DURHAM — Shy and agreeable, laughing yet not joking, Elise Lutz was a beautiful girl who had learned to hide a part of herself.
Born in China 14 years ago and adopted by a Wake Forest family when she was 9, Elise was badly burned as a toddler. Doctors can only guess that a boiling cauldron tipped over on her.
The accident left scars and melted her right ear into a clump of flesh, although her hearing remained intact. Elise covered the flaw under silky black hair, combed and pinned precisely so.
Hair was an unreliable disguise, but other solutions were worse.
A glue-on prosthetic fit so poorly it drew attention to what she hoped to hide. Plastic surgery failed, the whorls and curves of ears being notoriously difficult for even the most skilled surgeons to sculpt.
What Elise wanted, simply, was more than cosmetic. She yearned to let her hair fall as it may. She wanted that carefree part of herself restored.
And so on a Wednesday in June, she headed into an operating room at Duke University Medical Center to have a plastic surgeon cut off all that remained of her mangled ear and another doctor implant titanium bolts into her skull that would eventually hold a new ear.
A silicone ear. A Hollywood specialeffect.
For all the illusion, movies have set a standard of realism that can astound. Jay McClennen worked for 17 years aiming to please fickle Hollywood directors and wow a discerning public, transforming actors into "Truman" and "Nixon" and the "X-Men."
In the early 1990s, McClennen was among the first to use silicone in makeup, masks and body parts. A durable rubberlike compound, silicone is translucent and therefore more realistic-looking than the foam rubber latex long used in special effects makeup.
Silicone aged Brad Pitt into Benjamin Button, turned Hugh Jackman into Wolverine, and morphed umpteen unknowns into ghouls and monsters.
With fat budgets and the challenge to make fiction look real, McClennen and his movie makeup colleagues got fancy. They wove strands of red and blue silk thread through the silicone to mimic tiny veins, and implanted a thin sheet of red plastic into the prosthetic parts, so when backlit by bright lights or sun, they had the same rosy glow that real fingers, or noses or ears have from blood flow.
For McClennen, however, a classically trained sculptor from Ontario, Canada, movie work was as frustrating as it was artistically fulfilling.
"Sometimes you'd spend a month working on something and get it perfect, and a 25-year-old director is yelling at you," said McClennen, 43. "I wanted something that was more stable, and something that mattered more. Work in film didn't matter at all."
So McClennen left film to pursue forensic reconstruction - building faces on the remains of unidentifiable skulls to help law officers put a name to a soul. It was meaningful work, though not widely in demand.
A related field was medical anaplastology, creating prosthetics for people who have lost fingers, noses, eyes and other small body parts to trauma, cancer or birth defects.
Using his artistry and the technology pioneered for movies, McClennen could mask the scars that make real people feel ugly or scary.
"Hollywood was great to be a part of," he said. "They had the money and time to put into this research, which was really expensive. The medical field moves much slower because of money and time."
Armed with his movie know-how, McClennen moved to Durham two years ago, put his plaster bust of Hugh Jackman on the shelf and went to work at The Anaplastology Clinic with Jerry Schoendorf, one of the country's most experienced anaplastologists.
Schoendorf, a medical illustrator and leader in advancing anaplastology science, for years worked as part of the Duke Hospital staff. About two years ago, he struck out on his own, but he continues close collaborations with Duke surgeons and other doctors throughout the state.
There's mutual benefit in the relationship. Doctors can offer another option when a patient's injuries exceed their capacities to mold flesh-and-blood.
A little girl's ordeal
Elise had already been through a lot.
Her burns left scars that wiped out much of the hair-growing follicles on her head, so she underwent a series of painful procedures to expand the portions of her scalp that produced hair. Where there was once angry scarring, there is now a shiny cascade of locks.
Hair became her best shield after plastic surgery to reconstruct her ear was a disappointment.
Ears are as unique as fingerprints, and crafting them from a person's skin and rib cartilage is a massive technical challenge for plastic surgeons, more often than not producing unsatisfying results.
For Elise, the gnarled mass was difficult to disguise. She tried a traditional glue-on prosthetic ear, but it settled lower than her other ear, and the glue was gloppy and irritating.
"I think she wore it maybe five times," said her mom, Kim Williams.
Unable to offer much hope of a successful revision, her plastic surgeon instead directed the family to The Anaplastology Clinic.
"He told me they can make a prosthetic ear that looks more real than anything anyone can construct," Williams said. "And when we went there, we saw the possibility."
