Aesth. Plast. Surg.
14:249-257, 1990
Facial Disfigurement: Problems and Management of Social Interaction
and Implications for Mental Health
Frances Cooke Macgregor
New York, New York, USA
Abstract. The concern of this article is with the impact
of facial disfigurement on social interaction during brief
encounters, the ramifications of which have the potential
for psychological and social destruction. Largely ignored
by those interested in the social and psychological prob-
lems and rehabilitation of the functionally impaired, such
as the blind, the deaf, the amputee, the intent here is to
point up the major problems associated with facial disfig-
urement and to explore some of the ways of dealing with
them. The data on which this article is based were col-
lected over many years and are no longer new, but this
attempt to synthesize them for a particular purpose is.
Key words: Facial disfigurement--Social interaction--
Psychosocial problems--Rehabilitation
"It is difficult, my dear Lucius, to escape becoming the
person which others believe one to be. A slave is twice
enslaved; once by his chains and once again by the glances
that fall upon him . . ." [29]
The effect upon social interaction during brief en-
counters in daily life when the face of one of the
participants is disfigured is a subject that deserves
far more attention and systematic investigation than
Support for the research on which this article is based was
provided by the National Institute of Mental Health,
United States Public Health Service, the Milbank Memo-
rial Fund, the Society for the Rehabilitation of the Facially
Disfigured, and the Social Rehabilitation Service, United
States Department of Health, Education and Welfare.
Address reprint requests to Frances Cooke Macgregor,
M.A., Institute of Reconstructive Plastic Surgery, New
York University, 550 First Avenue, New York, NY 10016,
USA
Aesthetic
_ Plasuc
Surgery
9 1990 Springer-Verlag New York Inc.
it has received. And yet, as research has shown, for
those whose faces do not c o n f o r m to the n o r m it is
this very process that is a source o f unremitting
stress, anxiety, and anguish, all o f which h a v e nega-
tive implications for personality functioning and
mental health.
Problems of Social Interaction
In-depth studies of the social and psychological
problems associated with facial anomalies, b o t h con-
genital and acquired, c o n d u c t e d on 181 plastic sur-
gery patients m o r e than three decades ago showed
that the patients' m a j o r complaints and difficulties
centered around the patterns of interaction b e t w e e n
themselves and others [14-17].
I n t 9 8 7 , and m o r e than 500 patients later, we found
the complaints and p r o b l e m s to be the same. While
distressed each day b y the reflection in their o w n
mirrors, as m u c h if not m o r e hurtful and damaging
to their self-image and self-esteem is seeing their
own flawed faces reflected in the reactive behavior
of the nondisfigured. This is experienced m o s t often
during face-to-face encounters with strangers: when
traveling to work or school, shopping, entering and
eating in a restaurant, walking along the street,
standing in line. Attending to what m a y be m u n d a n e
affairs for those whose faces are u n r e m a r k a b l e is
fraught with potential hazards for those w h o look
different.
The need for social interchange and comingling
a m o n g humans is basic and strong. But so too is the
need for privacy, for preserving o n e ' s terri-
t o r y - b o t h personal and p h y s i c a l - - f r o m the intru-
sion of strangers. F o r m o s t people these needs are
met, but not for those who look different or h a v e
250
conspicuous facial defects. The "civil inattention"
[10] that is normally conferred by strangers on one
another and that makes it possible to move anony-
mously and unhindered in public places is a right
anc~ a privilege most longed for by facially disfigured
people who, unable to conceal their handicaps, are
vicl~ims of intrusions and invasions of privacy,
against which they have little or no protection. In
their efforts to go about their daily affairs they are
subjected to visual and verbal assaults and a level of
familiarity from strangers no otherwise dared: naked
stares, startle reactions, "double-takes," whisper-
ing, remarks, furtive looks, curiosity, personal ques-
tions, advice, manifestations of pity or aversion,
laughter, ridicule, and outright avoidance. Whatever
form the behaviors may take, they generate feelings
of shame, impotence, anger, and humiliation in their
victims.
The purpose of this article is to direct attention to
and further explore some of the problems inherent
in the interactive process that confronts the facially
disfigured in the establishment of social relationships
and in the maintenance of interactions--problems
that are often so trying and so difficult that protective
stratagems must be devised in order to survive. In
so doing my specific objectives are threefold: (1) to
gain more knowledge of the patterns and the pro-
cesses of social interaction between the disfigured
and the nondisfigured and their potential for social
and psychological destruction, (2) to examine ways
of reducing the roadblocks to social acceptance, (3)
to help define areas for further investigation. First,
however, despite its being self-evident, it is essential
to make the following points in order to place the
subject of this article in context.
