Healing Heroes: New Faces for Vets
Colonel Alan Sutton, Director of Maxillofacial Prosthetics at San Antonio Military Medical Center (SAMMC) and Wilford Hall Ambulatory Surgical Center, talks about prosthetic faces.
What does your department do?
Colonel Sutton: After the surgeons are finished trying to recreate the injury of the patient with skin, bone, and tissue, and if they can’t do that, then it is our turn to recreate realistic prosthesis out of plastics and silicones. We can help with facial injuries, facial prosthesis, ear prosthesis, eye prosthesis, or intraoral. So, we replace lost tissue with artificial parts.
Are you seeing it more often than you did a decade ago? Is it something that they want to do or something they resist doing?
Colonel Sutton: It is actually about the same. About two years ago we had an elevation in the number of war fighters we treat. We also treat cancer patients. They have been about the same as 10 years ago.
You not only treat war fighters, but you treat cancer patients too?
Colonel Sutton: Cancer patients who have warlike injuries. I teach a fellowship here. We have one student and she currently gets to learn about how to treat a cancer patient, but this also helps her treat war fighter injuries as well.
What are the different prosthetics you work with?
Colonel Sutton: When we have either a war injury patient or a cancer patient, sometimes they are missing eyes, ears, or noses. We can make them a silicone prosthesis that will help replace what was lost. Sometimes we will put a plastic piece inside the defect and we will have the ability to create custom silicone prosthesis that look lifelike. So the patient can walk around, go to the store, or go to McDonalds. Each piece is custom painted and even their hair is added to the prosthesis.
Is the hair real?
Colonel Sutton: This hair is real. The hair is usually donated by the patient. If there is a patient who doesn’t have a lot of hair, then we will walk the halls to find a donor and will clip people’s hair; usually when they are looking. We ask them for their hair.
You can actually find someone’s ears that you like and have them modeled after that?
Colonel Sutton: Yes. We ask the patient, if he would like to have a certain kind of ear. We have had some people that want their dad’s ears or their brother’s ears. Depending on how they fit to the current patient, we will modify them to make them look even better. If somebody is missing both ears, we will walk the hallways to find an ear donor. Shilo Harris is a famous one. My student at the time had really nice ears and Shilo wanted to just use his. So, we made an impression of his ears to use as the model for Shilo’s prosthetic ears.
Can you talk about the similarities between cancer patients and the troops that come back with war injuries?
Colonel Sutton: A lot of times these cancer patients may be missing a piece in their oral cavity and a lot of the injuries we see in the current war are to the head and neck. About 39% of the injuries are head, face and neck injuries. What can happen is if they take a bullet wound to the mouth, they may be missing part of their jaw and the same thing with cancer patients. I teach one student a year, called a fellow. If she or he would treat the cancer patients, they would get an idea of how to replace what is missing on a cancer patient. It is very similar to a head and neck war injury. We do see those kinds of patients. Also because of the Level 1 Trauma Center here at SAMMC, we do get some injuries from downtown as well.
If someone comes in here and they are missing an ear or an eye, what happens?
Colonel Sutton: So, the patient comes in and they have had cancer. We will make an impression of their face. We cover the soft tissue with Vaseline and gauze; then we paint on a material called hydrocolloid and it coats it like a facial. Then we put stone on top of the hydrocolloid so it is a solid piece that fits on the patient’s face to make the impression of their face. That is removed and then we have an image of what their face is. We pour it in this hard, dental stone and then we have a replica of their injury. From that we actually do a modeling of this in wax or clay to get an image of their other side. That is then converted through our methods into silicone, but with the new technologies we can make a digital image and get a virtual replica of the patient. If the patient had nasal carcinoma, he is going to have his nose removed. It will be very sensitive tissue to make an impression of, so in those cases, we have the ability to use stereophotogrammetry. We can take a picture and make a plastic mask, or face, without ever having to touch the patient. So this is the future here; to take a picture and then to have a way to sculpt and model based on just the photo.
You don’t have to put the actual cast on their face?
Colonel Sutton: Exactly.
Is that in use right now?
