The life-changing art of making facial prosthetics

Scalpel in hand, Caroline Reed shears off a strand of red thread that will represent the thin blood vessels in the white of my prosthetic eye. With smooth precision, while examining my other eye for reference, she paints them on to the surface with glue, demonstrating the technique to a new colleague.

Reed is what’s known as a maxillofacial prosthetist. In her clinic, high on the 25th floor of Guy’s Hospital in south London, she makes ears, noses, dental prosthetics, ocular prosthetics and larger orbital devices for when a patient has lost multiple features. The job is to balance art and anatomy, recreating in a matter of weeks what evolution has spent millions of years perfecting.

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In a medical context, facial prosthetics is a relatively niche practice. It is estimated that there are about 500 clinicians worldwide and 123 in the UK. The practice is rarely engaged with in a broader societal sense. Those who make facial prosthetics don’t attract many headlines, but when they do the freak show tropes are quick to emerge.

One US clinician was featured in a television series with tabloids referring to her as a “mad scientist” and “Dr Frankenstein”. For Reed, there’s nothing macabre in what she does. It’s about making art so realistic that people who’ve lost a part of their face, the most socially important part of the human body, can regain their self-esteem. For some of her patients, this can be the difference between feeling able to leave the house or not.

Reed, 43, feels that her profession, though mostly unknown, uniquely uses artistic creativity to help people through some of the most traumatic experiences of their lives. It is, however, a challenge to replicate the complexity of the human face with prostheses. “It’s not going to be static, like an art piece in one place that people come and look at, it’s on a person that’s moving around and active in their day — going to work, going out with friends — and it’s got to live up to all those different scenarios,” she tells me.

Reed’s patients tend to fall into three categories: those with congenital conditions, those who have suffered traumatic injuries and those with diseases such as cancer. But every prosthetic, down to the finest detail, is bespoke. No single patient is the same.

In 2002, at a family friend’s party a few days after my 16th birthday, I was hit in the eye by a firework that fell towards the onlookers after it was lit. I was transferred to St Thomas’ Hospital in London where I had an operation to try to reattach my retina. Post-operation, I could see the flickering outlines of fingers and shadows before the sight faded from that eye altogether.

Through my twenties, I was plagued by chronic pain in the eye. By the time I was 32, I’d had enough and underwent an operation to remove it, hoping to alleviate the pain. My surgeon described two procedures. Neither sounded appealing. An “enucleation” would remove everything in the eye socket, but I was to have an “evisceration”, where the cornea’s contents are removed, a ball is implanted for volume and the sclera, the white of the eye, is then sewn over it.

The procedure paved the way for using an ocular prosthetic, or glass eye in common parlance (actually acrylic), which sits on the “eviscerated” eye to give it some movement. This is how I first came to be in Reed’s clinic watching with surreal fascination as, in her hands, strands of red thread started to form a network of tributaries on either side of my newly painted blue iris.

When Reed was 17, she was at art college and looking to apply to university. She wanted to paint, but was unsure about how she’d find a profession with an art degree. The turning point came when she decided to pierce her own ears. “Luckily, I was a bit of a stupid teenager,” she says. The experiment did not go to plan and Reed ended up with keloid scars on her ear lobes, which is when the scars grow beyond the boundary of an initial wound and are often raised and misshapen. She was referred to a clinic to have keloid splints made to compress and shrink the scars. “I just sat in the office and I was looking around, and they had all these hand models, and I thought, what is this job?”

As an art student, Reed says she “used to do skeletal figures quite a lot, and skeletons and bones, but also people as well”. She realised there was a kind of symmetry between her work and that of a prosthetist. So at Manchester Metropolitan University, she studied dental technology, then required training, before being selected for a rare maxillofacial prosthetist training position at Queen Victoria Hospital in East Grinstead.

