asking personal questions, and avoiding topics that might be embarrassing or inap-

Facial Disfigurement: Problems and Management

propriate. It is during such encounters that those with deviant faces experience flagrant disregard for the rituals and rules governing social behavior. Not all forms of behavior experienced by the disfigured are as overt or blatantly intrusive as staring or asking personal questions. Nevertheless, they can be equally discomforting and stressful. These are the subtle and complex "small behaviors" that occur in everyday face-to-face interaction that seem to mean nothing but, as students of human behavior such as Goffman, Hall, and Birdwhistell have clearly demonstrated, do indeed mean something. In fact, they frequently provide more information than verbal exchange. These small behaviors are known as microlevels of communication or the "silent language" by which people unconsciously and sometimes consciously, send messages to one another without the use of words. Usually perceived on a subliminal level, they nevertheless have positive and negative effects on interaction. One microlevel, for example, is manifested kinesically, i.e., by body movements and tonus, postural and facial changes, head positioning, eye movements, gestures, and the like, by which people make statements about their feelings and attitudes [3]. Another mode of communication is paralinguistic: the tone and pitch of voice, rate of speech, hesitations, sighs, yawns, emotional overtones, and expressions that serve to underscore, qualify, or negate what is being said. A third mode of communication involves the significance of space (proxemics), i.e., the manner in which it is employed to increase or decrease one's personal and social distance from another [cf. 11]. In the spatial frame in which social interaction occurs there are, as in other modes of communication, culturally defined rituals and codes of conduct that govern our encounters and determine what is or is not appropriate in particular situations. For example, when engaged in conversation friends may stand (or sit) closer to each other than strangers, but the distance between the former will be greater than that between lovers and less than that between business acquaintances. Normal standing distance between strangers or acquaintances in our culture is from four to seven feet [cf. 12]. Should one person get too close, the automatic reaction of the other is to back away in order to increase the distance and allay feelings of discomfort. As Hall [ll, p. 204] points out, "Spatial changes give a tone to communication, accent it, and at times even override it." The matter of proximity to people is an ever-present problem for the disfigured. As victims of negative rather than positive attitudes and reactions, they tend to develop a heightened awareness of and sensitivity to what are or what may be construed as signs of discomfort, embarrassment, or rejection by the nondisfigured as indicated by the latter's use of silent

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language during face-to-face interaction. Thus, the perceived manifestations of avoidance and rejection about which disfigured persons complain are sometimes thought to be overstated, imagined, or even self-fulfilling prophecies because of their hypersensitivity to what otherwise might be regarded as unimportant or inconsequential behavior. While this may well be the case in some instances, systematic observations and experiments indicate that the nondisfigured do indeed tend to convey in covert and symbolic ways their discomfort when interacting with facially disfigured persons. This was demonstrated by Rumsey, Bull, and Gahagen [24] in a field experiment on the use of personal space when interacting with disfigured persons compared with the nondisfigured. The subjects were 450 members of the general public and a confederate presenting three different conditions: a "port-wine stain," a bruised and scarred face, and, as a control, a " nor m al " face. The results showed that the standing distance afforded the confederate when disfigured was significantly greater than when he had no disfigurement. Moreover, the subjects also elected to stand on the nondisfigured side of the confederate during interaction far more often than they did when his appearance was " n o r m a l . "

Management of Social Interaction The experience of having facial stigmata is to be made acutely aware of the incompatibility between oneself and one's social environment. Moreover, it is constantly reinforced by the uncertainty and dread of situations that not only interfere with " nor mal " interaction but produce feelings of impotence, shame, and anger. In the words of a 22-year-old man whose gross disfigurement was caused by an explosion: " I t ' s hell! You don't know which way to turn. You get stares from people every da y- -remarks--whispers--questions." A 30-year-old man with a congenital condition known as hemifacial microsomia said, "When I see the reaction of others to my 'Picasso' face it's like pouring turpentine into a raw wound." More disfigured people than is generally realized find that attempts to cope with problems of daily encounters are so trying that aloofness or total withdrawal are their only alternatives. Others, however, resort to a variety of strategems and protective devices in order to function in a hostile environment. Depending upon the individual and the particular situation, these may be overt or covert, aggressive or passive, hostile or receptive. For example, when stared at many individuals feign unawareness, some stare back. " I burn two holes in them," or retaliate with defiant remarks: "Take a good look." Still oth-

