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Epithetics: “What always counts is a holistic view of the human being“
Michael Rademaker; © private
In case of a tumor disease, a deformity or an accident, parts of the body or face of a person need to be reconstructed, often an epithetics specialist/ anaplastologist comes into play. His craft does not just require high empathy, but also the highest degree of technical skills.
Michael Rademaker, Managing Director of the Institute of Epithetics in Münster, Germany and a member of the Board of Directors of the German Federal Association of Anaplastologists and a member of the International Association for Surgical Prosthetics and Epithetics explained to MEDICA.de, what this profession entails and what kind of challenges result from it.
MEDICA.de: Mister Rademaker, you are the last resort for many patients with facial damage. What kind of people look for you?
Rademaker: They are in particular people that no longer can be helped by a surgeon. Of course there are also patients who do not wish to have any surgical intervention. A surgeon can still help in reconstructing a missing pinna or nose. The reconstruction of an entire eye however is a case for an anaplastologist. The most common cause of facial damage is tumor disease. This is followed by congenital deformities and accidents. Many patients that come to us are from our region, but we also have cases from other parts of Europe.
MEDICA.de: When you fabricate an epithesis you work together with a team of physicians, surgeons and sometimes also experts from rehabilitation hospitals. How does this collaboration work?
Rademaker: If needed, I participate in the planning and surgery. All specialists that are involved in the epithesis logistics are meeting with the patient for a preliminary talk. I might work together with the physician, the psychologist, the audiologist or the ophthalmologist. We review the fabrication of the respective epithesis or the implant surgery and discuss an individual method, that’s definitive for an optimal rehabilitation.
During surgery, the implant position is particularly interesting to anaplastologists. It can happen that despite the best planning, last minute changes need to be implemented. If the surgical team notices for instance that there is not sufficient room for the discussed implant or they need to deviate from the original planning with a surgical template, the anaplastologist helps advise. Surgical templates are small plastic plates that indicate the ideal anchorage points for the epithesis. Thanks to an image-guided 3D procedure, the surgeon is able to measure the skull of the patient. In addition, he can precisely determine the existing
MEDICA.de: The job of an anaplastologist does not just require craftsmanship, but also psychological sensitivity. How do you optimally support patients in their fears and doubts? Were you psychologically specifically trained for this?
Rademaker: Some patients come to me with specific questions. Many already have obtained some information via the Internet on Epithetics. I approach the fears and doubts of patients with sympathy and empathy. We take our time when we talk with a patient, because above all an honest education about realistic goals and limitations is important. After all, an epithesis remains a replacement – even though it offers many possibilities and clearly is able to improve the life of a person. The priority in every consultation is the holistic view of the human being and not just the focus on the diseased area. During their practice at the hospital, many anaplastologists are trained by a certified psychologist, who is not just attending to patients, but also the entire hospital team.
Each individual practicing anaplastologist has a different background history and often participates in International continuing education seminars. The International Association for Surgical Prosthetics and Epithetics and the German Federal Association of Anaplastologists establish exact guidelines for becoming an anaplastologist and conduct examinations. The associations issue guidelines for this profession, which in turn then set our corresponding standards.
The artificial body parts adjust easily and almost naturally to the patient's skin; © Michael Rademaker
MEDICA.de: How do you go about fabricating an epithesis? Do you base it on old pictures of the patient or if needed do you also fabricate a nose a patient would rather want?
Rademaker: If the natural nose of the patient had noticeable characteristics, we are able to adjust these. This is done based on the express wish of the patient. Photos can also serve as a guideline. It is important to include the affected person and relatives in your work. An epithesis is not just attached to the patient, but is developed in collaboration. The wishes of the patient need to be included as much as possible, true to the idea of nature being the role model. If the patient collaborates on the fabrication of his epithesis, the confidence that this epithesis will really help him also grows. At the same time he learns how much trouble and labor goes into fabricating the best possible epithesis.
First, a wax model of the epithesis is being created and multiple fittings are done. During the entire production process, the patient can watch with a mirror to see how the epithesis grows and changes. He can and should influence the entire development process. After all, thanks to his cooperation the silicone piece is getting more and more valuable. After the final fitting, the wax model of the epithesis is then fabricated in a solid form into a silicone epithesis.
MEDICA.de: Can all parts of the face be artificially reconstructed by you? What should particularly be paid attention to in a reconstruction?
Rademaker: Virtually all parts of the face can be reconstructed. If the impending damage appears to be extensive, before the scheduled tumor surgery the feasibility of a fabrication of an epithesis is being reviewed and discussed in great detail. Functions like talking and swallowing, but also an appealing human visual appearance is a very important decision criterion. Epithetics does not start until surgical reconstruction has finally reached its limits.
MEDICA.de: What kind of materials do you use to fabricate an epithesis?
Rademaker: The body of an epithesis is composed of medical grade silicone or acrylate. We use other material that is incorporated or worked into the supporting structure. Those are premium metals such as gold ligaments and titanium screws. They are located on the underside of the epithesis and serve as bracket elements. Of course eyelashes and hair can be seen on the surface and can be incorporated and also artificial eyes made of synthetic material.
MEDICA.de: Are there special standards you need to adhere to?
Rademaker: The Medical Devices Act issues the standards. We must adhere to them. The German Federal Association of Anaplastologists also has created guidelines for guidance and thus issued another standard we adhere to.
Patient with an artificial nose, which is directly attached to the skin; © Michael Rademaker
MEDICA.de: How do you optimally fasten an epithesis in a patient’s face?
Rademaker: In modern craniofacial epithetics, titanium implants are being used. Here, small magnets or clips are used to ensure an easy and secure fixation of the epithesis. If no implant fixation is wanted or is not possible, an epithesis can also be directly attached to the skin using skin adhesive or can even be worn attached to glasses.
There are two types of magnetic fasteners for an ear epithesis: one is to fasten an epithesis with an opposite magnet to a titanic screw, that’s recessed in the bone and has a magnetic attachment that penetrates through the skin.
A modern version is to attach the magnets subcutaneously. This means there is no area on the skin through which the epithesis was inserted and no magnets can be seen from the outside. The skin remains unbroken and looks untouched. There are also opposite magnets on the underside of the epithesis in this case.
MEDICA.de: Do you also study new possible materials and techniques for epitheses at your laboratory?
Rademaker: Each patient is an entirely individual case. That’s why we have to be very innovative. Particularly the interdisciplinary cooperation leads to small improvements all the time. We cannot expect a lot of research and thus resulting innovations from the industry, because the number of patients needing epitheses is very small. Here anaplastologists are challenged to look into new options and make small inventions.
MEDICA.de: Who assumes the cost for an epithesis fabrication?
Rademaker: Epitheses are aids. Consequently the costs are covered by statutory health insurance, except for a small co-payment. Other providers−like for instance worker’s compensation insurance or social security and pension authorities−also completely pay for an epithesis.
MEDICA.de: How long can you wear an epithesis in the best case scenario?
Rademaker: Epitheses are worn daily for more than twelve hours and with good maintenance and care wear out after one or two years. Then they are replaced. One scientific study has taken a closer look at the average life span of epitheses. For an ear epithesis fixed by implants that’s 18.3 months.
MEDICA.de: What is the greatest challenge of your job?
Rademaker: We are constantly trying to achieve the natural look of the patient as much as possible. We are not always 100 percent successful, because after all we are creating a substitute. But the pursuit of getting it 100 percent right is our challenge that remains throughout our entire career. For every patient, we have the desire and ambition to fabricate the best possible epithesis.
This interview was conducted by Diana Posth and translated by Elena O'Meara.