In all human relationships, it is the face that is the
symbol of or synonymous with the person. Inti-
mately connected with communication, both verbal
and nonverbal, and the region where the sense of
self is located, it is the focus of attention whenever
people meet. Because of its social significance, any
condition that distorts it and makes it ugly or un-
sightly to look at can take precedence over all other
personal and social traits and insidiously can become
the most important thing about that person.
For the majority of people their days involve face-
to-face encounters which, as pointed out by Goff-
man [9], Becker [1], and others, involve certain ritu-
als, behaviors, and rules of social conduct,that are
both learned and patterned and which people nor-
mally observe automatically and without thinking.
For example, in salutations or while addressing an-
other, proper eye conduct (in our culture) requires
looking at the face of the speaker with eye contact
that is neither a fixed gaze nor fleeting. With strang-
ers or new acquaintances there are rules about keep-
ing one's distance, asking personal questions, and
avoiding topics that might be embarrassing or inap-
Facial Disfigurement: Problems and Management
propriate. It is during such encounters that those
with deviant faces experience flagrant disregard for
the rituals and rules governing social behavior.
Not all forms of behavior experienced by the dis-
figured are as overt or blatantly intrusive as staring
or asking personal questions. Nevertheless, they can
be equally discomforting and stressful. These are the
subtle and complex "small behaviors" that occur in
everyday face-to-face interaction that seem to mean
nothing but, as students of human behavior such as
Goffman, Hall, and Birdwhistell have clearly dem-
onstrated, do indeed mean something. In fact, they
frequently provide more information than verbal ex-
change. These small behaviors are known as micro-
levels of communication or the "silent language" by
which people unconsciously and sometimes con-
sciously, send messages to one another without the
use of words. Usually perceived on a subliminal
level, they nevertheless have positive and negative
effects on interaction. One microlevel, for example,
is manifested kinesically, i.e., by body movements
and tonus, postural and facial changes, head posi-
tioning, eye movements, gestures, and the like, by
which people make statements about their feelings
and attitudes [3].
Another mode of communication is paralinguistic:
the tone and pitch of voice, rate of speech, hesita-
tions, sighs, yawns, emotional overtones, and ex-
pressions that serve to underscore, qualify, or ne-
gate what is being said.
A third mode of communication involves the sig-
nificance of space (proxemics), i.e., the manner in
which it is employed to increase or decrease one's
personal and social distance from another [cf. 11]. In
the spatial frame in which social interaction occurs
there are, as in other modes of communication, cul-
turally defined rituals and codes of conduct that gov-
ern our encounters and determine what is or is not
appropriate in particular situations. For example,
when engaged in conversation friends may stand
(or sit) closer to each other than strangers, but the
distance between the former will be greater than that
between lovers and less than that between business
acquaintances. Normal standing distance between
strangers or acquaintances in our culture is from
four to seven feet [cf. 12]. Should one person get too
close, the automatic reaction of the other is to back
away in order to increase the distance and allay
feelings of discomfort. As Hall [ll, p. 204] points
out, "Spatial changes give a tone to communication,
accent it, and at times even override it."
The matter of proximity to people is an ever-pres-
ent problem for the disfigured. As victims of negative
rather than positive attitudes and reactions, they
tend to develop a heightened awareness of and sensi-
tivity to what are or what may be construed as signs
of discomfort, embarrassment, or rejection by the
nondisfigured as indicated by the latter's use of silent
F.C. Macgregor
language during face-to-face interaction. Thus, the
perceived manifestations of avoidance and rejection
about which disfigured persons complain are some-
times thought to be overstated, imagined, or even
self-fulfilling prophecies because of their hypersensi-
tivity to what otherwise might be regarded as unim-
portant or inconsequential behavior. While this may
well be the case in some instances, systematic obser-
vations and experiments indicate that the nondisfig-
ured do indeed tend to convey in covert and sym-
bolic ways their discomfort when interacting with
facially disfigured persons. This was demonstrated
by Rumsey, Bull, and Gahagen [24] in a field experi-
ment on the use of personal space when interacting
with disfigured persons compared with the nondis-
figured. The subjects were 450 members of the gen-
eral public and a confederate presenting three differ-
ent conditions: a "port-wine stain," a bruised and
scarred face, and, as a control, a " nor m al " face.
The results showed that the standing distance af-
forded the confederate when disfigured was signifi-
cantly greater than when he had no disfigurement.
