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Beauty and the eye of the beholder: social consequences and personal adjustments for facial patients
Brimh Journul ot Plasfic Surgen ( 1986) 39.8 I-84 i.) 1986The Trustees of British Association of Plastic Surgeons
Beauty and the eye of the beholder: social consequences and personal adjustments for facial patients* E. M. ARNDT,
F. TRAVIS,
A. LEFEBVRE,
Departments of Social Work, Psychology Surgery), The Hospital for Sick Children,
A. NIEC and I. R. MUNRO
and Psychiatry and the Division Toronto, Canada
of Plastic Surgery
(Department
of
Summary-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.
Although Aristotle’s dictum that “Beauty is a greater recommendation than any letter of introduction” (Rozner, 1983) has only recently been subjected to scientific scrutiny, the psychological literature of the past decade seems to confirm it: attractive individuals are more likely than others to be seen as intelligent, friendly, and successful (Berscheid et al., 1971; Dion et al., 1972; Kalick, 1978). However, we still know very little about the psychosocial adjustment of patients who undergo facial reconstruction (Lefebvre and Munro, 1978; MacGregor, 1979; Lefebvre and Barclay, 1982). Within the normal range, we know that plastic surgery confers psychosocial benefits on the patient (Edgerton et al., 1960; Hay and Heather, 1973; Kalick, 1977) but systematic studies involving patients with maxillofacial and craniofacial deformities are lacking. Instead, case reports have primarily focused on personality and behavioural characteristics, psychopathology, the way individuals cope, and the social consequences for a person with a facial deformity (MacGregor, 1979).
This pilot study was undertaken to test three of the basic premises underlying all plastic and reconstructive surgery, in terms of maxillofacial and craniofacial patients: (i) The patient will feel more attractive, more confident, and generally happier after surgery than before it. (ii) His increased attractiveness will result in increased social ease and appeal. (iii) Surgery will improve his appearance in the eyes of people around him.
Materials and methods Twenty-two patients (13 girls and 9 boys): ranging in age from 8 to 17 years when first seen, were interviewed during assessment routines by a team consisting of a psychiatrist, psychologist, and social worker. Fourteen of these patients had rather severe disorders such as Crouzon’s syndrome while 8 had the less obvious deformity of a malocclusion (Table 1). Preoperatively, patients were asked to explain why they sought facial surgery and their expectations of it, both physically and psychosocially. In addition, they were asked to rate their present facial appearance on the Hay’s Rating Scale, which
* Bar.ed on presentations made at the VIII International Congress of Plastic Surgery, June 29 1983, Montreal, Quebec, and at the 41st Annual Meeting of the American Cleft Palate Associatlon. May 22 1984, Seattle, Washington.
81
82
BRITISH
Table .I Range of conditions Condition
No.
Malocclusion Hypertelorism Lateral facial dysplasia Crouzon’s syndrome Goldenhar’s syndrome Apert’s syndrome Pyle’s disease
8 4 3 2 1 3
I
ranges from 1 (perfect feature) to 9 (marked imperfection) (Hay and Heather, 1973). They were also asked to complete the Piers-Harris Self-Concept Scale for Children, an 80-item yes-and-no questionnaire designed for children aged 6 to 18 years (Piers, 1969). At the time of postoperative evaluations, 6 months and 2 years after surgery, the analyses were repeated and the patients were asked about the surgical experience, their satisfaction with the outcome, and possible changes in their personal and social life. Full-sized black and white frontal and profile photographs of the patients were rated by 15 adult volunteers using the Hay’s scale. There were 5 male and 10 female raters whose average ages were 37.4 and 34.2 years, respectively. The pictures were taken before and 1 year after facial surgery. Paired r-tests were used in all within-group statistical analyses. Differences were taken to be significant when p < 0.0 1. Results Table 2 shows the pre- and postoperative Hay’s Scale ratings (means and standard deviations, SD) Table 2
Comparison of pre- and postoperative the independent raters
(6 months-2
JOURNAL
OF PLASTIC
for patients with severe and mild deformities, their parents, and 15 independent raters. Improvement in all postoperative ratings by patients was highly significant (every p
Discussion Physical attractiveness is a legitimate and extraordinarily important psychological variable in the field of appearance. Attractive people are thought to be more sensitive, friendly, interesting, outgoing, and successful in their private and professional lives than unattractive individuals (Dion et al., 1972). They receive preferential social treatments years) Hay’s scale ratings by patients,
their parents and
Rating
Group (N) Severely affected (14) Patients Parents Raters Mildly affected (8) Patients Parents Raters* * One patient’s
photograph
WZiS
Preoperative
6 mopostoperalive
I yr postoperative
2 y postoperative
Mean
SD
Mean
SD
Mean
Mean
SD
6.3 6.2 6.3
1.54 1.37 1.83
2.5 2.6
1.16
2.1 2.4
1.07 0.84
7.3 6.5 4.2
1.58 1.41 1.44
2.0 2.5
2.3 2.5
0.46 0.53
not available
for rating.
