WO1982004389A1 - Morfoplasty - Google Patents

Abstract

A method of morfoplasty to esthetically reconstruct facial features including analysis by application of theatrical makeup for approval by the patient of the intended result and the formation of a plaster mask to indicate the thickness of the necessary implants, shaping of the silicone gel implants according to the results of the analysis and implantation of the shaped implants.

Description

MORFOPLASTY

The present invention refers to a morfo plasty or more specifically to a plastic surgery of the shape or the esthetic in a generally way and the inedi ted of its application will he clear through the exten sive and detailed description as follows: I - ESTHETICAL SURGERY

A Esthetical surgery of the face is divides in two dis tincts fields: Surgery of the form and shape and surge ry of the aging face.

With relation to the surgery of the sha pe, we have conventional technics universally accepted: Rinoplasty and Chinplasty. There are same maxilla assays, which are not yet well determined. Wi th relation to the aging surgery, we have face lifting, surgery of eyelids, Blefaroplasty and peeling.

Without doubts, a lot could and has been done with those resources but; we always felt that it was not sufficient to win a fight against a lack of esthetics of a face, since without doubts, esthetics is well above a simple nose or a chin, just as a surgery of aging face needs more resources than a simple lifting of the skin of the face. let see: a face is a complex structure made of few aparent structures cut in reality, we have infinite nuances and shapes that, when articulated a mong than, give the differents Types of faces that are circulating in the world. They are not only the combination of a pair of eyes, one nose and a mouth which enter in composition for all of the variations of faces known. There is mandibule, extremely important piece in the esthetical composition of a face, there is a maxilla, another really important piece, a frontal,with all its structures, temporal aparently not so important but that a lot of time, when not in harmony with the rest of the structures produce a big failing of the facial. esthetic, and so on... We can see that the esthetic of a face of a lot of sha pes and differents structures that's when are putting together, they compound a harmony that we must follow a conscientious and complex study, once that the archietecture of one face is complex and dependent of a lot of factores; much bigger and much important than one nose or a chin.

With relation to the aging face, plastic surgery has obtained excellent results when its does not tend to exagerate. A lot of times, wishing for a better result: a hiper skin lift can produce not only a scary expression to the patient but also take away the naturality of a face. For example, a seventy years old woman is submitted to a surgery of wrinkles and get the apearance of a fifty years old, no doubt there has been a significant gain, necessary but sufficien

Will the apearance od fifty years old of age desired by all?to. If so,what should be done in order to diminish even more?Of course, it will not be by lifting more the skin of the face. So how should one proceed in order to reach the apearance of 40, or even 30 years old? In order to get practical answers to those questions, we have Morfoplasty.

As the name says, MORFOPLASTY means plastic of the sahpe and no doubts, esthetic is based upon a form or shape. In general, esthetic is a balance of forms, in a harmonious whole which will transmit, as result, a notion of pleasant esthetic.

So, if we want to talk about esthetic - of a face, inicially we must think about shapes in per- feet harmony, which means more than a simple nose or a chin.

II - History of MORFOPLASTY

Morfoplasty is the fruit of unsatisfaction with the existing technic resources, in order to win a important fight against lack of esthetic.

Inicially, the seasonning that was followed was somebody with make up would get, with lighter and darker shades, as aparent modification of form. This is a well known fact among all beauticians, so I will not insist upon it. If it is possible to get such visual effects, a woman will be superior esthetically - when made up. Why not get the same results, (which in make up is temporary), definitely, through esthetic - surgery? The idea was very tempting and we started out with what we had in terms of material: the bone, through bone grafts. The first tentatives were made with poor results and difficult execution, since the bone is not an easy material to shape and not every accept to take out bones for esthetical reasons. The idea is scary. We thought about silicone, but how should one proceed? Since then, has been developped a Know How absolutely satisfactory which has been used for several patients with excellent results. At this stage of game, we had a very important way of fighting unbalanced shapes. - This way it has been decided what to put and where to put, two constant things for all our patients. Then, the hardest thing was "How much" to put and "Where" to put, since that varies with the individual though those we have differents types of esthetics of the face. From there started a new difficulty: to size up esthetically these two variants. So, through the orientation of a beautician, we got the definitions of "Where to put" - and "How much to put". So, from a plastic surgeon and - a beautician, two professionals following different methods but looking for the same results, came out a - study that defines basic concepts to the development of the face and how to proceed in order for that esthetic to tone, through laws and well defines relations. III - CONCEPTS OF FACE ESTHETICS:

Through the centuries, men normalized - all of his concepts, giving form to the different sciences in order to have each ramification of his knowledge cultivated through laws and norms. So, through time, physics was developped into a science, quemistry, arts, architecture, etc... Discoveries and inventions have been made and today, when we enter a school, of any level, we get informations which allow us to make those already made until today. This way, science evoluates and so does the well being of mankind, which is the maximum - expression of all nature's elements. Everything is made for mankind and in function of mankind. But, mankind, through its history, creating laws, norms and con cepts, forgot to normalize an esthetic of the face, may be the most important part as a human being, since its through the face that a human element comunicates, - shows his feelings, wins or looses the constant battle of love and human relation. So, such an important ana tomical area of mankind went through centuries without its esthetical base normalized. Up to now, when we see someone esthetically pleasant, we limit ourselves to the empirical sensation of the esthetic concept. Such a per son is pretty, or such a person is ugly, but should we ask why is he pretty or why is he ugly, we would not know or even give a diagnostic about esthetic unless - there is an esthetical deffect existing. This lack of diagnostic is acceptable for professionals in other areas but not for who pretends to create esthetic through surgery. As for example, the Americans sent three astronauts to the moon and brought them back because they have done twenty thousand equations and if one of them had failed, all three of them would have died. There were rigid norms in order to be successful. When you propose to create esthetic in someone, kept the right proportions, the problem is the same as NASA's with one difference, there are no equations and therefore, we continue to depend upon empiric. Such a fact is compatible with actual esthetic surgery which limits itself to correct esthetical defects existing, or, if someone has an ugly nose, we correct the nose, if someone has wrinkles, and so on... You'll note that as es thetic surgeon, up to now, limits himself to correct esthetical defects. He has not created esthetic by technical limitations or by lack of esthetical concepts. In compensation, this lack of compatible with morfo plasty since it is through it that we can correct the - esthetical defects previously existing and create esthe tic in a face. Such a resource changes everything . IV - TYPES OF FACES

