CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY

Hydroxyapatite/Collagen Composite Is
a Reliable Material for Malar
Augmentation
Antonio DAgostino, MD,* Lorenzo Trevisiol, MD,y Vittorio Favero, MD,z
Michael J. Gunson, DDS, MD,x Federica Pedica, MD,k Pier Francesco Nocini, MD, DDS,{
and G. William Arnett, DDS#
Purpose: To evaluate the long-term results of cheekbone augmentation using porous hydroxyapatite
granules mixed with microfibrillar collagen in a large group of patients.
Materials and Methods: Four hundred thirty patients who underwent zygomatic augmentation and in-
termaxillary osteotomy were evaluated clinically, radiologically, and histologically.
Results: Complications were found in 13 patients (1.56%). There were no relevant radiologic differences
in prosthesis volume after 1 month (T1) or after 24 months (T2) in any patient; there were no clinically
relevant differences in 110 patients after 36 months. At T1, the prosthesis had a granular structure and
the granules had not migrated; at T2, the prosthesis was staunchly adhering to the underlying bone.
Over time, the radiopacity of the material increased. Histologic results of 19 biopsy specimens obtained
from 8 patients 2 years after the procedure showed prominent ossification with low inflammation, con-
firming new bone formation over time. According to the visual analog scale, the patients were generally
satisfied with the aspects that were considered.
Conclusion: Hydroxyapatite and collagen composite used during malarplasty produced a successful
outcome. Its main drawback is a learning curve that is longer than for more frequently used implantable
biomaterials.
2016 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg -:1.e1-1.e15, 2016

Functional and esthetic facial rehabilitation has become
an important sector of maxillofacial surgery. Harmonic
facial features and natural proportions favor self-
confidence and psychological health. Facial defects or
asymmetries can result from soft tissue asymmetry or
bony framework alterations. Intermaxillary osteotomy
corrects skeletal malocclusions, aligns the upper incisor
sagittal and vertical planes, and improves the esthetics
of the lower third of the face, including the paralatero-
nasal area, the upper and lower lips, and the chin. While
the osteotomy procedure is being carried out, some
patients also might require contouring of the malar
soft tissue complex or other facial areas to improve mid-
face definition and to obtain greater facial harmony.

*Associate Professor, Department of Surgery, Unit of Maxillofacial
Surgery and Dentistry, University of Verona, Verona, Italy.
yAssociate Professor, Department of Surgery, Unit of Maxillofacial
Surgery and Dentistry, University of Verona, Verona, Italy.
zClinical Assistant, Department of Surgery, Unit of Maxillofacial
Surgery and Dentistry, University of Verona, Verona, Italy.
xPrivate Practice, Arnett and Gunson Facial Reconstruction, Santa
Barbara, CA.
kClinical Assistant, Department of Pathology and Diagnostics,
University of Verona, Verona, Italy.
{Professor and Chief, Department of Surgery, Unit of
Maxillofacial Surgery and Dentistry, University of Verona, Verona,
Italy.
#Private Practice, Arnett and Gunson Facial Reconstruction,
Santa Barbara, CA and Assistant Professor, Department of Oral and
Maxillofacial Surgery, Loma Linda University, Loma Linda, CA.
G. William Arnett is the assignee of U.S. patent 6506217 B1 (mold-
able postimplantation bone filler and method).
Address correspondence and reprint requests to Dr Favero:
Department of Surgery, Unit of Maxillofacial Surgery and Dentistry,
University of Verona, Ple LA Scuro, 10, Verona 37134, Italy; e-mail:
Vittorio_favero@yahoo.it
Received December 9 2015
Accepted January 28 2016
2016 American Association of Oral and Maxillofacial Surgeons
0278-2391/16/00144-0
http://dx.doi.org/10.1016/j.joms.2016.01.052