Fifteen years on, Reed says she’s still learning, due to the constant developments in techniques and materials. Her most formative experiences have often come when a patient’s prosthetic hasn’t gone to plan. She still thinks about one from her time at Queen Victoria Hospital whose prosthetic wouldn’t fit. Although not medically trained, Reed thought that something looked wrong and got the patient to see the head and neck team. They discovered that the patient had a recurrence of their facial cancer. “I was the only person seeing that patient. She didn’t have appointments somewhere else. So if I hadn’t seen that, what would have happened? I think about that a lot,” says Reed.

Her lab at Guy’s is a small and noisy place, a cross between a design technology workshop and a clinical laboratory. A five-person team also makes prosthetic fingers, nipples and breasts. One shows me a replica orbital prosthetic, the largest and most complex that they make. The silicone skin of the nose and top lip is mottled and lifelike, the moustache trimmed and a perfect inanimate eye looks calmly ahead.

The first stage in making a prosthetic is to make an impression of the missing facial part. Silicone, alginate or a mixture of the two is used for larger parts of the face, whereas alginate, the often pink or blue material employed in dentistry, is used for ocular impressions.

To make an eye like my own, the alginate is made to be more liquid than in dentistry, and an ocular impression tray, which looks like an inverted golf tee, rested on the surface of the patient’s eye. The alginate is then pumped on to the damaged surface to set. This is the most uncomfortable part of the whole process, akin to having sandpaper rubbed on an exposed eye, often taking several attempts to get right. Over a series of appointments, a wax prototype of the eye is made, carved and fitted to make sure the gaze aligns before an acrylic version is created and then painted.

The desire to replace missing facial parts is ancient. An artificial eye was found in a skull in Iran that is thought to date back to between 3000BC and 2900BC. Maxillofacial prosthetics was born in the 16th century, when French surgeon Ambroise Paré described facial prosthetics made of gold and silver. The Danish astronomer Tycho Brahe had a metal nasal prosthesis after losing part of his nose in a duel.

By the end of the 19th century, creating an impression of the missing part of a face was the first step for making facial prosthetics, but the discomfort for patients was worse before the modern materials and expertise of teams such as Reed’s. According to the Smithsonian, an estimated 20,000 soldiers returned from the first world war with facial injuries. Often a whole plaster cast would be taken of their damaged faces, another ordeal for already traumatised men. The origins of modern facial prosthetics began around this time, with clinics set up by the artists Francis Derwent Wood in London (nicknamed the Tin Noses Shop) and Anna Coleman Ladd in Paris.

These sculptors pioneered novel techniques and used new materials, but the prosthetics often didn’t last and very few of those 20,000 soldiers ever got to clinics. In the UK, some of the disfigured soldiers were sent to a hospital in Sidcup, near Kent, that purposely had no mirrors. If men did manage to catch a glimpse of their reflection, they often collapsed in shock. As one plastic surgeon at the time put it: “It is a fairly common experience for the maladjusted person to feel like a stranger to his world. It must be unmitigated hell to feel like a stranger to yourself.”

Lewis Davis is the first person I’ve met who also has a prosthetic eye. I’ve found a corner of Embankment Gardens in central London to meet the 44-year-old actor and entrepreneur, thinking we’ll need somewhere quiet to discuss the traumatic subject matter, but Davis’s rolling laughter is soon adding to the pleasant hubbub of a sunny weekday. Still, his voice catches when he tells me what happened to him.

Waking up in hospital one weekend in July 2017, Davis was informed by doctors that he’d lost sight in one eye in an accident. When the gauze was taken off his eye, he remembers that it just looked bloodshot, but things soon deteriorated: “My eye started losing mass in size, the pupil started to kind of retract in on itself. At one point I had what looked like a cat’s eye, so it was split where the pupil is.” Eight months later, he was referred to Reed’s team at Guy’s for a prosthesis.