SURGERY
SD
1.63 6.02
I .75
0.53 0.53 2.9
0.84
THE
EYE
OF THE BEHOLDER
83
BEAUTY
AND
Table 3
Comparison of pre- and postoperative (6 months-2 years) Piers-Harris scores RATING (%)* Preoperative
6 mopostoperative
? y postoperative
Group (N)
Mean
SD
Mean
SD
Mean
SD
Severely affected ( 14) Mildly affected (8)
49.10 23.75
24.85 18.58
82.00 82.00
22.63 11.45
79.79 79.10
22.24 9.61
* 10046 is maximum
self-esteem.
as they elicit favourable attitudes and behaviour in a variety of settings (Berscheid and Walster. 1974; Adams and Crossman, 1978). Attractiveness plays an important role in infant and child development (Hildebrandt, 1982) and in adult activities such as dating. Allen (1978) found that it was a more important criterion for dating choices than honesty, trustworthiness, or independence. It is no surprise, then, that self-esteem is generally high in attractive people (Berscheid et al., 1971; Mathes and Kahn, 1975), who are not only socially more active than unattractive people (Berscheid et al., 1971; Krebs and Adinolfi, 1975; Hildebrandt, 1982), but also socially more polished and assertive (Jackson and Huston. 1975; Goldman and Lewis, 1977). With the advent of modern surgical techniques, plastic and reconstructive surgery of the face has become an increasingly sophisticated instrument for intervention in a person’s life (Munro, 1979; Jackson et al., 1982). Before decisions for surgery are made, the question of whether the person requesting it would benefit from the procedure must be addressed. Our findings confirm that patients and their families find plastic and reconstructive surgery a highly beneficial mode of intervention. Postoperative changes in terms of physical appearance, selfesteem, academic performance. and social competence affect the quality of the patients’ lives positively, giving them a feeling of well-being and vitality. However, it appears that the benefits of facial reconstruction are less obvious to the man on the street who is unaware of the patient’s surgical experience. This study is an initial attempt to assess objectively the perceived improvements in patients with facial deformities. There are several obvious limitations to this pilot project. Our raters were few and may not have been representative of the general population. In addition. the large range of diagnostic categories produced a heterogeneous sample population. Furthermore, the black and
white photographs did not give a three-dimensional representation of the patients’ appearance and colour photographs or even videotapes of the patients would perhaps be better instruments for this study. They would better allow for such nuances as facial expressions, hairstyles, and skin blemishes that may affect the ratings. Finally, the raters’ biases have not been taken into account. A more systematic, large-scale, and long-term study is required to test these results. The specific importance of other patient variables such as age, intelligence, socioeconomic status, and nature of community in which the patients live. the quality of presurgical family adjustment, and their social network need further study as well. Nevertheless, it may be that the patient’s improved self-evaluation and confidence are the crucial variables in improving the quality of his life. If this is the case, then one can understand that his social ease is a secondary benefit after surgery that helps him overcome possible barriers of anxiety and prejudice related to his appearance. This, in turn, may positively influence society’s reactions toward the patient. Perhaps the best judge remains the patient himself who opted for facial reconstruction. Acknowledgements The authors thank Miss Ruth Koch-Schulte, MSW. Director of Social Work. for her support and encouragement. Dr R. B. Ross, Head. Division of Orthodontics for his valuable counsel, Mr Marko Katie, BA. for statistical analysis. and the Medical Publications Department for editorial assistance.