1.e1
1.e2
The first facial reconstruction techniques date to the
1970s, when silicone prostheses were commonly
used.1-3 Since then, other techniques using
autogenous or alloplastic materials have been used
by plastic surgeons for this type of esthetic surgery.
Autologous bone grafts to optimize facial harmony
were considered the gold standard for facial
reconstruction for many years,4 but lost popularity
because they were encumbered with donor-site
morbidity, were not easily molded, and were charac-
terized by unforeseeable resorption results over
time.5 Osteotomy procedures (Le Fort II and III) pro-
posed by various investigators, including Tessier,6 begin-
ning in the 1980s were later abandoned because of
high surgical invasiveness, technical difficulties in actu-
ating the procedures, unpredictability, and the frequent
necessity of using low osteotomies (Le Fort I) to
optimize the occlusal plane.6-9 Currently, implantable
biomaterials play a predominant role in these
procedures. Silastic has long been used in plastic and
esthetic surgery; it is easily positioned, does not need
stabilization, and has led to satisfying results in
facial contouring. However, it is associated with a
relatively large percentage of complications, including
infections, dislocations, formation of fibrous capsules,
lack of integration, and in some cases resorption of
native bone.10-12
Other alloplastic materials derived from polymers
and ceramics have been described in the literature.
Porous polyethylene (Medpor, Porex Corporation,
Newman, GA) is a widely used plastic allogenic mate-
rial to contour the face and in trauma medicine. It is
preshaped, easily positioned, and fixed with screws.
However, according to some surgeons, it is character-
ized by decreased malleability and adaptability at the
recipient site. Although the risks associated with the
use of this material are lower with regard to percent-
ages, the risks include malposition, a remarkable inci-
dence of early- and late-onset infections, formation of
pseudocapsules, and osseous integration failure.13-15
Another implant material, Gore-Tex, which is pre-
shaped and easy to position, is characterized by
long-term complications and results that are not
entirely satisfying; cases of bone graft extrusion,
seroma, and lack of integration over time have been
reported.16
Coral-derived porous hydroxyapatite (HA; Interpore
200, Interpore Orthopaedics, Inc., Irvine, CA), which
is available in granule and block forms, is another ma-
terial frequently used in maxillofacial procedures to
augment the splanchnocranium. According to the
literature, porous HA granules are stable over time
and are osteoconductive.17,18 Nevertheless, the
prosthesis requires hypercorrection, and in some
cases there might be problems linked to
irregularities in facial symmetry; it also seems to be
HYDROXYAPATITE FOR MALAR AUGMENTATION
structurally incapable of withstanding functional
load.19 Because porous HA granules are not preshaped
or prepackaged for prosthetic use, it is used less
frequently than the materials described earlier.
All biomaterials have short- and long-term advan-
tages and disadvantages depending on the point of
view. The aim of this study was to evaluate clinically,
radiologically, and histologically the long-term results
of porous HA granules used to contour the facial skel-
eton in a large group of patients.
Materials and Methods
The present study followed the Declaration of Hel-
sinki on medical protocol. This study was approved
by the institutional review board of the Verona Hospi-
tal (Verona, Italy) and all participants signed an
informed consent agreement. Over a 7-year period
(2005 through 2012), 430 patients (270 women and
160 men; mean age, 28 yr; range, 18 to 45 yr) under-
went procedures using porous HA granules to
augment the zygomatic region (total, 860 prosthesis)
and optimize facial esthetics during orthognathic sur-
gery. All procedures were carried out in the Arnett-
Gunson Center for Corrective Jaw Surgery (Santa Bar-
bara, CA) or the Unit of Dentistry and the Maxillofacial
Surgery Unit of the University of Verona Medical Cen-
ter (Verona, Italy). The treatment plan, which aimed to
achieve functional and esthetic improvement, was to
enhance the zygomatic region of patients with inade-
quate cheekbone projection or facial asymmetry of
the zygomatic arch.
All procedures were carried out using general anes-
thesia after prophylactic antibiotic administration
(ampicillin and sulbactam 1.5 g intravenously 1 hour
before surgery). In accordance with the patent of G.
William Arnett (U.S. patent 6506217), the prostheses,
which were handmade, were prepared by mixing HA
granules 5 mL (Pro-Osteon 200, Interpore Cross Inter-
national, Irvine CA), microfibrillar collagen hemostat
flour 1 g (Avitene, Davol Inc., Warwick, RI), and sterile