Searching through the past concepts of esthetic of the face, we find nothing but a practice developped by Leonardo da Vinci: The Morfograma. In these studies, da Vinci tried and gave dimensions between some anatomical structure, in order to obtain balance between them, but even so, stayed far away from creating esthetic, since the human figure that he designed for a morfograma in order to define facial relations without worrying about esthetic, or the esthetical concepts have changed in those five centuries which separate us from him, Anyway, it is a basic study of some importance, since until to day we value da Vinci's morfograma in order to make up a morfoanalyse of a face before performing a surgery.

Anyway, da Vinci's morfograma guides us but is not enough to create esthetic. Another study, already made by estheticians is the classification of different types of faces. So, we have as well defined types of faces, the following classifications: l) Oval face. 2) Square face. 3) Rhomboid face.

4) Triangular face.

5) Trapeze face.

6) Round face, etc... Of course, such studies are limited to the white and western people, which does not mean esthe tic. How many of these differents types of faces are ' pretty and how many are not ugly? A square face does not mean invariable pretty or invariable ugly. These studies, like da Vinci's morfograma is also used as orientation, but is far from representing a solution to the equation of esthetic of the face. Let see: Bruna Lombardi is pretty? Yes, for almost all the people. Why? Often answer is: "because there is harmony". Where is the ideal relation between the forms? Nobody' knows. Could she be prettier? How to proceed? Where to touch?

In order for us to start seeing things, some definitions are important and we'll divide the fa ce in secondary signs of esthetic: being that for the primary signs, the limit stays between the eyes, nose and mouth; the so-called small face. The secondary signs are the other anatomical elements of the face, which added up and analysed by its countour define faces as round, square, rhomboid, etc. So, by approximation, da Vinci's morfograma analyses the primary signs, as the secundary signs, basically define the differents types od faces.

The necessity to create laws that could guide us through a program, an analyse and a creation of esthetic made us see a face in a less simplified way as normally happens. Should we pay attention, we'll notice that as we see someone, we see a face as a unit and should we stare at one particular point of that face, generally it is because it has an important esthetical defect. That vision of the face as a unit, distorts totally an indivisual vision of each element. This fact could be responsable for the lack of diagnostic in the esthetic of a face. Since we notice that lack of visualisation of the anatomical element separetely and in as a whole, we'll define some basic concepts for the equation of the problem.

THE INTEREST POINT OF A FACE is the ana tomical element of more esthetical focus. It should be our departure point to build a facial architecture. It could be in the primary or secondary signs. Generally, it is in the secondary signs and a lot of time in stran ge places. It could be in the zingomatic angle, known as cheeks, or superior orbital ring, mandibule angle, etc... The interest point is not always easy to diagno se. If is trained it becomes easier to point out.

T HE EXTREME NEGATIVE OF A FACE is theanatomic element that is desavantageous for the esthetic of the face.

It is a point that, if not; analysed in details, will pass by as subjective element that breaks the harmoniousness of the face. It could be located in strange points and a lot of times, if not in most cases in points of difficult diagnosis. This point will break the harmony of the whole face, without us knowing why. Evidently, the extreme negative is easy to diagno se when there is an accentuated nasal hipertrofy. That's what gives the idea of a pretty face, but that , sometimes could break up the beauty and not let it - appear. It is obvious that somebody esthetically perfect, has more interest points and few extreme negatives subtils or a little visibles . So , in order to answer the question made behind, in respect of Bruna Lombardi, if she can get more pretty, we must to diagnose hers negati ves extremes (if she has) and bring them to the level of hers interests points.

That is why we see rinoplasties very - well done technically but do not give a satisfactory - global result. This is because the nose is not the extreme negative; and we see rinoplasties with technical defects that give sensational results, globally. This is because the nose is the extreme negative and as it got worked on, the whole face got better esthetically. But such fact must not be empirical, since the surgical results cannot depend upon empiric.

The nose, we do not know why, is always considered the big vilain of the face and is always responsible for the lack of harmony of the face, and such a fact is not always true. We must notice that the nasal piramidis mounted on a base called maxilla (a bone) and is responsable for one third of the face. This nose could look big for several reasons: 1) The maxilla has a good size and the nose is really big. In this case, a rinoplasty is undoubtedly indicated. 2) The maxilla is set in its anterior face and consequen tly the nose looks big. In this case, a rinoplasty is not indicated, once that the idea of a big nose is re lative to the maxilla's depression. In this case, we recomend that the maxilla comes out further, since that is the extreme negative. We had cases where the nose was interest point and the maxilla the extreme negative and the patient was insisting upon a rinoplasty.

