MIRROR IMAGE
ONES ALTER EGO OR HIGHER SELF
MEDICAL PROSTHETICS
FROM WAR VETERANS TO PRESENT TECHNIQUES
Between 1917 and 1925, some 5,000 service men were treated at Queen Mary’s and its associated hospitals. Drawing on 282 case notes of New Zealand casualties and over 2,000 British equivalents, the hospital also became the birthplace of modern anaesthesia, since the then-current method of placing either masks over the face was obviously unsuited to operations to correct facial injury. Despite extraordinary medical advances, the contemporary attitude to facial injury both before and after surgery was one of horror or disgust. Benches on the road were painted blue to warn local residents that men sitting on them might have a disturbing appearance.
(Kemp, Bruce, and Linney, 2004. P.71)
In 1918, in an article entitled ‘How the American Red Cross in London Mends Mutilated Faces’, Katherine de Monclos of the American Red Cross explains how the hospital for facial wounds in France was known as ‘A museum of horrors’. She explains: Pitiful hideousness of the veterans with wounded faces made them difficult to place’. And continues with ‘unless they continue wearing a bandage to hide the gaping hole, the absence of a chin or the loss of a nose.’
Later, a German ophthalmologist named Carl Ferdinand von Graefe wrote about the social impact of the faces destroyed in the wars: ‘We have compassion when we see people in crutches; but those who have suffered a deformation of the face, even if it is partially disguised by a mask, create disgust in our imagination.
All above text: (Kemp, Bruce, and Linney, 2004. P.71)
Facial surgeons have historically been associated with the restitution of physical appearance as opposed to surgery that saves lives. Restoration of the obliterated features creates a sense of ‘self’ and Identity, Ambroise Pare, the sixteenth-century sculptor and father of facial prostheses explains:
"When the whole nose is cut off from the face… It cannot be restored or joined again, instead of the nose cut away or consumed, it is requisite to substitute another made by art"
Kemp, Bruce, and Linney, 2004. P.73
Kemp, S., Bruce, V. and Linney, A. (2004) Future Face: The Human Face and How We See it. LONDON: Profile Books Ltd. P.78 and 79
THE OFFICERS WARD
THE SOCIAL AND EMOTIONAL EFFECTS OF FACIAL DISFIGUREMENT
THE FILM:
The officers ward is a world war I story based on a novel by Marc Dugain which tells the story of a handsome french officer, Adrien E., who spends five years in the specialist Val-de- Grace hospital near paris following serious facial damage from the impact of german shell. The films use of facial disfigurement is neither sensationalist nor sentimental. In a later scene, Adrien (the main actor) sees his rebuilt face for the first time, the camera pans across the ward and a nurse refuses Adriens request for a mirror to look at his face which is later revealed when he takes his bandages off in front of a window pane. The horror of his disfigurement causes serious emotional stress and he breaks down, questioning whether or not he should live.
Dupeyron, F. (2001). The Officer's Ward. [DVD] France: ARP Sélection. France 2 Cinéma
During world war 1, eighty years later, Sculptors Francis Derwent Wood in London and Anna Coleman Ladd in Paris were making similar masks for veterans whose faces had been surgically repaired but still appeared disfigured and distorted. Both, at the Masks for Facial Disfigurement Department in London and the Studio for Portrait Masks, were employed in aesthetic restoration for the psychological benefit of the subjects themselves.
The features were modelled onto a plaster cast of the disfigured face, and a paper-thin mask made from electrotype plate was produced from a mould. The end product was a silvered and painted mask held in place by spectacles soldered to the masks fragment of nose.
Kemp, Bruce, and Linney, 2004. P.76
Thomas, K, F. 2006. The art of clinical Anaplastology: Keith F.Thomas. n/a . S. Thomas.
ANAPLASTOLOGY
Alginate
Relatively cheap, safe, and popular material that originates from the dental field, and is therefore favoured by many maxillofacial prosthodontists. However, being an irreversible hydrocolloid, the impression and model must be constructed quickly to maintain dimensional stability.
