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The Psychopathology of Facial Deformity and Orthognathic Surgery

Introduction

The face has evolved as the most important of all human anatomical structures. It houses the principal receptors for sight, sound, taste and smell, has obvious and complex sexual significance, and the cere-bro-neuromuscular means of expressing speech and emotion. Facial attractiveness is one of our most important social and psychological characteristics and the psychopathology of facial deformity is a complex spectrum extending from emotional problems in the normally integrated individual to manifestations of personality disorders, neurosis, depression and psychosis.

1. Social Aspects of Facial Deformity

Those who are blessed with an attractive face are frequently perceived as being more friendly, sensitive and successful than those who are unattractive. This unfair social advantage does not take into account overriding compensatory factors such as intellect, personality and motivation. Certain facial stereotypes are inappropriately portrayed as being associated with particular characteristics, for example a Class III malocclusion may be perceived as aggressive or a marked Class II as weak or stupid. Bat ears and large noses are similarly a source of teasing in childhood, thus creating a hypersensitive awareness, which may undermine self-esteem and self-confidence. There is also evidence that unattractive individuals are discriminated against in a wide range of situations from early life through to adulthood. Perceptions of facial attractiveness are said to vary from person to person and amongst different ethnic groups. Probably as a result of international media influence, this preference is changing in favour of the white western European stereotype of beauty.

We now appreciate that dentofacial deformity may be a severe handicap in many situations. This supports the view that the majority of patients requesting orthognathic treatment must suffer in some way the effects of discrimination or imagined discrimination in order to make them seek treatment which has inherent discomfort and risks. Therefore a psychological assessment of all orthognathic patients is a vital part of the planning procedure as it enables the identification of a wide range of psychological problems. It is vital to identify any of these problems before inappropriate planning decisions have been made. Ideally a liaison psychiatrist or clinical psychologist would undertake this role, however where constraints are placed on providing the optimum service, the orthodontist or orthognathic surgeon must be responsible for the initial screening and identify and refer those patients of particular concern.

2. The Psychological Assessment

The social and psychological acceptance of aesthetic orthognathic treatment has increased the demand for treatment. Despite this the treatment plan should be based not only on aesthetics and function, but also on the patient’s perceptions of what they wish to obtain from treatment. Patients often perceive their facial appearance and in particular their profile, quite differently from clinicians. This emphasises the need for good communication from the outset when planning orthognathic procedures. The communication process is critical and will usually take several visits to accurately identify the patients’ subjective problems and the changes they are seeking. The clinician must then decide whether these expectations can be met. Unfortunately, there is no validated proforma for quantifying inappropriate psychological characteristics. Despite this, the following standardised approach is essential to avoid overlooking problem areas and should be done on a one-to-one basis and not in a large multidisciplinary clinic, where patients may be reluctant to disclose personal details. A number of patients will require referral to a liaison psychiatrist or clinical psychologist for a more thorough assessment before proceeding further. This decision will be based on a multistage triage procedure.

A. In addition to patients in whom the clinician intuitively feels concerns, those to be considered for referral include patients with:

B. There are a number of key interrelated questions which should be asked:

• What is the main complaint?

This question establishes how the patient perceives their problem. The accuracy of the complaint is not important, for example the patient may feel they have a prognathic mandible when actually they have a retrognathic maxilla. However, they must be able to recognise the problem and be relatively clear about it. Those who offer vague non-specific complaints such as “I just don’t like my face” tend to make poor surgical patients compared with those who are clear about their complaint — “I think my chin sticks out and is not symmetrical”.

• What does the patient expect from treatment?

This is very important and the way this question is phrased can influence the response. It is helpful to ask “How do you think this treatment will affect your life?” Those patients who want to look better and feel more self-confident are classified as expecting primary gain from treatment and tend to be good surgical patients. Patients requiring psychological assessment prior to agreeing to treatment include those who: (i) are concerned with secondary gain such as promotion, a better job or new partner

(ii) do not have any idea what they expect from treatment and

(iii) are not able to verbalise their answers to these questions.

• How long has he/she been concerned about their face? Why is he/she seeking treatment now?

Patients should always be asked how long they have had these concerns. Those who have become concerned only recently should again be assessed by a psychologist/psychiatrist as their worries may have been triggered by a recent life event such as redundancy, divorce, or bereavement. It is then appropriate to delay treatment until the patient has reached a more stable state before considering any intervention.

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