**2. Biomaterials**

**Polyacrylamide - Clinical Case 1:** CC, a female of 17 years old, came in our center for hemifacial hasimmetry. This anomaly wascharacterized by a progressive atrophy of the left hemiface. The patient did not present diplopy. The objective examination we observed the presence of slight atrophy of the left middle and inferior third of the face, including nasolabial region and the omolateral upper lip. A nasal pyramid deviation also appeared and confirmed by the anterior rhynoscopy, which also showed a left-convex deviation of the nasal sept. A Dimensional Computed Tomography scan was performed. This exam confirmed a maxillo- mandibular fault. Then an orthotic evaluation was performed to value muscular structures. We adopted a surgical approach which primarily provided an improvement of the respiratory activity. Then, we planned a filling of the atrophic soft tissues through infiltrations of Polyacrylamide. The infiltrations have been performed after 2 months from the septorhynoplastic surgery. Biomaterial (5ml) in the left nasolabial fold was filled. After 1 month from the beginning of the treatment, we noticed an evident reduction of the pre-existing deficit of the soft tissues. The clinical and Ultrasonography checks after 2,6, 12 and 24 months confirmed a correct integration of the used biomaterial.

Fig. 1. Lateral view of the patient before treatment

carried out in patients with autoimmune syndrome (Scl and PRS), LPS results people, HIV affected, and patients with congenital malformation (HMF). We have a diagnostic and therapeutic procedure uniform for all the patients; the first clinical evaluation concerns radiographic and laboratory examination, such as head and neck Dimensional Computed Tomography, Magnetic Resonance, Ultrasonography, Orthopanoramic x-rays, searches for ANA-ENA-Anti Cardiolipina anticorpal; specialized infective and immunologic consulence relating to the single patient has been committed. The 7% of the patients has been treated with a replenishment composed of the combination with porous polyethylene and polyacrylamide because of the wide loss of both skeleton and soft tissues. Some other

**Polyacrylamide - Clinical Case 1:** CC, a female of 17 years old, came in our center for hemifacial hasimmetry. This anomaly wascharacterized by a progressive atrophy of the left hemiface. The patient did not present diplopy. The objective examination we observed the presence of slight atrophy of the left middle and inferior third of the face, including nasolabial region and the omolateral upper lip. A nasal pyramid deviation also appeared and confirmed by the anterior rhynoscopy, which also showed a left-convex deviation of the nasal sept. A Dimensional Computed Tomography scan was performed. This exam confirmed a maxillo- mandibular fault. Then an orthotic evaluation was performed to value muscular structures. We adopted a surgical approach which primarily provided an improvement of the respiratory activity. Then, we planned a filling of the atrophic soft tissues through infiltrations of Polyacrylamide. The infiltrations have been performed after 2 months from the septorhynoplastic surgery. Biomaterial (5ml) in the left nasolabial fold was filled. After 1 month from the beginning of the treatment, we noticed an evident reduction of the pre-existing deficit of the soft tissues. The clinical and Ultrasonography checks after

2,6, 12 and 24 months confirmed a correct integration of the used biomaterial.

Fig. 1. Lateral view of the patient before treatment

representative clinical cases are presented:

**2. Biomaterials** 

**Clinical case 2:** E.M, female of 45 years referred about the appearance of a progressive facial asymmetry alterations interesting the lower third of the face in particular in the last 3 years. The tissue deficit was becoming clearer without any symptoms or alterations in the facial motility**.** (FIGURE 1) Therefore a Computed Tomography Scan of the face was performed, in order to evaluate the entity of such deficit. It shows marked deficit of the soft tissue, which was extending partially to the skeletal structures". During the objective exam conduced even with a photographic study, the loss of the symmetry was appreciating, in particular to the third lower of the hemiface. Problems related to the function of the facial nerve, were not noticed, and the patient did not refer facial hypoesthesia.

