Anatomy and Art

So, I was reading an article about 3D cinema and thought I would post it here.  It’s an argument against the survivability of 3D as a medium as put forth by Walter Murch, author of In The Blink of an Eye, and editor of such films as The Unbearable Lightness of Being, Apocalypse Now, and The Godfather.  I saw him speak once, when I was an undergrad in film school back in the 90s.  He had just finished working on Cold Mountain and he was fascinating to listen to. Truly, he is one of the Hollywood greats, known both for his editing, but also specific attention to sound design.

The article is here.
http://blogs.suntimes.com/ebert/2011/01/post_4.html

Then, as I was reading, I realized that this was Roger Ebert’s blog.  We heard last week that Roger Ebert had written something about the prosthetic chin he recently had made, and specifically mentions UIC’s very own Dr. David Reisberg.  It’s a really nice little article, and cool to see such a story written from the patient’s perspective.

http://blogs.suntimes.com/ebert/2011/01/after_surgery_i_studiously_avo.html

So thank you Roger Ebert, for the excellent blog.  And I guess this post can be tagged with both 3D and anaplastology!

Doing a little organizing of images over here tonight.  I’ve been in full on shutterbug mode around the clinic this month, and now it’s time to go through all those images for the presentations we are giving on Monday.  Once again, it’s a Power Point format, and once again I find myself wavering between a lot of text on the screen and being more image based.

The presentations we are giving are all with regard to a bench exercise we recently did wherein we created an auricular prosthesis with acrylic substructure and clips for implant retention.

For this one we started with an assigned treatment side impression from a patient, and a cast ear from a patient.  The cast ear was scanned with the laser scanner, and then milled into hard blue wax using a CNC milling, or rapid prototyping, process.  A vacuuform impression was then made from the blue wax model and we all individually poured hot wax into the form to create a working wax model of the shape for ourselves.

We also each poured casts reflecting the treatment side of a patient, and used these as bases on which to sculpt.  We were given clips, like those that a patient would use to attach a prosthesis if they had implants, and these were positioned along the stone bar replica of the treatment side casts.  And we were asked to create a light cure acrylic substructure to join these clips and provide stability to the prosthesis on the whole.  The working soft wax from the vacuuform impression was positioned on to the stone cast over the substructures that we created and fit individually to that positioning.

The sculpture was then perfected using a variety of sculpting tools, made smooth, and then lightly textured.

From this sculpture a mold was made.  First we cut keys into the stone cast itself.  Then the outer edges around the cast were boxed up (given walls.)  Then with a separator covering the stone (I believe in my case I used liquid foil), we poured new stone to fill in the space behind the back of the ear.  We only poured to the helical rim (outer edge of the ear) to prevent undercuts in our mold later.  Once this stone had fully set, I was able to cut keys into that layer, and cover the new stone with liquid foil as a separator.  I then mixed and poured new stone to create the top of my mold.

Once all aspects of the mold were set, it was time to melt the wax sculpture inside.  It’s always a little bit nerve wracking doing this, because you’re melting away the part you worked on the longest.  But you need to remove the wax completely and even steam or boil out any wax residue before you can go on to the next step.

With a clean mold, and with some kind of separator in place (I believe this time I used Colombia Model Gloss), and a properly prepped acrylic substructure (the substructures must first be cleaned with acetone, and then coated with a primer and let to sit for half an hour) you can pack your mold.  I chose to match my colors to a photo I found on the internet. I started by painting in my red glaze, as is customary.  I then moved on to plant a couple freckles, and place some vasculature using colored yarn.  I painted a tan glaze in along the areas of the ear most kissed by the sun, and a cartilage glaze in the areas where the cartilage is right against the skin and lightens the color, and a shadow glaze into the crevices and places that often appear darker in an ear.  Finally I poured my base silicone into the rest of the ear and closed the mold with the acrylic substructure attached to the bar.

In my case, I allowed my silicone to sit and bench cure over the next couple days and didn’t actually put it in the oven until later.  It is my understanding that they acrylic will not bind with the silicone without some time in the oven, so I didn’t want to skip that step later, even though the silicone had most likely fully cured by then itself.

When I opened the mold, there was a lot of run off, or flashing, to trim off of the silicone everywhere the mold’s pieces came together.  I also cut a whole where the ear would naturally open to provide hearing.  Most patients can still hear at least somewhat despite not having the external features of an ear, so generally an auricular prosthesis provides an opening to allow sound to travel.