References Adams, G. R. and Crossman, S. M. (1978). Physical Attractivenes.r: A Culturul Imperative. Roslyn Heights, NY: Libra Publishing. Allen, B. P. ( 1978). Social Behavior: Fact und Falsehood. Chicago: Nelson-Hall. Berscheid, E., Dion, K., Walster. E. and Waker. G. W. ( I97 1). Physical attractiveness and dating choice: A test of the matching hypothesis. Journal of E.xperimental und Social Psyhology. 7. 173.
84 Berscheid, E. and Walster, E. (1974). Physical attractiveness. In. L. Berkowitz (Ed.), Advances in Experimental and Social Psychology. Vol. 7. New York: Academic Press. Dion, K. K., Berscbeid, E. and Walster, E. (1972). What is beautiful is good. Journal of Personalirv and Social Psychology, 24.285. Edgerton, M. T., Jacobson, W. E. and Meyer, E. (1960). Surgical-psychiatric study of patients seeking plastic (cosmetic) surgery: Ninety-eight consecutive patients with minimal deformity. British Journal ofPlastic Surgery, 13, 136. Goldman, W. and Lewis, P. (1977). Beautiful is good: Evidence that the physically attractive are more socially skillful. Journal of Experimental and Social Psychology, 13, 125. Hay, G. C. and Heather, B. B. (1973). Changes in psychometric test results following cosmetic nasal operations. British Journal of Psychiafrv, 122.89. Hildebrandt, K. A. (I 982). The role of physical appearance in infant and child development. In H. E. Fitzgerald, B. M. Lester and M. W. Yogman (Eds.). Theory and Research in Behavioral Pediafrics. Vol. 1, New York: Plenum, 181. Jackson, D. J. and Huston, T. L. (1975). Physical attractiveness and assertiveness. Journal of Social Psychology, 96. 79. Jackson, 1. T., Munro, I. R., Salyer, K. E. and Wbitaker, L. A. (1982). Atlas of Craniomaxillofacial Surgery. St. Louis: Mosby, 1. Kalick, S. M. (1977). Plastic surgery, physical appearance, and person perceplion. Doctoral Dissertation, Harvard University. Kalick, S. M. (1978). Toward an interdisciplinary psychology of appearances. Psychiarry, 41,243. Krebs, D. and Adinolfi, A. A. (1975). Physical attractiveness. social relations, and personality style. Journal of Personality and Social Psvchology, 31, 245. Lefebvre, A. and Barclay, S. (1982). Psychosocial impact of craniofacial deformities before and after reconstructive surgery. Canadian Journal of Psychiatry, 21, 579.
BRITISH
JOURNAL
OF PLASTIC
SURGERY
Lefebvre, A. and Munro, I. (1978). The role of psychiatry in a craniofacial team. Plastic and Reconstructive Surgery, 61,564. MacGregor, F. C. (1979). After Plastic Surgery: Adaptation and Adjusnnenf. New York: Praeger. Matbes, E. W. and Kahn, A. (1975). Physical attractiveness. happiness, neuroticism, and self-esteem. Journal of Psychology, 90.27. Munro, 1. R. (1979). Craniofacial surgery. In W. C. Grabb and J. W. Smith (Eds.). Plastic Surgery, 3rd. Ed. Boston: Little, Brown, 13 I. Piers, E. V. (I 969). Manual,for the Piers-Harris Children’s SelfConcept Scale (The Way I See M_vselfl. Nashville: Counselor Recordings and Tests. Rozner, L. (1983). Facial plastic surgery for Down’s syndrome. Lance! 1. 1320.
The Authors Erika M. Arndt, MA, MSW, Social Worker, Department of Social Work. The Hosnital for Sick Children. Felicia Travis, Dip SC, dsychometrist. Department of Psychology. The Hospital for Sick Children. Arlette Lefebvre, MD, Department of Psychiatry, The Hospital for Sick Children. Ann Niec, BSc, Department of Psychiatry, The Hospital for Sick Children. Ian R. Munro, MA, MB, BChir, FRCS(C), Department of Surgery, The Hospital for Sick Children.