Therefore the patient underwent to fill of the facial soft tissues with biomaterial. The biomaterial was implanted in the left middle and inferior third of the hemiface; moreover it has been noticed a partial resorption of the biomaterial at the end of treatment. A total of 3 infiltration has been performed for a tot of 8ml of infiltrated biomaterial. (FIGURE 2)

Fig. 2. Lateral view of the patient after treatmet

**Clinical Case 3:** E.D.E, male of 55 years old, immuno-compromised patient, affected by HIV from 20 year. He had underwent to the Highly Active Anti-Retroviral Therapy treatment (HAART) from about ten years. The patient referred the appearence of an atrophy in the middle third of face, he had developed a lypodistrophy lesion of soft tissues**.** (FIGURE 3)

Fig. 3. Particular of the lypodistrophy area

Facial Remodelling and Biomaterial 449

**Bio-bone - Clinical case 6:** ML, 19 years old female, came up to our attention for a mandibular lesion. It was an occasionally finding of a Magnetic Risonance carried out previously after a lipothymia event. This mandibular 8 lesion was an osteolytic one, positioned in the left ramous under 3.6 to 3.8 roots. Patient had not simpthoms, and the clinical exam didn't show any visible or touchable lesion in the fornix gum, or at the corresponding teeth. Patient only referred a mononucleosis infection six months before. Computed Tomography of the Head and Neck and Orthopanoramic x-rays were carried out

Fig. 5. Frontal view of the patient before treatment

Fig. 6. Frontal view of the patient after treatment

Fig. 7. Pre operative Orthopanoramic x-rays

(FIGURE 7) .

The patient was stable from clinical and infective point of view, confirmed by hematologic exams; so that we decided to underwent the patient to biomaterial infiltration with Polyacrylamide. The sites of treatment were the areas where the atrophy and the lypodistrophy are happened. Clinical-aesthetic and infective results in six years of follow-up were good. (FIGURE 4)

Fig. 4. Particular of the the lypodistrophy area after treatment

**Polyalkylimide - Clinical case 4:** D.L.B, a male of 30 years old, showed an atrophy of the middle and inferior third of the face. The patient eight years before, referred a not treated facial trauma. The objective exam showed the presence of a moderate atrophy of the rigth hemiface, associated to aesthetic and functional alterations. In particular, a combination of the right orbital-malar asymmetry complex, and a rigth orbital oenophtalmo was noticed as well. 7. The patient referred about the appearance of dyplopia. It has not been well clarifyied. The patient underwent before further clinical and radiological checks exams to study the soft tissues, and to evaluate the ocular motility, so as a Perry Romberg Syndrome was suggested for diagnosis. A surgical treatment was planned to correct the oenophtalmo and to restore the ocular motility correcting the dyplopia disfunction. On the other hand, this surgery has been performed with the goal of resolving the atrophy and the face's deformity through the use of porous polyetilene. Afterwards, a treatment of polyackylimide infiltrations has been planned. The patient, after 1 week from the treatment with biomaterial, presented a good tolerance and a total restoration of the facial eurytmia. An ultrasonographic evaluation was performed to value the integration of the biomaterial after 6,12 and 24 months; this exam showed a compartment of the biomaterial implanted, associated to fibrotyc branches compatible with the basal pathology.

**Porous polyethylene - Clinical Case 5:** S.B, a female of 40 years old, referred facial asymmetry. The objective exam showed a skletal deformity of mandibular and maxillary component, associated to mycrogenia**.**(FIGURE 5)

The patient presented a congenital nose deformity too. The surgical treatment was planned with mandibular promotion by means graft of porous polietylene. Then in the same surgical step a graft "on lay" of septal cartilage was positionated on the nasal dorsum. Ultrasonographic checks after 1 month, 23 months and 6 months were optimal; radiologic exams were performed to check the planted biomaterial. These investigations verified a good tolerance and a well fixed of the biomaterial**.** (FIGURE 6)

The patient was stable from clinical and infective point of view, confirmed by hematologic exams; so that we decided to underwent the patient to biomaterial infiltration with Polyacrylamide. The sites of treatment were the areas where the atrophy and the lypodistrophy are happened. Clinical-aesthetic and infective results in six years of follow-up

**Polyalkylimide - Clinical case 4:** D.L.B, a male of 30 years old, showed an atrophy of the middle and inferior third of the face. The patient eight years before, referred a not treated facial trauma. The objective exam showed the presence of a moderate atrophy of the rigth hemiface, associated to aesthetic and functional alterations. In particular, a combination of the right orbital-malar asymmetry complex, and a rigth orbital oenophtalmo was noticed as well. 7. The patient referred about the appearance of dyplopia. It has not been well clarifyied. The patient underwent before further clinical and radiological checks exams to study the soft tissues, and to evaluate the ocular motility, so as a Perry Romberg Syndrome was suggested for diagnosis. A surgical treatment was planned to correct the oenophtalmo and to restore the ocular motility correcting the dyplopia disfunction. On the other hand, this surgery has been performed with the goal of resolving the atrophy and the face's deformity through the use of porous polyetilene. Afterwards, a treatment of polyackylimide infiltrations has been planned. The patient, after 1 week from the treatment with biomaterial, presented a good tolerance and a total restoration of the facial eurytmia. An ultrasonographic evaluation was performed to value the integration of the biomaterial after 6,12 and 24 months; this exam showed a compartment of the biomaterial implanted,