3) The maxilla has a nice projection, and is narrow at its transversal dimension giving a relative feeling of a big nose when looking straight at the face. In this case it is indicated a transversal increase of the maxilla and never a rinoplasty.

4) The nose has a good size and the maxilla is set back. The maxilla has to be corrected which could or not be associated with rinoplasty.

5) The nose is fine and the frontal is set back giving the feeling of a bigger nose. In this case, the frontal has to be set forward. In addition to these most frequent options, there are several other possibilities to give the feeling that the nose is bigger, when in reality, it is all relative.

Is the same relationship that we fell when we see the Redeemer Jesus Christ image on the Corco vado. Seem from the Rio de Janeiro city, we hare the sen sation of a small Christ, because it is putting on a small pedestal; at the sea level we'll have the sensation of a big size. So, with this example, moving tothe nose and face as a whole, we'll find that a nose could be big by itself or because it has a small pedestal (ma xilla, or even the whole face). We must find out what will be better: to make the nose smaller or make the nose bigger in order to get a better balanced face. By the exposed behind, we can see that the analysis of a nose depends not only of intrinsical factores of the own nose, as to the relativity of the face's dimensions and the nasal bone. This same reasoning we'll be moved to any face's structure that we must to work for a better esthetic.

So, if we can see that a maxilla must to be set more forward, we have a diagnose in hands, but a maxilla can be set forward with or without esthetic and this depends of a lot of factores, basically, doing in teresting points in thi s anteriorisation, once that there are fines anteriorisation, followed of esthetic.

On the other hand, how would that oval face be esthetically if it were square? Or how would that oval face be with a big nose, if corrected, the maxilla set forward, as accentuated cheek and a rhomboid face? These combinations started to get complicated and different forms of esthetic to appear giving options which make it more difficult for the surgeon and the patient and we have to be careful not to fall into empirical. How should we proceed?

In view of the said options, new concepts had to be considered: The face has been divided into three parts:

The superior part, composed of the frontal and temporal and obritary contours up to and including the eyebrows.

The middle part which is the most complex one, composed by the eyes, nose and superior lip, containing basically the maxilla as important boned element. The inferior part, composed of the inferior lip and the whole chin. Each anatomical element of each part is analysed individually and we judge through points (fron 0 to 10) as analysed by a professional in the subject (esthetician or surgeon).

Such an individual study of the elements is done after the morfograma and the morfoanalysis and the various interest point and extreme negatives diagno sed. By the referred jugment or analysis. Each point of the face is measured esthetically and the points that have to be modified start to appear but a new element has been created, after observation that some elements, for example, the superior part is articulated with elements of the inferior part, for example, and those points have as extreme tie and are esthetically composed in a very closed manner, even through they are in extreme parts. Such articulations of parts are called "sectorial conjunctis". Some of them are easily perceptible, as in the profile, the contour of the forehead and the nose and so on. Some sectorial conjunctis are made of combinations not at all thought about, like the angle of the mandibule and the angle of the nasal dorsum. There are a lot of sectorial conjunctis and being able to notice them makes it easier to diagnose. The interest points and the estreme negatives. Sometimes, we have a sectorial conjunctis which is the only interest point of a face. A lot of time, we have two sectorial conjunctis that are fine by themselves but put together are not. Enethough each one in particular is fine they do not go well together. In this case, one of them is the nicest within the shole and is closen as departure point for programming the surgery, in order to make the worst one combine esthetically with the other one.

So, we start to have in hands, a whole dissection of the elements compound of one face, seem in the point of view esthetic .and the things begin to make it clear to the professional eyes. After the study of the sectorial conjunc tis, already defined (and we believe that there are stil a lot of sectorial conjunctis to do defined), we have the size of the different important angles of the face and measurements which were given to us by orthodontists. Then, we have a complete and global picture of the face, with each anatomical element diagnosed, not only indivi dually but also together, all measured and appraised in the esthetical point of view. Then, we can make up our mind and have a more exact, opinion on what to propose to the patient as surgical suggestion.

As we see, the study of the esthetician or the surgeon in morfoplasty has rules, definitions, angles measurements. Based upon that study, we get to an agreement with our patient as to the need of rinoplasty or any other surgery. Our preoccupation is to offer technical resources which are practical and have more sophisticated visible results not only correcting estheticals defects existing but also creating esthetic in order parts. Creating new interest points in a face that apparently presents only a nose or any other structure as an extreme negative, to the patient's eyes; but which after studying, in most cases has extreme ne gative in the sectorial conjunctis unnoticed to the pa tient. In the joining efforts of the plastic surgeon and the esthetician come out a new universe in esthetical surgery of the face. How could they congrega te? The esthetician is then called the programmer of the esthetical surgery and does the described work. To analyse the patient esthetically and suggest solutions, first, to the patient and then to the surgeon, in order to establish a paralel between the work of the architect and the work of the enginner who will execute the job, in this case the surgeon and his team. The patient /- should participate directly to the decision, first, in order to satisfy his need, secondly, in order for him to accept his new features. Nobody should decide for him. The surgeon and his team diagnose and offer suggestions so that the patient decides through created technology, about his new face. Most of the time, the question asked is: Will I change a lot? The answer is: It all depends upon your choise, since it is possible to act in any desirable away. Follows an old Chinese proverb that says that a good image is worth more than a thousand words. So, let' s work and find a way to give to our patient a real image of what will be his future face. This study before surgery is very important to the surgeon also since through it he can measure how much to put and meke it clear as to where to put. Inicially, we use theatrical make up which has always been used to create defects, or make the acrtor older than he really is. So, we tried theatrical make up to create esthetic for the patient and result was great:' first, we give the exact feeling of what we'll done and how it will come out, making the patient participate di rectly and objectively to the choice. Second, because it would define to the surgeon where to put, but failing in the determination of How much to put, since as one takes it off, the size and thickness would be lost. Then, we use plaster compresses, which placed in the area of the face previously studied in the morfoanaly sis, in order to correct the extreme negatives existing and detected would correct the exact point of estheti cal need and almost always, would allow the patient to see the difference and be able to aprove of them imme diately. When these compresses dry off, they are made up with skin color base in order to take away the shock ing white color, which gives a false feeling of dimen sion.