saline solution 5 mL (Fig 1A,B).
The mixture is shaped using sterile instruments and
according to the desired result in relation to the pa-
tients features. Initially, the material is very malleable.
After it has been shaped, it is warmed for at least
150 minutes under a 150-W heating lamp and allowed
to stiffen. Shaping is carried out at the end of an
orthognathic procedure (Le Fort I), because the
same upper vestibular incision is used after debriding
the area between the infraorbital nerve medially and
the zygomatic arch laterally, creating pockets (whose
sizes should match those of the prostheses) within
the zygomatic bones (Fig 2A,B); this is a very impor-
tant detail that will prevent prosthesis displacement.
Careful hemostatic control of the recipient site is
DAGOSTINO ET AL
FIGURE 1. A, B, Preparing the prosthesis.
DAgostino et al. Hydroxyapatite for Malar Augmentation. J Oral Maxillofac Surg 2016.
extremely important. If the prosthesis is positioned
more laterally, then the more the inter-zygomatic
diameter will be augmented. Likewise, if the pros-
thesis is positioned more medially, then the sagittal
projection will be improved. No internal fixation is
needed to stabilize the prostheses; instead, extraoral
compressive dressings are applied to stabilize
the implants.
All patients included in the study underwent a clin-
ical assessment and participated in at least a 3-year
follow-up (mean follow-up, 6 yr; range, 3 to 10 yr).
Clinical evaluations consisted of quantifying short-
and long-term complications linked to inflammatory
or infectious problems or the need for other proce-
dures, implant stability (absence or presence of
clinically appreciable signs of resorption), and photo-
graphic records taken 1 to 3 years after surgery.
Seventy-six of the 430 patients agreed to complete
the visual analog scale (VAS), a psychometric response
scale that measures a continuum of values on a scale of
0 to 100. In this study, patients were asked to judge the
naturalness of the facial contour of the zygomatic arch:
they were instructed to give a grade of 0 if they judged
the prosthesis appeared unnatural and to give a grade
of 100 if they were completely satisfied with their new
profile. They also were asked about symmetry: they
were asked to give a grade of 0 if one side seemed
different from the other and a grade of 100 if the 2
sides were exactly the same. The third parameter
was the implants natural feel: they were asked to
give a grade of 0 if the prosthesis seemed foreign to
their body and a grade of 100 if it seemed part of their
body. The patients were asked to define their satisfac-
tion with the implant as a grade of 0 if they were
entirely dissatisfied and 100 if they were
completely satisfied.
All patients underwent imaging after 1 month (T1)
and after 24 months (T2). One hundred ten of the
1.e3
430 patients also agreed to undergo cone-beam
computed tomography (CBCT; NewTom 3G device;
QR srl, Verona, Italy) at least 36 months after surgery
(T3). Signs of resorption of native bone and variations
in the structure and radiopacity of the implanted pros-
thetic material were evaluated by a blinded observer
(the radiologist who analyzed the CBCT); these phe-
nomena were evaluated over a long period
($36 months) in 110 of the patients studied.
Biopsy samples were obtained from implants in 8
patients who required removal of fixation screws
from the upper jaw 2 years after surgery. Once the pa-
tients gave informed consent, biopsy samples were
taken using trephine burs (inner diameter, 2 mm;
outer diameter, 3 mm) and 19 samples of prosthetic
material were collected. Each sample was taken so
that a portion of the prosthesis in the entirety of its
width from the periosteum to the native bone could
be collected, and the periosteum side was marked
with a pen. The material collected was fixed in form-
aldehyde buffered with 4% phosphate and washed in
the buffer. After decalcification with Osteodec (Bio-
Optica Milano Spa, Milan, Italy), the sample was dehy-
drated using increasing concentrations of alcohol and
xylene and then embedded in paraffin. Morphologic
and immunohistochemical analyses of bone samples
were performed to evaluate remodeling and eventual
osteogenesis. Four-micrometer-thick sections were
stained with hematoxylin and eosin, and immunohis-
tochemistry was performed on subsequent sections
using 2 monoclonal antibodies specific for cathepsin
K (clone CK4, Novocastra, Newcastle, UK; clone
3F9, Abcam, Cambridge, UK) to stain osteoclasts
and for CD56 (clone 123C3.D5, 1:100; Thermo Scien-
tific, Grand Island, NY) to stain osteoblasts, as previ-
ously described.20 Cathepsin K is fundamental for
the degradation of type I collagen in bone resorption
mediated by osteoclasts21 and CD56 stains resting and
1.e4 HYDROXYAPATITE FOR MALAR AUGMENTATION

