Monday, January 19, 2009

Body Image and Facial Burns – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I came across this article, Body Image and Facial Burns, in the journal Advances in Skin & Wound Care.  It is a short, but interesting article.  I came away feeling they had fallen short on my expectations from the title and what the authors state as the purpose of the article:
This article reviews the literature (PubMed, Medline, and Ovid databases) on the effect of facial burns on body image and discusses the theory and research behind normal and altered body image. Facial burns illustrate the clinical application to provide efficacious treatment strategies for people with disfigurement.

There are 58 articles listed in their reference, but in the body of the article they don’t state the total number of  articles they did find with their search.  Nor do they define the criteria for the articles they did review, only that
Although body image models have been proposed, only a small body of literature relating to facial disfigurement exists. These models, although theoretical, provide a framework for managing altered body image.

I did enjoy the section on the theory of body image. 
Schilder defined body image as "the picture of our body which we form in our mind, that is to say the way in which our body appears to ourselves."
Schilder noted body image was fluctuant, varying with age, mood, or clothing.
Price proposed the body image model, comprising body reality, body presentation, and body ideal.
Body reality is an individual's phenotype and depends on genotype and environmental factors.
Body presentation refers to an individual's dress, adornment, and behavior.
Body ideal is how an individual desires to appear. It comprises various facets including physical dimensions and body function.
Body reality and presentation are compared with the body ideal, consciously and subconsciously. Body ideal, in accordance with Schilder, alters with time and environment and may be emotionally influenced. These factors are suggested to be in a state of balance; altering one may cause compensatory change in the others.
The article goes on to discuss primary and secondary socialization and several different models (ie fear-avoidance model of psychosocial difficulties following disfigurement).  The article goes on to discuss the importance of faces:
Faces facilitate understanding of our identity and ancestry and provide clues to age and mood.  A person's face is the main point of focus during social interaction-providing conscious and unconscious expressions.   Approximately two-thirds of communication is nonverbal, mediated principally by facial expression.
Facial disfigurement describes the visual effect of scars, skin grafts, asymmetry, or altered pigmentation. It may cause disruption to body image and, especially if there is loss of self-recognition, constitute a major life crisis.

Then tries to condense the findings from the reviewed articles, but it left me with little to “hand my hat on”.
Some researchers have found more psychological problems in adolescents and persons in their early 20s. 
However, Robinson et al  found no correlation of patient age or duration of disfigurement with levels of anxiety and depression, although only 13 participants younger than 27 years were included in their study.
Yet, this supports other work suggesting that the development of effective coping mechanisms determines psychosocial outcomes.

If  Sir McIndoe is correct (as quoted in the article), then have we gone backwards by getting rid of wards and having only private rooms?  Is the need for infection control harming the treatment of psychological aspects of facial trauma?
Sir Archibald McIndoe made groundbreaking advances reconstructing allied air-force pilots who were burned in World War II. He noticed that the burns of the men on the ward healed better than the officers who had been kept in cubicles: "Camaraderie was the obvious answer. The officers on their own tended to fret, lose their appetite, and think too much about their disfigurement.’

The conclusion section is better in my opinion.

Body image models, although they have limitations, provide a framework for the analysis and treatment of disfigured individuals. For some, a blemish may cause huge anxiety; others with far more disfiguring burns may cope well.
Experiences and levels of perceived social support sculpt an individual's self-esteem and interpretation of specific situations. This seems to alter emotional and behavioral responses more than demographic or physical characteristics. Those who do well tend to confront their anxieties, whereas those who avoid them develop negative coping strategies and fare worse.
Various modalities can be used in the management of facial disfigurement, including surgery and psychosocial therapies. Efficacious psychological interventions must target specific cognitive and behavioral elements that predispose individuals to experience distress as a consequence of their disfigurement.
Future research using qualitative and longitudinal techniques needs to be conducted to rigorously evaluate these psychosocial interventions and enable the demolition of this last bastion of discrimination.

Actually, I got more out of the article going back through it a second and third time to write this review.  Still I wanted more of a black and white conclusion and there can’t be at this time (and maybe never will be).


A comment from the second article listed below:
Patients undergoing cosmetic surgery, like most of the general population, have emotional and social concerns specific to aspects of facial appearance, albeit to a greater degree.  Perhaps this greater level of concern is a cause for action to undertake cosmetic surgery. For the most part, these concerns do not represent pathologic states, and, in fact, the incidence of body image psychosocial disorders is quite low in this population.
This study validates the fact that a positive change in a feature of concern is accompanied by a resultant lessening of concern related to that feature. This "cause and effect" phenomenon stands in stark contrast to a true body image disorder wherein no amount of surgical alteration will yield the preferred decrease in associated distress.

Body Image and Facial Burns; Advances in Skin and Wound Care,  Vol 22, No 1, pp 39-44, January 2009;  David CG Sainsbury, BMedSci (Hons), MBBS, MRCS (Eng)
Impact of Cosmetic Facial Surgery on Satisfaction With Appearance and Quality of Life; Arch Facial Plast Surg. 2008;10(2):79-83; Jason A. Litner, MD, FRCSC; Brian W. Rotenberg, MD, FRCSC; Maureen Dennis, BA, RN; Peter A. Adamson, MD, FRCSC

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