Although having a facial disfigurement secondary to trauma, a birthmark, a birth defect or some abnormality does not affect a patient’s health; society deems it often leads to stigmatisation and limitations of opportunities afforded to others.

1. 40 Aesthetic Medicine • October 2016
FACIAL DISFIGUREMENT www.aestheticmed.co.uk
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Dr Patrick Treacy on the aesthetics
of beauty and the social stigmatisation
of facial disfigurement
F
acial disfigurement is the state of having one’s facial
appearanceharmedmedically,eitherfromadisease,
birth defect, or trauma. Although this perceived
defect does not usually affect a patient’s health; the
conditionleadstosocialstigmatisationandisolation
and incurs limitations of privileges and opportunities
otherwiseaffordedto thosewithouttheproblem.
Itisestimatedthatpresentlythereareabout40,000adults
and children in the UK (one in 150 people) with significant
facial disfigurements and one in 500 children is seriously
enough affected by facial disfigurement to result in severe
psychosocial problems, poorself-esteemanddepression.
Studies have shown that the general population respond
to people with a facial disfigurement with prejudice,
intolerance, less trust and respect and often try to avoid
making contact or having to look at them. Although modern
reconstructive surgery and medical treatments help in
making some of the unusual features less noticeable they
usually don’t remove them completely and the patients
have to employ coping strategies, including the avoidance
of social contact, alcohol misuse, and aggression. For those
affected,itcanturnasimplesocialeventintoamajorordeal.
CAUSES OF FACIAL DISFIGUREMENT
The causes of facial disfigurements are highly variable. At
oneendofthescalearepatientswhoarebornwithsignificant
craniofacial abnormalities such as Apert syndrome, while at
the other, we have less aesthetically challenging problems
secondarytoskinconditionssuchascysticacne,birthmarks
or possibly vitiligo. In between, we have a myriad of cases
secondary to diseases such as elephantiasis or leprosy or
because of congenital disfigurements caused by conditions
like neurofibromatosis.
A few years ago, facial lipodystrophy syndrome (HLS) was
a major problem for many HIV patients undergoing long-
termuseofhighlyactiveantiretroviraltherapy(HAART).The
psychological facial wasting effects of the condition were
extremely distressing and these patients had high levels of
Challenging
beauty

2. 41Aesthetic Medicine • October 2016
FACIAL DISFIGUREMENTwww.aestheticmed.co.uk
S K I N / D E R M AT O L O G Y
depression,suicideaswellassocialwithdrawalandisolation.
Infact,aUKstudyshowedthat47%ofpatientswithHLShad
HRSDscoresforseveredepression.Itwasforthisreasonand
the lack of proper aesthetic therapy to manage this complex
condition that I pioneered a facial endoprosthesis technique
toreplacethemalarfatpadintheAilesburyClinicsomeyears
ago. It restored dignity to these otherwise socially isolated
patients.Thankfully,thenewanti-AIDSdrugsdonotgiverise
tothesetypesofproblems.
Weaved into this myriad of pathologies are those who
have already suffered great emotional trauma because of
benign or malignant facial cancers, scarring secondary to
road traffic accidents or burns etc. While skin conditions like
acne scarring or vitiligo may not immediately appear to be of
major psychological concern, these patients often disguise
their facial disfigurements through camouflage techniques
and live a life behind a mask of coloured creams. I personally
witnessedthisphenomenontreatingoneofthemostfamous
faces in the world for vitiligo a few years ago. Whatever the
cause, society presently dictates that people with a facial
disfigurement are perceived to be less physically attractive,
less socially desirable and less likely to find an acceptable
spouse.Inthisarticle,Iwilltryandanalysewhatactuallydrives
such a bias in every cultural society on earth, especially as it
is guided towards people who have already often been the
victimofgrosstraumaorunfairness.