FIGURE 2. A, Placement of the implants in the subperiosteal pockets. B, Cone-beam computed tomogram showing final position of the pros-
thesis in the malar area. Prostheses differ in shape and size owing to the asymmetric nature of the defect to recontour.
DAgostino et al. Hydroxyapatite for Malar Augmentation. J Oral Maxillofac Surg 2016.

activated osteoblasts.22 Vital areas were identified looking for nucleated osteocytes. Then, applying
by checking the section stained with hematoxylin immunohistochemical analysis, the presence of osteo-
and eosin under an optical microscope and clasts was evaluated by staining of cathepsin K
DAGOSTINO ET AL
antibody23 and osteoblasts reactive to CD56.22 Per-
centage of new bone formation, percentage of fibrous
tissue, and presence of the biomaterial also were
investigated.
Results
CLINICAL EVALUATION
Clinical evaluation (Table 1) of patients showed that
prosthesis malposition, which was noted in 6 cases,
was probably due to excessively large subperiosteal
pockets in which the prostheses were positioned.
The inappropriate dimension led to a caudal rather
than contralateral slippage of the prosthesis. Five cases
of partial resorption were noted; all were linked to
inadequate hemostasis of the recipient site or in
some cases to massive bleeding at the patients awak-
ening. There were 2 cases of early infection
(<30 days) requiring removal of the prosthesis. There
were no cases of late-onset infection, dehiscence, fis-
tula, or thinning or alteration of overlying soft tissues.
Comparison of photographs taken 1 and 3 years later
confirmed the registered clinical data (Figs 3-6).
Some patients reported bilateral edema and pain in
the zygomatic region during the first month after
surgery. Thirteen patients (1.56%) had some kind of
complication; 2 (0.2%) had infectious complications.
The VAS was completed by 76 of the 430 patients
(Table 2). The patients substantially agreed on their
perception of the primary parameters characterizing
the result. On a scale of 0 to 100%, the average judg-
ment about the natural contour of the zygomatic pro-
file was 85.83  22.22 of 100 (median, 95.19). The
average judgment about symmetry was 85.68 
23.00 (median, 96.44). The average judgment about
the implants natural feeling was 80.30  26.28 of
100 (median, 92.10). The patients average general
Table 1. CLINICAL COMPLICATIONS
Prostheses
Complications (N = 860), n (%)
Malposition requiring 6 (0.72)
secondary correction
Partial or total resorption 5 (0.64)
requiring secondary
correction
Dehiscence 0 Arem et al2 and Moos et al3 were among the first to
Fistula 0 describe pioneering experiences with Proplast to
Infection 2 (0.2)
Thinning of overlying soft tissue 0 1970s. These procedures were followed by autologous
Total 13 (1.56)
DAgostino et al. Hydroxyapatite for Malar Augmentation. J Oral
Maxillofac Surg 2016.
1.e5
satisfaction with the result was 84.41  23.96 of 100
(median, 96.72).
RADIOLOGIC EVALUATION
Except for the cases of partial or complete resorp-
tion (n = 5; 0.64%), the imaging data collected at T1
showed that the prosthesis maintained its granular
structure and that the granules had not migrated to
the surrounding soft tissues (Fig 7). The structure
of the prosthesis was radiotransparent compared
with the compact portion of the zygomatic bone. At
T2, the prosthesis seemed to adhere staunchly to the
underlying zygomatic bone in all patients. The gran-
ular structure was still distinguishable, although it
was less evident, and the partial radiotransparency
had evolved to a radiopacity similar to that in the
compact part of the native bone, making it impossible
to distinguish the interface between the prosthesis
and bone (Fig 8). That tendency continued, according
to the imaging data available at T3, toward progressive
loss of definition of the granular architecture and an
almost complete radiopacity and apparent corticaliza-
tion of the bone in contact with the prosthesis. The
interface between the prosthesis and bone at T3
appeared indistinguishable (Fig 9).
HISTOLOGIC EVALUATION
The persistence of porous HA and of macrophages,
although without inflammatory infiltrate, was found in
all samples (Table 3). Fibrous stroma was found in 50%,
and the presence of new osteogenesis and mature
bone was found in 70% of cases. According to biopsy
findings, the presence of mature bone was found
only at the periosteal side (marked with a pen), and
the presence of new formation of immature bone
was found entirely on the deep side of the native
bone with a bone maturation gradient proceeding
from the periosteal to the deep side (Fig 10). Immuno-
histochemical investigations uncovered some
cathepsin K protease contained in the cytoplasm of
the macrophages, thus indicating the presence of oste-
oclast activity localized around the HA residues (Fig
11). The anti-CD56 antibodies indicated greater new
osteogenesis activity at the side of the biopsy sample
adjacent to the native bone (deep), confirming the re-
sults of histomorphometric analyses (Fig 12).
Discussion
enhance the lower third of the face at the end of the
onlay bone grafts that were initially collected from the
rib and iliac crest and later from the calvarial bone.
Although those grafts that were positioned for esthetic
1.e6 HYDROXYAPATITE FOR MALAR AUGMENTATION