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ers feel too helpless to do anything. " I just look away. What can you d o ? " Personal questions also elicit different responses depending on such factors as the individuals asking the question, the context in which it is asked, the form and manner in which it is put, and how it is interpreted by the receiver. Questions from strangers, if not ignored or brushed aside with "I was in an accident" or "the war" (etiologies more socially acceptable than other given causes), may evoke flippant even hostile replies: "I was in a ring wrestling with a bear." " G o d hit me with a frying pan . " "I got it from sticking my nose somewhere I shouldn't." "Mind your own business." Such responses, while possibly meeting a momentary need of the individual, not only incrase the social distance between the interactants but serve to truncate any potential there might have been for incipient interaction. There are individuals with visible stigmas w h o employ more positive methods for managing social encounters. One of these is "deviance disavowal" [cf. 6], a stratagem used by those who look different in an attempt to "normalize" their situation and to "break through" or gain acceptance. For example, following temporary discharge from a hospital with a badly burned face and joining a group for the first time, a young athlete made a point of explaining the cause of his Condition: " I immediately go over to one or two people and mention the accident and my plastic surgery treatments so they won't get embarrassed and wonder what they should say." A college student with congenital absence of both ears found ways of diverting attention from his handicap: " I talk fast to people or give them a hand at something they might be doing. This keeps them from thinking about me or asking questions." Some individuals find it strategic to make light of their impairments on first encounters in order to reduce tension and social distance: A woman whose face was marred by a beauty treatment found it effective when entering a room of people to announce facetiously, "Please excuse the case of leprosy." Others provide time to lessen the shock of their appearance. Aware of the unnerving effect his cancer-caused disfigurement had upon people, a real estate agent described his technique for establishing a relationship: "When I have an appointment with a new contact I try to be standing at:a distance, so the person will have more time to see me and get adjusted to my appearance." Though less common, some individuals attempt to destigmatize their afflictions and make acceptance less difficult by using themselves as the target of jokes. On a television show to raise funds for the handicapped, a participant, admitting that the loss of his eye had been an embarrassment in high school, drew laughter about such incidents as the night he

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spent with his girl and wakened to hear her dog crunching on his glass eye. Some disfigured people attempt to overcome interactional barriers by using or exploiting their handicaps to help others or to educate the public. They visit patients in hospitals, give talks to school children, become counselors, write books [221, or organize self-help or support groups. Not all facial deviations are immediately apparent. Some, such as malformed ear, may be noticed one time but not the next. In certain situations a particular type of anomaly, e.g., a large nose or receding chin, may evoke laughter or ridicule or suggest a stereotype. Complaining about the ambiguous nature of his handicap (a twisted mouth caused by congenital facial paralysis which became noticeable only when he smiled or laughed) a college student said: " I am always on pins and needles. The worst part of it is that you forget about it. No one says anything. Then, bang! All of a sudden someone makes a face like mine. It puts salt in the wound and brings it up all over again. It would be better if something were said every day." The effect of erratic and unpredictable reactions has been shown to play a significant part in the differential in adjustment to facial deviance between persons with severe disfigurement and those with moderate or mild deviations. As reported elsewhere [17, pp 86-88], the evidence indicates that consistently negative reactive responses permit the former to be forewarned, hence psychologically and emotionally prepared, whereas the inconsistency and unpredictability of reactive responses, whether they will be acceptive or rejective, tend to put the latter in a precarious position, thus reinforcing their feelings of anxiety and tension. Regardless of the type or degree of disfigurement, however, the fact is that it does create contexts in the interactive process in which one's deficiency "is no sooner perceived than it is multiplied by reflection from other minds" [cf. 5].

