Christine has a scarred upper lip from a road accident. She was riding a bicycle when a car collided with her, causing multiple injuries including a fractured mandible, nose and palate. The first time she saw her face when she recovered consciousness some five days later it was bloodstained and indented with gravel. Her teeth were missing, her lips swollen and her skin black with bruises.
Although Christine's disfigurement is now minimal she has suffered great psychological damage. Her perception of herself today is distorted and all she can see is that initial mirror image from the immediate aftermath of the accident.
Living with facial disfigurement, whether due to birth defect, trauma or disease, can affect individuals profoundly and many lose their objectivity about their appearance.
Such psychological damage has been difficult for doctors to quantify but now a Manchester portrait artist thinks she may have uncovered a radical new approach to coping with marred features.
Alison Levy, a postgraduate researcher at Manchester University, has worked closely with 12 volunteer patients to produce a series of portraits contrasting individuals' actual appearance with their own perceptions.
The results were startling and highlighted the distorted mental images which can be so debilitating. The research also had a very cathartic impact on the volunteer patients, aged two to 73, in 83 per cent of cases.
Christine, for example, thought that Ms Levy's original portrait of her totally diminished her disfigurement and looking at the portrait and analysing it was painful.
After the analysis, which included detailed questionnaires and interviews, the second portrait was produced reflecting accurately each patient's perception of their appearance. In Christine's case it was wildly exaggerated. "The exercise proved very positive because once she could compare her portraits and see how exaggerated her perception was, she was then able to look at the original portrait with more ease and acceptance," Ms Levy said.
Ms Levy attended many plastic surgery clinics and operations as well as a clinical psychologist's session with prospective patients and was pleased to find that the psychologist found the portraits a useful tool to aid assessment of disfigured patients.
In some cases the research also gave patients awaiting plastic surgery a visual expression of their perceived ideal facial appearance in the form of modified portraits.
The results showed that patients with congenital disfigurement had fewer problems than patients who had been victims of a trauma or disease. There was found to be no simple relationship, however, between the amount of damage caused by disfigurement and the severity of the mental trauma.
Three quarters of patients in the accidental trauma group and three quarters in the disease group had distorted perceptions of their appearance compared to a quarter of the congenital group. Gender was not a significant factor.
Ms Levy said plastic surgery offered the means to improve a patient's chance of survival and quality of life where technically possible. Various forms of counselling could help patients' psychological recovery and were useful in understanding individuals' reasons for undergoing surgery and their expectations.
However, she added: "It is difficult for any of these professionals to gain a clear picture of how patients perceive their own facial appearance. If this were possible, as I hope my study proves, patients would be better understood and their subsequent treatment could be more easily prescribed."