I think the trickiest part in trimming was trying to get around the clips in the back.  I think this will become easier as I get better with razor knives.  I certainly hope so anyways.

I did some last minute extrinsic coloring using the A-564 silicone.  I used the technique where you sprinkle powdered sugar over the silicone while it is still wet and allow it to cure that way only to wash the sugar off later and keep the texture it’s left behind.  This prevents the prosthesis from being overly shiny by breaking up the surface subtly.

All in all, I think that the ear looks pretty good.  I would post a picture, but I’m not sure we can given that the original shape did come from a patient, even if the coloring didn’t.  So you’ll just have to believe me when I tell you of its finesse 🙂

Anyways, that’s the process more or less.

This just in, breaking footage of malaria caught in the act of breaking into and infecting a red blood cell!

This footage comes to us from the Institute of Medical Research out of Melbourne  Australia.  The invading parasite is called Plasmodium, and it has been known to kill nearly 1 million people worldwide each year.

You can read more about the video here at New Scientist.
http://www.newscientist.com/blogs/nstv/2011/01/malaria-caught-breaking-and-entering-red-blood-cell.html

So, I’ve seen a lot of photographs where the underlying anatomy gets drawn in over the surface anatomy.  I’m actually pretty fond of that style of portraying how anatomy fits inside.  But yesterday I stumbled onto this picture.

It would seem that instructor and sports therapist, Gillian Higgins has perfected the art of painting the underlying anatomy straight on to the surface, and does so repeatedly with her horse to teach horse owners about what’s inside.

This Youtube video gives a nice quick summary of her endeavors.

You’ve got to admit, that’s pretty cool!

One of the things that has been particularly emphasized in my anaplastology training is the usefulness of rapid prototyping.  Wikipedia defines rapid prototyping as “the automatic construction of physical objects using additive manufacturing technology.”  My own understanding has always been that it includes both additive and subtractive manufacturing.  Either way, you get to essentially print out 3D objects from a file, and that’s pretty cool.

For clinical usage, this is particularly helpful alongside a laser scanner.  If you have both, you can scan in casts made from impressions taken from patients, alter them digitally, and then print out the altered models for use in your own physical creation.  The catch is that technology is expensive.  The party line has traditionally been that rapid prototyping in particular is expensive.  But the touch of awesome is that those prices seem to be coming down.

At the clinic we have a CNC milling machine.  It’s a big deal.  Maybe just a year ago the clinic was featured in the news and that very machine was photographed to represent our cutting edge technology.  And it is useful in what we do.

Just a few weeks ago I was visiting Texas, and an old friend mentioned a 3D printing company where you could send your own files for manufacturing, Shapeways.com.  They charge by the square centimeter.  And it’s affordable enough for my friends to be using it to make game pieces. That’s clearly not as practical as having your own machine, but it does show a movement in accessibility.

Then just last week someone was posting an article from Cornell University on the AMI list about how 3D printing may soon be a household capability.  I have to think that whether or not that is the case, clinically at least, this technology is about to be very accessible. I’m glad that we are learning to use it now.

Of course all that being said, I haven’t heard a word about laser scanners coming down in price yet.  But knock on wood, it’s bound to happen too.  And I, for one, know a thing or two about digital manipulation.  All of my animation software is directly applicable to just such work.

This is something that I can do.

Well I am officially back in Chicago after winter travels, and yes, winter is right where I left it here.  On Monday I’ll be starting back up with anaplastology in UIC’s Maxillofacial Prosthetics Clinic again.  And then mid semester, around the beginning of March I’ll be heading down to Texas to intern with The Medical Art Prosthetics Clinic in Dallas.  If I play my cards right, this looks to be my last semester with UIC.  First and foremost on the list with that comes finishing up my project research in time to present this semester.  That’s the patient education piece on those craniofacial surgeries.  It’ll be tricky, with all the intern hours and moving around the states I’ll be doing, but it is possible.  I’m also looking at taking on a bit of video work, digitizing some tapes of interviews with some of the victims of thalidomide poisoning from those cases back in the 60s.  I’m also still selling prints from that painting and keeping the Cafe Press store.  I’d actually really like to find the time to paint some more here, but it’s difficult getting to do everything.  For right now, I’m just trying to get my home in order for the upcoming week.  It’s been a great vacation, and now I guess it’s time to get back to work.

