To Cover or Not to Cover: Prosthesis Users Have Their Preferences

When Alina Miller underwent surgery for a transtibial amputation of her left leg in January 2016, she knew her life was going to change, but she was prepared.

The amputation surgery was her ninth operation. Miller broke both feet and her back when she jumped from her fourth-floor apartment's balcony after the building in Aurora, Colorado, was set on fire by an arsonist in August 2012. Her left foot never healed properly. It was a mass of scar tissue, her toes wouldn't bend, and she was in constant pain. "It was just easier to do the amputation than to have more surgery," says Miller, 28. "I woke up happy," Miller remembers about the surgery. "I was taking selfies with the nurses, and I told them I wanted a pink cast."

Miller was in her first prosthesis with a basic carbon fiber socket by early March that year. Initially, she worried about matching it to her outfits, but those efforts faded quickly. "I realized that I was never going to be able to get them to match," she says.

Instead, she says, "I was going to build some excitement into my leg. It's not a death sentence because you have an amputation, and you certainly don't have to give up being fashionable."

Patient Preference

While the older population tends to prefer natural skin tones for their prostheses, Hans Wulf Jr., CP, who has been with Infinite Technologies O&P, Fairfax, Virginia, since 2012, says, "Everyone likes different designs, whether it's to be artistic or just express themselves."

Julian Wells, CPO, FAAOP, clinical manager of Arm Dynamics' Kansas City, Kansas, location, agrees that natural skin tone covers are becoming less popular. It depends on the type of cover, the perspective of the wearer, and the environment where they intend to use the device, he says. "There's still a demand for skin tone or cosmetic covers," Wells says. "But each person is unique in what they consider an acceptable aesthetic for their prosthesis. In general, if the cover is designed to enhance the capability of the device by increasing the durability, protecting it from dirt, dust, or water, or allowing the patient to personalize their prosthesis in a unique way, the trend over the past ten years has been very positive."

Debra Latour, OTD, MEd, OTR/L, who has been a user of prosthetic technology for 61 of her 62 years, believes there has been a paradigm shift in thinking and values as it relates to prosthetic covers. "In the mid-90s, ideas were related to cosmesis first and then perhaps function," she says. "Now function has become very important. With the new technologies that include materials, form no longer has to be compromised."

Within the last decade there has been a major shift in the perception, design, and message of prosthetic limbs, says Scott Summit, an industrial designer who cofounded Bespoke Innovations, San Francisco, in 2009 and sold it in 2012. "Aimee Mullens, Amy Purdy, and Chad Crittenden have shifted the focus from ‘dis-abled' to ‘super-abled', and transformed the idea of a prosthetic leg from the traditional, utilitarian device to something enabling and beautiful," he says.

Fairings, by recreating the image of a leg into something expressive, personal, and designed, have also played a role, he says. "Fairings offer an additional dividend; people who wear them now engage freely with strangers, as if the fairing offers a tacit invitation to connect, while a traditional or lifelike leg often creates an awkward wall between people. A parent no longer tells their child not to stare, since the fairing is there to be seen."

Blending Into the Crowd

Zach Harvey, CPO, Creative Technology Orthotic & Prosthetic Solutions, Denver, says prosthetic foam covers came into existence years ago with the advent of endoskeletal components. "Exoskeletal legs were the mainstream many years ago and the size and shape of the leg was important as well," he says. "Active amputees benefit from carbon fiber feet, the taller the better in terms of return on energy." However, many of these feet are hard to cover and resemble smaller versions of running feet, Harvey says. "The blades look cool and many people with little exposure to prosthetics think so too," he says. "They draw more attention, but it's generally positive attention."

When it comes to user preference the question is: Do they want a cover, or do they tend to shy away from them? There are those like Miller who embrace the uniqueness of their prostheses and select covers or finishes that display their creativity or individuality. Miller has a socket for almost every occasion, including dressing for a summer afternoon, an evening out, or going to the gym.

Some prosthesis users, however, don't want the attention having an amputation brings. They feel more comfortable blending into the crowd, according to Harvey and Wells. "They would rather the prosthesis look like a leg or an arm," Harvey says. "For some it might just be something to fill the pant leg out for dress slacks. For others, the need for detail with fingernails and toenails is important."

Diana Gazzano Gibson, who has a transhumeral amputation of her right arm, wears a high-definition custom silicone restoration from Arm Dynamics. They fabricated her arm specifically for her wedding day, and she also wears it in some business situations.

