Medical team gives Oregon woman a new face

Using thin, narrow strips of wax, the two men began to build a new face.

The first strips went where the patient's eyes would be, ensuring that they would be positioned properly. Then wax was molded into a nose, the tops of the cheeks and the eyelids.

As the men, both specialists in maxillofacial prosthetics, worked, they routinely checked their wax model against a photo of a pretty, smiling teen girl. Although taken years ago, the image was the best guide they had of Chrissy Steltz's appearance.

Steltz was 16 when a 12-gauge shotgun accidentally went off within about five feet of her. She was completely blinded by the blast that blew away her nose, part of her right eye, and her left eye, eyelid and eye muscles, said Eric Dierks, MD, DMD, a maxillofacial surgeon at Legacy Emanuel Medical Center in Portland, Ore.

For years, Steltz wore a black sleep mask to cover the damage.

Now 27 and a mother, she came to the hospital in July to receive a prosthetic face to replicate her original features.

She wanted the prosthesis so she could appear more normal in public and to her 1-year-old son.

"He's at an age where he will grow up knowing me with my face, like everybody else," Steltz said.

Most facial prostheses replace a single missing feature. A prosthesis with two eyes and a nose like Steltz's is more rare, said David Reisberg, DDS, a maxillofacial prosthodontist, professor and medical director of the Craniofacial Center at the University of Illinois Medical Center at Chicago.

The first documented facial prostheses date to mid-16th century Europe, but even before that, there were crude facial replacements shaped from materials such as clay, wood or papier-mâché.

About 50 years ago, U.S. medical schools started teaching how to craft more life-like prostheses of silicone painted to resemble a person's natural skin, Reisberg said.

In the last 20 years, doctors have perfected a technique -- used in Steltz's case -- in which the prosthesis can be fitted easily with thin magnets imbedded in the silicone that attach to titanium implants in the patient's facial bones.

"It's a transference of skill and technology from the dental field," Reisberg said.

Prosthetic preparations

Dr. Dierks first saw Steltz the day after her accident. The gunshot had carved "a transversely oriented trench" down her face. But despite her extensive injuries, she had little neurological damage.

"It's unusual to have this kind of wound and still have the patient survive," he said. "This is about as bad and penetrating as it gets."

Dr. Dierks' colleague Bryce Potter, MD, DMD, was the maxillofacial surgeon who originally treated Steltz. Dr. Potter referred her to Larry Over, DMD, MSD, a maxillofacial prosthodontist in Eugene, Ore., to have a facial prosthesis made. Steltz went for the initial treatment planning, but didn't return until 2008, delayed by health insurance issues and her pregnancy, she said.

To prepare her face for the prosthesis, Dr. Dierks in 2009 removed her right eye and opened her sinuses, which were occluded by an earlier fibula bone graft. In February, he removed some fixation hardware from earlier surgeries and placed eight cylindrical titanium implants in two semicircles radiating out from the center of her face.

Three months later, he replaced one loose implant and used a laser to thin the skin around the other implants. Each was given a magnetic cap to correspond with thin magnets imbedded in the prosthesis, making it easy for Steltz to put it on and take it off.

"It kind of centers it so that it goes on right every time," Dr. Dierks said.

To build the prosthesis, Over called on longtime colleague David Trainer, a maxillofacial prosthetist in Naples, Fla. Trainer, who has been making facial prostheses for nearly 30 years, flew to Portland July 3.

Trainer and Over made an impression of Steltz's face to capture the exact location of the implants and cast a replica in dental gypsum. "Then we start sculpting on that in wax what's missing from Chrissy's face," Trainer said. "You kind of set down a base and the gaze you're looking for. Then you start building up in wax the muscle and tissue."

Trainer paid special attention when positioning the eyes, which were custom-ordered and made of an acrylic resin. "You try and get a focal point of three or four feet in front of you and position them so they're not just staring blankly, so they're not looking like a shop mannequin."

Once the wax mock-up was complete, Trainer and Over made a two-piece mold to capture its shape. The wax was removed and the mold was filled with silicone, which was then cured at about 200 degrees. The eyes and eyelashes were then attached, and oil-based paints were used to match Steltz's natural skin tones.

An emotional moment

On July 8, Steltz put the completed prosthesis on for the first time for her family. "My mom cried. My sister was happy. She was really excited," Steltz said.

A prosthesis like Steltz's typically would cost about $25,000, but Dr. Dierks, Over and Trainer volunteered their time and made it largely from donated materials.

Steltz wears the prosthesis every day, taking it off at night. She cleans it using a mild antiseptic soap and stores it in a special container until wearing it again.

"I feel very lovely. I feel like a regular person again," she said. "I feel like now when I talk about this, people will listen. Before, when I was wearing the sleep shade, I didn't feel like they were really listening. I felt like they just felt sorry for me and weren't really listening to what I was saying."

The prosthesis should last about three years if well-cared for. After that, the mold can be used to make another. Steltz won't need a new mold until she's older.

In the meantime, there's more work ahead. Part of her jaw was shattered, and she's in physical therapy to increase jaw movement. Dr. Dierks will remove scar tissue from her neck, and later this year, Over will do dental implants to replace two front teeth she lost in the shotgun blast. "We want Chrissy to be beautiful," Dr. Dierks said.

He said Steltz is an ideal patient and that working with her is one of the highlights of his career.

"She has been such a delight and such an inspiration. She helps me remember why I do what I do."