FIGURE 3. Patient 1 at preoperative assessment. A-C, Class III dentoskeletal malocclusion, vertical excess, and mild malar deficiency in pro-
jection and contour treated with multisegment Le Fort I osteotomy, bilateral sagittal split osteotomy, and bilateral malarplasty with porous hy-
droxyapatite prosthesis.
DAgostino et al. Hydroxyapatite for Malar Augmentation. J Oral Maxillofac Surg 2016.
DAGOSTINO ET AL 1.e7

FIGURE 4. Patient 1. A-C, Postoperative assessment 24 months after the procedure.

DAgostino et al. Hydroxyapatite for Malar Augmentation. J Oral Maxillofac Surg 2016.
1.e8 HYDROXYAPATITE FOR MALAR AUGMENTATION

FIGURE 5. Patient 2 at preoperative assessment. A-C, Class I dentoskeletal malocclusion with vertical excess, mandibular left deviation, and
asymmetry in soft tissues and hard tissues of the right zygomatic region treated with multisegment Le Fort I osteotomy, bilateral sagittal split os-
teotomy, and bilateral asymmetrical malarplasty with porous hydroxyapatite prosthesis.
DAgostino et al. Hydroxyapatite for Malar Augmentation. J Oral Maxillofac Surg 2016.
DAGOSTINO ET AL 1.e9

FIGURE 6. Patient 2. A-C, Postoperative assessment after 24 months.

DAgostino et al. Hydroxyapatite for Malar Augmentation. J Oral Maxillofac Surg 2016.
1.e10 HYDROXYAPATITE FOR MALAR AUGMENTATION

Table 2. VISUAL ANALOG SCALE OUTCOMES

Patients, n Natural Contour Symmetry Natural Feel Satisfaction

76 85.83  22.22; 85.68  23.00; 80.30  26.28; 84.41  23.96;

95.19 (88.19, 99.91) 96.44 (87.14, 100) 92.10 (70.86, 99.39) 96.72 (79.77, 100)

Note: Data are presented as mean  standard deviation; median (quartiles 1, 3).
DAgostino et al. Hydroxyapatite for Malar Augmentation. J Oral Maxillofac Surg 2016.

