Before he picks up a scalpel, James Smartt OPC ’91 often picks up a pencil and a sketchpad.

Smartt, a pediatric plastic surgeon at Children’s Medical Center in Dallas and an assistant professor of plastic surgery at University of Texas Southwestern, performs highly complicated operations, most of them on children. He can repair genetic deformities, affect reconstructions after a traumatic injury or reverse damage caused by cancer. Those operations can take all day, and any time spent under anesthesia is risky. Prep work, such as the kind he does with pencil and paper, helps Smartt anticipate what he is going to see before he alters it in the operating room.

Each case is different, of course, but he uses one to illustrate the sort of work he does. In 2012, a young girl came to him after being successfully treated for cancer. But the cancer had eaten away her orbit, the set of bones that make up the eye socket, causing one of her eyes to sag centimeters below the other. She needed a graft to rebuild her face and manipulate several pieces of bone into new positions. Like all plastic surgery, this required a delicate mix of art and artifice, but this was nothing like a nose job or tummy tuck. The stakes couldn’t have been higher: a successful outcome could give this girl a chance at a normal life.

Working from photographs and in appointments with the patient herself, Smartt got out his sketchpad, observing the structure of her face and imagining how it ought to look. He also ordered a detailed CT scan, which produced a three-dimensional image of the girl’s skull that Smartt could examine and manipulate on his computer. With the use of a special 3D printer in his office, he then produced an exact replica of the patient’s skull in plaster of Paris, which he marked up to note areas where he would need to lengthen, shorten or realign bone. Only now was he ready for surgery.

Jim Smartt operated on this child when she was three years old to restore the bone around her eye socket, which was damaged by cancer

3D printing is a technology that did not exist even a decade ago, but it has made a tremendous difference in his work.

“It’s crazy,” Smartt marveled. “Once you get the patient open and you can look at the bone, it is literally exactly what you have printed out.” In fact, the 3D model is so accurate that Smartt often keeps it next to him in the operating room, so he can check it as needed.

One of the most remarkable aspects of Smartt’s practice is the degree to which it marries an artist’s eye with a surgeon’s technical skill. These surgeries require Smartt to cut the skull in several places and then move the pieces around, sometimes filling in holes with bone grafts. He moves slowly, gingerly, taking care not to damage the eyeball and optic nerve. He holds his bone grafts in place with tiny plates and screws that dissolve after about a year.

All that advance work, particularly the 3D modeling, is critically important. By helping Smartt understand what he is going to find, it can also significantly shorten the operation. Rebuilding this girl’s eye socket took about 10 hours, and it could have taken as much as three or four hours more without the model.

“It has saved me hours in the operating room,” Smartt said.

The path from Penn Charter to the operating theater was not a straight one for Smartt and included time honing his powers of observation in several photography classes he took with longtime PC art teacher Randy Granger.

“Spending time with Randy made me a much more astute observer of the visual world,” Smartt said. “His class was all about visual assessment and criticism, so it all still resonates with me.”

That is certainly gratifying for Granger, who called developing their powers of observation “one of the most important things kids learn.” It is also one that yields benefits both in school and afterwards, as Smartt himself illustrates. “I think Jim could have gone in a number of different directions and made a contribution,” Granger said.

He nearly did. After PC, Smartt attended the University of Chicago, where he majored in political science. He was not sure what he wanted to do, but ultimately went to medical school at the University of Pennsylvania. He specialized in plastic surgery because he was drawn to that unique mix of art and artifice.

“That was the appeal the first time I saw somebody do this,” he explained. “This is quality of life surgery, it’s transformative. It’s not like taking out appendixes.”

After completing his residency at Children’s Hospital of Philadelphia and a fellowship in craniofacial surgery at the Seattle Children’s Hospital, Smartt moved to Dallas and his current post in 2012. He keeps a busy schedule, performing two to five complex surgeries a week on a variety of conditions, including craniofacial anamolies and cleft palate or lip.

That doesn’t leave much time for recreation, but Smartt manages to indulge his love of electronic dance music. “I’m consumed by it,” he laughed. He even has a disco ball hanging in his operating room.

The young woman in this case recuperated, her face restored to its normal alignment thanks to Smartt’s keen eye and technical skill. It is not too much to say that he has given her back her future.

“We hope so,” Smartt said.