Requests for reprints to: Mrs E. Arndt, Department of Social Work, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1x8.
Beauty and the eye of the beholder: social consequences and personal adjustments for facial patients* E. M. ARNDT,
F. TRAVIS,
A. LEFEBVRE,
Departments of Social Work, Psychology Surgery), The Hospital for Sick Children,
A. NIEC and I. R. MUNRO
and Psychiatry and the Division Toronto, Canada
of Plastic Surgery
(Department
of
Summary-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.
Although Aristotle’s dictum that “Beauty is a greater recommendation than any letter of introduction” (Rozner, 1983) has only recently been subjected to scientific scrutiny, the psychological literature of the past decade seems to confirm it: attractive individuals are more likely than others to be seen as intelligent, friendly, and successful (Berscheid et al., 1971; Dion et al., 1972; Kalick, 1978). However, we still know very little about the psychosocial adjustment of patients who undergo facial reconstruction (Lefebvre and Munro, 1978; MacGregor, 1979; Lefebvre and Barclay, 1982). Within the normal range, we know that plastic surgery confers psychosocial benefits on the patient (Edgerton et al., 1960; Hay and Heather, 1973; Kalick, 1977) but systematic studies involving patients with maxillofacial and craniofacial deformities are lacking. Instead, case reports have primarily focused on personality and behavioural characteristics, psychopathology, the way individuals cope, and the social consequences for a person with a facial deformity (MacGregor, 1979).
This pilot study was undertaken to test three of the basic premises underlying all plastic and reconstructive surgery, in terms of maxillofacial and craniofacial patients: (i) The patient will feel more attractive, more confident, and generally happier after surgery than before it. (ii) His increased attractiveness will result in increased social ease and appeal. (iii) Surgery will improve his appearance in the eyes of people around him.
Materials and methods Twenty-two patients (13 girls and 9 boys): ranging in age from 8 to 17 years when first seen, were interviewed during assessment routines by a team consisting of a psychiatrist, psychologist, and social worker. Fourteen of these patients had rather severe disorders such as Crouzon’s syndrome while 8 had the less obvious deformity of a malocclusion (Table 1). Preoperatively, patients were asked to explain why they sought facial surgery and their expectations of it, both physically and psychosocially. In addition, they were asked to rate their present facial appearance on the Hay’s Rating Scale, which
* Bar.ed on presentations made at the VIII International Congress of Plastic Surgery, June 29 1983, Montreal, Quebec, and at the 41st Annual Meeting of the American Cleft Palate Associatlon. May 22 1984, Seattle, Washington.
81
82
BRITISH
Table .I Range of conditions Condition
No.
Malocclusion Hypertelorism Lateral facial dysplasia Crouzon’s syndrome Goldenhar’s syndrome Apert’s syndrome Pyle’s disease
8 4 3 2 1 3
I
ranges from 1 (perfect feature) to 9 (marked imperfection) (Hay and Heather, 1973). They were also asked to complete the Piers-Harris Self-Concept Scale for Children, an 80-item yes-and-no questionnaire designed for children aged 6 to 18 years (Piers, 1969). At the time of postoperative evaluations, 6 months and 2 years after surgery, the analyses were repeated and the patients were asked about the surgical experience, their satisfaction with the outcome, and possible changes in their personal and social life. Full-sized black and white frontal and profile photographs of the patients were rated by 15 adult volunteers using the Hay’s scale. There were 5 male and 10 female raters whose average ages were 37.4 and 34.2 years, respectively. The pictures were taken before and 1 year after facial surgery. Paired r-tests were used in all within-group statistical analyses. Differences were taken to be significant when p < 0.0 1. Results Table 2 shows the pre- and postoperative Hay’s Scale ratings (means and standard deviations, SD) Table 2
Comparison of pre- and postoperative the independent raters
(6 months-2
JOURNAL
OF PLASTIC
for patients with severe and mild deformities, their parents, and 15 independent raters. Improvement in all postoperative ratings by patients was highly significant (every p
Discussion Physical attractiveness is a legitimate and extraordinarily important psychological variable in the field of appearance. Attractive people are thought to be more sensitive, friendly, interesting, outgoing, and successful in their private and professional lives than unattractive individuals (Dion et al., 1972). They receive preferential social treatments years) Hay’s scale ratings by patients,
their parents and
Rating
Group (N) Severely affected (14) Patients Parents Raters Mildly affected (8) Patients Parents Raters* * One patient’s
photograph
WZiS
Preoperative
6 mopostoperalive
I yr postoperative
2 y postoperative
Mean
SD
Mean
SD
Mean
Mean
SD
6.3 6.2 6.3
1.54 1.37 1.83
2.5 2.6
1.16
2.1 2.4
1.07 0.84
7.3 6.5 4.2
1.58 1.41 1.44
2.0 2.5
2.3 2.5
0.46 0.53
not available
for rating.