Cosmesis also tends to be more important for hands than feet, Harvey says. "Hands are always exposed where feet can be covered up," he says. "Even so, many fashionable amputees want to wear sandals and have nice-looking toes, which can be more important than filling out the shape of a leg."

While some prosthesis users like the look of fairings, others look for durability or fashion, says Harvey, who has made countless covers. Some of those include fabricating a transtibial socket with a hollow exoskeletal shell that extended to the foot just to give the calf shape, using an embossing powder and a shiny fabric to make a leg that sparkles, fabricating a basic continuous cover that would not tear at the knee joint, and making a cover to fill out a thigh section for a client with a hip disarticulation who wanted to avoid tearing his pants.

An increasing number of people with amputations like the uncovered, high-tech look, says Wells. "We live in a time where words like robotic, bionic, and cyborg are part of our vocabulary, and some patients think it's interesting or fun to describe themselves using those terms." One of Wells' clients, Gerry Kinney, has bilateral transradial amputations and loves the bionic look. Kinney enjoys the attention from people asking about his prostheses.

Older women often want covers to help their prostheses look more natural, according to Wulf. "They want to be able to wear their skirts to church and have their prosthesis look like their contralateral limb," he says. Younger women, by contrast, want more artistic and stylish covers, and many men like the Terminator look, Wulf says, but still may choose to have a cover. "In my experience, men are getting the covers because they are worried about ruining their componentry due to their environment, whether that be near the water or [from] the work that they do."

Latour still has some of her early devices, which did include covers, she says. The inception of covers relates to the idea of cosmesis and blending in with society so not to appear different, she says. "Unfortunately, many of these covers were not lifelike and attracted more attention because the color did not match well," she says. "The advent of silicone and more sophisticated materials has helped to change things."

Prior to working in Colorado, Harvey worked at Walter Reed National Medical Center, Bethesda, Maryland, and found that most of the veterans he has worked with do not use prosthetic covers. "I believe this was part of the military's protocol [if they came through a military hospital], and the rapid changes in socket and components that we offered," says Harvey, although he once created a cover that contained a secret compartment to smuggle documents. "Covers were simply the last thing we had time to do," he says, but there were some veterans who were insistent on covers, whether those were traditional foam covers or 3D-printed fairings.

For children, forget about foam covers, the experts say. "Children tear up foam covers in a matter of minutes," Harvey says. "Exoskeletal systems are still a viable option here." Harvey does a lot fabric-based designs for children as well as adults to make the prosthesis more personalized. "It's a matter of preference for the adult or the child whether they want the lamination to be skin-toned or have a fabric design."

While Wulf says his pediatric patients love showing off a new design, Wells says he has not experienced a trend with children or adults in either direction. "There are so many factors that involve the choice to cover or not cover the prosthesis," Wells says. "If a child is insecure with the appearance of their device, they may choose a skin tone cover in an effort to blend in and be less noticeable. Another child may prefer a cover or finish that's colorful and creates more of a ‘cool factor' in their mind and among their peer group."

For the most part, Latour says her preference is no cover. "They have slowed down the function of both my body-powered and my externally powered devices," she says. "When I have had a cover, they often rip, look very shabby, and they soil easily. No one wants to be walking around with a dirty-appearing, torn up hand, especially if you're a therapist."

Though Latour's go-to prosthesis is a body-powered device, she recently received an i-limb quantum hand from Touch Bionics. "It does have a glove, which I am less than enthusiastic about, but I am looking forward to using this device," she says.

The Emergence of Prosthetic Art

The O&P journey for Frederick "Kurt" Pauloz, BS, CP, LPe, began in October 1983 when he lost his leg below the knee in a single-car accident. "My residual limb has quite a bit of split-thickness skin grafting on about half of my limb, causing many skin problems the first half-dozen years," Pauloz says. "The constant trouble with skin pressure and breakdown left me utilizing a standard endoskeletal [transtibial prosthesis]."

The cosmetics failed quickly due to the removal and reapplication for adjustments to the socket and alignment, says Pauloz, who became a prosthetist in 1994 and started Fred's Legs in Florida in 1997, where he worked until he retired several years ago. When he started practicing in the mid-1990s, standard cosmetic finishing with a foam cover was the norm. "About 95 percent of prosthetics were covered with conventional soft foam covers, allowing for close imitation of the good leg," he says. "Prosthetic art then was unheard of."