Colonel Sutton: It sure is. We use stereo photogrammetry on every patient with a facial injury, even some of the intraoral with a serious defect. We will do it on the intraoral patients as well.
How long have some of these techniques been practiced?
Colonel Sutton: Back at the turn of the century with World War I, they were making very similar prostheses to these. Anna Ladd Coleman Watts, I believe that was what her name was, would take an impression of the patient’s face with the defect from the war injury out of plaster and then turn that into a plaster mold through her methods. Then she would have her technician hammer out pieces of tin and that could be placed on the war fighters’ face. Then they would hand paint those. So this technique dates back well over 100 years.
So what has changed then? What has made it more inconspicuous?
Colonel Sutton: The silicones have changed. Obviously we don’t use tin anymore. Occasionally we will use some resins. If it is a small prosthesis, sometimes we can paint custom plastics that we use. The silicones have really helped us since they were invented. We now have some silicones that have good tear strength. They are very soft, like human skin and they are fairly resistant to degradation. They will last a few years versus just a year. Some of the older silicones only lasted about a year. When you are paying approximately $5,000 to $10,000 per prosthesis, you want it to last a little bit more than a year. So, the new silicones are a little more stable. We add colors, not only externally to the outside of the ear, but internally as well. When we mix the silicone to a certain color, those will stay a little bit longer than the external. External colors tend to peel off over time. We teach the patient how to remove their ear so as they can remove it and put it back on so they won’t get a wear spot on the prosthesis. Some of the other advances are that we can put titanium implants in the patient’s skull. In those cases, we will put little titanium implants in and we can screw on a stainless steel keeper. In this prosthesis, there are a couple of magnets, so it is very easy for the patient to just clip on their ear. That is a really great advancement with the craniofacial implants and it has really helped us with all kinds of prosthesis retention. Without the craniofacial implants, the patient has to apply some adhesives to put the ear in place and may mistakenly orient the ear. The magnets will help orient it so no adhesive is required, resulting in less skin irritation.
How long does it take to make an ear?
Colonel Sutton: We can typically do an ear in a few days. Total work time is probably 8 to 10 hours. We always like to tell the surgeons that what you do in 1 day, probably will take us a week. The ratio of what they do versus us is probably about 8 times more. The process requires the sculpting of wax to fit the patient. We turn that into a mold that has 3 pieces and we bring that back to the patient. Then we color it. We make sure it looks really good and blend it to the current tissue that they have. Then that has to set for 24 hours to seal. Sealing it will set the colors. Each of these processes takes about a day at a time. Our anaplastologist is a lot quicker than our student and definitely quicker than I am, but it takes probably a full week of appointments to finish prosthesis.
This is pretty much a last resort for someone who can’t get some sort of surgery to have their face reconstructed?
Colonel Sutton: Not always. Some of the intraoral prostheses that we make are interim. It gets them through the hard times. It lets them speak and swallow. Then they are awaiting reconstruction with tissue, the plastic surgeon, or the oral surgeon. Even the otolaryngology department gets involved in reconstruction. So, they may just be waiting for reconstruction. Following that healing period, they can go back in and find some tissue to apply to the face. Of course, then they can remove the prosthesis, which is probably the best. There are certain injuries that maxillofacial prosthetics are the primary treatment method; that would be for severe oral defects that we have to use an obturator. The maxillofacial prosthetic obturator is the treatment of choice when there is no way to reconstruct what was lost.
Is this the only place in the military where people can come get this done or are there other centers?
Colonel Sutton: There are multiple centers. The Navy has a center up at Bethesda Walter Reed. We also have trained 10 maxillofacial prosthodontists throughout the Air Force, and we have 3 other centers that also have maxillofacial prosthetic capabilities. That would be Travis, Wright Patterson, and soon Keesler. We also have a technician training program which is brand new. The Navy has been gracious enough to train our technicians. We currently have 2 technicians trained as maxillofacial prosthetic technicians and we have one here at SAMMC. One is going to finish up in January and is going to Travis. It is a team approach. You need to have a maxillofacial prosthodontist and an anaplastologist, or a trained maxillofacial prosthetic technician. We currently have a full team here and soon we will have a full team at Travis. We have a full maxillofacial team at Wright Patterson. You see our department is quite small. We interface with over 20 hospital departments; speech, ENT, plastics, oral surgery, etc. If we get a lot of patients, we could probably be quickly inundated, but it has not happened.
