Plastic Surgery in Children
with Down Syndrome
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by Len Leshin, MD, FAAP
Copyright 2000, All rights reserved
Go to List of Past Abstracts One of the more commonly shared characteristics of children with Down syndrome is the effect on facial features. The vast majority of children with Down syndrome have extra skin at the inner corners of the eyelids ("epicanthal folds"), slanting rather than horizontal eye openings ("slanted palpebral fissures"), and a flattened nasal bridge. They may also have a flattened mid-facial region and a downturned lower lip. Another common feature is a protruding tongue with an open mouth.
Send Me Email In the 1970s, a group of people began recommending plastic surgery as a way to change the facial features common to Down syndrome. The surgeries can be categorized into two groups: surgeries aimed at reducing the size of the tongue, thus attempting to improve function of the tongue and reduce mouth breathing; and the surgeries aimed at improving the appearance of the face, called "facial reconstruction." I will discuss these categories separately.

Facial Reconstruction

It is the nature of plastic surgeons to attempt to improve upon the human form. This view can be best seen in the following excerpt:
It is a challenge for the aesthetic surgeon to make good-looking people more handsome. But it is even more rewarding to "normalize" people who are isolated because of their ugly facial expression so that they may be reintegrated into a group of friends from which they may have already anxiously withdrawn. Children with Down's syndrome are frequently concealed from the public by their parents. The children suffer from two disadvantages: Their mental abilities are limited and they have ugly facial features.(1)
The above author's view toward Down syndrome is certainly not unique among plastic surgeons:
Until recently, children with Down syndrome could not escape the stigma of their characteristic facial features, which instantly labelled them as "retarded" no matter how well they functioned.(2)
The immediate goal of reconstructive surgery is to improve the appearance of the face. Surgical procedures used toward this goal include partial resection of the tongue, correction of the down-turned lip, lifting of the nasal bridge, removal of fat from the neck, placing implants in the zygomatic bones (cheeks), removing the epicanthal folds and making the palpebral fissures more horizontal. Several studies have been published by surgeons showing approval by parents of the results of plastic surgery(2,3,4). However, one of these studies(2) also showed that independent raters found no improvement in appearance.

The purpose of the surgery, however, is not merely to improve appearance but to improve social acceptance of people with Down syndrome. One study has suggested that people with Down syndrome are subject to decreased acceptance by their peers on the basis of facial features alone(6). The argument on behalf of facial reconstruction states that as parental expectations for school achievement and job opportunities increase, that modifying the face (along with the conventional therapies) can increase the opportunities for success in society.

It does appear to be true that, after facial reconstruction, parents have been pleased with the resulting change of appearance of their child.(1,2,4,7) However, studies have not demonstrated any significant impact of the change in facial appearance on the children's social functioning.(8,9) Further, some studies have disputed the notion that the appearance of children with Down syndrome has a deleterious affect on how they are perceived.(10,11)

There are no simple answers to this controversy. Some parents and doctors will ask why shouldn't a child with Down syndrome be made to look more "ordinary," if possible? Our society accepts removing birthmarks, pinning ears and other surgical corrections of minor defects in children. Other parents and doctors ask if appearance is so important that we should subject a child, who is often of a pre-school age, to such major surgical procedures. While making this decision, parents and doctors should keep the following in mind:

Persons with Down syndrome should be afforded all medical and educational services that are available to other children without this chromosomal disorder. Moreover, their appearance including hairstyle, dress attire and general hygeine should be such to enhance their acceptance and integration in society. Persons with Down syndrome should be accepted for what they are and offered a status that observes their rights and privileges as citizens, and in a real sense preserves their human dignity.(10)