Strains of Interaction A high psychological cost is exacted from disfigured persons to counter the threats inherent in the social world. The time and psychic energy that could be channeled into more positive aspects of living are too often consumed by preoccupation with the way one looks, vigilant attention to the reactive behavior of others, and the mobilization of defense mechanisms, all of which are detrimental to mental and emotional health. Not atypical is the case of a 29year-old woman who had suffered traumatic injury to her face five years earlier. Seeking additional reparative surgery her presenting complaints included both psychological and somatic distress, e.g., night-

Facial Disfigurement: Problems and Management

mares and migraine headaches. She had reached a point, she said, where she feared all forms of faceto-face interaction because of the effort required to maintain her emotional equilibrium. " I suffer tremendous fatigue, especially when I have to travel on subways. I have such anxiety facing people. I'm afraid of new people and I won't go anywhere. Even going to the beauty parlor is an ordeal" [cf. 19, p 131. In a similar vein, a 33-year-old woman--formerly known for her extraordinary beauty--whose face had been totally transformed by an auto accident, described the strain of trying to cope with the handicap of her startling appearance. It had become "too great," she said, explaining her heavy drinking. "I am tired of always trying to be charming, to compensate for what I lack. It's such an endless effort. If only my face could be made to look normal enough for me to be able to sit back and rest once in a while and not always force myself to be entertaining or interesting and to create an atmosphere which will distract others from my disfigurement" [cf. 18, p 41. But the strains inherent in the interactive process between the disfigured and the nondisfigured are by no means confined to the former. Facial deviations also have an unsettling effect on the latter. Given the nature of the defect and the immediate, sometimes visceral, reactions it evokes, what otherwise might be a normal encounter is marked by feelings of aversion, discomfort, and anxiety. Compounding these difficulties is the fact that the guidelines and unspoken rules of conduct for interchanges are not as clear as are those governing ordinary encounters. Worse still is the lack of familiarity with the needs and problems presented by this unique handicap. Most people are uncertain as to what they should or should not do and say or not say when talking with a disfigured person, and their fear of showing discomfort precludes spontaneity and increases tension. Even ordinary interchanges are filled with potential pitfalls and faux pas, and such commonplace remarks a s " Y o u ' r e looking well today" and "Plain as the nose on your face" suddenly become horrifying slips of the tongue. Unlike those situations involving the aged, the amputee, or the blind with whom relationships can be established by the fact of their special and welldefined needs for assistance and the general knowledge and understanding of the public about such matters, there is nothing of this nature that can be applied to making contact with the disfigured. They don't require assistance in crossing a busy street or special ramps or wheelchairs to move about in public. What they do require and what they ask for is the unflinching eye contact that tells them they too are "members of the human race." Perhaps no other mode of communication between the disfigured and nondisfigured is so critical

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to the interactive process and the self-image of the disfigured individual as eye behavior, the significance of which has been underscored by Simmel [26]: "The union and interaction of individuals is based upon mutual glances. This is perhaps the most direct and purest reciprocity which exists anythere . . . So tenacious and subtle is this union that it can only be maintained by the shortest and straightest line between the eyes, and the smallest deviation from it, the slightest glance aside, completely destroys the unique character of this union . . . The interaction of eye to eye dies in the moment in which directness of the function is lost. But the totality of social relations of human beings, their self-assertion and estrangements, would be changed in unpredictable ways if there occurred no glance of eye to eye. By the glance which reveals the other, one discloses himself. By the same act in which the observer seeks to know the observed, he surrenders himself to be understood by the observer. The eye cannot take unless at the same time it gives . . . . " Those with facial stigmata are acutely sensitive to a falter in eye movement or eye avoidance, which for them are endowed with special significance. " M y appearance detracts from what I s a y , " said a woman whose facial paralysis prevented complete closure of one eye and turned her smile into a grimace. " I notice people look over my shoulder when they talk. It makes me self-conscious--as though they didn't want to look at me. I'm embarrassed. I'd rather have them look at m e - - b a c k and f o r t h - - y e t not stare." And another, comparing her damaged nose to a "pig's snout": " W h e t h e r or not I talk with strangers depends upon the way they look at me. They often get a strange expression and I can tell that my nose makes them sick. They make a funny face or cast their eyes aside. If this happens I look down or turn my head. But ifa person looks squarely into my eyes without glancing at my nose, it makes me feel at ease and I can answer questions or talk without feeling self-conscious and a s h a m e d . " The role of shame in encounters between the disfigured and nondisfigured is, interestingly enough, one that has been greatly neglected by psychologists. Yet the research on which this article is based reveals that it is a predominant feeling associated with facial deviance and central to the problem. Shame, according to the dictionary, is a painful emotion caused by a consciousness of one's own shortcomings. So intolerable is this emotion that when feelings of shame are aroused the universal tendency is to turn away, look down or away, hide the face, avoid s c r u t i n y - - a reaction that reflects the symbolic values attached to it and which, in our culture, is implicit in the words " s h a m e f a c e d , " "lose f a c e , " " f a c e value," and so on. Representing one's personal self and being the locus of psychological intimacy [20], the face serves