Moreover, the subjects also elected to stand on the
nondisfigured side of the confederate during interac-
tion far more often than they did when his appear-
ance was " n o r m a l . "
Management of Social Interaction
The experience of having facial stigmata is to be
made acutely aware of the incompatibility between
oneself and one's social environment. Moreover, it
is constantly reinforced by the uncertainty and dread
of situations that not only interfere with " nor mal "
interaction but produce feelings of impotence,
shame, and anger. In the words of a 22-year-old
man whose gross disfigurement was caused by an
explosion: " I t ' s hell! You don't know which way to
turn. You get stares from people every da y- -re-
marks--whispers--questions." A 30-year-old man
with a congenital condition known as hemifacial mi-
crosomia said, "When I see the reaction of others
to my 'Picasso' face it's like pouring turpentine into
a raw wound."
More disfigured people than is generally realized
find that attempts to cope with problems of daily
encounters are so trying that aloofness or total with-
drawal are their only alternatives. Others, however,
resort to a variety of strategems and protective de-
vices in order to function in a hostile environment.
Depending upon the individual and the particular
situation, these may be overt or covert, aggressive
or passive, hostile or receptive. For example, when
stared at many individuals feign unawareness, some
stare back. " I burn two holes in them," or retaliate
with defiant remarks: "Take a good look." Still oth-
251
ers feel too helpless to do anything. " I just look
away. What can you d o ? "
Personal questions also elicit different responses
depending on such factors as the individuals asking
the question, the context in which it is asked, the
form and manner in which it is put, and how it is
interpreted by the receiver. Questions from strang-
ers, if not ignored or brushed aside with "I was in
an accident" or "the war" (etiologies more socially
acceptable than other given causes), may evoke
flippant even hostile replies: "I was in a ring wres-
tling with a bear." " G o d hit me with a frying pan . "
"I got it from sticking my nose somewhere I
shouldn't." "Mind your own business." Such re-
sponses, while possibly meeting a momentary need
of the individual, not only incrase the social distance
between the interactants but serve to truncate any
potential there might have been for incipient inter-
action.
There are individuals with visible stigmas w h o
employ more positive methods for managing social
encounters. One of these is "deviance disavowal"
[cf. 6], a stratagem used by those who look different
in an attempt to "normalize" their situation and to
"break through" or gain acceptance. For example,
following temporary discharge from a hospital with
a badly burned face and joining a group for the first
time, a young athlete made a point of explaining the
cause of his Condition: " I immediately go over to
one or two people and mention the accident and my
plastic surgery treatments so they won't get embar-
rassed and wonder what they should say." A college
student with congenital absence of both ears found
ways of diverting attention from his handicap: " I
talk fast to people or give them a hand at something
they might be doing. This keeps them from thinking
about me or asking questions."
Some individuals find it strategic to make light of
their impairments on first encounters in order to
reduce tension and social distance: A woman whose
face was marred by a beauty treatment found it effec-
tive when entering a room of people to announce
facetiously, "Please excuse the case of leprosy."
Others provide time to lessen the shock of their
appearance. Aware of the unnerving effect his can-
cer-caused disfigurement had upon people, a real
estate agent described his technique for establishing
a relationship: "When I have an appointment with
a new contact I try to be standing at:a distance, so
the person will have more time to see me and get
adjusted to my appearance."
Though less common, some individuals attempt
to destigmatize their afflictions and make acceptance
less difficult by using themselves as the target of
jokes. On a television show to raise funds for the
handicapped, a participant, admitting that the loss
of his eye had been an embarrassment in high school,
drew laughter about such incidents as the night he
252
spent with his girl and wakened to hear her dog
crunching on his glass eye.
Some disfigured people attempt to overcome in-
teractional barriers by using or exploiting their hand-
icaps to help others or to educate the public. They
visit patients in hospitals, give talks to school chil-
dren, become counselors, write books [221, or orga-
nize self-help or support groups.
Not all facial deviations are immediately apparent.
Some, such as malformed ear, may be noticed one
time but not the next. In certain situations a particu-
lar type of anomaly, e.g., a large nose or receding
chin, may evoke laughter or ridicule or suggest a
stereotype. Complaining about the ambiguous na-
ture of his handicap (a twisted mouth caused by
congenital facial paralysis which became noticeable
only when he smiled or laughed) a college student
said: " I am always on pins and needles. The worst
part of it is that you forget about it. No one says
anything. Then, bang! All of a sudden someone
makes a face like mine. It puts salt in the wound and
brings it up all over again. It would be better if
something were said every day."
The effect of erratic and unpredictable reactions
has been shown to play a significant part in the differ-
ential in adjustment to facial deviance between per-
sons with severe disfigurement and those with mod-
erate or mild deviations. As reported elsewhere [17,
pp 86-88], the evidence indicates that consistently
negative reactive responses permit the former to be
forewarned, hence psychologically and emotionally
prepared, whereas the inconsistency and unpredict-
ability of reactive responses, whether they will be
acceptive or rejective, tend to put the latter in a
precarious position, thus reinforcing their feelings
of anxiety and tension.