PREJUDICE AND BELIEFS
Before we start this exploratory journey, let us define two
underlying words; prejudice and belief. The word prejudice
comes from the word prejudgment, making a decision
before becoming aware of the relevant facts of a case. In
recent times, this word has gained prominence when used
to refer to legal judgments toward people or a person
because of a bias against their gender, religion, race/
ethnicity, sexuality or possibly social class. Prejudice is a
baseless and usually negative attitude toward members of
a particular group. Common features of prejudice include
negative feelings, stereotyped beliefs, and a tendency to
discriminate against members of the group. While specific
definitions of prejudice given by social scientists often
differ, most agree that it involves prejudgments (usually
negative) about members of a group. >

3. 42 Aesthetic Medicine • October 2016
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Belief on the other hand is the psychological state in
which an individual holds a conjecture or premise to be true.
Because our beliefs are the primary determinant of what
we do and feel, and even what we perceive, all prejudice
can usually be traced to belief systems. Both beliefs
and prejudices themselves change with time. Twentieth
century Britain has seen many prejudices enacted against
differing races and religions. In the early part
of the twentieth century British people
were convinced that Irish immigrants
were not as good as themselves, in
later years, Jamaicans, Pakistanis
and Nigerians have taken that
role. These beliefs have in turn
also been expressed about
Catholics, Jews and more
recently Muslims.
Just as we look back at
cultural practices of ancient
Rome with repulsion, future
generations will probably
look back at these prejudices
with similar reactions. It is
impossible for us to try and
understand the Roman thinking
that feeding Christians to lions was
acceptable as a spectator sport. These
beliefs were accepted two thousand
years ago as these people were seen as
a threat to the society that existed then. And they were
probably right. History has decided that Christian religion
would displace the Roman deities and their ministers would
give rise to their own prejudices in turn, especially in the
period after the Reformation. So, a belief is really just a
statement about a perceived reality that we individually
experience as the truth. But, in fact, no belief describes
the truth about reality. Without exception, beliefs are
arbitrary interpretations of events by individuals. Physical
objects and events certainly occur in the world, but the
meaning that we give the events exists only in our minds,
not in the material world. If this is so, why is the prejudice
against facial disfigurement so strong and why has it
survived the ages?
CONCEPTS OF BEAUTY
At the outset, it would be easy to
blame the stigmatisation of people
with facial disfigurement on
the emphasis that our modern
image conscious society places
on physical appearance.
There is continual pressure,
through media and other
marketing tools for people
of every age to conform to
what is a perceived normal
appearance. Throughout the
centuries, facial beauty has
beenperceivedbymanycultures
as a human quality that provides a
sensory experience of pleasure or
goodness. Beauty has generally been
associated with that which is good and
ugliness has been associated with evil.
The Byzantine Emperor was considered God’s Vice-
Regent on Earth and his beauty was taken as an essential
complement to the perfection of Heaven. For this reason,
many deposed emperors were facially disfigured by being
blindedorhavingtheirnosescutofftodisqualifythemfrom
ever reclaiming the throne. During this period of history,
society believed that facial “disfigurement” involved
the entity being out of balance and harmony with nature
It is estimated that presently
there are about 40,000 adults
and children in the UK (one in
150 people) with significant facial
disfigurements and one in 500 children
is seriously enough affected by facial
disfigurement to result in severe
psychosocial problems, poor
self-esteem and depression

4. 43Aesthetic Medicine • October 2016
FACIAL DISFIGUREMENTwww.aestheticmed.co.uk
S K I N / D E R M AT O L O G Y
and ugliness engendered a deeply negative perception
of a person. This simplistic approach to ugliness and by
associationtofacialdisfigurementsisstillreinforcedtoday
at every stage by the media and by our education system.
Consider our current classic children’s fairy tales, where
the Ugly Sisters equate ugliness with evil and Cinderella
with all things wonderful or indeed the tale of
the Sleeping Beauty or the evil old witch in
HanselandGretel.Itisalsoreinforcedon
our TV screens (Ugly Betty) and with
filmandvideovillainssuchasFreddy
(in Nightmare on Elm Street) and
John Merrick (in Elephant Man).