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also as the persona, or social facade, which, developed during the socialization process, one presents to the outside world. But lacking normal appearance as well as the protective devices of expression, the facial deviant feels threatened and exposed; this in turn produces feelings of shame. It is this emotion that plays a profound role in both coloring and interfering with the interactive process between the disfigured and the nondisfigured. Although not focusing on the concept of shame per se, Goffman's [8] attention to the subject of "face-saving" is germane to this discussion. In his analysis of the ritual elements in social interaction of ordinary people, he stresses the importance of the rule of self-respect and considerateness so that each of the participants may maintain f a c e (author's italics), " b o t h his own and the face of the o t h e r . " Facesaving, he contends, is a "condition of interaction," a term that is far less metaphorical for the disfigured than for " o r d i n a r y p e o p l e . " Nevertheless, as indicated earlier there are nondisfigured individuals who, by their indiscreet actions or remarks, whether the result of ignorance of an abnormal need to violate the intimacy of others, make " f a c e - s a v i n g " an insuperable task. For those who want to help the disfigured maintain face and move more easily in the public domain, there is no substitute for looking straightforwardly into their faces. Only the acknowledgment that he/ she exists can provide the disfigured person with a sense of "belonging to the human r a c e , " instead of being '~a breed a p a r t " or " c r e a t u r e s from another planet." It would seem safe to say that the average person has great compassion for those with flawed faces. H o w e v e r , complex psychological mechanisms aside, some people are so aesthetically repelled and even threatened by the sight o f an abnormality that, despite genuine feelings o f sympathy and compassion, they are unable to cope with or maintain a faceto-face situation. Others find interaction difficult because they are distracted or " p u t o f f " by a defect, even a relatively mild one such as a scarred lip or crossed eye, areas which happen to be those by which we most actively send signals to one another. Because we rely so much on feedback by way of facial expression and the transitory m o v e m e n t s of muscles (there are some 100 of them) that indicate agreement, surprise, interest, and other nonverbal messages to which we in turn respond, we are disconcerted when these modes of communication are impaired. Unable to " r e a d " the other person and frustrated by the ambiguity that is created, we become hesitant and awkward. While some impairments lead to false clues and interpretations, others provide no clue at all. Cases in point are those with severely burned faces or with a condition known as "Moebius s y n d r o m e , " a bilateral facial paralysis

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that causes the face to be immobile and almost totally expressionless. Since there is little or no feedback, attempts at interchange have been likened to "talking to a s t a t u e . " E v e n for professionals this masklike quality impedes interaction and creates problems. " I t is striking to this e x a m i n e r , " the psychologist reports, " t h a t because of [the patient's] facial scarring (the result of burns) it is difficult if not impossible to ' r e a d ' the usual clues (facial grimaces, etc.) that a clinician uses in dealing with an individual." M a n y disfigured persons valiantly try to attain smooth interaction and m a k e it easier for others, but at a cost and with mixed results. A middle-aged w o m a n said: I try to make things easier for others--to be cheerful--but I'm not always up to it. I told a young girl in a store who gave me a look of commiseration, "Don't feel sorry for me; I'm a happy woman 9 I smiled at her. I wanted to show her I was a human being--never mind the face. We, the facially disfigured, are so much a breed apart. Disfigurement is a tremendous barrier to interaction, not with people who know us, but with people we just meet. We want to be accepted as an equal, not a victim of fate. And I have to do an awful lot of overcompensating. I'm very well aware of this. I walk in a very assured way, for instance9 I know also that if I expect rejection I'll get it 9 . . that if I look dejected and embarrassed, people are less at ease, and their responses are negative9 But when I smile, hold my head high, and appear confident, their responses are more likely to be positive9 It is the repetition of such incidents that I find emotionally draining; they are abrasive and have a cumulative effect. They tend to cause a person to become hardened and, to ward off danger, to develop coping mechanisms and a defense superstructure . . . . Unfortunately the skills and competencies in establishing relationships do not necessarily guarantee an easier or better life. The psychological costs of daily affronts, effort, and emotional strain are more often disproportionate to the social gains, and as long-term longitudinal studies have demonstrated [cf. 18, 19], frequently eventuate in depression, social withdrawal, even alcoholism, though not necessarily in that order.