Regardless of the type or degree of disfigurement,
however, the fact is that it does create contexts in
the interactive process in which one's deficiency "is
no sooner perceived than it is multiplied by reflection
from other minds" [cf. 5].
Strains of Interaction
A high psychological cost is exacted from disfigured
persons to counter the threats inherent in the social
world. The time and psychic energy that could be
channeled into more positive aspects of living are
too often consumed by preoccupation with the way
one looks, vigilant attention to the reactive behavior
of others, and the mobilization of defense mecha-
nisms, all of which are detrimental to mental and
emotional health. Not atypical is the case of a 29-
year-old woman who had suffered traumatic injury
to her face five years earlier. Seeking additional re-
parative surgery her presenting complaints included
both psychological and somatic distress, e.g., night-
Facial Disfigurement: Problems and Management
mares and migraine headaches. She had reached a
point, she said, where she feared all forms of face-
to-face interaction because of the effort required to
maintain her emotional equilibrium. " I suffer tre-
mendous fatigue, especially when I have to travel
on subways. I have such anxiety facing people. I'm
afraid of new people and I won't go anywhere. Even
going to the beauty parlor is an ordeal" [cf. 19, p
131.
In a similar vein, a 33-year-old woman--formerly
known for her extraordinary beauty--whose face
had been totally transformed by an auto accident,
described the strain of trying to cope with the handi-
cap of her startling appearance. It had become "too
great," she said, explaining her heavy drinking. "I
am tired of always trying to be charming, to compen-
sate for what I lack. It's such an endless effort. If
only my face could be made to look normal enough
for me to be able to sit back and rest once in a while
and not always force myself to be entertaining or
interesting and to create an atmosphere which will
distract others from my disfigurement" [cf. 18, p 41.
But the strains inherent in the interactive process
between the disfigured and the nondisfigured are by
no means confined to the former. Facial deviations
also have an unsettling effect on the latter. Given the
nature of the defect and the immediate, sometimes
visceral, reactions it evokes, what otherwise might
be a normal encounter is marked by feelings of aver-
sion, discomfort, and anxiety.
Compounding these difficulties is the fact that the
guidelines and unspoken rules of conduct for inter-
changes are not as clear as are those governing ordi-
nary encounters. Worse still is the lack of familiarity
with the needs and problems presented by this
unique handicap. Most people are uncertain as to
what they should or should not do and say or not
say when talking with a disfigured person, and their
fear of showing discomfort precludes spontaneity
and increases tension. Even ordinary interchanges
are filled with potential pitfalls and faux pas, and
such commonplace remarks a s " Y o u ' r e looking well
today" and "Plain as the nose on your face" sud-
denly become horrifying slips of the tongue.
Unlike those situations involving the aged, the
amputee, or the blind with whom relationships can
be established by the fact of their special and well-
defined needs for assistance and the general knowl-
edge and understanding of the public about such
matters, there is nothing of this nature that can be
applied to making contact with the disfigured. They
don't require assistance in crossing a busy street or
special ramps or wheelchairs to move about in pub-
lic. What they do require and what they ask for is
the unflinching eye contact that tells them they too
are "members of the human race."
Perhaps no other mode of communication be-
tween the disfigured and nondisfigured is so critical
F.C. Macgregor
to the interactive process and the self-image of the
disfigured individual as eye behavior, the signifi-
cance of which has been underscored by Simmel
[26]:
"The union and interaction of individuals is based upon
mutual glances. This is perhaps the most direct and purest
reciprocity which exists anythere . . . So tenacious and
subtle is this union that it can only be maintained by the
shortest and straightest line between the eyes, and the
smallest deviation from it, the slightest glance aside, com-
pletely destroys the unique character of this union . . .
The interaction of eye to eye dies in the moment in which
directness of the function is lost. But the totality of social
relations of human beings, their self-assertion and es-
trangements, would be changed in unpredictable ways if
there occurred no glance of eye to eye.
By the glance which reveals the other, one discloses
himself. By the same act in which the observer seeks to
know the observed, he surrenders himself to be under-
stood by the observer. The eye cannot take unless at the
same time it gives . . . . "
Those with facial stigmata are acutely sensitive to
a falter in eye movement or eye avoidance, which
for them are endowed with special significance. " M y
appearance detracts from what I s a y , " said a woman
whose facial paralysis prevented complete closure
of one eye and turned her smile into a grimace. " I
notice people look over my shoulder when they talk.
It makes me self-conscious--as though they didn't
want to look at me. I'm embarrassed. I'd rather have
them look at m e - - b a c k and f o r t h - - y e t not stare."