If film makers or novelists
were to treat race or sex in
the way that they presently
portray beauty or ugliness
they would probably be subject
to society’s revulsion and
possible legal prosecution. Then
why is society still disrespectful
and uncompassionate to people
who are usually not contributory
in any way to their condition? What
causes us to turn away in revulsion from
a person with a congenital, traumatic, or
malignant facial condition rather than
being compassionate and comforting them?
SYMMETRY
Symmetry of facial form leads to a person having more
sexual partners and more satisfactory relationships
and this is similar across every culture. In fact, if facial
symmetry as a means for determining beauty has indeed
an evolutionary basis, then this would explain why it is
present in every human culture and even suggests our
stigmatisation of facial disfigurement may actually be
innate. This would happen if there was an evolutionary
benefit to society to allow it to remain in every culture
across so many millenniums.
Many scientists now believe that this revulsion may be
an innate defense mechanism designed to protect society
against disease and bad genes. It is well known that a three-
month old baby will smile and develop a bonding
relationshipquickerwithasymmetricalface
than they will with their own mother.
This is probable evidence that this
is not learned behaviour. A recent
experiment by the BBC Inside
Out team demonstrated
presenter Julia Hankin made
up with tattoo ink by a
make-up artist - to give the
appearance of a prominent
port wine stain. In the
course of the programme
she took a seat on a busy
busroute.Ittook65minutes
before someone would sit
next to her. Later, on the same
journey with the make-up off,
it was a very different story and
someone took the seat next to Julia
after about 30 seconds. Professor Nichola Rumsey, from
the Centre for Appearance Research at the University of
West England performed similar research on the London
tubeandfoundthatpeoplechosenottositnexttosomeone
when they had a disfigurement on their face.
Psychologists like Valerie Curtis, a behavioural scientist
at the London School of Hygiene and Tropical
Medicine believe that the emotion of disgust
is similar to fear. “Fear evolved to keep
you away from large animals that
want to eat you from the outside,”
but “disgust evolved to keep you
away from smaller animals that
kill you from the inside.” Our
subconscious minds constantly
scan the environment for signs
of potential diseases, she says.
If we see one, disgust kicks
in and we avoid that object
or person like the plague. It
appears that even if we know
thesepeopleareperfectlyhealthy,
our minds are responding to them as
if they’re not.
Soisthereanythingwecandotochange
our behaviour? Education is probably a good
start. We should strive to make atypical appearance
more familiar and mundane, possibly following the lead
set by Channel 4 and showing people with these types of
appearances on television more often. As doctors we >
Many scientists now believe
that this revulsion may be an
innate defense mechanism designed
to protect society against disease and
bad genes. It is well known that a three-
month old baby will smile and develop
a bonding relationship quicker with
a symmetrical face than they will
with their own mother
Throughout the centuries,
facial beauty has been perceived
by many cultures as a human
quality that provides a sensory
experience of pleasure or goodness.
Beauty has generally been associated
with that which is good and
ugliness has been associated
with evil

5. 44 Aesthetic Medicine • October 2016
FACIAL DISFIGUREMENT www.aestheticmed.co.uk
S K I N / D E R M AT O L O G Y
>> Dr Patrick Treacy is CEO of Ailesbury Clinics, chairman of the Irish Association of Cosmetic Doctors and
Irish regional representative of the British College of Aesthetic Medicine (BCAM). He is also president of
the World Trichology Association. Dr Treacy has won a number of awards for his contributions to facial
aesthetics and hair transplants including the AMEC Award in Paris in 2014. Dr Treacy also sits on the
editorial boards of three international journals and features regularly on international television and radio
programmes. He was on the scientific committee for AMWC Monaco 2015, AMWC Eastern Europe 2015,
AMWC Latin America 2015, RSM ICG7 (London) and Faculty IMCAS Paris 2015 and IMCAS China 2015.
