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One of the most commonly shared characteristics of children with Down's syndrome is the effect on facial features. The vast majority of children with Down's syndrome have an epicanthal folds, a slanted palpebral fissures and a flattened nasal bridge. Another common feature is a protruding tongue with an open mouth. The surgeries can be categorized into two groups: techniques aimed at reducing the size of the tongue, and surgeries aimed at improving the appearance of the face, called "facial reconstruction". Indications and limits of these categories are discussed separately. Moreover, the tongue reduction presents further anesthesiological problems. Parents should be not pressured into consenting to plastic surgery, and plastic surgery should never be considered a standalone therapy. Parents should get all information about the procedures, including risks, performed on their children to best make an informed decision, also in order to avoid unnecessary pain to the children and the adolescents with Down's syndrome.

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