Cosmesis: Can It Be Defined?

Members of the Staff

Any discussion of cosmesis is almost certain to result in differences of opinion about its importance, as well as argument concerning a precise meaning of the word itself. We say, in reference to a prosthesis or component, that "it looks good" or "its appearance is satisfactory."

But to whom? To the prosthetist who created the device? To the orthopedist and therapist who observe and approve its performance? The patient, who must wear and use it? His parents, his schoolmates?

The prosthetist1s definition of cosmesis is quite naturally influenced by his commitment to function. But what of the teen-ager, whose sole and overwhelming--however transitory--concern may be social acceptance? Or the parents, who are likely to be struggling with very real and disturbing conflicts about their child's deficiency?

These are only some of the questions which suggest that the problem of cosmesis, particularly as it concerns the child amputee, is complex, highly important, and still not satisfactorily evaluated and defined.

At the Child Amputee Prosthetics Project, it has always been the primary concern of the professional staff to provide the child with function--to give him the tools to effectively assist him in his play, for a child needs to learn to play in order to later learn to work in the adult world.

But we are well aware that every patient accepted into this Project has cosmesis problems which may be quite as important to him as problems of function. An interplay of factors exists here: function, cosmesis, and acceptance are almost inextricably allied and involve both the child and his parents. Only sometimes have our efforts been successful, and perhaps the best we can do at the present is to pose problems, share opinions, and offer tentative solutions to a few of the secondary aspects of this important problem of cosmesis.

Probably there are as many definitions of the term "cosmesis" as there are prosthetists, physicians, therapists, patients, and their parents. Quite obviously, the problem is different in each individual case. Furthermore, the problem changes as the young patient matures. The infant amputee is unaware that a problem exists, although it is very real and likely to be disturbing to his parents. As the child grows older, he begins to make comparisons and perhaps asks why he is physically different. Later, during pre-adoles-cence and adolescence, cosmesis may be all important to him. In late adolescence, as he begins to give serious thought to a career, function is likely to assume much greater importance for most types of work. However, if he were giving thought to a career which would involve close contact with the public, as for example a salesman or a lawyer, cosmesis would still merit consideration.

Psychosocial Considerations

Each patient-- and each parent also --has individual cosmetic requirements , which perhaps cannot be completely met, but which cannot be totally ignored. Quite frequently it is very difficult to determine just what is acceptable to the individual child or parent-particularly if the child himself is not yet old enough to verbalize his needs. The very young child is not thinking of what the hook or hand will do or what it looks like. It is no threat to him, but his parents may be threatened, and very much so. These parents need to be helped to accept this child as he is and to formulate constructive plans for his future.

The child himself will very soon become aware of and concerned about the curiosity of strangers. As he becomes increasingly aware of the outer world and his relationship to it, the opinion of society, and particularly of his peers, becomes increasingly important to him. This desire for social approval ordinarily reaches its climax during adolescence (easily observable in the teen-age conformity in dress and manner).

In our preoccupation with function, we may unconsciously tend to judge, depreciate, and, to some degree, look down on those parents and youngsters who value cosmesis above function. If this happens, it is most certainly communicated to the parents and child in many ways, posing still another problem for them. It is most important to remember that our culture is one which places an inordinate value on physical beauty and appearance, and social acceptability is a basic need for all of us.

Precisely what do we ask of the patient? If we stress function, do we, in effect, ask the patient to make some kind of compromise between our standards and what the public demands of him? In other words, do we hand him the problem to solve?

We must be cautious in assessing any patient's adjustment--or lack of adjustment--to his handicap on the basis of whether or not he attempts to conceal his deficiency. The desire to conceal must be seen in its proper perspective: television commercials bear witness to the very natural human desire to appear at our best.

Design and Fabrication Problems

The pros thetist has a number of major cosmetic problems to contend with. Quite understandably, the patient and/or his parents want a prosthesis which is as lifelike as possible--and preferably undetectable. A few parents immediately and permanently reject the prosthesis when they discover that their unrealistic expectations cannot be fulfilled.

At some time in the future the prosthetist, with the assistance of engineers and chemists, may be able to reproduce prosthetically the appearance and functional characteristics of a normal limb, but at the present time this is an area of compromise. And to many people a not totally convincing representation is more disturbing, even downright grotesque, than a prosthesis which is quite unaffectedly functional in design.

However, some of the materials presently available to the designer are very useful in obtaining improved cosmesis, and a number of these are now being used in either experimental or production settings. A number of new plastics and other synthetics show great promise, but these materials require very careful testing and evaluation-procedures which can only be accomplished by major research efforts .

This Project is presently engaged in a series of design studies utilizing some of these new materials, in an attempt to provide more functional and cosmetic prostheses for both upper- and lower-extremity patients.

Fig. 1 and 2 illustrate two of a number of terminal device designs now being evaluated as part of an upper-extremity design study.

There are several new plastics which, while not identical to the color and texture of the human skin, do convey something of its softness and warmth. These new terminal device designs represent an attempt to combine improved function with an aesthetically satisfactory appearance, but without trying to imitate repre-sentationally the characteristics of the missing part. It can be seen that these designs bear slight resemblance to the conventional hook, with its shiny, almost surgical look. It has been interesting to observe that these new designs have been accepted most readily by people who have no preconceived notion of prosthesis design; however, many specialists have also expressed interest and approval. It appears that only those who might be termed "semieducated" react with an attitude of "But that doesn't look like a hook! Or a cosmetic hand, either!" Perhaps an indication that cosmesis may be, at least partially, no more than a matter of familiarity without curiosity.

