Anatomy and Art

So, if you’ve been reading along here you already know that I’m presently up in Dallas finishing up my clinical practicum, and thus the anaplastology track with UIC’s biomedical visualization graduate program. My internship has been here, with Medical Art Prosthetics, and I couldn’t be happier with the exposure I am getting here to new techniques and working with different patients.

So right inside this building, up on the 3rd floor is where the magic happens.  People come in from all over Texas, and sometimes further for the quality prostheses created inside.  In just the short time I have been here, I’ve already seen patients and been a part of problem solving for individual needs. I’ve learned new impression taking and transfer methods and worked with new pigments, and different types of molds than anything I’d worked with previously.

The clinic was originally founded by anaplastologist Greg Gion MMS, CCA. I have only had the opportunity to speak with him on the phone so far, as he is currently based in Wisconsin now, but I am very much looking forward to meeting him in Sarasota next week at the International Association of Anaplastology conference.  As I understand it, this clinic was the first maxillofacial prosthetics facility to be owned and operated by a medical artist.  And now he’s made it happen again with the newer clinic out in Wisconsin.

These days it is anaplastologist Allison Vest, MS, CCA who you will find at the Medical Art Prosthetics clinic though. She is the anaplastologist I have been primarily working with, and I learn something of value from her every time I go in there.  Sometimes we talk about business and what goes in to running a private practice.  Other times we talk about materials or different techniques.  The last time I was in there, I got to open up a mold that I was particularly excited about.  It was a complicated piece, but it worked!  I’m so lucky to get to learn from her.

Also, working alongside Allison, Colette Shrader, MS, has been hard at work launching her own branch of Radiant Impressions, custom breast prostheses, as an alternative to surgical breast reconstruction.  It’s fun seeing her again since meeting her through UIC in Chicago originally.

Also as part of my internship arrangement with Allison, I am doing an observationship with anaplastologist Suzanne Verma, MAMS over at Baylor College of Dentistry, here.

Suzanne is great.  I came and visited her once before and had a great experience doing so.  This time I’m still soaking in information right and left with her, but I’m also getting the chance to follow along with the care of a patient over time.  I think that working with patients and trouble shooting individual difficulties and preferences is one of my favorite things about anaplastology.

All in all, this is proving to be a very valuable time in my training, and I feel fortunate to get to soak in so much exposure to various ways of doing things.

Well, I’m one week in to the Dallas portion of my clinical practicum and so far so good.  I love seeing how different people work.  Everyone has their own ways.  Everyone has experienced different types of cases.  And yet certain practices and materials pop up everywhere.

So far I am finding that there is great room for individuality in the practice of anaplastology.  It’s really about problem solving, and there are usually many ways to solve a problem.  To me, I feel that much of my training revolves around a better understanding of the materials at hand, being exposed to different types of solutions, learning what goes with what, and most importantly, the safety considerations necessary since we are dealing with patients and not just our own projects.

I feel fortunate to have the opportunity to take in wisdom from such a variety of sources.  Between the split internship between Chicago and Dallas in the first place, and now getting to intern with a private practice along side weekly observation of another university/hospital setting, I feel like I am getting a well rounded view of how this field comes together.

By the way, here is the drive I made last weekend…

And in just a couple weeks I’ll be flying down and across the gulf to Sarasota, Florida, for the annual meeting of the International Anaplastology Association, where I will get to meet even more professionals and widen my view that much further.  I’m looking forward to it.

Check out that inferior alveolar nerve! So this is something that I’ve been working on these past couple weeks.  First it was getting the braces modeled and aligned.  And then most recently, it’s been the nerve.

The race is on to get this animation on track.  My time gets so divided between my work with this and my time at the clinic that it gets down right overwhelming at times.  Right now, I’m doing what I can to have everything modeled and all my shots planned out and ready for render once I get to Texas.  I hit the road in a week, so the countdown is on.  Then I’ll be working with two clinics in Dallas while I complete the rendering and final stages of my animation, and write my final paper in preparation for my defense for graduation.

Earlier this week I wrapped up my side job, so at least that’s out of the way.  It was actually really refreshing work.  I was digitizing some old vhs tapes for a woman who had documented cases of thalidimide related birth defects back in the 80s.  It was nostalgic for me, going through video footage like that and talking someone through the possibilities of what could be done.  Plus it’s reassuring getting my old tricks figured out on the new machine.  I can happily report that I am still video capable over here.

This week will be my last chance for any in person questions I may have about my project research before I go.  And at the clinic I will be wrapping things up with the patients I have been seeing, and also with the new bench assignment I’ve been doing, making a finger prosthesis that matches me.

It’s a lot to get done!  And I still have to pack!  Eek!

Lately, between seeing patients at the clinic, I’ve been learning a bit about somato prostheses, specifically what goes into taking impressions of hands and fingers and building a prosthesis from there.  I’ve really only been through the impression taking process so far.  We did that with algenate, much like you would an ear or a nose.  Getting an entire hand out is difficult and takes some finagling, but I did it.  I was then able to mix up and pour yellow dental stone into the algenate impression.  Slowly I peeled away the algenate to reveal the stone cast created in the process.  I have to say that all those years of being a picky eater as a child have served me well in my recent years.  Between anatomical dissections, and delicate separations of materials for my anaplastology classes, it’s a fine trick, being able to precisely remove one thing from another.

Once all of the algenate was picked away, we made a few adjustments to the cast to clean it up and make it non-stick, and from this process, I now have my very own replica of my right hand.

Since then I’ve repeated the process for just two fingers, and I now have copies of my first two fingers of each hand, also in stone.  The next step in this bench exercise is to amputate one of the stone fingers (which as it turns out is a little bit scary to think about even though it’s just in stone).  And from there I will learn about the sculpture and silicone creation process of making a finger prosthesis.

From what I’ve read, such prostheses help people hold a pen or pencil, type, play an instrument, any number of things, as well as maintain a more normal appearance.  I look forward to working with these types of patients in the months to come.

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.

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.

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 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.

I often find myself thinking about where this whole scholastic track that I’ve put myself on will lead.  Will I actually get to be an anaplastologist?  Will I find myself working in animation?  Will I discover new innovations in how 3D animation software can be utilized to design and develop prostheses?  Will my time in the clinic afford me important experience with which to make educational animations and films?  Will I wind up doing something completely different?  The truth is, I just don’t know.  I came out here to get in to anaplastology with the intention of focusing on hands and fingers as a specialty, and just within the year medicare and various insurance companies stopped covering somato (and therefore finger and hand) patients for any anaplastologist not actively working with a licenced prosthetist.  Who could have anticipated that?  To keep competitive in facial prostheses I need to stay in practice with osseo integrated prostheses.  Next year I will be an intern, either with the clinic where I spend so much time now, or somewhere else.  While the thought of moving is daunting, I can’t help craving another view at this new world I’ve found.  This March I will be attending the annual International Association of Anaplastology conference for the first time.  It was a tough decision signing up for anything in March when I don’t know where I’d be living and therefore traveling from to attend yet, but I’m glad now that I registered.  I’m really looking forward to connecting with others in the business and getting more pieces in how the whole puzzle fits together.  Anyway, these are the meanderings of your sleepy blogger tonight.  Goodnight to you all.