Epithetics through the ages
From the “golden nose” to modern facial prosthesis
The exact beginning of facial prosthetics will likely remain shrouded in the mists of medical history. The first, albeit only literary, accounts of “epitheses” (artificial facial parts) date back to the time of the pharaohs. For example, there were reports of ears made of wax. The Indian story from the 2nd century AD about a Brahmin who lost his nose in a sword fight and had a painted artificial nose made of lacquer is particularly interesting. In ancient China, there were supposedly epitheses made of wax, clay, or wood, which were used to very inadequately conceal severe mutilations caused by illness or war, leaving them completely unprotected against the elements.
The particularly frequent total loss of the eye led to numerous attempts to create an aesthetically pleasing epithesis, for example, from leather, silk, metal, or animal hides. Gold helmets with thin, hammered mask inserts, which were made for warriors in antiquity, may also have been worn as epitheses after injuries.
It wasn’t until the 16th century that we find genuine evidence of artificial facial features. For example, a portrait of the Princess of Eboli shows that she wore an artificial eye, and the portrait of the astronomer Tycho Brahe, who lost part of his nose in a duel, depicts a small metal nasal prosthesis.
At this time, medical literature also began to address the possibilities of concealing severe facial defects. Artificial noses made of gold or silver for wealthy patients and papier-mâché for poorer ones were produced according to drawings by the surgeon Paré at the beginning of the 16th century. These prefabricated noses, which hardly adapted to the defect, were tied around the head with thread. Orbital or ear prostheses, on the other hand, were anchored in the cavity using springs.
Few people could afford such prostheses. The average person with a facial deformity left their defect unconcealed. Even the occasional attempts at surgical (plastic) facial surgery undertaken in the 16th century were abandoned for the next two centuries – presumably due to the high pain and risk of infection, as well as the limited aesthetic success.
At the end of the 18th century, the story of Johann Beck, mutilated by syphilis, caused a sensation. He marketed his self-made obturator prosthesis made of sponge and a nasal prosthesis made of wood by appearing as a “demonstration object” for doctors at fairs, charging them money. Similarly, a locksmith earned his living with a silver chin coated in flesh-colored wax. This chin contained an artfully fitted sponge inside to prevent excessive salivation. Copperplate engravings documented the individual steps of the prosthesis techniques and the prosthesis retention.
The beginning of modern epithesis technology
At the end of the 18th century, dentists were among the first to regularly and expertly engage with epithetics as part of the development and advancement of dental prosthetics. Modern dental and epithetic techniques began with the porcelain-based prosthetics developed by the Parisian dentist Nicolas Dubois de Chemant (1753-1824). This porcelain material also allowed for the creation of highly adaptable facial epitheses. Chemant produced teeth, obturators, and chin and nose epitheses.
Finally, rubber prostheses were manufactured using a multi-layered process, molded on a plaster model and dyed flesh-colored, as was also done in Berlin by the Royal Dentist Pierre Ballif. Ballif extensively studied the possibilities of a more durable attachment of the artificial facial parts.
With improvements in prosthetic technology, multi-part prostheses for multiple defects became possible. The story of a French gunner who lost large parts of his face to shrapnel during the Franco-Belgian War of 1832 has been passed down. A field doctor made a movable lower jaw face mask suitable for eating and speaking.
After rubber, the lightweight, easily malleable celluloid was tested in 1869, followed later by aluminum, and from 1889 onwards by porcelain and glass for eyes attached to spectacles. Gelatin prostheses were then introduced in 1913, although the patient had to replace them daily using a mold.
Plastics and computers: The path into the new millennium
After World War II, the plastics commonly used today, such as initially polyvinyl chloride (PVC) and later polymethyl methacrylate (PMMA) and silicones, were employed as materials. Due to their excellent dimensional stability, load-bearing properties, and high aesthetic appeal, they almost instantly replaced all previously known materials.
In addition to plastics and titanium as a particularly dimensionally stable, low-irritant material for the substructure, as well as skin-friendly adhesives, advances in the surgical techniques of craniofacial surgery and implantology, in the form of osseointegration, have led to a significant improvement in patients’ quality of life. Implant anchors via bar-and-rider constructions or magnets provide a firm hold for an epithesis and thus give the patient security in everyday life.
Nowadays, prostheses are made of soft medical-grade silicone and attached using a variety of methods. These methods include attaching the prosthesis to glasses, gluing, retention in undercuts, and, in recent years, the standard method of fixation using extraoral implants with screwed-on magnets.
Literature:
Prof. Dr. A. Renk (1997) 400 Years of Facial Prosthetics – A Historical Overview of the Development of Epitheses.
Schwipper V., Tilkorn H. (Eds.): Advances in Craniofacial Surgical Epithetics and Prosthetics. Einhorn-Presse Verlag GmbH, Reinbek