SURGERY
SD
1.63 6.02
I .75
0.53 0.53 2.9
0.84
THE
EYE
OF THE BEHOLDER
83
BEAUTY
AND
Table 3
Comparison of pre- and postoperative (6 months-2 years) Piers-Harris scores RATING (%)* Preoperative
6 mopostoperative
? y postoperative
Group (N)
Mean
SD
Mean
SD
Mean
SD
Severely affected ( 14) Mildly affected (8)
49.10 23.75
24.85 18.58
82.00 82.00
22.63 11.45
79.79 79.10
22.24 9.61
* 10046 is maximum
self-esteem.
as they elicit favourable attitudes and behaviour in a variety of settings (Berscheid and Walster. 1974; Adams and Crossman, 1978). Attractiveness plays an important role in infant and child development (Hildebrandt, 1982) and in adult activities such as dating. Allen (1978) found that it was a more important criterion for dating choices than honesty, trustworthiness, or independence. It is no surprise, then, that self-esteem is generally high in attractive people (Berscheid et al., 1971; Mathes and Kahn, 1975), who are not only socially more active than unattractive people (Berscheid et al., 1971; Krebs and Adinolfi, 1975; Hildebrandt, 1982), but also socially more polished and assertive (Jackson and Huston. 1975; Goldman and Lewis, 1977). With the advent of modern surgical techniques, plastic and reconstructive surgery of the face has become an increasingly sophisticated instrument for intervention in a person’s life (Munro, 1979; Jackson et al., 1982). Before decisions for surgery are made, the question of whether the person requesting it would benefit from the procedure must be addressed. Our findings confirm that patients and their families find plastic and reconstructive surgery a highly beneficial mode of intervention. Postoperative changes in terms of physical appearance, selfesteem, academic performance. and social competence affect the quality of the patients’ lives positively, giving them a feeling of well-being and vitality. However, it appears that the benefits of facial reconstruction are less obvious to the man on the street who is unaware of the patient’s surgical experience. This study is an initial attempt to assess objectively the perceived improvements in patients with facial deformities. There are several obvious limitations to this pilot project. Our raters were few and may not have been representative of the general population. In addition. the large range of diagnostic categories produced a heterogeneous sample population. Furthermore, the black and
white photographs did not give a three-dimensional representation of the patients’ appearance and colour photographs or even videotapes of the patients would perhaps be better instruments for this study. They would better allow for such nuances as facial expressions, hairstyles, and skin blemishes that may affect the ratings. Finally, the raters’ biases have not been taken into account. A more systematic, large-scale, and long-term study is required to test these results. The specific importance of other patient variables such as age, intelligence, socioeconomic status, and nature of community in which the patients live. the quality of presurgical family adjustment, and their social network need further study as well. Nevertheless, it may be that the patient’s improved self-evaluation and confidence are the crucial variables in improving the quality of his life. If this is the case, then one can understand that his social ease is a secondary benefit after surgery that helps him overcome possible barriers of anxiety and prejudice related to his appearance. This, in turn, may positively influence society’s reactions toward the patient. Perhaps the best judge remains the patient himself who opted for facial reconstruction. Acknowledgements The authors thank Miss Ruth Koch-Schulte, MSW. Director of Social Work. for her support and encouragement. Dr R. B. Ross, Head. Division of Orthodontics for his valuable counsel, Mr Marko Katie, BA. for statistical analysis. and the Medical Publications Department for editorial assistance.