With this work done by the esthetician, the surgeon has the exact measurements for his work with prevision of the patinet and his own choice. with that the importance of the esthetician in this pre-operatory study is clear, and defined by us as surgical project. The definitions of interest point, extreme negative and sectorial conjunctis, allow us to take advanta ge of the proper characteristics of each face that is studied in an important esthetical way without pretending to make a Bo or Lollobrigida's face, which would be without doubts a caos, and would be unsuccessful. As previously focussed, the morfoplasty has been developped upon a Enow How which allow to use solid silicone in vast facial areas, by a previous project, where the final veredict is given by the patient itself. It is important to make It clear that the mate rial used in morfoplasty is solid silicone. Such a fact is specially important since the use of solid silicone is well known and accepted in medicine all over the world, even that its use is already wide and with atten dance post-operating since a long date.

In other hand, exists the liquid silicone, that's also known since a long date, like those prejudicial consequences for the human organism, and in many developped countries the use of liquid silicone is TERMINATIVELY FORBIDDEN, in function of laboratoy studys which prove this prejudicial consequences. As, for example, the PDA (Pederal Drugs Administrations), american organism that's controls the use and coomercialization of the drugs in the United States of America, forbid the use of liquid silicone in the whole territory' od that country. But why this war against the liquid silieone? The liquid silicone, when injected in a human' organism, it dwells in the soft tissues, like muscles, cellular sub-cutaneous, etc., and besides to cause one reaction away from the control of the medico which had prescribed, is partially fageceous with the blood's cell (they pass to the interior of that cells) and they finished deposited in kidney, brin, lungs, and in all the organism's organs, wi th micron-lesions in those organs. These micron-lesions are accentuated with the continuous use of the liquid silicone, as to cause lesions of great risk in the receiver organism. Besides this fact, are relatively frequents bigs ulcerations and with hard consequencies to the place that received the injection.

Such a fact is very divulged in medician literature specialized and a lot of disastrous results are exposed in medician congress. This notion is of a FUNDAMENTAL IMPORANCE , as a public explanation, since we are today, passing by through one fase of restart the consumption the liquid silicone.

This fase of restart the consumption the liquid silicone which has been used in a large scale in many patients, can take to the action with unexpected consequences to the population, in the anxiety to solve their problems of esthetic order, parallelly to the fact that they have not the necessary Informations, they throw in the combative technics and forbidden by the in ternational medician comunity. So, the MORFOPLASTY using technics usually accepted, substitute the use of liquid silicone, with a large and previous study, without risks more than the risks knowing by everybody. Since We know of the unsuccess of using liquid silicone in live organs we have developped our Know How of silicone used in morfoplasty from a product made by Dow Coming called: 382 Medical Grade Elastromer. That silicone comes in form of gel that is mixed to the catalizer agent which is also furnished by Dow Corning and dryes up taking the sahpe desired by the surgeon.

Before we enter directly in the description of the method of the moulding used, we have to make a general abstract thats what exists today in commer ce with relationship with the solid silicone that we can use for inclusions in a face. Of the own Down Corning, we have prosthesis, of the kinds: the solid si licone prosthesis, in four sizes: small, medium small, medium and large, and we have either the prosthesis cal led gel filled in three sizes; as follows: 3 mm., 5 mm. and 7 mm. We have of the Dow Corning, the prosthesis for the implantation of the nasal bone, that are prefabricated in three sizes, as follows: small, medium and large. There are also the silicone blocs, which havent's any definitive shape and they are able to furnish pieces which have to be sculptured by the surgeon.

Of a French manufacturer, we have implantations for the chin, in four sizes, classified, as follows: 1, 2, 3 and 4. There are also implantations for chin denomined by the catalog of the own representative:pre-full chin, which by order, cames in every size. / There are the implantations for noses, small and large, implantations for malar bone, zigomatics prosthesis and silicone blocs. That are the products that are in commerce today and besides having the size predeterminated and determinated by the manufacturer, and they are only for the chin malar and zigomatic. As you can tell, we focus the whole face, which with this technical knowledge receives any quantity of solid silicone, of type 382 Medical Grade Elastromer and in any facial area. So, after the morfoanalyses and morfograma, is doing a analyse of each point of the face, under the esthetic prism with the correction of the negatives extremes and the suggestions of a new face is made to the patient by the apposition of plaster in compress in the diagnostic regions. This plaster could be placed in the frontal area (completely or partially) in the tempo ral fossaes, could be a combination of both regions, and also expanded to the nasal dorsum with relation to the superior third. In the midle third, the plaster can occupy the wall before the maxilla, zingomatic an gle and the zingomatic region, and be of various size, in function of the necessity. In the inferior third, the plaster can be placed in the mandibule and in the horizontal ramus of mandibule so as getting to the angle of the mandibule. Note that, evidently, this plaster is placed on the skin of the patient defining the new countours of the patient's face.

