Making Faces

Science meets sculpture to mask injuries, congenital defects and the ravages of cancer.

BY DIANE DUKE WILLIAMS

Jean Cohen models her latest prosthetic eye, after the finishing touches of Ann Vitale's steady hands, below.

Step-by-step to creating a natural-looking eye prosthesis. Download graphic PDF FORMAT 112 K

“Making these is definitely an art...
I was amazed by the creativity of the lab.”

SHAWN HALL

Born without a left ear, John Sharp endured unsuccessful surgeries that attempted to make a substitute from living tissue. Later, a snap-on ear prosthesis, created by W. Donald Gay, DDS, and Ann Vitale, provided a successful solution.

ON ANN VITALE'S FIRST DAY AT WORK in the School of Medicine’s maxillofacial prosthetics laboratory, a 16-year-old girl walked in with a hole in her face—one of her eyes and the cheek below were missing after surgery to remove a cancerous tumor.

“Right then, I knew this was going to be a challenging job,” says Vitale, a maxillofacial prosthetics technician. “You really help to give people their lives back. After all surgical avenues have been explored, and surgeons have done what they can to save the patients’ lives, we do what we can to preserve their social acceptance.”

For 22 years, W. Donald Gay, DDS, associate professor of otolaryngology, and Vitale have worked as a team to rebuild the faces of patients ranging from 3 to 80 years old. In a lab with beaker-lined shelves, a plaster-mixing machine and a high-speed grinder, they craft artificial ears, noses, eyes and dental devices for patients with birth defects or those who have lost part of their faces because of cancer surgery or injury.

“We take kids who don’t feel normal, and we help them become normal,” says Gay, a maxillofacial prosthodontist. “And we help adults who can’t be normal adults—they can’t work or socialize—and we make it possible for them to resume those activities.”

Four years ago, surgeons worked 13 hours to remove a rare cancer that was pressing on Jean Cohen’s left eye and making it bulge. The procedure required the removal of the eye, left eye socket and part of her sinuses, leaving a deep cavity.

“I wasn’t concerned about dying or having cancer,” says Cohen, a 70-year-old retired surgical head nurse from Creve Coeur MO. “I was concerned about how my grandchildren would view me.”

While her incision healed and she underwent radiation treatment, Cohen covered the site with a black patch. Acquaintances and strangers questioned her everywhere she went, and the patch made her grandchildren uncomfortable. If it slipped, they would say, “Grandpa, tell Grandma to fix her patch.”

But Cohen’s life changed after she visited the maxillofacial prosthetics laboratory and received a custom-made facial prosthesis. “I’ve been able to blend more into society and feel more comfortable,” says Cohen, who volunteers at a local hospital and baby-sits her grandchildren. “I was concerned that my appearance might shock Dr. Gay or Ann, but they’re very professional and warm,” she says. “They make me feel totally at ease and have a great sense of humor.”

W. Donald Gay, DDS, and maxillofacial prosthetic technician Ann Vitale working in the laboratory.

The School of Medicine’s maxillofacial prosthetics laboratory is one of approximately 150 similar prosthetics labs in the United States, most of which are affiliated with medical centers. The Washington University laboratory is unique because while most prosthetic technicians specialize in one type of prosthesis—eyes, ears, noses or dental devices—Vitale, under the supervision of Gay, makes them all.

The facial prostheses are constructed of silicone, and the goal is to make them unnoticeable to the casual observer from three to six feet away. Most are attached with a medical adhesive each morning and worn until bedtime. They normally last two to three years.

In a relatively new development in the maxillofacial prosthetics field, implants in facial bones now enable some patients—about 10 percent—to snap on their prostheses. More patients might opt for these devices, called bony implants, if Medicare paid for them, says Gay.

In 1990, surgeons placed a bony implant on the side of John Sharp’s head. Born without a left ear, he spent his youth growing his hair long to cover the defect, always conscious that he was a little different. Now 47, he snaps on his prosthetic ear each day and says the prosthesis has made a tremendous improvement in his life.

“I look more symmetrical and more normal,” says Sharp, who works for the U.S. Postal Service in Peoria IL. “I’m much less self-conscious and can wear glasses and sunglasses now.”

After five years as a general dentist in the U.S. Army, Gay decided to specialize in prosthodontics, which includes crowns, bridges, dentures and partial dentures, and maxillofacial prosthetics—eyes, ears, noses and inside parts of the mouth. He has no regrets. “I’m so glad I took the road I did, because it’s been extremely rewarding,” he says.

During an initial consultation, Gay makes the first impression of a patient’s face. To craft an eye or an ear, he uses a reverse image of the intact portion of the face to measure for the prosthesis and then passes that information on to his technician.

Vitale joined the lab 22 years ago after graduating from the dental technology program at Southern Illinois University at Carbondale. Blending art with science, she creates two to three finished facial prostheses each month. The painstaking process requires her to not only understand the science of metals, acrylics and silicones, but also to spend many hours sculpting and painting.

“This is a process that’s done by tiny increments and adjustments,” says Vitale. “Every little bit of wax that I add and then may have to take off can make the difference between a patient being extremely happy or just moderately happy.”

Vitale spends hours with patients, tweaking the wax patterns for their prostheses or trying to tint the skin tone perfectly with her palette of paints. If she’s working on an eye prosthesis, she chooses from a large selection of prosthetic eyes to match the person’s iris color. This stock eye is then incorporated into the final prosthesis.

Vitale and Gay must also address patients’ emotional concerns. Many of the patients they see are depressed when referred to the laboratory. Patients with supportive families usually adjust to their prostheses, but patients without a solid support system often struggle. “They’re the ones who are the hardest to rehabilitate, because you can do everything physically and technically, but you have trouble getting through to the psyche,” says Gay.

Shawn Hall’s wife has been by his side from the very beginning, when he first noticed a loose tooth in the top left side of his mouth. On his 30th birthday, he had the tooth pulled, and his gum would not stop bleeding. Almost a month later, on his first wedding anniversary, Hall found out he might have cancer. He did—an extremely aggressive bone cancer of which there have been only 200 reported cases in the past 50 years.

Six months later, following intensive chemotherapy to shrink the tumor and save his left eye, Hall had surgery, not knowing whether he would still have his eye when he awoke. Doctors did have to remove the eye, some cheekbone below it, and part of the inside of his mouth.

Still, Hall remains upbeat. “The day I got my prosthesis from the lab was awesome,” says Hall. “Making these is definitely an art, and I was amazed by the creativity of the lab.”

Although he had to quit his job after he was diagnosed with cancer, Hall recently returned to school and is studying database administration.

Whenever Vitale sends a patient like Hall out of the laboratory with a new prosthesis, she feels lucky that her job is to help people feel normal again. “I’m motivated by the fact that these patients can walk down the street, and, to the casual observer, look no different than you or I.”