purposes were considered the gold standard in the
1980s, they have since been abandoned because of
donor site morbidity, the difficulty in modeling non-
adaptable graft materials, and, in particular, the unpre-
dictable results of graft volumetric maintenance.5,24-27
Brusati et al7 and Denny and Rosenberg8 who pro-
posed using Le Fort III osteotomies to obtain esthetic
results initially followed the method described by Tess-
ier6 to harmonize facial disharmonies and his sugges-
tions on modifying and simplifying those
procedures. Those methods foresaw midfacial
advancement, at times in conjunction with bone graft-
ing and stabilization. Given the high surgical invasive-
ness of these procedures, the need for an extraoral
(coronal sub-palpebral) approach, the technical diffi-
culty in carrying them out, and controlling occlusal
problems, they are no longer used in traditional or-
thognathic surgery and currently are used only in
cases of malformations in pediatric patients. The low
zygomatic maxillary osteotomy proposed by Bell
et al28 in 1988 is a technique that corrects defects in
a transverse direction of the zygomatic region,

FIGURE 7. Cone-beam tomogram, coronal slice, at 1 month after surgery.

DAgostino et al. Hydroxyapatite for Malar Augmentation. J Oral Maxillofac Surg 2016.
DAGOSTINO ET AL
FIGURE 8. Cone-beam tomogram, coronal slice, at 24 months after surgery.
DAgostino et al. Hydroxyapatite for Malar Augmentation. J Oral Maxillofac Surg 2016.
requiring an augmentation of the bizygomatic diam-
eter, but also necessitating9 grafts composed of onlay
bone grafting material (eg, HA granules) if an increase
in the sagittal projection of the malar bone is clinically
necessary. Traditional orthognathic and plastic sur-
geries have moved in the direction of using allogeneic
material, or rather so-called implantable biomaterials.
The ideal material should be biocompatible and osteo-
conductive and show a high degree of reabsorption
that is predictable over time.17 More specifically,
biocompatibility presupposes an inert chemical state,
an absence of toxicity, an inability to induce hypersen-
sitivity responses, and a low rate of infections.
Gore-Tex (polytetrafluoroethylene), a widely used
prosthetic bone graft material, presents a sufficient de-
gree of volumetric stability over time. Because it is pre-
shaped, it is easily positioned and can guarantee
satisfying esthetic results. However, it needs to be sta-
bilized with screws, it is difficult to adapt it to the
recipient site, and it is characterized by a relevant
rate of infectious complications. Moreover, Gore-Tex
implants remain slippery because there is no host
1.e11
tissue ingrowth and they carry an increased risk of
infections, seroma formation, and extrusion.16,29-31
Although rigid screw fixation is a very effective and
efficient method of fixing malar implants, there are
complications, such as the pneumatocele described
by Garner and Jordan.30 The low biocompatibility of
the material probably plays a part in this type of
complication.
Silicone derivatives likewise present a series of ad-
vantages and disadvantages. They are available in pre-
shaped forms, are easily positioned, and do not need
to be stabilized with screws, characteristics that
explain their wide use. According to many investiga-
tors, such as Metzinger et al11 and Mommaerts et al,9
the percentage of residual malposition asymmetry
varies from 15 to 35%. Nevertheless, silicone im-
plants lack the potential for vascularized healing, pro-
mote thick capsule formation, cause resorption of the
underlying bone, and display a tendency of shifting
or extruding over long periods.10,32 In the present
study, the complications were probably linked to
the limited osteoconductive properties of the
1.e12 HYDROXYAPATITE FOR MALAR AUGMENTATION

FIGURE 9. Cone-beam tomogram, coronal slice, at 36 months after surgery.

