Q&A with Juan Garcia: Artistry and Medicine for Healing and Hope

Juan Garcia is an Associate Professor in the Department of Art as Applied to Medicine at the Johns Hopkins University (JHU) School of Medicine and the Clinic Director for the Facial Prosthetics Clinic. He is one of fewer than 40 Board Certified Clinical Anaplastologists (CCA) in the world, a designation for professionals skilled in making facial, ocular, and somatic reconstructive prostheses and other custom medical devices that restore symmetry and normal appearance to malformed, disfigured or absent parts of the human body.

IAM Lab: Tell us about the Department of Art as Applied to Medicine at Johns Hopkins.

JG: Art as Medicine has a rich history at JHU dating back to its founding in 1911. Max Brodel, who was a famous medical illustrator, founded the department. Back then, it was primarily focused on medical illustration as a method for teaching. In the 1940s, the University of Maryland, (also in Baltimore), was a pioneer in facial prosthetics because of its strong dentistry program. Carl Clark at the University of Maryland wrote one of the original textbooks on facial prosthetics. He had a student named Elizabeth “Betty” Blumenthal who quickly became a key member of the JHU department. It was Betty who brought facial prosthetics services to the department. Today, we have the Facial Prosthetics Clinics and are one of just a handful of anaplastology training programs in the United States.

IAM Lab: What is the artistic skillset required for facial prosthetics?

JG: It’s really about medical sculpting. The typical process is to take an impression of the unaffected side, such as an ear, or of a relative’s face in the case of a nose, make a model of that impression out of gypsum stone and use that as the visual aid for sculpting the prosthetic device on top of an impression of the affected side. The artist has to mentally mirror image what he or she is seeing off of the unaffected impression as they are sculpting. It’s not something that just happens naturally, this ability to sculpt in mirror image. Over time you develop the skill. There’s a need for knowledge of chemistry too. Back in the 1940s, they were mixing waxes and compounds to use in various stages of making the prostheses. Now we are using silicone, but you have to know how to pigment the silicone to match skin. It’s not a quick process; my patients come for five hours at a time for a constant process of sculpting, fitting and color matching.

IAM Lab: How much scientific or medical training do you need to do this job well?

JG: In order to safely create these devices, you have to understand anatomy, both on the surface and deeper structures. You need to understand different tissue types you’re encountering and how the nasal structures differ from those in the orbit of the eye, for example. Students in our master’s program are required to take the same anatomy class as medical students here at Johns Hopkins.

IAM Lab: You are meeting and treating patients at an incredibly difficult time in their lives, when they may feel like life is over after losing significant sections of their face to cancer, for example. How does combining artistry with medicine help to rehabilitate patients?

JG: Well, I’m trained as a medical artist, but I’m also a human being. These are people who would normally not be going out of their houses at all. Something precious has been taken from them, and they’re traumatized. When I’m working and interacting with them, they take off the bandages, and it’s often the first time that’s happened outside of the immediate family. There is value to them realizing they can interact with the outside world.

In large part, the measure of success of what I do is to get the patient back to that sense of whole, the ability to go to work or live a normal life. When I first started doing this I thought, wow, I’m now making medical art that is on people’s faces. In the end, it’s a custom sculpted piece of silicone that’s there. I always tell patients right at the very onset, I can’t make you something that no one will ever be able to detect or a perfect replacement. But hopefully, if I do my work well, it passes unseen and helps that patient to feel whole again.

IAM Lab: You say they aren’t a perfect replacement, but before and after photos of your work are remarkable. Are there people making facial prosthetics who are not artists? Are the outcomes different?

JG: In short, yes and yes. There’s a patient that comes to mind that had a prosthetic that was made by a dental professional. The device really looked awkward. It wasn’t shaped appropriately. Edges were not handled correctly. There was no projection of a nose. They used a questionable attachment system to hold it in place. Advanced degrees don’t necessarily mean a good outcome for this type of work. The device must have a functional as well as an aesthetic purpose. It can’t just be something that covers the hole or misshapen area; it has to look natural. Otherwise, we instantly recognize that something looks awkward. Our eyes are trained to do that, and this can be unnerving for both the observer and the patient.

IAM Lab: Is technology a good replacement for artistry? Can you just 3D print a new ear or nose? What are the benefits and limitations of technology in your field?

JG: We currently cannot 3D print an ear or nose that looks natural, in part because you can’t print in silicone. They’ve already announced UV curable silicones, but as far as printing something that’s compatible against the skin for an extended period of time, that’s durable and flexible, that doesn’t degrade, that can be tinted and has a very thin edge, that may be a little ways off, if they can get to that at all.

As far as technologies right now, we use surface scans. You can use a handheld scanner and basically draw out the shape of the feature you want to capture, say an ear, either on a patient or on a model so you can get the subtle details without motion. You can obtain a very high resolution 3D model that can then be mirror imaged, reduced and enlarged. You can take another 3D shape, say a nose of another individual and digitally subtract it from the impression, using digital sculpting tools. You can manipulate those 3D models — bend, fold, crease, draw and sculpt — as if they were digital clay.

IAM Lab: Is that how you’re working today?

JG: It’s a mix, because at the very end I have to get off that digital wagon and have to cast the silicone prosthesis from a mold no matter what. You’ve got to consider the cost as well as time. Digital isn’t always faster, better, cheaper. It can be very time consuming and expensive to build the digital files and 3D print the molds. There is also real benefit in an iterative process that comes from making the prosthetic by hand. It is very difficult to replicate all the possible movements in a human face digitally to see how a device would move and fit. In my opinion, you currently get a better outcome by testing wax prototypes on a real live patient.

IAM Lab: What applications of arts as applied to medicine are you most excited about today?

JG: I’m excited about our collaboration with the Carnegie Center for Surgical Innovation. It’s a creative space for physicians and research faculty to interact with biomedical engineers, imaging specialists and medical artists to come up with unique solutions to problems. I just created a small customized splint to help correct the shape of an infant’s ear. I’m also working with a dermatologist to cast a specialized surgical device for drug testing. The applications are really endless, and we’re doing exciting work.

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