Social Skills The quality of interaction depends upon the participants involved, yet it appears that to a large extent the responsibility for initiating and achieving smooth interchange rests with the disfigured. It is they who, by their d e m e a n o r and behavior, both overt and covert, set the stage for the tone and flow of the interchange 9 As a young war victim observed: It is better to take the first step to create a pleasant atmosphere, but one has to pass over the first reactions and

Facial Disfigurement: Problems and Management

this needs practice. For the wounded person who has had the time to observe this it is easier than it is for a normal person who knows little or nothing of this kind of suffering. ff the mouth [which in this case was the affected part] is distorted, one must not try to smile too much at the first sign of understanding if it turns into a grimace. Fortunately, the eyes help you smile. Though the face is the focus of attention, perceptions of and responses to people are influenced by other factors. F o r example, it is not u n c o m m o n to be attracted to a beautiful or h a n d s o m e face only to have o n e ' s interest d i m m e d by a slumped posture, eye avoidance, atonal voice, and lack of affect, or, conversely, to find a homely person attractive because of presence, personality, and overall configuration (Gestalt). A prime e x a m p l e of this p h e n o m e non was Eleanor Roosevelt, who admittedly was considered an "ugly duckling" [23]. H o w e v e r , by her bearing, poise and her full attention to the other person, she elicited the m o s t positive of responses. A graphic example of h o w the perception of ugliness can be altered by personality characteristics is provided by John H e r s e y ' s [13] description of his first meeting with the writer Sinclair Lewis: The first impression, as he walked ahead of me into his living room, sat down and lit a cigarette, was of a thin man put together with connections unlike those of most human beings. Next, piercing pale blue eyes, the bluer for being lashed into the pink face of a red-head. Thinning light red hair, ill brushed and tufted, over a wide dome of a forehead. Then, in better focus, terrible cheeks, riddled, ravaged and pitted where many precancerous keratoses had been burned away by dermatologists' electric needles. Narrow, dry lips, and a slender chin. I would have sworn that he was hideously ugly until he started to talk, when his face suddenly turned on, like a delicate, brilliant lamp 9 . . one forgot his cadaverous face. To test the role of social skills in interaction between conspicuously disfigured and nondisfigured persons, in a controlled study, R u m s e y [25] enlisted a professional actor to conduct 12 identical interviews: six with a large port-wine stain (hemangioma) on his face and six without. F o r half of the disfigured and nondisfigured interviews he b e h a v e d in a socially skilled m a n n e r - - a p p r o p r i a t e eye contact, gestures, paralanguage, and so on. F o r the rest, the actor b e h a v e d in a fashion consistent with that observed of genuinely disfigured p e r s o n s - - e y e s downcast, flat tone of voice, and lack of assertion. Analysis of the videotape showed that the level of social skills used by the actor was m o r e important than the presence or absence of disfigurement, in relation to both the objective b e h a v i o r of the subjects and in the impressions they f o r m e d of the a c t o r ' s personality and behavior. While this study confirms the general findings of other investigators, it should be kept in mind that in

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the case of a port-wine stain it is essentially the obtrusive red and purplish color of the skin that spoils the face and is distracting, while other conditions such as distortions or invasions of tissue and bone caused by t r a u m a or disease m a y present a different order of problem. Given the opportunity, h o w e v e r , those w h o possess interpersonal skills and self-assurance are able to make the process of interaction less difficult and taxing for both interactants. Indeed, in refusing to accept the rejection of a society o b s e s s e d with beauty and physical perfect i o n - - " Y o u either have to face it or live in a corn e r " - - s o m e individuals manage to o v e r c o m e the m o s t difficult of hurdles, but not without a price. Following a devastating auto accident and the ruination of her once beautiful face, a 20-year-old w o m a n seriously contemplated suicide or entering a c o n v e n t where she would be "hidden from the world 9 . . I was terrible looking. I had a carnival f a c e . " Eventually she decided to rejoin the social world. It was not easy.