DAgostino et al. Hydroxyapatite for Malar Augmentation. J Oral Maxillofac Surg 2016.

derivatives and to a chronic inflammatory reaction to stable over time, but it is difficult to position,13
extraneous bodies (chronic inflammatory because of its rigidity, and to contour surfaces of com-
peripheral reaction). plex skeletal structures. It needs to be stabilized with
As in the cases cited earlier, Medpor (porous poly- screws. The complication rate varies from 5 to 20%
ethylene) is a material that is widely used for surgical and it is associated with a relatively large percentage
purposes and in trauma patients. It is preshaped and of early- and late-onset infections (1 to 12%).33,34
Medpor creates a fibrous capsule, it is not
osteoconductive, and it is not very inert with respect
Table 3. HISTOLOGIC EVALUATION OUTCOMES to immunologic responses.14
Different researchers have described using porous
2-yr Postoperative Histologic
Findings (19 Specimens) %
HA as onlay bone grafts for the facial skeleton.35,36 In
a study by Moreira-Gonzales et al17 on the use of HA
Hydroxyapatite granules 100 in procedures to contour the face, the percentage of
Macrophages (foreign body 100 complications was relatively small (5.6%); more specif-
reaction) ically, 4.3% had contour irregularities and 1.3% had
Fibrous stroma 50 infection and extrusion of granules requiring overcor-
New bone formation and 70 rection of 15% of the required volume. An animal study
mature trabecular bone showed that, in contrast to the rapid resorption of
DAgostino et al. Hydroxyapatite for Malar Augmentation. J Oral autologous grafts, porous HA matrix had long-term
Maxillofac Surg 2016. permanence with maintenance of contour and osseous
DAGOSTINO ET AL
FIGURE 10. Zygomatic bone specimen harvested 24 months after
prosthesis placement. The bone maturation gradient proceeds from
the periosteal (asterisk) to the deep side (hematoxylin and eosin
stain; magnification, 10).
DAgostino et al. Hydroxyapatite for Malar Augmentation. J Oral
Maxillofac Surg 2016.
incorporation.37 Concerning the biocompatibility of
HA, the results of a study by Campioni et al38
showed that porous HA plus microfibrillar collagen
was characterized by a high rate of cell proliferation
and favored cell adhesion (Saos-eGFFP) on its own sur-
face. This would seem to satisfy the criteria necessary
for biocompatibility, that is, the absence of toxicity
and being chemically inert. Concerning long-term sta-
bility, porous HA seems to be stable in some condi-
tions, such as not being placed under a functional
load,19 which, of course, is the case at the zygomatic re-
gion or other areas subject to facial contouring. The
FIGURE 11. Osteoclast activity localized around hydroxyapatite residues (immunohistochemistry with cathepsin K; magnification, 10 and
20).
DAgostino et al. Hydroxyapatite for Malar Augmentation. J Oral Maxillofac Surg 2016.
1.e13
authors also used porous HA for mandibular recontour-
ing and paralateronasal and infraorbital augmentation,
with satisfactory results. Another condition for stability
is that it should not be attained by osteosynthesis. Sta-
bility seems to depend on an adequately sized subper-
iosteal pocket that holds the graft in place and prevents
the granules from migrating to the soft tissues and
adequate hemostasis at the recipient site; this will
decrease intra- and postoperative bleeding so that the
initial prosthetic volume is decreased. The grafts stabil-
ity also depends on the surgeons proficiency in view of
the findings of malposition and partial resorption
found in the present sample (1.36%) that were prob-
ably linked to a too-small or too-large subperiosteal
pockets or inappropriate management of hemostasis.
In the present cases, secondary correction was
achieved by fat grafts harvested under local anesthesia.
Fat grafts represent a good option for facial recontour-
ing in orthognathic surgery, as discussed by others.39
Lipofilling generally presents with low morbidity,
with only superficial bruising of the harvested areas
or other minor complications, such as acute edema,
ecchymosis, and redness, which have been
described as relatively frequent. However, major
adverse effects, such as blindness, also can occur,
although at a much lower rate.40 Firm knowledge
of the vascular anatomy is mandatory to prevent
related complications. A certain amount of unpre-
dictable resorption also has been observed.41,42
Compared with HA, the indications for fat grafting
focus more on minor defects and on other areas of
the face, such as nasolabial folds, marionette lines,
cheeks, upper and lower lips, and labial tubercles.
When using fat grafts for severe malar deficiency, it
is generally difficult to achieve a satisfactory and
