Media broadcasts stories of children with facial anomalies being "saved" from bullying via plastic surgery. Cases range from port wine stains and scars from cleft lip repairs to things even more noticeable, like a very misshapen nose. Although the surgical-repair approach seems to many like a no-brainer, medical professionals who care for children with facial anomalies see these cases as much more complicated. I asked Cassandra Aspinall, a senior social worker in the Craniofacial Center at Seattle Children's Hospital, to explain. Aspinall has worked at Seattle Children's for 27 years. Our discussion is lightly edited for clarity.
AD: If a child is being bullied over some facial anomaly, why shouldn't we see plastic surgery as the easy fix?
CA: Making decisions about surgically "fixing" someone's appearance is much more complicated than making a decision to medically manage asthma or diabetes. Some surgeries done on facial anomalies are meant to manage human interaction by changing appearance, and human interaction is always complex. When I work with these families, I try to find out what has been done to stop other people's reactions to the child's facial difference. I can't think of any situation where a person who is being singled out because of racial or ethnic differences would be told that that they should just change their race or religion to avoid someone else's prejudice.
What risks do you bring up when families are considering reconstructive surgeries?
Of course the physical risks that come with any surgery, but also the risks of changing one's appearance. A child and family may unexpectedly face stress after surgery from having "given in to the bullies," from feeling not strong enough to cope.
The trend in the pediatric care of children with socially-challenging anatomies seems to be toward team care -- social workers and psychologists as well as medical and surgical specialists.
It is. We're trying to do more to immediately support the patient, but also improve long-term outcomes. We may provide the most expert surgical treatment to a patient, but if the patient does not experience the change as positive, or if the change is short-lived because environmental issues are not addressed, then harm can ensue. The "problem being treated" has to be assessed rather than assumed. Other factors will also affect how an individual fares: how other people react, whether or not the family suffers financially from treatments. A multidisciplinary team can also work to reduce the trauma sometimes caused by medical interventions, an under-recognized concern.
When a child is born with a noticeable birth anomaly, parents often worry that that child will never be lovable. (Actually, all parents probably worry about this for all children.) What's the best way to address that worry?
The most important thing to do is to explicitly address it. The reactions of others can be a problem, but those reactions--or fears that those reactions will occur--must not be our only focus. We try to help families and young children by supporting identity formation that puts the medical condition in the background while staying focused on what a given child enjoys or finds interesting in the world, and helping others to do the same. All children can learn to be with those who support them and move away from those who do not. They can learn that one can choose to change oneself (including one's body) to satisfy the views of a few or one can align with those who share common interests and worldviews.