And another, comparing her damaged nose to a
"pig's snout": " W h e t h e r or not I talk with strangers
depends upon the way they look at me. They often
get a strange expression and I can tell that my nose
makes them sick. They make a funny face or cast
their eyes aside. If this happens I look down or turn
my head. But ifa person looks squarely into my eyes
without glancing at my nose, it makes me feel at ease
and I can answer questions or talk without feeling
self-conscious and a s h a m e d . "
The role of shame in encounters between the dis-
figured and nondisfigured is, interestingly enough,
one that has been greatly neglected by psycholo-
gists. Yet the research on which this article is based
reveals that it is a predominant feeling associated
with facial deviance and central to the problem.
Shame, according to the dictionary, is a painful
emotion caused by a consciousness of one's own
shortcomings. So intolerable is this emotion that
when feelings of shame are aroused the universal
tendency is to turn away, look down or away, hide
the face, avoid s c r u t i n y - - a reaction that reflects the
symbolic values attached to it and which, in our
culture, is implicit in the words " s h a m e f a c e d , "
"lose f a c e , " " f a c e value," and so on.
Representing one's personal self and being the
locus of psychological intimacy [20], the face serves
253
also as the persona, or social facade, which, devel-
oped during the socialization process, one presents
to the outside world. But lacking normal appearance
as well as the protective devices of expression, the
facial deviant feels threatened and exposed; this in
turn produces feelings of shame. It is this emotion
that plays a profound role in both coloring and inter-
fering with the interactive process between the dis-
figured and the nondisfigured.
Although not focusing on the concept of shame
per se, Goffman's [8] attention to the subject of
"face-saving" is germane to this discussion. In his
analysis of the ritual elements in social interaction
of ordinary people, he stresses the importance of the
rule of self-respect and considerateness so that each
of the participants may maintain f a c e (author's ital-
ics), " b o t h his own and the face of the o t h e r . " Face-
saving, he contends, is a "condition of interaction,"
a term that is far less metaphorical for the disfigured
than for " o r d i n a r y p e o p l e . " Nevertheless, as indi-
cated earlier there are nondisfigured individuals
who, by their indiscreet actions or remarks, whether
the result of ignorance of an abnormal need to violate
the intimacy of others, make " f a c e - s a v i n g " an insu-
perable task.
For those who want to help the disfigured maintain
face and move more easily in the public domain,
there is no substitute for looking straightforwardly
into their faces. Only the acknowledgment that he/
she exists can provide the disfigured person with a
sense of "belonging to the human r a c e , " instead of
being '~a breed a p a r t " or " c r e a t u r e s from another
planet."
It would seem safe to say that the average person
has great compassion for those with flawed faces.
H o w e v e r , complex psychological mechanisms
aside, some people are so aesthetically repelled and
even threatened by the sight o f an abnormality that,
despite genuine feelings o f sympathy and compas-
sion, they are unable to cope with or maintain a face-
to-face situation. Others find interaction difficult be-
cause they are distracted or " p u t o f f " by a defect,
even a relatively mild one such as a scarred lip or
crossed eye, areas which happen to be those by
which we most actively send signals to one another.
Because we rely so much on feedback by way of
facial expression and the transitory m o v e m e n t s of
muscles (there are some 100 of them) that indicate
agreement, surprise, interest, and other nonverbal
messages to which we in turn respond, we are dis-
concerted when these modes of communication are
impaired. Unable to " r e a d " the other person and
frustrated by the ambiguity that is created, we be-
come hesitant and awkward. While some impair-
ments lead to false clues and interpretations, others
provide no clue at all. Cases in point are those with
severely burned faces or with a condition known as
"Moebius s y n d r o m e , " a bilateral facial paralysis
254
that causes the face to be immobile and almost to-
tally expressionless. Since there is little or no feed-
back, attempts at interchange have been likened to
"talking to a s t a t u e . " E v e n for professionals this
masklike quality impedes interaction and creates
problems. " I t is striking to this e x a m i n e r , " the psy-
chologist reports, " t h a t because of [the patient's]
facial scarring (the result of burns) it is difficult if not
impossible to ' r e a d ' the usual clues (facial grimaces,
etc.) that a clinician uses in dealing with an indi-
vidual."
M a n y disfigured persons valiantly try to attain
smooth interaction and m a k e it easier for others, but
at a cost and with mixed results. A middle-aged
w o m a n said:
I try to make things easier for others--to be cheerful--but
I'm not always up to it. I told a young girl in a store who
gave me a look of commiseration, "Don't feel sorry for
me; I'm a happy woman 9 I smiled at her. I wanted to
show her I was a human being--never mind the face.
We, the facially disfigured, are so much a breed apart.
