title: Assessing nonacceptance of the facial appearance in adult patients after complete treatment of their rare facial cleft.
abstract: BACKGROUND
  Treatment of patients with severe congenital facial disfigurements is aimed at restoring an aesthetic and functional balance. Besides an adequate level of satisfaction, an individual's acceptance of facial appearance is important to achieve because nonacceptance is thought to lead to daily psychological struggles. This study objectified the prevalence of nonacceptance among adult patients treated for their severe facial clefts, evaluated risk factors, and developed a screening tool.
  
  
  METHODS
  The study included 59 adults with completed treatment for their severe facial cleft. All the patients underwent a semistructured in-depth interview and filled out the Body Cathexis Scale.
  
  
  RESULTS
  Nonacceptance of facial appearance was experienced by 44% of the patients. Of the nonaccepting patients, 72% experienced difficulties in everyday activities related to their appearance versus 35% of the accepting patients. Acceptance did not correlate with objective severity or bullying in the past. Risk factors for nonacceptance were high self-perceived visibility, a troublesome puberty period, and an emotion-focused coping strategy. Also, the presence of functional problems was shown to be highly associated.
  
  
  CONCLUSIONS
  The objective severity of the residual deformity did not correlate with the patients' acceptance of their facial appearance, but the self-perceived visibility did correlate. The process of nonacceptance resembles the process seen in patients with body dysmorphic disorders. Surgical treatment is no guarantee for an improvement in acceptance and is therefore discouraged for patients who match the risk factors for nonacceptance unless it solves a functional problem. The authors therefore recommend screening patients for nonacceptance and considering psychological treatment before surgery is performed.
  
  
  METHODS
  This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.
authors.affiliation: Department of Plastic and Reconstructive Surgery, Erasmus University Medical Centre, Room Ee 15.91, Dr. Molewaterplein 50, 3015GE, Rotterdam, The Netherlands. m.vandenelzen@erasmusmc.nl
authors.forename: Marijke E P
authors.initials: ME
authors.lastname: van den Elzen
authors.forename: Sarah L
authors.initials: SL
authors.lastname: Versnel
authors.forename: Hugo J
authors.initials: HJ
authors.lastname: Duivenvoorden
authors.forename: Irene M J
authors.initials: IM
authors.lastname: Mathijssen
mesh_terms: D000328:Adult; D000368:Aged; D003717:Denial, Psychological; D005147:Facial Bones / Q000002:abnormalities; D005260:Female; D006801:Humans; D008297:Male; D008342:Mandibulofacial Dysostosis / Q000175:diagnosis / Q000453:epidemiology / Q000523:psychology* / Q000601:surgery*; D008875:Middle Aged; D009056:Mouth Abnormalities / Q000175:diagnosis / Q000453:epidemiology / Q000523:psychology* / Q000601:surgery*; D009426:Netherlands; D015995:Prevalence; D011788:Quality of Life / Q000523:psychology*; D019651:Plastic Surgery Procedures / Q000379:methods* / Q000706:statistics & numerical data; D012649:Self Concept; D012720:Severity of Illness Index; D055815:Young Adult