On a cold, stormy day a patient with a deep, o p e n wound in her cheek, the result of radical surgery for cancer, arrived late for her a p p o i n t m e n t in the Plastic Surgery Clinic. N o t only was she suffering nagging pain, but a taxi driver, seeing her face, hurriedly drove off, and a second one was rude. H e r anger knew no bounds. " W e l l , " said the interviewer, " Y o u certainly needed this l i k e . . . " and stopped short. N o t missing a beat, the patient continued: "Two holes in the h e a d ! " And b o t h burst into laughter. While the focus of this article is on the p r o b l e m s and m a n a g e m e n t of social interaction, we m u s t k e e p in mind two of the major forces that underlie the problems associated with facial disfigurement as opposed to those associated with functional disabilities. One of these forces, as d e m o n s t r a t e d below, is the ancient and fallacious correlation still made, even among the educated, b e t w e e n facial abnormalities and negative c h a r a c t e r traits.

I would look at myself in the mirror and think "How can I go out on the street with this awful face? What kind of clothes can I wear that will not make me look ridiculous? What kind of hat can be worn with a face like this?" I knew that now I must do everything possible to make myself presentable and to distract attention from my face. I must keep my hands and nails just so, wear the most beautiful but simple clothes, pay great attention to my hair, wear the most attractive perfumes--everything to help myself look interesting. But these things were not enough. Before my accident I had only been interested in having fun: occasional love affairs, traveling, and sports. I had few intellectual interests. Now I realized I must read everything new that came out, be well versed in the important topics of the time, be more gay and amusing than ever before. I must win people with my c h a r m . . . I had to pretend to be gay at any price [for details see 18, pp 3-14].

There was, however, little fear of Barbie amongst those fifty-odd Frenchmen who worked closely with him. They were part of Barbie's 120-strong "personal army," all members of the most aggressive pro-Nazi groups in the town which Barbie gradually drew towards him. One of the most infamous of these, from the French Nazi Party (the PPF), was Francois Andre, an ex-communist. Known as the "Gueule Tordue" his face had been atrociously deformed in a road accident. With a mouth twisted into the shape of a gaping wound, he had no need to convince anyone of his natural brutality. [4]

A salient aspect of this case was that by this w o m a n ' s self-presentation, her dress, her charm, and her ability to project herself as a " n o r m a l " person who h a p p e n e d to have a handicap, those features which at first glance were so startling seemed to recede into the background. Such instances are not u n c o m m o n , but crucial to their o c c u r r e n c e is the matter of time. Like " B e a u t y and the B e a s t , " a s y n d r o m e that offers cold comfort to the nonbeautiful, perceptions of others can and do change, but only if given the opportunity to establish o n e ' s identity and dissipate first impressions. E v e n this, however, does not guarantee smooth sailing9 What in normal situations would be considered c o m m o n p l a c e remarks, in these contexts can b e c o m e dreadful faux pas. Since apologies or explanations only tend to c o m p o u n d e m b a r r a s s m e n t , the burden of saving the situat i o n - i f it can be s a v e d - - a n d the face of the offender falls upon the disfigured person. The following is an example of a skillful extrication.