Disfigurement is a tremendous barrier to interaction, not
with people who know us, but with people we just meet.
We want to be accepted as an equal, not a victim of fate.
And I have to do an awful lot of overcompensating. I'm
very well aware of this. I walk in a very assured way, for
instance9 I know also that if I expect rejection I'll get it
9 . . that if I look dejected and embarrassed, people are
less at ease, and their responses are negative9 But when I
smile, hold my head high, and appear confident, their
responses are more likely to be positive9
It is the repetition of such incidents that I find emotion-
ally draining; they are abrasive and have a cumulative
effect. They tend to cause a person to become hardened
and, to ward off danger, to develop coping mechanisms
and a defense superstructure . . . .
Unfortunately the skills and competencies in es-
tablishing relationships do not necessarily guarantee
an easier or better life. The psychological costs of
daily affronts, effort, and emotional strain are more
often disproportionate to the social gains, and as
long-term longitudinal studies have demonstrated
[cf. 18, 19], frequently eventuate in depression, so-
cial withdrawal, even alcoholism, though not neces-
sarily in that order.
Social Skills
The quality of interaction depends upon the partici-
pants involved, yet it appears that to a large extent
the responsibility for initiating and achieving smooth
interchange rests with the disfigured. It is they who,
by their d e m e a n o r and behavior, both overt and
covert, set the stage for the tone and flow of the
interchange 9 As a young war victim observed:
It is better to take the first step to create a pleasant atmo-
sphere, but one has to pass over the first reactions and
Facial Disfigurement: Problems and Management
this needs practice. For the wounded person who has had
the time to observe this it is easier than it is for a normal
person who knows little or nothing of this kind of suffering.
ff the mouth [which in this case was the affected part] is
distorted, one must not try to smile too much at the first
sign of understanding if it turns into a grimace. Fortu-
nately, the eyes help you smile.
Though the face is the focus of attention, percep-
tions of and responses to people are influenced by
other factors. F o r example, it is not u n c o m m o n to
be attracted to a beautiful or h a n d s o m e face only to
have o n e ' s interest d i m m e d by a slumped posture,
eye avoidance, atonal voice, and lack of affect, or,
conversely, to find a homely person attractive be-
cause of presence, personality, and overall configu-
ration (Gestalt). A prime e x a m p l e of this p h e n o m e -
non was Eleanor Roosevelt, who admittedly was
considered an "ugly duckling" [23]. H o w e v e r , by
her bearing, poise and her full attention to the other
person, she elicited the m o s t positive of responses.
A graphic example of h o w the perception of ugli-
ness can be altered by personality characteristics is
provided by John H e r s e y ' s [13] description of his
first meeting with the writer Sinclair Lewis:
The first impression, as he walked ahead of me into his
living room, sat down and lit a cigarette, was of a thin man
put together with connections unlike those of most human
beings. Next, piercing pale blue eyes, the bluer for being
lashed into the pink face of a red-head. Thinning light red
hair, ill brushed and tufted, over a wide dome of a fore-
head. Then, in better focus, terrible cheeks, riddled, rav-
aged and pitted where many precancerous keratoses had
been burned away by dermatologists' electric needles.
Narrow, dry lips, and a slender chin. I would have sworn
that he was hideously ugly until he started to talk, when
his face suddenly turned on, like a delicate, brilliant lamp
9 . . one forgot his cadaverous face.
To test the role of social skills in interaction be-
tween conspicuously disfigured and nondisfigured
persons, in a controlled study, R u m s e y [25] enlisted
a professional actor to conduct 12 identical inter-
views: six with a large port-wine stain (hemangioma)
on his face and six without. F o r half of the disfigured
and nondisfigured interviews he b e h a v e d in a so-
cially skilled m a n n e r - - a p p r o p r i a t e eye contact, ges-
tures, paralanguage, and so on. F o r the rest, the
actor b e h a v e d in a fashion consistent with that ob-
served of genuinely disfigured p e r s o n s - - e y e s down-
cast, flat tone of voice, and lack of assertion. Analy-
sis of the videotape showed that the level of social
skills used by the actor was m o r e important than the
presence or absence of disfigurement, in relation to
both the objective b e h a v i o r of the subjects and in
the impressions they f o r m e d of the a c t o r ' s personal-
ity and behavior.
While this study confirms the general findings of
other investigators, it should be kept in mind that in
F.C. Macgregor
the case of a port-wine stain it is essentially the
obtrusive red and purplish color of the skin that
spoils the face and is distracting, while other condi-
tions such as distortions or invasions of tissue and
bone caused by t r a u m a or disease m a y present a
different order of problem. Given the opportunity,
h o w e v e r , those w h o possess interpersonal skills and
self-assurance are able to make the process of inter-
action less difficult and taxing for both interactants.