It can be putting in isolated regions, if the necessity asked for, and putting in all those said regions, depends of each study face. Once dried and made up with a skin color base, it is different re gions in order to measure its in those different areas. Once these measurements are taken, they have to be respected in order to make the prosthesis, which after be' ing place must reproduce exactly the shapes obtained wlth the plaster.

This plaster clearly, by its various shapes, sizes and thicknesses, thar we cannot use those prefabricated prosthesis existing on the coomerce, since not only they are limited to the chin, malar and maxilla but have predetermined sizes and shapes. In order to make the prosthesis, we use various ways: FIRST : - When we analyses the patient ' s face , we measu re the basic size of the face and based on those measurements we choose a human cranium which looks like our patient's, not only by the measurements but also by the shapes (for someone who knows about anatomy, such a thing is not difficult).

Then, this cranium is washed and scraped, in order to have it very clean. If we wish, for example, an inclusion in the maxilla and in the whole chin, evi dently we make the prosthesis for those areas only. We mix the components of 382 Medical Grade Elastromer, as specified by the manufacturer, we mix then well and wait for the beginning of the vulcanization of the gel. In this moment, the gel is placed on the maxilla and chin of the cranium and, with a spatula, we spread the silicone in the desired areas, in order to get as close as possible to the thickness of the plaster. We wait for a complete vulcanization of the silicone and with the help of a needle, we prick the silicone in all its extension and we measure the thickness in each different area. In this position of the silicone, we do not worry about the holes from where the infra-orbiral and mental nerves emerge which are covered by gel in vulcanization. Once the measurements of the whole silicone is taken, we know if the thickness we have is enough or not. If it's not enough, we prepare new quantities that are put ever the already spread one while stil in the gel phase, for a perfect adherence with the already vulcanized silicone previously spread. We measure again the thickness by the described method and always trying to get more /- thickness than the ones indicated in corresponding regions of the plaster. In order to obtain the exact desired thickness, we start roughing it out with a knife in such a way that we obtain the right thickness in the right areas of the plaster. So, we have a prosthesis that once included, will give, once applied in the pa tient's face, the shape of the plaster.

Once, our prosthesis is prepared, stil on the cranium used as base, we make the necessary roughing out for the fitting in the vascular nervous plexus, which are respected during surgery. Once our prosthesis ready, it is removed from the base and it has the desired sizes, extentions and shapes and can occupy the whole front wall of the maxilla, with the fitting in "U" for the infra-orbital nerve, the zingo matic bone, and the right and left zingomatic arches. For the mandibule, we repeat the same process of molding and the prosthesis of the mandibule could be limited to the chin, has the size of the chin and horizontal ramus of the mandibule, the mandibule angle and same ascencing ramus of the mandibule. When we need one single piece for the mandibule, that one piece is made with all. the described segments. For the temporal fossae, we use the same method, modeling a prosthesis from the lateral orbital ring and occupying the necessary area and previously detected in our pre operatory studies, in the indicated thickness. For the frontal region, the same method already described can be used, with the molding of the prosthesis doing over the frontal region of the based cranium (the same of the moulding).

For the frontal region, can be utilized another method of prosthesis moulding, when the prosthe sis could reach also the nasal-dorsum, mainly in the correction of the forms of the glabellae, nasal base and nasal dorsum. In such cases, an acrylic mask of the patient's face is made, in the following way: We put liquid vaseline over the face to be molded, we spread any molding material used by dentists for dental fixtures. We could use alginato, for example. Two straws are put in the patient's nasal orificies for his breath ing and the molding material is applied all over the fa ce when stil soft. We wait for it to dry and soon after we spread some plaster on the outside surface. When the molding material and the plaster are all dried up, we take this set off, which has the patient's face all mark ed up in negative. Once we have that mask in negative in hand, we prepare the plaster or the acrylic or another molding material, and it is applied stil soft and humid in the negative, until it dryes up completely and takes the shapes of that negative. Once dryed, this material is removed from the set that had the impressed negatives, and we have, then, an exact replica of the patient's face. With that replica, the molding of the prosthesis of the frontal area and nasal dorsum can be made. We 11 mit our molding in this type of masks to the frontal and nasal dorsum, because those areas have little thick ness of soft tissues over the bonestructure and the ana tomical bone variations are very big, mainly when we ha¬ve to make inclusions in people of different ethnic /- groups. Wherever it is placed, whether it's on the era nium, on the maskm the molding technic is the same and follows the same principles.

With these technics for molding prosthe sis, we have done and placed prosthesis in the following areas: 1) Frontal bone.

2) Temporal region (temporal fossaes). 3) Frontal region more glabellae.

4) Anterior wall of maxilla.

5) Anterior wall of maxilla more zingomatic bone. 6) Anterior wall of maxilla, more zingomatic bone and zingomatic arch.

7) Canina fossae.

8) Incisive fossae.

9) Chin. 10) Chin more horizontal ramus of mandibule. 11) Chin more horizontal ramus of mandibule, and angle of mandibule. 12) The same of 11 more ascendant ramus of mandibule. In the mandibule, as in the maxilla, are doing the enca sements of the mentoniano nervus, in shape of "U", just to discharge the forame metodiano.