It was to see him that I had come to Israel, anxious to find out for myself if he was human, if there was any humanity in him. I had hoped to find myself in the presence of a disfigured creature, a monster whose unspeakable crimes would be clearly legible in his three-eyed face. I was disappointed: Adolf Eichmann seemed quite normal, a man like other men--he slept well, ate with good appetite, deliberated cooly, expressed himself clearly and was able to smile when he had to. The architect of the Final Solution was banal, just as Hannah Ahrendt had said. [28] The removal of deep-rooted stereotypes and prejudices is a slow and a r d u o u s p r o c e s s . Yet w h a t e v e r attempts are made to educate and foster understanding and a c c e p t a n c e of the disfigured, as has b e e n accomplished with other groups of h a n d i c a p p e d people, they are severely attenuated b y zeitgeist factors in our sociocultural milieu that a d d to the invidious basis for discrimination and generalized rejection of the ugly. There is nothing new a b o u t the o b s e r v a t i o n s that physical characteristics h a v e a profound influence in the social world in which we live and that preferential treatment is given to those w h o are p e r c e i v e d as physically attractive. But o u r increasing o b s e s s i o n with external a p p e a r a n c e (looking young and beautiful) and its glamorization, as exemplified b y the cos-

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metic industry, the mass media, image makers, and the proliferation of cosmetic plastic surgeons, is such that other human qualities are made to seem less important by comparison. The importance and rewards of physical beauty are further legitimized by the recent flow of psychological studies begun in the 1970s [7], showing that attractive people are not only more in demand and more likely to succeed, but are perceived to be smarter, more personable, and better adjusted. It is not surprising, then, except for the delay in time, that a 1987 study finds that physical attractiveness has a positive effect on mental health [27]. Considering the above, it should be no mystery why there are countless numbers of disfigured persons among us who keep a low profile. By seeking refuge in their small circumscribed worlds and shunning face-to-face encounters, they remain a hidden people, a fact that accounts for the widespread ignorance of a major social problem. At the same time, there are countless others who, despite embarrassment and pain, refuse to submit to or be daunted by the constraints imposed by their particular stigma. But wanting and attaining satisfying interaction are factors that are not mutually inclusive, for the problems to be overcome require efforts on the part of both interactants as well as a high degree of awareness, empathy, and social skills. For some, such qualities are innate but for others they must be learned. These particular areas have been the most overlooked and neglected in the entire process of the rehabilitation of the facially handicapped. Normally the rehabilitation process begins with plastic surgery, the primary device for releasing people from the stigmatic effects of facial deviance. As a result of major breakthroughs in techniques and methods in the 1970s through to today, reconstructive and reparative plastic surgery for complex problems presented by craniofacial deformities, severe burns, and trauma can now be undertaken. Results may be and often are dramatic, but this depends on the type and severity of the anomaly, among other variables. As is often erroneously assumed, surgical intervention does not guarantee a " n e w " or normal face, but rather a transformation from less presentable to more presentable, an achievement that is a compromise, one that spells the difference between total withdrawal and participation in the social world with less than full acceptance. At the medical centers where reconstructive surgery takes place, additional rehabilitative measures are usually provided, such as psychotherapy, psychological counseling, social service, group therapy, parental guidance, and cosmetology instruction, to help the patient adjust to his/her condition. Where research is encouraged, pre- and postoperative studies are conducted, usually by psychiatrists and clini-

Facial Disfigurement: Problems and Management

cal psychologists who, primarily interested in the intrapsychic impact of disfigurement, focus on such factors as anxiety levels, depression, cognitive growth, personality adjustment, body image, ego strength, and self-esteem [2, 21]. Once the surgical regimen, which may involve intermittent procedures over a period of months or even years is completed, those for whom satisfactory aesthetic results remain beyond the skills of modern surgical techniques are still unable to blend unnoticed in a crowd. It is about time, as well as essential, that more attention be given to the symbolic nature and uniqueness of facial disfigurement as a handicap and its consequences for social adjustment and mental health. Preliminary work has demonstrated that if we are to ease or make less devastating the plight of disfigured people, more attention should be focused on what special sensitivities and skills are required in initial encounters between them and the nondisfigured and in the establishment of interpersonal rel a t i o n s - t h e most difficult of hurdles. There are numerous fruitful areas for investigation, for example, (1) how and to what extent doe s nonverbal communication influence the quality of interaction, (2) what is the role of shame in militating against smooth interaction, (3) to what extent is the social distance disfigured persons experience a function of their appearance or their demeanor. Since our society is not yet structured for dealing with facially disfigured people nor for accepting the defect for what it is rather than the symbolic characteristic ascribed to it, the burden of adjustment and coping seems to fall more upon the disfigured than the nondisfigured. Nevertheless, the process of establishing a relationship requires effort on the part of both individuals involved. It is not unlike two people learning to dance: first hesitant, awkward, and out of sync, but given time and a high degree of awareness it can become mutually rewarding. References