Pauloz estimates that it was the late 1990s when O&P clinicians started seeing small examples of prosthetic art. "Skin-tone colors never quite matched, so it's not like you couldn't tell," he says. "I knew early on people would like a different look. With our first prototype, Sleeve-Art Prosthetic Cover, I knew instantly we were onto something special."

Before wearing his prototype, Pauloz says people were apprehensive about speaking to him about his prosthesis. "They didn't want to offend me," he says. On his first trip out wearing the prototype, "Six people stopped me within 45 minutes to talk to me about the cool look," he says.

Pauloz's current prosthesis cover is colorful neon hearts against a black background. He says he believes that O&P is trending away from "old fashioned leg-like cosmetics to new, progressive individual expressions of personality. More men are seeking prosthetic art rather than females, but they are quickly catching up."

Embracing the Prosthetic Art

Companies such as San Francisco-based UNYQ and Alleles Design Studio, Victoria, British Columbia, Canada, have been providing affordable, personalized upper- and lower-prosthetic fairings via 3D-printing technologies for more than a half-dozen years.

The fairings are not only known and popular among those who choose to add that level of personalization to their prosthetic limb, but more designers are getting involved, offering their own interpretation of the concept, Summit says. "I suspect that the major manufacturers of prosthetic hardware are now exploring ways to bridge that gap between raw utility and high design," he says. "The leg we will see five years from now will be a thing of beauty, like a perfect motorcycle or watch, showcasing the wearer in their finest light."

Prosthetic devices were traditionally practical to a fault, and therefore invited being hidden beneath beige covers, Summit says. "The purpose of the fairing was to return the body's symmetry and uniqueness, while remaining unapologetically man-made. The fairing was never meant to be a disguise or camouflage, but instead is a tribute to the wearer's individuality," he says.

Custom silicone covers, designed by trained professionals, have shown how closely a prosthesis can mimic human skin tones and variations, Wulf says.

It has been Wells' professional experience that part of accepting and utilizing a prosthesis is taking "ownership and being proud of the appearance of the device." Having worked in O&P for nearly 18 years, Wells says he has witnessed numerous changes in demeanor when a patient is given the opportunity to select or create the finished look of his or her prosthesis. There's a metamorphosis, he says. "There have been several cases where a patient begins their journey being passive and protecting their limb from public view and then shifts to a more confident disposition when the aesthetic of the prosthesis meets their expectation," he says.

Lately Wells has been working with different composites and finishes that are designed to enhance the look of the device. "We made a young patient happy by adding LED lights with selective cutouts in the frame that make the arm glow." Wells has also been working on a custom, stamped leather cover for a myoelectric prosthesis that will give a "nice combination of high-level technology and traditional leather work."

There is a difference in what people are willing to display as a cover, Pauloz agrees. He uses the example of a teenage patient who was being drawn into a gang. "We were hesitant initially to work with him, but he was a budding artist," Pauloz says. "He designed a detailed, hand-drawn, colored image and I was thrilled to give him what he wanted. Granted, probably not what most others would want, but it helped him to grow successfully away from trouble. It definitely became a life changer for this young man."

Yeas and Nays

Covers can provide or increase the level of protection against the elements, the clinicians agree. Covers can also provide resistance to excessive wear on moving components within the device, Wells says. The end results, however, are all the same: "The purpose of a prosthetic cover is to increase the functionality of the device," he says.

Custom covers also have their detriments—mainly that they are labor intensive to fabricate and maintain. And though payer sources are not always amenable to paying for custom covers, the answer is always no unless one asks. "It's not always a blanket denial from insurers," Wells says. "There has to be a justifiable, functional need for a prosthetic cover."

Replicating the human form involves a volume of work, and the materials are subject to failure if exposed to the wrong environment, the clinicians say. In addition, covers wear out, and unlike human skin, fail to heal from scratches and abrasions. Misconceptions and stereotyping of prosthetic covers can also occasionally get sticky because of the designs people have chosen. "I've heard a number of stories about non-vet amputees being thanked for their service…," Harvey says.

Ultimately what it comes down to is how a person feels about his or her prosthesis.

"When a person feels good about how their prosthesis looks, whether it's lifelike, high tech, or uniquely creative, they take a more positive approach to the challenges of prosthetic rehabilitation," Wells says. "Being proud of what one is wearing is a huge step in that effort."

Betta Ferrendelli can be contacted at betta@opedge.com .

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