SECOND: - Instead of molding the prosthesis using direc tly the silicone over the bone, as described, we use a molding material, like optosil, or anyother material for molding and we mold what will be the desired prosthesis like the description of the first mathod, with this ma terial, having a exactly form desired for the prosthesis. Once having this material in hands, with the desired sha pe, we use a muffle (recipient of the solid walls for receive material in its interior, with plaster or acrylie) which will be fulfilled with material like plaster or acrylic, which have to be putting until occupying onepart of this muffle. This material must to be putting in the begin of the fase of rigidify, the optosil, or any other material of molding used, but already with the prosthesis form desired is putting and partially immersed in the plaster or acrylic, just to leave the same giving the exacts contours of the desired piece. Then, we have a material face of molding (plaster or acrylic) dry, with the optosil or anyother corresponding material, which has the shape of the prosthesis desired parti ally immersed and partially salient of the surface of plaster or acrylic. We pass then, a thick camade of vaseline over all that surface and we complete than all fulfilling of the muffle and the complete immersion of optosil, or corresponding material. We wait the complete drying of this new face and then we took the set of the recipient and the two drying fases which determinates the two pieces which separeted between them, having the negative optosil used like a copyer of the prosthesis shape. The optosil, or corresponding material is taken off and a residual hole have the exact form of the desired prosthesis. This hole is filled of silicone al ready in the gel phase. In both faces and everything is putting under comprehension, until complete silicone vulcanization. In the plaster fase or the acrylic for the formation of the hole with a desired shape, as the silicone vulcanization, must be used a vibrator, in order to complete the withdrawing of the air bubbles of all the used materials. After the complete silicone vulcanization inside the space made by the optosil inside the plaster, the two faces of the plaster or acrylic are separeted and we have the prosthesis ready and in the desired shape in order to be included. THIRD: - A replica is done of the desired prosthesis, as described in the second method and the piece is molded, so it is immersed in metal with a low fusion point, the bronze, as example and after the metal drying, this is sectioned in the midle, the used material for the molding is eliminated and we have, in the metal, the hole for the prosthesis, as described in this method. Once, the prosthesis are ready, they are sterilized as the ma nufacturer's specifications and then ready for inclusion in human beings. For the upper part of the face, we use a coronary incision, with undermining sub-perios teum for the front part until the upper orbital ring.

If the inclusion of the prosthesis reaches the ring and could have a possibility of compression of the supra-or bital nerve, this is taken off its forame by on osteoto my or the portion that separates it from the orbit, or then, during surgery a "U" is made to fit the prosthe sis into the nerve . The undermining in the temporal fos saes is made on fascia of the temporal muscles. Por the inclusion in the front area the fixation of the prosthe sis to the bone, we make a hole in the bone at the upper orbital ring, bilateralt for the fixation of the prosthe sis with thread Mononylon 2-0. If the inclusion were to reach the nasal-dorsum, the undermining subperiosteum proceeds by the same access way to the nasal dorsum and, if necessary, go down to the level of the nasal point, separating at this level, the skin that covers the nasal dorsum. If the inclusion has to lift up the nasal dorsum to a reasonable amount, we make a vast undermining of the periosteum of the orbit, so that we get a better space and a better sliding of the periosteum and soft tissues, without exagerated tension over the included prosthesis. Should it also be necessary to make an inclusion for the prosthesis in the temporal fossaes, we make incisions near the temporal lines and, with an elevator, we extract the temporal muscles from their beds, up to the necessary area in order to get a perfect accomodation of the prosthesis. The prosthesis are accomodated in the desired positions, generally accomodating in the side orbital ring and cover up by the muscle, which is sutured in its own bed sheltering the prosthesis in the space between the bone and the lifted muscle. The front cut is then put back in its original place, with the prosthesis giving the previous ly desired contours, which werefigured out with the plaster. We sutured the skin and apply a bandage compressing, moderately. We leave no drainage. MEDIUM THIRD OF THE FACE:

For the medium third of the face, we make an upper vestibular incision, feeling the tip of the bistoury reaching the bone. This vestibular incision can start from the canina incisive group up to the premolar group or even the anterior molar group, depending upon the need. Then, a sub-periosteum is done, with an elevator, of the whole anterior maxilla wall, being carefull to maintein intact the infra-orbital nerve. If need be, this under mining goes to the zingomatic bone area, following the same plan up to the zingomatic arch. If necessary, the under mining reaches also the lateral orbital ring always respecting the sub-periosteum clivage plan.

Once we have the space ready for the in elusion of the prosthesis, bilaterally, these are inclu ded in the convenient space provided. Por a better fixa tion of the prosthesis, we use a deverdin needle which is introduced through the skin, right over the zingomatic arch, until its extremities become present in the space created by the superior vestibular incision, pass ing under the zingomatic arch. We fix it, at its end, to a Mononylon 3-0 thread and we traction that needle, until we feel its point go over the zingomatic arch and we exteriorized it again inside the cavity where the prosthesis will be adapted. We have, then, a nylon /- thread going under the zingomatic arch and with both ends free, one under the arch and the other on the top. The prosthesis are then introduced and the ends of the thread are tied over the prosthesis in such a way that they are fixed to the zingomatic arch. Sometimes, it is necessary to fracture the prosthesis in order to get a better adaptation to the anterior maxilla wall.