stable result in symmetry and projection.43,44 The
stability of HA appears to be linked to the
materials osteoconductive properties because it is
gradually replaced by native bone tissue with a
colonization gradient from the periosteum to the
1.e14
FIGURE 12. Osteoblasts identified with CD56 antibody. Greater
new osteogenesis activity at the side of the biopsy sample adjacent
to native bone (immunohistochemistry; magnification, 1 and
20).
DAgostino et al. Hydroxyapatite for Malar Augmentation. J Oral
Maxillofac Surg 2016.
basal cortical bone, as shown by the studys
histologic findings, which are in accord with the
morphologic volumetric data described by
Mendelsson et al18 and Grybauskas et al.45
The present radiologic findings confirmed that the
prosthetic material changes over time; initially, it is
radiotransparent with a granular structure, but over
time shows increasing uniformity and radiopacity,
which presupposes that the material will be resorbed
and eventually replaced by cortical bone. A volumetric
reduction of approximately 10 to 20% of the original
volume 18 to 24 months after the procedure was
described by Mendelsson et al18 and Grybauskas
et al,45 and this is a factor that should be considered
at the preoperative planning stage. The studies cited
earlier also described how the biomaterial, after an
initial compaction period of approximately 4 months,
tends to achieve remarkable volumetric stability, with
a negligible decrease in size during the follow-up obser-
vation period. The first cases of malar augmentation
using HA were reported 10 years ago; those clinical out-
comes are in line with the findings of the present study.
However, the data could not be considered because of
the lack of adequate records, mostly because at the time
standard preoperative radiographic measurements
were taken in 2 dimensions. Concerning the technical
characteristics, the material is shaped by hand, which
implies that it is possible to achieve various forms and
dimensions according to the needs of the individual
patient; this is particularly useful in cases of asymmetry
HYDROXYAPATITE FOR MALAR AUGMENTATION
of the zygomatic region. On the one hand, the prepara-
tion of the prosthesis has a relatively long learning
curve compared with other preshaped biomaterials;
on the other hand, the resulting naturalness and sym-
metry are excellent given the patients high VAS scores.
Shortening intraoperative time might be possible with
the use of preoperative CT planning of custom-made
prostheses, although this would increase the overall
cost of the treatment plan. A possible compromise
might be the adoption of a ready-to-use prosthesis
that can be adapted according to the patients needs.
In contrast to other biomaterials, HA seems to be char-
acterized by a low rate of early- and late-onset infections
(0.2%). This finding has been confirmed by other
reports17 and is in agreement with the hypothesis
that porous HA has an antibacterial effect.46 Coloniza-
tion of bone tissue, the fact that screws are not needed
to fix the prosthesis, and a high degree of biocompati-
bility47 contribute to limiting the occurrence of postop-
erative and long-term infectious phenomena.
Concerning 1-piece and segmental Le Fort I osteoto-
mies of the upper jaw, it should be remembered that
healing of the osteotome site is seldom complete
because of the long-term possibility of bacterial
contamination through the nasal passages.
The present results represent the conjoined efforts
of 2 centers specializing in the treatment of dentoske-
letal deformities and harmonization of facial contours.
The large number of patients makes it one of the most
extensive studies on this procedure found in the liter-
ature. In light of what has emerged from this study,
porous HA seems to have excellent biocompatible
and osteoconductive properties. In fact, the low rate
of complications found and the radiologic, histologic,
and molecular biological findings support this affirma-
tion and are in agreement with data of other studies
found in the literature. Porous HA prostheses for zygo-
matic augmentation led to long-term stable esthetic re-
sults, and most patients expressed a high degree of
satisfaction. These advantages are counterbalanced
by the relatively long time needed to prepare the pros-
theses and the long learning curve involved in creating
the subperiosteal pocket and a slight hypercorrection,
which seem necessary to address the short-term volu-
metric reduction. Given the characteristics described
in this study, porous HA granules with microfibrillar
collagen seems to be an excellent choice when
surgery to harmonize the zygomatic region and to
correct facial asymmetry is being planned.
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