**Porous polyethylene - Clinical Case 5:** S.B, a female of 40 years old, referred facial asymmetry. The objective exam showed a skletal deformity of mandibular and maxillary

The patient presented a congenital nose deformity too. The surgical treatment was planned with mandibular promotion by means graft of porous polietylene. Then in the same surgical step a graft "on lay" of septal cartilage was positionated on the nasal dorsum. Ultrasonographic checks after 1 month, 23 months and 6 months were optimal; radiologic exams were performed to check the planted biomaterial. These investigations verified a

Fig. 4. Particular of the the lypodistrophy area after treatment

associated to fibrotyc branches compatible with the basal pathology.

good tolerance and a well fixed of the biomaterial**.** (FIGURE 6)

component, associated to mycrogenia**.**(FIGURE 5)

were good. (FIGURE 4)

Fig. 5. Frontal view of the patient before treatment

Fig. 6. Frontal view of the patient after treatment

**Bio-bone - Clinical case 6:** ML, 19 years old female, came up to our attention for a mandibular lesion. It was an occasionally finding of a Magnetic Risonance carried out previously after a lipothymia event. This mandibular 8 lesion was an osteolytic one, positioned in the left ramous under 3.6 to 3.8 roots. Patient had not simpthoms, and the clinical exam didn't show any visible or touchable lesion in the fornix gum, or at the corresponding teeth. Patient only referred a mononucleosis infection six months before. Computed Tomography of the Head and Neck and Orthopanoramic x-rays were carried out (FIGURE 7) .

Fig. 7. Pre operative Orthopanoramic x-rays

Facial Remodelling and Biomaterial 451

Radiological and clinical exams with Computer Tomography Dental Scan and Telecranium x ray in two proiections with cefalometric study were performed to evaluet bony and soft tissues. After 1 month surgery was performed: two fixures with abutment have been positioned in the right mastoid bone, Then the left auricular was positionated to restablish the normal structures of the face. In the same surgical time, two porous polyetylene prosthesis were implanted in the malar region, to restore the sagittal diameter of the middle third of the face; other two porous polyetylene prosthesis were implanted on the mandibular angle and one more prosthesis was implated on the sinphisis, to restore the transversal and sagittal diameter of the thrid inferior of face. After three mounths an auricular prosthesis associated to Polyacrylamide implant, was positioned in bilateral preauricular area **(FIGURE 10).** Clinical and radiological follow-up demonstrated a good

The ideal biomaterial should be easy to implant and to remove, and simple to be identified by a low-dose radiation and low-cost radiologic technique. Authors wanted to evaluate ultrasonography (US) as a technique in monitoring biomaterial status after operation. Ultrasonography has been shown as an excellent way to visualize clinical features and a possible pathologic process of an implanted biomaterial; it is a non-invasive, low-radiation and low-cost dose radiologic technique. Reconstruction in facial deficit diseases needs adequate biomaterial to implant and a careful patients observation, that is, both clinical and radiologic. Ultrasonography is a fundamental component of the follow up of implanted biomaterial patients. the use of synthetic materials instead of an autolog tissue is codified from years and is widely diffused. In the last years, maxillofacial surgery has adopted poliacrilamide for the soft tissue, which is already used in esthetic surgery such as ''last generation filler'' to overwhelm the defects of the time such as wrinkles and furrows. Such material has replaced paraffin and silicone fluid used in the 1960s, and collagen and analogs used in the 1980s.In the same years, Conley and Baker experienced some slow-resorption synthetic materials that, when inserted in the derma, overwhelmed cutaneous imperfections. The biomaterials used until that moment were all very well tolerated, but they introduced the disadvantage of being ''statics'' materials, concrete, and above all, temporary. In the last few years, poliacrilamide has replaced, in part, the use of these

integration of implants and the biomaterial.