It’s now well into lunchtime, and as Embankment Gardens fills with people on their breaks, we begin to discuss what it’s like to “feel like a stranger to yourself”. I describe to Davis how, a few nights after my evisceration surgery, the plastic shield covering the wound fell out. Despite repeated attempts, I couldn’t fit it back underneath the eyelid, continually irritating the bloody coagulation beneath. It wasn’t the discomfort that was causing me distress, but the amount of time I was spending in the mirror with my altered appearance. For me, being in public now came with a self-consciousness that made it difficult to switch off. Davis says it is like “having fancy dress on almost. It’s a different person looking back at you.”

Research conducted by the charity Changing Faces found that 33 per cent of people with a “visible difference” have experienced a hate crime. The charity prefers to use this phrase over the legal term “disfigurement”. Even so, in popular culture, people with visible differences are often portrayed as villainous or pitiful characters. The last three James Bond films have all featured villains with disfigured faces. Before Reed made his prosthetic, Davis wore a patch to cover his damaged eye. He says that once he went to support a friend who was appearing on the TV talent show The Voice. “There was such a backlash online about me standing in the wings next to Emma, people calling me a pirate. ‘Who’s the pirate? She’s going to have to walk the plank when she gets home.’”

He isn’t interested in people’s pity. When meeting new people, he often prefers to get on the front foot and disclose that his eye is a prosthetic. Research has shown that the anonymity of those with visible facial differences is often lost through intrusive stares and questions. Other studies show that when engaging with someone with a visible facial difference, people will subconsciously stand further away.

It is estimated that there are 569,000 people in the UK with “facial disfigurements”, with one in four reporting mental health issues at some point as a result. There is little support available within the NHS; where it does exist, psychologists tend to be part of teams in services such as burns or cleft lip and palate. Davis tells me that for a while he became less outgoing “and kind of wanted to just step into the corner”.

On my second visit to her clinic in mid-May 2023, Reed remains calm and cheerful despite juggling her growing patient list, a PhD on people with facial differences and motherhood. On her desk are a number of 3D-printed jaws, which she is further sculpting and refining for use as surgical aids. Her colleague Sameera Patel, who made my eye under Reed’s close supervision shortly after qualifying, happens to be working on an ocular. Enthusiastically, she pulls a tray of what looks like pear drop sweets on to her desk.

These are colour guides for a patient’s sclera and start at an almost bluish off-white, moving through a greenish-grey to a creamy yellow. Reed and her team prefer to paint prosthetics with the patient in the room to match the prosthetic against the person’s skin or eye colour. It’s a relaxing stage of the process, like sitting for an embodied portrait. “There are lots of tiny little dots we’ll put in eyes, just a flick of colour,” Reed tells me, “and it will make a difference because those are in the natural eye. It will all add together to make it look more lifelike.”

Another reason for painting in person is that no two people have the same eye colour. Eyes can also appear darker or lighter depending on the lighting conditions. Patel tells me that this is a particular challenge with lighter blue, green and hazel eyes as striations and detail are more visible to the naked eye, and they can appear different throughout the year or even when a person is under the weather. “I’ll still have a patient with a blue eye come in, you paint it up and find the right colour. You go to fit it and you think, why is your eye grey today?” she says.

After the first world war, progress in the field was marked by material developments in organic chemistry, particularly the invention of silicone and acrylic. In 1979, the first silicone ear prosthesis was attached to a patient’s head using surgically implanted metal fastenings.

Reed and her team make prosthetics mostly by hand, but digital technology is increasingly becoming part of their work. The 3D-printed jaw that I saw Reed working on is created using scanners and software to reconstruct segments of the skull for surgical planning. This is predominantly the digital work her team does but, with her colleagues at King’s College London’s Academic Centre of Reconstructive Science, they are experimenting with facial scanners and 3D-printing silicone. She believes that one day a silicone prosthetic such as a nose will be designed, 3D-printed and fitted for a patient, but they aren’t there yet. The depth of colour and lifelike finish of silicone skin is still best achieved by hand.