References Adams, G. R. and Crossman, S. M. (1978). Physical Attractivenes.r: A Culturul Imperative. Roslyn Heights, NY: Libra Publishing. Allen, B. P. ( 1978). Social Behavior: Fact und Falsehood. Chicago: Nelson-Hall. Berscheid, E., Dion, K., Walster. E. and Waker. G. W. ( I97 1). Physical attractiveness and dating choice: A test of the matching hypothesis. Journal of E.xperimental und Social Psyhology. 7. 173.
84 Berscheid, E. and Walster, E. (1974). Physical attractiveness. In. L. Berkowitz (Ed.), Advances in Experimental and Social Psychology. Vol. 7. New York: Academic Press. Dion, K. K., Berscbeid, E. and Walster, E. (1972). What is beautiful is good. Journal of Personalirv and Social Psychology, 24.285. Edgerton, M. T., Jacobson, W. E. and Meyer, E. (1960). Surgical-psychiatric study of patients seeking plastic (cosmetic) surgery: Ninety-eight consecutive patients with minimal deformity. British Journal ofPlastic Surgery, 13, 136. Goldman, W. and Lewis, P. (1977). Beautiful is good: Evidence that the physically attractive are more socially skillful. Journal of Experimental and Social Psychology, 13, 125. Hay, G. C. and Heather, B. B. (1973). Changes in psychometric test results following cosmetic nasal operations. British Journal of Psychiafrv, 122.89. Hildebrandt, K. A. (I 982). The role of physical appearance in infant and child development. In H. E. Fitzgerald, B. M. Lester and M. W. Yogman (Eds.). Theory and Research in Behavioral Pediafrics. Vol. 1, New York: Plenum, 181. Jackson, D. J. and Huston, T. L. (1975). Physical attractiveness and assertiveness. Journal of Social Psychology, 96. 79. Jackson, 1. T., Munro, I. R., Salyer, K. E. and Wbitaker, L. A. (1982). Atlas of Craniomaxillofacial Surgery. St. Louis: Mosby, 1. Kalick, S. M. (1977). Plastic surgery, physical appearance, and person perceplion. Doctoral Dissertation, Harvard University. Kalick, S. M. (1978). Toward an interdisciplinary psychology of appearances. Psychiarry, 41,243. Krebs, D. and Adinolfi, A. A. (1975). Physical attractiveness. social relations, and personality style. Journal of Personality and Social Psvchology, 31, 245. Lefebvre, A. and Barclay, S. (1982). Psychosocial impact of craniofacial deformities before and after reconstructive surgery. Canadian Journal of Psychiatry, 21, 579.
BRITISH
JOURNAL
OF PLASTIC
SURGERY
Lefebvre, A. and Munro, I. (1978). The role of psychiatry in a craniofacial team. Plastic and Reconstructive Surgery, 61,564. MacGregor, F. C. (1979). After Plastic Surgery: Adaptation and Adjusnnenf. New York: Praeger. Matbes, E. W. and Kahn, A. (1975). Physical attractiveness. happiness, neuroticism, and self-esteem. Journal of Psychology, 90.27. Munro, 1. R. (1979). Craniofacial surgery. In W. C. Grabb and J. W. Smith (Eds.). Plastic Surgery, 3rd. Ed. Boston: Little, Brown, 13 I. Piers, E. V. (I 969). Manual,for the Piers-Harris Children’s SelfConcept Scale (The Way I See M_vselfl. Nashville: Counselor Recordings and Tests. Rozner, L. (1983). Facial plastic surgery for Down’s syndrome. Lance! 1. 1320.
The Authors Erika M. Arndt, MA, MSW, Social Worker, Department of Social Work. The Hosnital for Sick Children. Felicia Travis, Dip SC, dsychometrist. Department of Psychology. The Hospital for Sick Children. Arlette Lefebvre, MD, Department of Psychiatry, The Hospital for Sick Children. Ann Niec, BSc, Department of Psychiatry, The Hospital for Sick Children. Ian R. Munro, MA, MB, BChir, FRCS(C), Department of Surgery, The Hospital for Sick Children.
Requests for reprints to: Mrs E. Arndt, Department of Social Work, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1x8.