The suture stritches are done in two plans, in the periosteum, we use Mononylon 3-0 and in the mucosae, we use Dexon 4 or 5-0 thread. We leave no drainage. For the inferior third, of the face, we use also an intra-oral incision and inferior vestibular, up to the inferior canina areas. The incision is made up to the periosteum level and we make a sub-periosteum under mining of the whole chin. The undermining follows by the horizontal ramus of the mandibule, without any other incision, avoiding the mental forame, respecting the mental nerve. When the inclusion of the prosthesis has to go up to the mandibule angle, we complete with intra-oral incision, in the mandibule bone which is located in the angle of the oral face and we go with that incision laterally up to the last molars, always having the end of the bistoury leaning on the bone surface. We proceed with the undermining of the external face of the mandibule angle, with the help of an elevator, until we reach the external angle of the mandibule, in order to extract completely the masseter muscle of the mandibule. After this undermining, we use a specially designed elevator for the estraction of the periosteum of the inferior fa ce of the mandibule. If need be, we lead the inicially described undermining, done by the vestivular Incision in order to get the whole mandibule undermined from its periosteum anteriorly and laterally. The undermining goes up where it is necessary to make the Inclusion of the prosthesis, which is made by the vestibular incision intercanina and the end of the prosthesis reached all the way to the mandibule angle and is fitted In the right position. Once the conveniente flexibility is given in the used material, we start the introduction of another extremity in its side, by the opposite extremity of the inter-canina vestibular incision, until the encasement of the prosthesis extremity in the correspondent angle. we have, then, the prosthesis adapted in its correct po sition. In order to eliminate the possibility of altera tions in the size between the prosthesis and the receptive mandibule, we maintain both end of the prosthesis fitted in their position and we measure the eventual excess of the prosthesis, by the chin incision. We, then, make an incision in the chin level of the prosthesis and we dry up the excess which is visible and wesure the prosthesis with Mononylon 3-0 thread. The plans are sutured with Mononylon 3-0 at the periosteum level andthe mucosae is sutured with Dexon 4 or 5-0. We leave no drainage. After the incision of the prosthesis in their positions, we can through the patient's protographs and the studies made with the plaster, evaluate our margin of mistake, which has not oscilated over 5% between the obtained result and the programming. As far as post-operatory, with a two years follow-up, we have seen that the capsule that co vers the silicone is strong enough to suport the reinsertion of the chewing musculate, whether It's the tem porae muscle of the Masseter muscle and there is no va riation in the position of the prosthesis, whether rela xed or while chewing.

The size and thickness of the prosthesis vary in each case, depending upon the esthetical need of eachone. We have reached a meximum thickness of 15 mm., for a minimum of milimeter, when the prosthesis ends in a light contour (as almost always).

The silicone 382 Medical Grade Elastomer is proper for all described, in function of its fie xibility and its low specific weight. We don't believe that anyother silicone, with vulcanization that are sold in blocs can adapt in the same way like 382, in the differents curvatures and anatomies shades of which region includes even with a conscience that the prosthesis are molded over a like maxilla, and is almost possible thats in a simple sculpture in the blocs can give all the caracteristics of one face of maxilla, or mandibule, or even frontal.

Claims

C L A I M S

1. "MORFOPLASTY", that, after the morfoanalyse and the morfograma, is doing one analyse. of which point of the face, over the esthetical prism, characterized with the fact that the plaster is putting in the frontal region (completely or in part) in the temporal fossae, with a combination of both regions, expanding also to the nasal dorsum, with relation to the superior third, and in this part the plaster can occupy the anterior maxilla wall, the zingomatic angle and the figomatic region and have differents sizes, and in the Inferior third the plaster can be putting in the chin; in the chin plus horizontal mandibule ramus, and can reach its angle.

2. "MORFOPLASTY", in accordance with the claim 1, charac terized by the plaster, maked up with skin base, is taking off the face and perforated with a meedle in differents regions in order to be measured the thick ness of the same, and once done this measures must be repeted for the prosthesis confection, and after their inclusion, must exactly reproduce the obtained shapes with the plaster apposition.

3. "MORFOPLASTY", in accordance with the claims 1 and 2, characterized by the fact of, in the prosthesis doing, are mixed up the compounds of 382 Medical Grade Elas tomer and be kept the moment of the started the vulca nization of the gel, which is superposed in maxilla and in the mandibule of the cranium previously chosen and with a spatula spread the silicone in vulcanization in the desired regions, in order to have a thick ness mearly possible like that defined by the plaster.

4. "MORFOPLASTY", in accordance with the claims 1,2 and 3, characterized by the fact of, in order to reach the exactly thickness desired, we start to cutt off with a bistoury, in order to give the desired coun tours in the prosthesis, until to reach the desired thickness in the correspondents points in the plas ter, and when its finished will be with a shape near ly by one that was reached in the plaster, when apl lied over the patient's face.

5. "MORFOPLASTY", in accordance with claims 1,2,3 and 4, characterized by the fact of, once prepared the prosthesis, over the cranium used as molding base, are doing the necessaries cut off to the mortises in the vascular-nervous, which are respected during the surgical act, and once ready the prosthesis, the same is detached of the based cranium and has the dimensions, extensions and desired shapes and can occupy all the anterior maxilla wall, with the mortises in "U" for the infra-orbital, zigomatic bone and zigomatic arch right and left.

6. "MORFOPLASTY", in accordance with claims 1,2,3,4 and 5, characterized by the fact of, in the frontal region, when the prosthesis must to reach also the na sal dorsum, mainly in the correction of the forms of the glabellae, nasal base and nasal dorsum, an acrylic mask of the patient's face is made and we pass liquid vaseline and over the same is spread anyother molding material and stil use alginato.