DISFIGUREMENT SUPPORT GROUPS
BELL’S PALSY SUPPORT
• Bell’sPalsyAssociation–TheonlyUK-registeredcharitydedicatedsolelyto
providinghelpandinformationtopeoplewithBell’spalsy.www.bellspalsy.org.uk
• Facial Palsy UK – Charity supporting people who are affected by facial paralysis.
www.facialpalsy.org.uk
BIRTHMARK SUPPORT
• The Birthmark Support Group – A UK-based support group for anyone with a
birthmark.www.birthmarksupportgroup.org.uk
BURNS SUPPORT
• TheChildren’sBurnsTrust–TheChildren’sBurnsTrustiscommittedtoproviding
supportforburn-andscald-injuredchildrenandtheirfamilies.www.cbtrust.org.uk
CLEFT LIP AND PALATE SUPPORT
• Cleft Lip & Palate Association (CLAPA) – CLAPA is the only UK-wide voluntary
organisation specifically helping those with, and affected by, cleft lip and
palate. www.cbtrust.org.uk
CRANIOFACIAL CONDITIONS SUPPORT
• Headlines – Support for those affected by craniosynostosis and associated
conditions. www.headlines.org.uk
• The Craniofacial Society – A society for the study of cleft lip and palate and
other craniofacial anomalies. www.craniofacialsociety.org.uk
DISFIGUREMENT SUPPORT
• Changing Faces – Support for people who have disfigurements of the face or
body from any cause. www.changingfaces.org.uk
EPIDERMOLYSIS BULLOSA SUPPORT
• DEBRA – A UK charity for people with the genetic skin blistering condition
epidermolysis bullosa (EB). www.debra.org.uk
NEUROFIBROMATOSIS SUPPORT
• The Neuro Association – Help, support and advice for those affected by either
form of neurofibromatosis and their families. www.nfauk.org
PROTEUS SYNDROME SUPPORT
• Proteus Family Network – A UK support group for families and individuals
affected by Proteus syndrome. www.proteus-uk.org
RETINOBLASTOMA SUPPORT
• Childhood Eye Cancer Trust (CHECT) – A UK-wide charity for families and
individuals affected by retinoblastoma. www.chect.org.uk
SCARRING SUPPORT
• The Scar Information Service – Providing information on scarring, scar
therapies and support organisations. www.smith-nephew.com
STURGE-WEBER SYNDROME SUPPORT
• Sturge-Weber Foundation – Support and information on different aspects of
Sturge-Weber syndrome, a rare neurological disorder. www.sturgeweber.org.uk
TREACHER COLLINS SYNDROME SUPPORT
• TreacherCollinsFamilySupportGroup–Support,adviceandfriendshipforpeople
withTreacherCollinssyndromeandtheirfamilies.www.treachercollins.net
VITILIGO SUPPORT
• The Vitiligo Society – Support for people with vitiligo and their families in the
UK and the Republic of Ireland. www.vitiligosociety.org.uk
XERODERMA PIGMENTOSUM (XP) SUPPORT
• XP Support Group – Support for people with xeroderma pigmentosum and
other related conditions and their families. www.xpsupportgroup.org.uk
must respect and give supportive care to patients with
facial disfigurements. For this reason, I have provided an
extensive list of specialist organisations such as Changing
Faces or the Disfigurement Guidance Centre in the United
Kingdom who provide support to people living with facial
disfigurement and offer advice on all types of treatment.
It’s important for parents to learn about their child’s
condition and not to be afraid to ask their consultant as
many questions as possible. Being better informed about
your child’s condition will help them to learn how to cope
with it. There are also easy-to-learn, practical skills to
help parents overcome some of the common challenges
and uncertainties they may face. Children start becoming
curious about their appearance from an early age and
learn from watching their parents deal with challenging
situations. AM