Tongue Reduction

Children with Down syndrome often have an open mouth and protruding tongue, though this appears to be worse in early childhood. The protruding tongue is due to a combination of several factors: a smaller than average oral cavity, enlargement of the portion of the tongue that lies near the tonsils, and a lack of muscle tone of the tongue. Tongue reduction, also called a "partial glossectomy," consists of removing a wedge of tongue to make it smaller and shorter. Some doctors recommend it for aesthetic reasons, as it helps the child keep his or her mouth closed while breathing and eating.(1,4,12) Certainly mouth-breathing can be detrimental, causing increased drooling and pushing forward the lower profile of the face and teeth. However, the most frequent motivation for this surgery seems to be the hope that it can improve speech intelligibility of the child with Down syndrome. There have been several reports of improved speech(1,3,4) but these were all subjective. Two studies using objective criteria found no improvement in intelligibility of speech following this surgery.(13,14) One study found that after partial glossectomy, speech was judged by observers as better when the subject was viewed talking as opposed to heard unseen on a tape(15), implying that the operation improved the aesthetics of speech. More studies are needed on the cause of speech difficulties in children with Down syndrome before this can become a well-accepted surgical procedure.

Summary

Despite being in use for over twenty years, there is still not a lot of solid evidence in favor of the use of plastic surgery in children with Down syndrome. As with all children, this decision finally rests with the parents. Parents should not be pressured into consenting to plastic surgery, and plastic surgery should never be considered to be a stand-alone therapy. Parents interested in these procedures should be aware that these are usually major surgeries involving general anesthesia and days if not weeks of recuperative time. Parents should get all information about the procedures, including risks, and talk to other parents who have had the procedures performed on their children to best make an informed decision.

References:

  1. Olbrisch, RR. Plastic and aesthetic surgery on children with Down's syndrome. Aesth Plast Surg 9:241-248, 1985.
  2. Arndt EM, Lefebvre A, Travis F and Munro IR. Fact and fantasy: psychosocial consequences of facial surgery in 21 Down syndrome children. Brit J Plast Surg 39:498-504, 1986.
  3. Lemperle G & Radu D. Facial plastic surgery in children with Down's syndrome. Plastic and Reconstr Surg 66:337-342, 1980.
  4. Wexler MR et al. Rehabilitation of the face in patients with Down syndrome. Plastic and Reconstr Surg 77:383-393,1986.
  5. Saviolo-Negrin N & Cristante F. Teachers' attitudes toward plastic surgery in children with Down's syndrome. J Intell Disab research 36:143-155, 1992.
  6. Strauss RP et al. Social perceptions of the effects of Down syndrome facial surgery: a school-based study of ratings by normal adolescents. Plastic and Reconstr Surg 81:841-846, 1988.
  7. Olbrisch R. Plastic surgical management of children with Down's syndrome: indications and results. British J Plastic Surg 35:195-200, 1982.
  8. Kravetz S et al. Plastic surgery on children with Down syndrome: parents' perceptions of physical, personal and social functioning. Research Develop Disabil 13:145-156, 1992.
  9. Katz S & Kravetz S. Facial plastic surgery for persons with Down syndrome: research findings and their professional and social implications. Amer J Mental Retardation 94:101-110, 1989.
  10. Pueschel SM, Montiero LA, Erickson M. Parents' and physicians' perceptions of facial plastic surgery in children with Down's syndrome. J Mental Defic Research 30:71-79, 1986.
  11. Cuningham C et al. Is the appearance of children with Down syndrome associated with their development and social functioning? Develop Med Child Neuro 33:285-295, 1991.
  12. Champion P et al. Plastic surgery for macroglossia in Down syndrome. NZ Med J 105:268-269, 1992.
  13. Parsons CL et al. Effect of tongue reduction on articulation in children with Down syndrome. Amer J Mental Defic 91:328-332, 1987.
  14. Margar-Bacal F et al. Speech intelligibility after partial glossectomy in children with Down's syndrome. Plastic and Reconstr Surg 79:44-47, 1987.
  15. Klaiman P et al. Changes in aesthetic appearance and intelligibility of speech after partial glossectomy in patients with Down syndrome. Plastic and Reconstr Surg 82:403-408, 1988.

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