Fig. 10. Frontal view of the patient after treatment

**3. Ultrasonography monitor follow-up** 

These images were likely suggestive for adamantinoma. That hypothesis led to a particular operative interventation with the aim of a definitive diagnosis and treatment. In fact the histologic exam would have led, or not, to a mandibular resection. So left mucous fornix section was performed in order to uncover the mandibular bone from 3.6 to 3.8 dental elements and to dissect the bone through osteotribe, as long as the lesion was found. Strangely enough the surgical finding was a rarefaction of the bone, no capsular structure or any other elements that could help with the diagnosis were observed as well. Consequently a conservative surgical technique was carried on, such as cutting out the bone box with 3.7 and 3.8 because of their roots inclusion in the osteolitic lesion as well. The missing bony part was filled with a demineralized bone matrix, in order to prevent iatrogenic fracture. So before performing a mandibular ramous resection, we have been waiting for the definitive histologic diagnosis. Unfortunately, against every expectation, it resulted as a follicular cyst within Candida A. yeasts. It was performed a batteriologic exam that resulted positive for C. Albicans too and for Hafnia alveii. Antibiotic and antimicotic therapies were carried out for a long period. After three months patient underwent to a Orthopanoramic x-rays, that revealed the biomaterial integration but a surgical interventation of removing bio-bone it was necessary in order to assure the complete eradication of the Candida infection**.**  (FIGURE 8)

Fig. 8. Post operative Orthopanoramic x-rays

**Porouse polyethylene and Polyacrylamide - Clinical case 7:** R.A, a male of 40 years old, affected by the Goldenhar syndrome, he underwent to differentreconstructive surgical treatments, to restore the normal symmetry of the face soft tissues. The patient showed a facial asymmetry characterized by an atrophy of the right hemifacial soft tissues, associated to auricular agenesys, and a behind-positioning of the left auricle.(FIGURE 9)

Fig. 9. Frontal view of the patient before treatment

These images were likely suggestive for adamantinoma. That hypothesis led to a particular operative interventation with the aim of a definitive diagnosis and treatment. In fact the histologic exam would have led, or not, to a mandibular resection. So left mucous fornix section was performed in order to uncover the mandibular bone from 3.6 to 3.8 dental elements and to dissect the bone through osteotribe, as long as the lesion was found. Strangely enough the surgical finding was a rarefaction of the bone, no capsular structure or any other elements that could help with the diagnosis were observed as well. Consequently a conservative surgical technique was carried on, such as cutting out the bone box with 3.7 and 3.8 because of their roots inclusion in the osteolitic lesion as well. The missing bony part was filled with a demineralized bone matrix, in order to prevent iatrogenic fracture. So before performing a mandibular ramous resection, we have been waiting for the definitive histologic diagnosis. Unfortunately, against every expectation, it resulted as a follicular cyst within Candida A. yeasts. It was performed a batteriologic exam that resulted positive for C. Albicans too and for Hafnia alveii. Antibiotic and antimicotic therapies were carried out for a long period. After three months patient underwent to a Orthopanoramic x-rays, that revealed the biomaterial integration but a surgical interventation of removing bio-bone it was necessary in order to assure the complete eradication of the Candida infection**.** 

**Porouse polyethylene and Polyacrylamide - Clinical case 7:** R.A, a male of 40 years old, affected by the Goldenhar syndrome, he underwent to differentreconstructive surgical treatments, to restore the normal symmetry of the face soft tissues. The patient showed a facial asymmetry characterized by an atrophy of the right hemifacial soft tissues, associated

to auricular agenesys, and a behind-positioning of the left auricle.(FIGURE 9)

(FIGURE 8)

Fig. 8. Post operative Orthopanoramic x-rays

Fig. 9. Frontal view of the patient before treatment

Radiological and clinical exams with Computer Tomography Dental Scan and Telecranium x ray in two proiections with cefalometric study were performed to evaluet bony and soft tissues. After 1 month surgery was performed: two fixures with abutment have been positioned in the right mastoid bone, Then the left auricular was positionated to restablish the normal structures of the face. In the same surgical time, two porous polyetylene prosthesis were implanted in the malar region, to restore the sagittal diameter of the middle third of the face; other two porous polyetylene prosthesis were implanted on the mandibular angle and one more prosthesis was implated on the sinphisis, to restore the transversal and sagittal diameter of the thrid inferior of face. After three mounths an auricular prosthesis associated to Polyacrylamide implant, was positioned in bilateral preauricular area **(FIGURE 10).** Clinical and radiological follow-up demonstrated a good integration of implants and the biomaterial.

Fig. 10. Frontal view of the patient after treatment
