Plastic Surgery in Children
by Len Leshin, MD, FAAP
|Copyright 2000, All rights reserved
|One of the more commonly shared characteristics of children with Down syndrome is the effect on facial features. The vast majority of children with Down syndrome have extra skin at the inner corners of the eyelids ("epicanthal folds"), slanting rather than horizontal eye openings ("slanted palpebral fissures"), and a flattened nasal bridge. They may also have a flattened mid-facial region and a downturned lower lip. Another common feature is a protruding tongue with an open mouth.|
|In the 1970s, a group of people began recommending plastic surgery as a way to change the facial features common to Down syndrome. The surgeries can be categorized into two groups: surgeries aimed at reducing the size of the tongue, thus attempting to improve function of the tongue and reduce mouth breathing; and the surgeries aimed at improving the appearance of the face, called "facial reconstruction." I will discuss these categories separately.|
It is a challenge for the aesthetic surgeon to make good-looking people more handsome. But it is even more rewarding to "normalize" people who are isolated because of their ugly facial expression so that they may be reintegrated into a group of friends from which they may have already anxiously withdrawn. Children with Down's syndrome are frequently concealed from the public by their parents. The children suffer from two disadvantages: Their mental abilities are limited and they have ugly facial features.(1)The above author's view toward Down syndrome is certainly not unique among plastic surgeons:
Until recently, children with Down syndrome could not escape the stigma of their characteristic facial features, which instantly labelled them as "retarded" no matter how well they functioned.(2)The immediate goal of reconstructive surgery is to improve the appearance of the face. Surgical procedures used toward this goal include partial resection of the tongue, correction of the down-turned lip, lifting of the nasal bridge, removal of fat from the neck, placing implants in the zygomatic bones (cheeks), removing the epicanthal folds and making the palpebral fissures more horizontal. Several studies have been published by surgeons showing approval by parents of the results of plastic surgery(2,3,4). However, one of these studies(2) also showed that independent raters found no improvement in appearance.
The purpose of the surgery, however, is not merely to improve appearance but to improve social acceptance of people with Down syndrome. One study has suggested that people with Down syndrome are subject to decreased acceptance by their peers on the basis of facial features alone(6). The argument on behalf of facial reconstruction states that as parental expectations for school achievement and job opportunities increase, that modifying the face (along with the conventional therapies) can increase the opportunities for success in society.
It does appear to be true that, after facial reconstruction, parents have been pleased with the resulting change of appearance of their child.(1,2,4,7) However, studies have not demonstrated any significant impact of the change in facial appearance on the children's social functioning.(8,9) Further, some studies have disputed the notion that the appearance of children with Down syndrome has a deleterious affect on how they are perceived.(10,11)
There are no simple answers to this controversy. Some parents and doctors will ask why shouldn't a child with Down syndrome be made to look more "ordinary," if possible? Our society accepts removing birthmarks, pinning ears and other surgical corrections of minor defects in children. Other parents and doctors ask if appearance is so important that we should subject a child, who is often of a pre-school age, to such major surgical procedures. While making this decision, parents and doctors should keep the following in mind:
Persons with Down syndrome should be afforded all medical and educational services that are available to other children without this chromosomal disorder. Moreover, their appearance including hairstyle, dress attire and general hygeine should be such to enhance their acceptance and integration in society. Persons with Down syndrome should be accepted for what they are and offered a status that observes their rights and privileges as citizens, and in a real sense preserves their human dignity.(10)
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