1. Becker E: Socialization, command of performance and mental illness. Am J Sociol 67:494-501, 1962 2. Belfer M, Harrison MA, Pillemer FC, Murray JE: Appearance and the influence of reconstructive surgery on body image. In: Macgregor FC (ed): Social and Psychological Considerations in Plastic Surgery. Clinics in Plastic Surgery. Philadelphia: W.B. Saunders, 1982, vol 9, No 3, pp 307-315 3. Birdwhistell RL: Kinesics in Context: Essays on Body Motion Communication. Philadelphia: Univ Pennsylvania, 1970 4. Bower T: Klaus Barbie: Butcher of Lyons. London: Michael Joseph, 1984, p 53 5. Cooley CH: Human Nature and the Social Order. New York: Scribners, 1922, pp 259-260 6. Davis F: Deviance disavowed: the management of strained interactions by the visibly handicapped. Social Problems 9:120-130, 1961

F.C. Macgregor

7. Dion K, Bershied E, Walster E: What is beautiful is good. J Personal Social Psychol 24:285-290, 1972 8. Goffman E: On face work. Psychiat J Study Interpersonal Processes 18:213-231, 1955 9. Goffman E: The nature of deference and demeanor. Am Anthropol 58:473-502, 1956 10. Goffman E: Behavior in Public Places. New York: Free Press, 1963, pp 83-88 11. Hall ET: The Silent Language. New York: Doubleday, 1959, pp 204-209 12. Hall ET: The Hidden Dimensions. New York: Doubleday, 1966, pp 107-122 13. Hersey J: My summer job with Sinclair Lewis. New York Times Book Review May 10, p 36, 1987 14. Macgregor FC: The Sociological Aspects of Facial Deformities, Master's thesis, University of Missouri, 1947 15. Macgregor FC, Schaffner B: Screening patients for nasal plastic operations: some sociologic and psychiatric considerations. Psychosom Med 12(5):277-291, 1950 16. Macgregor FC: Some psychosocial problems associated with facial deformities. Am Sociolog Rev 16:629-638, 1951 17. Macgregor FC, Abel TM, Bryt A, Lauer E, Weissman S: Facial Deformities and Plastic Surgery: A Psychosocial Study. Springfield, IL: Charles C Thomas, 1953 18. Macgregor FC: Transformation and Identity: The Face and Plastic Surgery. New York: Quadrangle, 1974

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19. Macgregor FC: After Plastic Surgery: Adaptation and Adjustment. New York: Praeger, 1979 20. NuttinJ: Intimacy and shame in the dynamic structure of personality. In: Reymert MR (ed): Feelings and Emotions. Mooseheart Symposium in Cooperation with the University of Chicago. New York: McGrawHill, 1950, pp 343-352 21. PertschukMJ, WhitakerLA: Social and psychological effects of craniofacial deformity and surgical reconstruction. In: Macgregor FC (ed): Social and Psychological Considerations in Plastic Surgery. Clinics in Plastic Surgery. Philadelphia: W.B. Saunders, 1982, vol 9, No 3, pp 297-306 22. Piff C: Let's Face It. London: Sphere, 1986 23. Roosevelt E: Personal communication, 1942 24. Rumsey N, Bull R, Gahagen D: The effect of facial disfigurement on the proxemic behavior of the general public. J Appl Social Psychol 12:137-150, 1982 25. Rumsey N: Psychological Problems Associated with Facial Disfigurement, unpublished Ph.D. thesis, North East England Polytechnic, 1983 26. Simmel G: From his Soziologie, cited in Park RE, Burgess EW: Introduction to the Science of Sociology, 2nd ed. Chicago: University of Chicago Press, 1924, p 358 27. Umberson D, Hughes M: The impact of physical attractiveness on achievement and psychological wellbeing. Social Psycholog Quart 50:227-236, 1987 28. Wiesel E: Essay, Time Magazine, May 11, p 93, 1987 29. Wilder T: The Ides of March. New York: Harper and Row, 1948, p 114