-Retarding of alginate set, and therefore prolonging the working time:
May be achieved by adding up to 1% of sodium acid phosphate to the overall weight of the alginate. Alternatively, the following formula of adding no .5% to water, i.e. approximately 5 L water +25 g sodium acid phosphate, will provide a ready-made solution that will slow the set of alginate by up to 8-10 minutes, depending on the ambient room temperature. This solution may be added 1:1 with normal water to reduce the same time to approximately 5 minutes
-It is useful as a quick duplicate material for simple non-complex models.
Silicones
silicone impression materials have become much more popular both for intra-and extra oral techniques. A wide variety of silicone is available in variable setting times and durometer are now readily accessed. They range from low to high viscosity permitting greater control during the technique.
Silicone should be the choice of material for obtaining impressions of limbs and associated defects. The silicones are predominantly two-part condensation cure, and use tin colourist, which ensures a very low shrinkage.
Plaster of Paris bandage
this is a cheap, very versatile material that is extremely useful for reinforcing silicone impressions prior to pouring the model cast, if used correctly it will also produce a high definition impression.
Thomas, K, F. 2006. The art of clinical Anaplastology: Keith F.Thomas. n/a . S. Thomas. P.P. 64, 65
Direct adhesive fixation:
Although this method of retention can provide adequate retention, the constant application removal of adhesive usually leads to early deterioration of the thin silicone margins, therefore, choice of adhesive is an important factor.
-Ultimately a strong adhesive that will provide good retention, whilst also permitting easy removal and cleaning would be the material of choice, however very rarely are all of these qualities present in commercially available skin adhesives.
Accumulation of moisture on the internal surface of the prosthesis, as a result of condensation due to the presence of warm damp air being expelled during breathing, remains a constant problem. Choice of a D7 must therefore incorporate the ability of the adhesive to perform adequately in the presence of moisture.
Superior attention is often afforded by use of a solvent based adhesives such as secure B – 400, or secure extra – Strong B – 460. These adhesives have proved to be very retentive in the presence of moisture, water and soft tissue movement. Medical adhesive remover 6531 (Kryolan, Bonn, Germany) is used to clean the adhesive.
Thomas, K, F. 2006. The art of clinical Anaplastology: Keith F.Thomas. n/a . S. Thomas. P.P. 75
Sculpting:
wax is added to the base plate and the shape of the prosthesis is formed by moulding the soften wax using the thumbs and index fingers to reproduce the approximate shape of the lost tissue. Care should be taken to replicate a mirror image of the contours of the remaining soft tissues recorded by the impression allowing for any anomalies that may present a result in surgical defect.
The prosthesis margin should be kept as soon as possible, so as to blend into the surrounding tissue.
SCULPTING TECHNIQUE: EYELIDS:
photographs may be useful for primary approximate eye alignment on the model and any approximate islands coping, however, the sole use of photographs for alignment or sculpting is not advocated.
It is important that the sculpting records the most consistent appearance of the eye. Softened and rolled strips of wax are adapted to form the approximate upper and lower eyelid relationship; further wax is added to create more detailed form of both eyelids.
By studying the thickness of the eyelids, and more natural relationship may be achieved is the addition of the approximate thickness of both upper and lower eyelid indicates correct back vertex alignment.
Thomas, K, F. 2006. The art of clinical Anaplastology: Keith F.Thomas. n/a . S. Thomas. P.P. 76
MAXILLOFACIAL PROSTHETICS
POOLE HOSPITAL VISIT TWO OF THREE
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Unfortunately, I was unable to retrieve the photographs taken from the first visit to Poole hospital. However, the medical staff were kind enough to allow my visit on another two occasions afterwards. I learnt a lot about intrinsic painting whilst visiting, colour placement and the importance of accurate measuring in order for the prosthesis to fit.