It wasn't only Hollywood advancing the art of anaplastology.
About 30 years ago, an implant technology used to secure dentures began being adapted throughout Europe and the United States to hold small prosthetics, eliminating the need for gooey glues that can irritate skin.
The process involves drilling holes in the skull where titanium anchors are screwed in. Titanium bonds to bone, in what is dubbed osseointegration.
Once the anchors are integrated into the skull after several months, metal posts are then screwed into the anchors and protrude from the head, providing a firm fixture that a prosthetic can fasten onto securely with clips or magnets.
The fastening system provides for a prosthetic that is almost undetectable. People can run, swim, water ski.
"Our work emphasizes realism," Schoendorf said.
For years, Schoendorf wanted to use the implant technology, but he couldn't get approval when the clinic was part of Duke. Now running an independent practice, he began using the technology this year.
Already, 15 patients have had or started the process of implanting the apparatus for nose, eye and ear prosthetics. Excluding the medical expenses, an anchored prosthetic costs about $8,500, where a traditional glue-on runs $5,000.
"It's not for everyone," Schoendorf said, noting that cancer patients are often ruled out because radiation can impair the ability of bones to bond with the titanium.
For Elise to get an implant with a snug fit, all that remained of her natural ear had to be removed - a no-going-back prospect.
"I'm nervous," she said beforehand.
Her surgery in June involved two stages. Dr. Jeffrey Marcus, an oral and plastic surgeon at Duke, took about 90 minutes to remove the ear tissue and create a smooth plane for the prosthetic to rest against.
Scarring from the burns and previous surgeries complicated his work. "I'm trying to just work with the hand I'm dealt," Marcus said.
Next up was Dr. David Kaylie, a head and neck surgeon at Duke. His job was to implant the two titanium anchors. It was exacting work to place them according to a template McClennen and Schoendorf created for the fastening system.
The anchors also had to be screwed into the bone to a precise point, like spark plugs. Once the anchors fused to the bone, that precision allowed Kaylie to attach the metal posts into the anchors without over tightening and dislodging the implants from the bone.
Kaylie's work took less than an hour, and Elise was home by the end of the day.
But the wait was just beginning.
A year-round swimmer, she gave up much of her summer season to recover. And when she began Montessori school in the fall, she still needed to comb her hair just so.
The sculptors at work
Fashioning Elise's ear was a painstaking process. While she healed over the summer and into the fall, McClennen and Schoendorf used plaster casts of the right side of her head, plus molds of her left ear to create her prosthetic.
"We need a very accurate impression of the area where her ear will go," Schoendorf said. "We want the shape of the skin, and where the abutments go. We need to determine this exactly, because after a certain point, it's difficult to reverse."
Even a slight misfit of the prosthetic could put stress on the implants and compromise their stability.
McClennen also fussed with the aesthetics, working to make a mirror image of her good left ear that would blend in with her scarred skin on the right.
A wax model unveiled in October offered a tantalizing hint of what was to come. It nestled onto the metal apparatus extending from Elise's head and gave every appearance of reality.
"Oh my God," Williams said as McClennen attached the ear. Elise stole a quick look from the hand mirror, smiling.
McClennen warmed the wax to make small whittles. He strived for perfection in wax, which would be used to cast the permanent piece in silicone. He even marked where they would insert a tube in the lobe, for pierced earrings.
Then he and Schoendorf set about pulling tins of paint from a palette on the wall, mixing colors to match Elise's caramel skin tones.
"I think I'll stop," Schoendorf said, holding a dollop of paint against her ear. "It may be too dark."
There was no discernable difference between the color he mixed and the color of Elise's good ear. It was flawless.
With earrings to match
Elise's new ear was ready on the day before Thanksgiving.
She was anxious.
In her pocket was a pierced earring she wanted to wear home, a dangling silver medallion etched in her initials, a gift from her mom. She wore the match on the left.
McClennen had the ear in a white box, a present from a masterful artist. He lifted it out and gently snapped it onto the scaffolding that was now a permanent fixture on her head.
Like that, Elise Lutz was whole - a beautiful girl with nothing to hide.
"Wow!" Williams exclaimed, tearing up. "Oh, wow! Elise!"
Elise grinned at her new self and modeled her perfectly real ear.
She shook her head. Shyly. Tentatively.
Her silver medallion earrings slapped merrily, her hair fell as it may.
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