Indeed, in refusing to accept the rejection of a soci-
ety o b s e s s e d with beauty and physical perfec-
t i o n - - " Y o u either have to face it or live in a cor-
n e r " - - s o m e individuals manage to o v e r c o m e the
m o s t difficult of hurdles, but not without a price.
Following a devastating auto accident and the ru-
ination of her once beautiful face, a 20-year-old
w o m a n seriously contemplated suicide or entering a
c o n v e n t where she would be "hidden from the world
9 . . I was terrible looking. I had a carnival f a c e . "
Eventually she decided to rejoin the social world. It
was not easy.
I would look at myself in the mirror and think "How can
I go out on the street with this awful face? What kind of
clothes can I wear that will not make me look ridiculous?
What kind of hat can be worn with a face like this?" I
knew that now I must do everything possible to make
myself presentable and to distract attention from my face.
I must keep my hands and nails just so, wear the most
beautiful but simple clothes, pay great attention to my
hair, wear the most attractive perfumes--everything to
help myself look interesting. But these things were not
enough. Before my accident I had only been interested in
having fun: occasional love affairs, traveling, and sports.
I had few intellectual interests. Now I realized I must
read everything new that came out, be well versed in the
important topics of the time, be more gay and amusing
than ever before. I must win people with my c h a r m . . .
I had to pretend to be gay at any price [for details see 18,
pp 3-14].
A salient aspect of this case was that by this w o m a n ' s
self-presentation, her dress, her charm, and her abil-
ity to project herself as a " n o r m a l " person who
h a p p e n e d to have a handicap, those features which
at first glance were so startling seemed to recede into
the background. Such instances are not u n c o m m o n ,
but crucial to their o c c u r r e n c e is the matter of time.
Like " B e a u t y and the B e a s t , " a s y n d r o m e that of-
fers cold comfort to the nonbeautiful, perceptions
of others can and do change, but only if given the
opportunity to establish o n e ' s identity and dissipate
first impressions. E v e n this, however, does not guar-
antee smooth sailing9 What in normal situations
would be considered c o m m o n p l a c e remarks, in
these contexts can b e c o m e dreadful faux pas. Since
apologies or explanations only tend to c o m p o u n d
e m b a r r a s s m e n t , the burden of saving the situa-
t i o n - i f it can be s a v e d - - a n d the face of the offender
falls upon the disfigured person. The following is an
example of a skillful extrication.
255
On a cold, stormy day a patient with a deep, o p e n
wound in her cheek, the result of radical surgery
for cancer, arrived late for her a p p o i n t m e n t in the
Plastic Surgery Clinic. N o t only was she suffering
nagging pain, but a taxi driver, seeing her face, hur-
riedly drove off, and a second one was rude. H e r
anger knew no bounds. " W e l l , " said the inter-
viewer, " Y o u certainly needed this l i k e . . . " and
stopped short. N o t missing a beat, the patient contin-
ued: "Two holes in the h e a d ! " And b o t h burst into
laughter.
While the focus of this article is on the p r o b l e m s
and m a n a g e m e n t of social interaction, we m u s t k e e p
in mind two of the major forces that underlie the
problems associated with facial disfigurement as op-
posed to those associated with functional disabili-
ties. One of these forces, as d e m o n s t r a t e d below, is
the ancient and fallacious correlation still made,
even among the educated, b e t w e e n facial abnormali-
ties and negative c h a r a c t e r traits.
There was, however, little fear of Barbie amongst those
fifty-odd Frenchmen who worked closely with him. They
were part of Barbie's 120-strong "personal army," all
members of the most aggressive pro-Nazi groups in the
town which Barbie gradually drew towards him. One of
the most infamous of these, from the French Nazi Party
(the PPF), was Francois Andre, an ex-communist. Known
as the "Gueule Tordue" his face had been atrociously
deformed in a road accident. With a mouth twisted into
the shape of a gaping wound, he had no need to convince
anyone of his natural brutality. [4]
It was to see him that I had come to Israel, anxious to find
out for myself if he was human, if there was any humanity
in him. I had hoped to find myself in the presence of a
disfigured creature, a monster whose unspeakable crimes
would be clearly legible in his three-eyed face. I was dis-
appointed: Adolf Eichmann seemed quite normal, a man
like other men--he slept well, ate with good appetite,
deliberated cooly, expressed himself clearly and was able
to smile when he had to. The architect of the Final Solution
was banal, just as Hannah Ahrendt had said. [28]
The removal of deep-rooted stereotypes and prej-
udices is a slow and a r d u o u s p r o c e s s . Yet w h a t e v e r
attempts are made to educate and foster understand-
ing and a c c e p t a n c e of the disfigured, as has b e e n
accomplished with other groups of h a n d i c a p p e d peo-
ple, they are severely attenuated b y zeitgeist factors
in our sociocultural milieu that a d d to the invidious
basis for discrimination and generalized rejection of
the ugly.