This is a nice little story about an anaplastology case covered by Fox News.
http://www.foxnews.com/health/2010/12/21/hollywood-style-special-effects-girl-new-ear/?test=faces

The anaplastologist featured, Jerry Schoendorf, was once a student at UIC in the very same program I am currently finishing.  He is currently working with The Anaplastology Clinic out of Durham, North Carolina.  Judging by his bio there, he certainly sounds like a real leader in the field.

I just wanted to take a moment to wish all of you reading the happiest of holidays.  May you all enjoy good health, good company, and good fortune in the year to come.

I was recently asked about a comment I had made in another post regarding insurance policies and their coverage for anaplastology.  The other post wasn’t really about that, but the truth is, this is something I think a lot about.  It isn’t really something I know much about though.  I mean I’ve certainly kept my ears open for snippets of information here and there around our clinic, and the clinics I’ve visited over the years.  Most of what I’ve gathered from all of that though, is simply that dealing with insurance companies is going to be a royal pain if I should ever open my own clinic.  And given my own skill set and history with handling bureaucracies I’ve pretty much decided well ahead of time that I am not someone who should open a private practice until I believe that I can cover the costs of hiring someone else to handle that aspect for me.  I’m more the type who has spent large swatches of their adult life without any health insurance because I find such bureaucracies so challenging to navigate.

But here I am, author of this little blog, and it occurs to me that maybe I should do a little looking into just what kind of coverage is available out there for anaplastology cases.  So I called a couple of places with questions.  Now, my first attempt at this was late on a Friday night (which sadly probably does speak zounds about my personal life these days.)  I tried to reach Blue Cross Blue Shield, but found myself on hold for roughly half an hour.  It was at this point that I came to the conclusion that I was likely waiting on line with people who had real emergencies and not just a curious streak, so I decided to call back later.  The following week, I found myself thinking about it again during regular business hours and I decided to try again.  This time I started with Medicare.

The number I called to reach Medicare was 1-800-633-4227.  I was on hold less than six minutes, but then when I did reach someone, it was impossible to get any real answers.  First, the woman answering had never heard of anaplastology.  She was very nice about looking up as much as she could for me though.  Eventually she was able to tell me that they covered the replacement of arms, legs, eyes, and orthopedic braces for the back, foot, or neck.  She suggested that I call individual clinics to ask about whether Medicare was accepted or not.  After a 25 minute conversation she attempted to connect me with another branch, but there was no hold music this time, and after 15 minutes I decided that the transfer must not have gone through and hung up.  So that was disappointing.

Next I went back to Blue Cross Blue Shield.  The number I called was 1-800-633-4227.  They were much trickier to even get to the hold part, with a lot of push button questions, none of which offered an option for questions about anaplastology coverage of course.  And then when I did get to the hold part of the call, I couldn’t help but write down the phrase “discussing policy benefits is not a guarantee” which was actually part of the recorded loop playing while you were on hold.  I mean I guess I get it, but hearing it over and over again while I waited just played into some pre-conceived notions I already have going about these guys.

When I finally did get through with someone, he was very adamant about how there were no over all options or plans.  It got me wondering about how much negotiation is really involved in setting up an insurance plan.  I tried to use the example of seeking coverage for visits to an anaplastologist regarding two missing fingers.  I thought that would make things easier, and also should let me know if there are differences in the way facial and somato cases are handled.  I was told that the question didn’t really make sense, because coverage packages vary, and as an individual seeking to set up a service plan, you wouldn’t be able to get care for a pre-existing condition anyways.  So basically it could only ever come up if someone with a coverage plan in place was to loose those fingers while insured and they would then have to check their plan for coverage at that point.  I was shocked.  I didn’t think discluding coverage for pre-existing conditions was even legal anymore, but I guess it is.  The man I was speaking with then tried asking me about the code for the service I was trying to ask about.  It sounds like there are ways to look up specific procedures if you have the right insurance code to search under, but I didn’t have anything like that.  In the end, the most information I was able to gather about BCBS’s coverage was at the following link which describes prosthetics coverage, discluding lower limb prostheses.

http://medicalpolicy.hcsc.net/medicalpolicy/home?ctype=POLICY&cat=DME&path=/templatedata/medpolicies/POLICY/data/DMEQUIPMENT/DME104.001_2009-04-01#hlink *

*On second review, I realize that to get to the intended page you must first click to agree (I believe the agreement is not to hold them to anything they say), and then perform a search for the word prosthetics, search all, and then select “Prosthetics, Except Lower Limb Prosthetics”

I was also given a number to dial for providers, 1-800-972-8088, and I tried that but it was after hours when I did.  I did notice that the initial phone options were limited to the categories, medical, pharmacy, dental, and behavioral health.  So I think that even if I had caught them in their regular hours I might not have been able to establish much.