Have you seen the war injuries change at all since you have started doing this? Has it presented any challenges to you to making prosthetics?
Colonel Sutton: They are about the same. SAMMC gets all the burn patients, war injuries. We used to support the dental services in the military corporation by saying that 15% of debilitating injuries were dentally related. This has been for every war, since the beginning of war. However, 39% of the current injuries from OIF and OEF are head and neck face injuries; 65% of these are to the face. So, it has actually gone up. When war is down, this is a good thing for the war fighter. However, our training opportunities for these types of injuries will also be lower. Fortunately, training opportunities still arise because of local trauma, injuries, and cancer, even though we are currently seeing a decrease in the number of war fighters that we see.
Is that a good or bad thing?
Colonel Sutton: It is good for the patients. It is tough for the training program.
Can you discuss further how you use the new and the old techniques?
Colonel Sutton: You can see the wrinkles in the skin gland orifices. You can see all those on this face cast, but on the 3DMD process, we are finding out that we can’t quite capture all the wrinkles. It is not quite as fast. The turnaround time for the traditional moulage is a few hours. The turnaround time for a 3DMD and stereolithography model is 8 to 17 hours. We are trying to use advanced technologies, but at certain times the older methods are quite a bit quicker. We are consistent in our processes. We know how to do them faster. A lot of us are learning digital and virtual manipulation. It is a whole learning thing; just like anytime a new phone comes out. You have to figure out how it works. We sit down with the companies and go through the product. We actually provide a lot of input for changes to the product, things that we need that they depend on us to tell them. With digital technologies, stereolithography, stereophotogrammetry, and others, we are trying our best to use them because they are noncontact. We don’t have to touch the patient. I think in the future, we will be able to make prostheses using digital imagery, but we have had to modify them with some old school methods just to make sure that they are adequate. So we are getting there maybe in 10 years.
Where do you see things going?
Colonel Sutton: I hope to see more digital imagery. The cameras are better, the process, and the computers are better. We currently have a system in the other room that is 5 megapixel cameras. We started out with 2 megapixels. Just the quality of the image is better and faster processing speeds. I see that as we progress. We will progress even more into the digital imagery in forming prosthesis and hopefully we can get some printers. There are actually some printers that can print in 3-dimensional images. I don’t have one here. Hopefully in the future we will be able to print a silicone replica of what we want or prosthesis. I see that in the near future, probably in 5 to 10 years for sure. We will still need the artists to design the missing part like an ear on the computer. We can also bank the design into the system; so if we need to pull out an ear from our ear bank, we can take it out and use it for someone else. I see the future as very similar to what we do now, but with the imagery and the capability with the computer modeling software.
So the patient can go shopping for the kind of ears they want?
Colonel Sutton: We have ear banks. We have pictures of ears. We have collections of ears. We have eye banks with different colored eyes. On some of our war fighters we make them a regular eye that matches the other one. In addition, we may offer them a theme eye. They might have a favorite character in a movie, a white eye or whatever. It can uplift their moral and make them feel better. They pop in a stock eye and or their theme eye and have some humorous discussion. We have already created normal ears for Shilo and he wanted some theme ears; so we are going to make some Spock ears. They are very cool and it is fun for us too.
You should have some humor when you are doing all of this stuff?
Colonel Sutton: A lot of humor. Cancer patients and wounded warriors have been through a lot. They are usually awesome patients. They have experienced something that many of us don’t even understand. I like to approach it with humor and I think they appreciate it. They come in with an idea of ears. We had a patient want his brother’s ears and they were huge. So, we asked his wife and she said she did not really like those Dumbo ears, so we called them Dumbo ears and he got a chuckle out that. Once you deliver the prosthesis, it is a good day. You can see them change. They can go outside. They can walk around. They could be sitting right next to you and would not be able to tell that they had prosthetic ears.
END OF INTERVIEW
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