I ask Reed about the technological advances that are on the horizon, and she tells me she has mixed feelings. She enjoys the artistic side of sculpting and painting prosthetics, but it might be a different job when techniques eventually become digital. Simultaneously, she says she can’t deny the potential benefits. Scanning a patient’s face would mean that they would avoid the claustrophobic process of having a material impression made. Printing realistic silicone skin might be far off but, for prosthetics like my own, in 2021 Moorfields Eye Hospital in London 3D-printed an eye for a patient. The technology is now part of clinical trials.

Time-saving tools might also prove useful in the years ahead, partly because the human papillomavirus is thought to be causing head and neck cancers in younger age groups, but also because more people survive facial cancers and require prosthetics. Reed already has more patients than she can deal with and hopes staff now coming through a Scientist Training Programme and MSc at King’s will help. Despite new technology, she still feels the human element is vital. “Although you’ve got that facial scan and everything might look accurate, I still feel that you need that stage of actually checking on the patient that it does fit.”

Reed and I have come down to the almost empty staff canteen a few floors below the clinic. She has a window of 40 or so minutes in a busy day of appointments and lab work. The quiet of the canteen and silent views over a busy London feel an appropriate place to ask her about the sensitivity of dealing with patients during the most traumatic times of their lives.

She tells me that, when it comes to how patients feel about their prosthetic, she puts her own opinions about her work to one side. “They have to feel confident with it, they don’t want me putting doubts in their minds because I’m a perfectionist,” she reasons. She marvels at the resilience of some of her patients. “You could see a patient, with quite a large loss of their face for example, and they manage it so well. You’re just absolutely baffled by how well they are doing.”

We talk about how people with visible facial differences are often mistreated and Reed bristles with anger as she describes something she came across while researching her PhD. In a study, a researcher is made up with a birthmark condition in order to record how pedestrians react. One man approaches the researcher and says, “You are the ugliest person I have ever seen.” Reed relays this to me with exasperation, “You think ‘Why? Why do you think that’s OK?’ It just baffles you, really, that people think that that’s OK.”

Reed’s PhD is a study into how the public reacts to a person with a facial difference and if that changes when they wear a prosthetic. It’s an unstudied area and she hopes her findings might help patients to contextualise people’s responses to them. Results might reveal, for example, that staring often comes down to curiosity rather than negativity, which, if the case, might help to inform and reassure patients ahead of treatment.

I meet Davis again in the waiting room on the 25th floor. He has allowed me to come along to a review with Reed of his new prosthetic. It’s been several weeks since his last appointment, where it was fitted. Reed looks directly at Davis to assess the eye and then moves behind him to get his perspective as he looks in a mirror. She takes the prosthetic out, disinfects it and warms a knife so that she can add a thin layer of wax before putting the eye back in, raising Davis’s eyelid ever so slightly. The process goes on for an hour before his prosthetic has the perfect shape. It will be remade in acrylic and fitted again at his next appointment.

“I’ve been doing the job for 15 years. I’m still a little bit nervous when I go to fit something,” Reed tells me, her voice quickening. “You think, ‘Oh god, I really hope it looks OK, I really hope it looks OK.’” She needn’t worry. After making the most subtle changes to Davis’s eye, it’s a perfect match. For him, the prosthetic means he doesn’t have to worry about his appearance as much and allows him to refocus his life. He’s recently had major auditions at Paramount Studios and the BBC. For Reed, satisfaction comes from the effect her work can have on patients. “Seeing the impact on them is sometimes quite a moment that makes you stop and think, ‘OK, yeah, this is really important what we’re doing.’”

As I leave the clinic after Davis’s appointment, I realise there’s a good chance that I’ll be a patient of Reed’s for life. Every six months, I will return to have the prosthetic checked and polished. A biannual reminder of how her work has made it easier for me and others to navigate the world.

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