Lower-Extremity Problems

Cosmesis enters into almost every aspect of fitting and training, and this is true for both upper-and lower-extremity amputees. There are, for example, a number of problems related to lower-extremity prosthesis design, fitting, and wear which urgently need further study.

One of the most serious problems is that of shoes for the lower-extremity amputee. The basic difficulty is that the patient cannot interchange heel heights without causing malalignment of the prosthesis, which in turn causes gait deviations and possible stump breakdown.

Most children wear several pairs of shoes: school shoes, dress shoes for parties and Sunday School, tennis shoes and hiking boots, and rainboots or galoshes. Furthermore, all children want to go barefoot at every opportunity, and if the unilateral amputee removes the shoe from his normal foot, one leg is shorter than the other. If the other shoe is removed also, the prosthetic foot can be severely damaged in a very short time. (Has there ever been a child who, unattended, could resist a mud puddle?) There is now, however, a "bootie" covering available, which is a partial solution to this problem.

Shoes are particularly important to adolescent girls. They want to change shoe styles to match their wardrobe, and it is extremely difficult to find the proper heel heights.

The new fashion of knee-length and above-knee skirts is another problem for the female amputee, and a cosmetic covering is almost mandatory for the teen-age girl. These coverings are very expensive and quite fragile; they rip and tear easily and are impossible to repair. They also stain easily, and discolorations are often impossible to remove.

Cosmetic coverings are also not easy to replace; they must be removed by the prosthetist, and a complete replacement is necessary. If the girl does not use a cosmetic covering, she must cope with the artificial appearance of the prosthesis, which seldom matches the skin color of the normal leg. Also, if there is no covering on the prosthesis, the knee mechanism is very apparent; with the new dress styles, this is particularly important. The girl may use, instead of a cosmetic covering, a cotton surgical stocking covered with a nylon stocking; but here again there is a matching problem.

The knee joint eventually chews up stockings and other coverings (even the boys' trouser legs), sometimes in a very short time.

Straps and harnesses also pose both cosmetic and hygienic problems--particularly if they are permanently secured to the prosthesis, as is usually the case. If the above-knee or phocomelic patient wears a Silesian bandage, the bandage is probably made of either nylon or cotton webbing, permanently attached, and gets dirty in a short time. Ideally, such bandages should be interchangeable, with permanent Dot fasteners on the prosthesis itself. (This is a particularly serious problem with the infant who is not toilet-trained.)

It is difficult to achieve acceptable cosmesis in the design of prostheses for Syme's and partial foot amputees, because of the bulky contour of the ankle resulting from the posterior-medial wall opening, which must be fastened with straps and buckles. In addition, the soft insert liners cause hygienic problems. At this Project, a tentative solution has been found in the use of hard sockets--although this technique may increase the possibility of circulatory and skin breakdown problems. However, it has been used with considerable success, as illustrated by the case of the patient shown in Fig. 3 and 4 Fig. 5 and 6 . This youngster has bilateral congenital "Chopart" amputations (plus bilateral upper-extremity defects). When she was admitted to this Project she wore the prostheses shown in Fig. 3 and 4 . The examining physician observed shin area abrasions caused by the deteriorated liners of her prostheses, and also discolored areas due to chafing. The prostheses were extremely heavy, and the patient was very distressed by their ungainly appearance. She also had gait problems.

A new prescription written for this patient specified bilateral Syme's plastic hard-socket prostheses without Windows, but with standard SACH feet and cuff suspensions. The prospect of surgical removal of the lateral bulk of the feet was considered, but the fit and appearance of the new prostheses was most gratifying, and function was greatly improved. The patient now walks with a narrower base, with even step length and rhythm, and both limbs swing in the line of progression. Hygiene problems, which had occurred because of the use of soft insert liners, have been minimized. This patient has had her present prostheses for more than a year, and no circulatory problems have developed.

These are only a few of the problems which the prosthetist and therapist must attempt to solve when treating the lower-extremity amputee. Among upper-extremity patients, the problems are no less numerous or complex: all the factors previously mentioned enter the picture. Harnessing is a major cosmetic problem, particularly with girls, but perhaps an even bigger problem is the cosmetic hand. It is difficult to decide whether or not to offer a cosmetic hand to a child; it is hard to determine how badly the child really wants it and whether he is fully aware of the implications of abandoning function. Also, important economic considerations may be involved: a cosmetic hand is considerably more expensive than the standard functional terminal device, yet it is hard to tell a child that a cosmetic hand is a luxury.

The adult amputee must make a difficult but still clearcut decision: Is function or cosmesis more important to him in his work and his social life? In many cases he is obliged by economic necessity to choose function, and usually it is also his own preference.

But what of the child or adolescent, who is unaware or uncertain of his needs and desires? Any physician, prosthetist, therapist, or social worker who treats a limb-deficient child influences him, whether consciously or not, in making this decision. The responsibility is no light burden; the problem is still unsolved, although certainly not insoluble; the unanswered questions are numerous but challenging.

Our present prostheses are the result of attempts to develop a simple yet functional device for use by adults in pursuing a livelihood. These devices have been adapted for use by children, and the youngsters have, in most cases, put them to good use and demonstrated good acceptance. Eventually they will provide us with the definitions and directions we are searching for--if we continue to be alert to their real needs.

Members of the Staff of Child Amputee Prosthetics Project University of California Los Angeles, California