USEFUL TECHNIQUES: RELEVANT TO PROJECT:
Spatulate the air our on a palette, to remove any bubbles
Use the darker colours first, use a disposable dental brush to apply colours
Techno Vent dry pigments mixed with a silicone elastomer for the colouring and then add a anti slump the colour swatches, this way the colour doesnt move. The base colour doesnt have anti slump- it needs to flow around the other colours and tie them together
Putting the silicone in the freezer allows a longer working time, its stops the catalysing process.
Magnets for the prosthetics, fast cast resin around the magnet with two holes either side. This creates a mechanical bond for the silicone to grip to.
Platinum cure gel- technovent 120 pounds for one pot, ratio 10:1. Plat Gel is also similar but a ratio of 1:1.
Below: Thomas, K, F. 2006. The art of clinical Anaplastology: Keith F.Thomas. n/a . S. Thomas. P.184
Images and Text: Thomas, K, F. 2006. The art of clinical Anaplastology: Keith F.Thomas. n/a . S. Thomas. P.80
Colouring. Trimming. Finishing
-The appearance of skin colour is dependent on both Ambien indirect light and temperature, both of which will have an effect on the appearance of any silicone prosthesis present. It is therefore important to understand the limitations of achieving a colour matching of the silicone prosthesis to the natural skin tissue.
A simple technique for obtaining correct colour formula is to construct silicone samples of varying colour matches and skin types.
-Once the base silicone is nearly complete in terms of colour match, try adding some red, yellow ochre, and green to hone the colour more accurately. The failure to add sufficient red and green to a base mix is a common fault, however, if an overbalance of red occurs then adding green will neutralise the problem.
Extrinsic staining:
the procedure should be performed with great subtlety, and if the instrument is a colouring procedure has been performed correctly only minimum deal colouring should be necessary. Extrinsic staining may be considered to be the process that brings the prosthesis to life by adding subtle details such as freckles, veins, hairs an natural areas such a shadow.
MAXILLOFACIAL PROSTHETICS
POOLE HOSPITAL, FINAL VISIT. FOCUS ON INTRINSIC COLOURING
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METAMERISM:
-Matching of the apparent colour with spectral power distributions that differ from one another, in all lights.
USEFUL KNOWLEDGE:
-Use the plastic wraps to check colour translucency. Always match the base colour first and then the detail colours, take good quality photographs of the model/ patients skin to get an accurate match- natural daylight. Go to the room where it will be shown and take photographs in order to get an accurate match
Oven the prosthetic to speed up the cure time of the silicone. To take off the shine you can add bicarbonate soda to the surface, before curing and then boil it off.
Once the base silicone is nearly complete in terms of colour match, try adding some red, yellow ochre, and green to hone the colour more accurately. The failure to add sufficient red and green to a base mix is a common fault, however, if an overbalance of red occurs then adding green will neutralise the problem.
Intrinsic colouring:
a very important element of the overall colouring process. It involves the incorporation of internal colour within the silicone prosthesis. The technique permits the layering of colour, which in turn replicates the depth of colour, and creates a natural appearance. Of paramount importance in the technique, is the establishment of underlying skin colour. This is the overall colour of the skin shade, it does not account for any vascular, freckle or cartilage tissue colour. It is commonly referred to as the base colour. The base colour can be established by observing the tissue under pressure. By applying pressure to the skin tissue adjacent to the defective area, the vascular appearance can be removed to illustrate the underlying lighter skin colour, which will form the basis of the base colour.
-Skin colour is based on levels of translucency and opacity. It is important to realise that the levels of translucency and opacity vary from silicone to silicone; therefore, different silicone elastomers will require varying levels of opacity in order to gain the correct balance.
-When attempting to match skin colour it should be remembered that skin is predominantly opaque, however, it has a translucent quality at the surface. If this balance is reversed and it is assumed that skin is primarily translucent, a colour match that appears to have agreed all watery quality will result.