There is nothing new a b o u t the o b s e r v a t i o n s that
physical characteristics h a v e a profound influence
in the social world in which we live and that preferen-
tial treatment is given to those w h o are p e r c e i v e d as
physically attractive. But o u r increasing o b s e s s i o n
with external a p p e a r a n c e (looking young and beauti-
ful) and its glamorization, as exemplified b y the cos-
256
metic industry, the mass media, image makers, and
the proliferation of cosmetic plastic surgeons, is
such that other human qualities are made to seem
less important by comparison. The importance and
rewards of physical beauty are further legitimized
by the recent flow of psychological studies begun in
the 1970s [7], showing that attractive people are not
only more in demand and more likely to succeed,
but are perceived to be smarter, more personable,
and better adjusted. It is not surprising, then, except
for the delay in time, that a 1987 study finds that
physical attractiveness has a positive effect on men-
tal health [27].
Considering the above, it should be no mystery
why there are countless numbers of disfigured per-
sons among us who keep a low profile. By seeking
refuge in their small circumscribed worlds and shun-
ning face-to-face encounters, they remain a hidden
people, a fact that accounts for the widespread igno-
rance of a major social problem.
At the same time, there are countless others who,
despite embarrassment and pain, refuse to submit to
or be daunted by the constraints imposed by their
particular stigma. But wanting and attaining satisfy-
ing interaction are factors that are not mutually in-
clusive, for the problems to be overcome require
efforts on the part of both interactants as well as a
high degree of awareness, empathy, and social skills.
For some, such qualities are innate but for others
they must be learned. These particular areas have
been the most overlooked and neglected in the entire
process of the rehabilitation of the facially handi-
capped.
Normally the rehabilitation process begins with
plastic surgery, the primary device for releasing peo-
ple from the stigmatic effects of facial deviance. As
a result of major breakthroughs in techniques and
methods in the 1970s through to today, reconstruct-
ive and reparative plastic surgery for complex prob-
lems presented by craniofacial deformities, severe
burns, and trauma can now be undertaken. Results
may be and often are dramatic, but this depends on
the type and severity of the anomaly, among other
variables. As is often erroneously assumed, surgical
intervention does not guarantee a " n e w " or normal
face, but rather a transformation from less present-
able to more presentable, an achievement that is a
compromise, one that spells the difference between
total withdrawal and participation in the social world
with less than full acceptance.
At the medical centers where reconstructive sur-
gery takes place, additional rehabilitative measures
are usually provided, such as psychotherapy, psy-
chological counseling, social service, group therapy,
parental guidance, and cosmetology instruction, to
help the patient adjust to his/her condition. Where
research is encouraged, pre- and postoperative stud-
ies are conducted, usually by psychiatrists and clini-
Facial Disfigurement: Problems and Management
cal psychologists who, primarily interested in the
intrapsychic impact of disfigurement, focus on such
factors as anxiety levels, depression, cognitive
growth, personality adjustment, body image, ego
strength, and self-esteem [2, 21]. Once the surgical
regimen, which may involve intermittent procedures
over a period of months or even years is completed,
those for whom satisfactory aesthetic results remain
beyond the skills of modern surgical techniques are
still unable to blend unnoticed in a crowd.
It is about time, as well as essential, that more
attention be given to the symbolic nature and unique-
ness of facial disfigurement as a handicap and its
consequences for social adjustment and mental
health. Preliminary work has demonstrated that if
we are to ease or make less devastating the plight of
disfigured people, more attention should be focused
on what special sensitivities and skills are required
in initial encounters between them and the nondis-
figured and in the establishment of interpersonal re-
l a t i o n s - t h e most difficult of hurdles. There are nu-
merous fruitful areas for investigation, for example,
(1) how and to what extent doe s nonverbal communi-
cation influence the quality of interaction, (2) what
is the role of shame in militating against smooth
interaction, (3) to what extent is the social distance
disfigured persons experience a function of their ap-
pearance or their demeanor.
Since our society is not yet structured for dealing
with facially disfigured people nor for accepting the
defect for what it is rather than the symbolic charac-
teristic ascribed to it, the burden of adjustment and
coping seems to fall more upon the disfigured than
the nondisfigured. Nevertheless, the process of es-
tablishing a relationship requires effort on the part
of both individuals involved. It is not unlike two
people learning to dance: first hesitant, awkward,
and out of sync, but given time and a high degree of
awareness it can become mutually rewarding.
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