7. "MORFOPLASTY", in accordance with claims 1,2,3,4,5, and 6, characterized by the fact that two straws are put in the patient's nasal orificies for his breathing and the molding material is apply all over the face when stil soft, and after its drying and we spread a little of plaster in the outside surface and once completely the material drying of molding-plaster, we take this set off, which has the patient's face all marked up in negative.

8. "MORFOPLASTY", in accordance with claims 1,2,3,4,5,6 and 7 characterized by the fact that, once we have that mask in negative, we prepare the plaster, for molding, or acrylic or anyother molding material, the same is applied stil soft and humid in the negative, until its dryes up completely and takes the shape of that negative, and once dryed, this material is remo ved from the set which had the impressed negative and consequentely, the exact replica of the patient's fa ce.

9. "MORFOPLASTY", in accordance with claims 1,2,3,4,5,6, 7 and 8, characterized by the fact that instead of molding the prosthesis using directly the silicone over the bone, we use a molding material, like the optosil, or anyother material for molding, and that will be the exact desired shape for the prosthesis, and after that is used a muffle which will be fulfil led with plaster or acrylic material, which have to be putting until occupying one part of this muffle and this material must to be put of the vulcanization of the optosil, or anyother material, of the used mol ding, with the shape of the desired prosthesis, and it is immersed partially in plaster or acrylic.

10. "MORFOPLASTY", in accordance with claims 1,2,3,4,5,6, 7,8 and 9, characterized by the fact once done the replica of the desired prosthesis, the molded piece will be Immerse in metal with a low fusion point, like the bronze, and after its drying this is sectioned in the middle, the used material for molding is eliminated and than we have in the metal, the ho le for molding of the prosthesis.

11. "MORFOPLASTY" characterized by the fact that for the surgery of the upper third of the face, we use a co ronary incision, with undermining sub-periosteum for the frontal region, until the upper orbital ring and if the inclusion of the prosthesis reaches the ring and could have the possibility of compression of the supra-orbital nerve, this Is taken off its forma by on osteotomy of the portion that separates it from the orbit, or then during the surgery a "U" is made to fit the prosthesis into the nerve, and the undermining in the temporal fossaes is made on fascia of the temporal muscles.

12. "MORFOPLASTY" in accordance with claim 11, characte rized by the fact of for the inclusion in the front region the fixation of the prosthesis to the bone, we male a hole in the bone at the upper orbital ring, bilateralt for the fixation of the prosthesis with thread Mononylon 2-0 and if the inclusion were to reach the nasal-dorsum, the undermining sub-periosteum proceeds by the same access way to the nasal dorsum and, if necessary, go down to the level of the nasal point, separating at this level the skin that covers the nasal dorsum.

13. "MORFOPLASTY", in accordance with claims 11 and 12, characterized by the fact that for the inclusion of the prosthesis in the temporal fossaes, we make inci sions near the temporal lines and with an elevator we extract the temporal muscles from their beds, up the necessary area in order to get a perfect accomo dation of the prosthesis which generally accomodating in the side orbital ring and cover up by the muscle, which is sutured In its own bed sheltering the prosthesis in the space between the bone and the listed muscle.

14. "MORFOPLASTY", in accordance with claims 11,12 and 13, characterized by the fact that for the medium third of the face, we make an upper vestibular inci. sion, feeling the tip of the bistoury reaching the bone. This vestibular incision can reach from the canina incisive group up to the pre-molar group or even the anterior molar group, depending upon the need. Then, a sub-periosteum is done, with an eleva tor, of the whole anterior maxilla wall being cara ful to maintain intact the infra-orbital nerve.

15. "MORFOPLASTY", in accordance with claims 11,12,13 and 14, characterized by the fact that for better fixation of the through the skin, right over the zingo matic arch, until its extremities become present in the space created by the superior vestibular incision, passing under the zingomatic arch, and we fix it, at its end, to a Mononylon 3-0 thread and we traction that needle, until we feel its point go over the zin gomatic arch and we esteriorized it again inside the cavity where the prosthesis will be adapted. We have, then, a nylon thread going under the zingomatic arch and with both ends free, one under the arch and the other on the top.

16. "MORFOPLASTY", in accordance with claims 11,12,13,14 and 15, characterized by the fact that for the inferior third of the face, we use an intra-oral incision and inferior vestibular, up to the inferior canina areas. The incision is made up to the periosteum le vel and we make a sub-periosteum undermining of the whole chin, the undermining follows by the horizontal ramus of the mandibule, without any other Incision, avoiding the mental forame, respecting the mental nerve.

17. "MORFOPLASTY", in accordance with claims 11,12,13,14, 15 and 16, characterized by the fact that when the in elusion of the prosthesis has to go up the mandibule angle, we complete with intra-oral incision, in the mandibule bone which is located in the angle of the oral face and we go with that incision laterally up to the last molars, always having the end of the bis toury leaning on the bone surface, and we proceed with the undermining of the external face of the man dibule, with the help of an elevator, until we reach the external angle of the mandibule, in order to extract completely the masseter muscle of the mandibule.

18. "MORFOPLASTY", in accordance with claims 11,12,13,14, 15,16 and 17, characterized by the fact that after this undermining, we use a specially designed elevator for the extraction of the periosteum of the infe rior face of the mandibule, in the ascendent, as in the angle and horizontal face of the mandibule, in order to get the whole mandibule indermined from its periosteum anteriorly and laterally.