Honestly I think I’m more confused now, having attempted to clarify information than I was before making these calls.  I’d made the calls in an attempt to understand how anaplastology was covered by the major insurance providers.  I was interested specifically in if there is a difference between how facial and somato prostheses are covered, or if that idea is just a misconception I picked up by not having the full story.  But in the end, I think I just learned more about why no one likes dealing with insurance companies.  And I once again spooked myself about the prospect of ever needing them with regard to my own health.  To be fair, I spook easily about that particular topic, but really, I have yet to understand how anyone ever gets treated for anything in today’s day and age.  And I find that terrifying, both as a human who sometimes needs medical care just like anyone else, and also as someone learning to be a clinician, who at some point will need to understand the system from the side of the care-givers as well.

Recently I went through the process of getting prints made of a painting.  Real ones.  Good ones.  Expensive ones.  I have to say that the process has been a little bit terrifying.  For starters, let’s face it… I’m not exactly the greatest business mind out there.  But I gave this some thought as to what was reasonable to charge, how many I would make, how many I thought I could sell, and did a little research into what it would cost me.  Unfortunately, the first estimate of what it would cost me reflected less than half of the ultimate total costs I wound up spending.

At first it was a matter of having having gotten my estimates based on the image size without doing the math on what the added border for framing would be.  I’d expected there to be added cost for that, but I had underestimated how much.  Secondly I had to rescan the image.  Letting the printers scan your painting is not an inexpensive endeavor.  But in this case, I believe it was both necessary and worth it.  Between those first two points though, I wound up deciding to make fewer prints than I had originally intended.  It’s good that I didn’t make as many though, because the next blow came when I went to pick up the prints and found that their scan had picked up so much detail, that it had practically x-rayed my painting.  I didn’t catch it immediately.  At first glance, all I saw was that they had gotten the red right (no small detail, that), and that the new scan had not shown the same problem as the scan I had done previously.  I left happy.  But then as I was packaging up my first print for shipping, I saw that there were mistakes, familiar mistakes.  I kept wanting to dab a bit of paint here or there to fix them, and then I realized that I was having the exact same thought process I’d had while finishing the painting in the first place.  I was seeing mistakes brought back that I had already fixed, and I couldn’t send that to paying customers.  So I called the printers back.  I went through Gamma to do all of this.  Their tech who had done the scan for me had already left for the day, so I had to make plans to go back later that week after my finals (and yeah, taking on this process at the end of my semester, maybe not the greatest plan of action.)

I had purchased a digital copy of the scan as well, so I was able to review that as well.  I was surprised when I didn’t see the same detail from the under layer there.  But just now, just today, when I opened the image in Photoshop I did.  It’s the strangest thing, the detail is in there, but I wasn’t seeing it in the raw file.  It’s actually kind of a relief to see it now.  I couldn’t for the life of me figure out how I was getting added detail from the printing process.  Anyway, despite picking up those covered brush strokes, it really is a beautiful scan.  Here is smaller version of what they got…

So I was able to go back in and discuss things with them.  It’s been a good thing, having the painting handy for all of this, not just for rescanning purposes, but also as something to bring in while talking about the desired outcome of the prints.  I’m fortunate that the buyer wanted me to hold on to it for the time being, and that I’ve been able to do all of this despite the sale.

They saw the problem, and we decided to have the prints redone with different settings.  Unfortunately, this brought my costs up considerably.  Since I hadn’t paid for giclee printing (which comes with the opportunity to approve proofs) my options were limited in terms of how to handle this.  They did make an effort to work with me though, and while I lament loosing so much of my profit margin, I am very happy with the way the 2nd set of prints came out, and the product I can now deliver to my clients.

In the end, I only wound up making six of them.  I’d initially thought about leaving the window open to further printing down the line, or making 12 all at once and just selling them off over time.  Especially considering the added costs along the way, I am happy that I only opted to create the six of them.  At present three of them have been paid for and shipped off to buyers.  One is spoken for, to be paid for and picked up in January.  And I may have a fifth buyer in the works.  All in all, this has been quite the learning experience, and something that I hope to do again and again with other works, though hopefully with less nervousness and better planning along the way.  It’s tricky though.  You don’t know if something is right or not until you see it.  You can’t know.  But I do know a little more about what to look for, and what to ask for now.  So here’s hoping that next time I can be a little less neurotic artist about things, and a little more savvy seller of my art.