Restoration of facial contour in Romberg's disease and hemifacial microsomia: experience with 118 cases

Physiopathologic Bases of Moebius Syndrome: Combining Genetic, Vascular, and Teratogenic Theories

Moebius syndrome (MBS) is a congenital cranial dysinnervation disorder (CCDD) characterized by a bilateral palsy of abducens and facial cranial nerves, which may coexist with other cranial nerves palsies, mostly those found in the dorsal pons and medulla oblongata. MBS is considered a "rare" disease, occurring in only 1:50,000 to 1:500,000 live births, with no gender predominance. Three independent theories have been described to define its etiology: the vascular theory, which talks about a transient blood flow disruption; the genetic theory, which takes place due to mutations related to the facial motor nucleus neurodevelopment; and last, the teratogenic theory, associated with the consumption of agents such as misoprostol during the first trimester of pregnancy. Since the literature has suggested the existence of these theories independently, this review proposes establishing a theory by matching the MBS molecular bases. This review aims to associate the three etiopathogenic theories at a molecular level, thus submitting a combined postulation. MBS is most likely an underdiagnosed disease due to its low prevalence and challenging diagnosis. Researching other elements that may play a key role in the pathogenesis is essential. It is common to assume the difficulty that patients with MBS have in leading an everyday social life. Research by means of PubMed and Google Scholar databases was carried out, same in which 94 articles were collected by using keywords with the likes of "Moebius syndrome," "PLXND1 mutations," "REV3L mutations," "vascular disruption AND teratogens," and "congenital facial nerve palsy." No exclusion criteria were applied.

Treatment of Progressive Hemifacial Atrophy by Cartilage Graft and Free Adipofascial Flap Combined with Three-Dimensional Planning

BACKGROUND

Progressive hemifacial atrophy (PHA) is a rare disease characterized by progressive atrophy of skin, soft tissue, muscles, and underlying bone structures. For severe PHA patients with obvious bone deformities, skeletal framework reconstruction is needed in addition to soft-tissue augmentation. The authors propose a new combinatorial surgical method using rib cartilage graft and free adipofascial flap for restoring facial symmetry. To improve the surgical accuracy, preoperative three-dimensional planning and printing was used.

METHODS

Twelve patients with severe facial atrophy were included in the authors' study. Three-dimensional facial image analyses were performed preoperatively to quantify the facial asymmetry. Rib cartilages were harvested and sculptured to the appropriate shape created by three-dimensional planning and fixed to the atrophic bone. The circumflex scapular artery-based adipofascial flap was transplanted to repair soft-tissue deficiency. A residual small monitor flap was left with the adipofascial flap. A revision surgery was performed to perfect the repair if the contour was suboptimal 6 months postoperatively.

RESULTS

The adipofascial flaps survived in all 12 patients. All patients achieved good healing without complications. At 1 more year after surgery, the rib cartilage was still in position and rarely absorbed. The morphologic and volumetric difference between the affected side and the unaffected side was improved significantly postoperatively. All patients were satisfied with the results, and no more additional operations were required.

CONCLUSION

The combinatorial surgery of rib cartilage graft and free adipofascial flap in the setting of three-dimensional planning and printing can be a good choice in restoring facial symmetry in severe cases of PHA.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Application of free serratus anterior muscle-fascial composite tissue flap and facial lipofilling in repairing progressive hemifacial atrophy

INTRODUCTION

Progressive hemifacial atrophy (PHA) is a nonnegligible disease, and its treatment currently lacks consensus. We aim to conduct an analysis of PHA patients to summarize the postoperative effect. Moreover, we introduced the free serratus anterior muscle-fascial composite tissue flap as a safe and novelty surgical procedure for moderate-severe PHA.

METHODS

This clinical study included four patients who received a free serratus anterior muscle-fascial composite tissue flap and 19 patients who received Coleman fat transplantation. Preoperative (preoperative photograph and imageological examination) and postoperative (postoperative photograph, complications, therapeutic effect, and satisfaction) assessments were performed for all PHA patients. Body Image Concern Inventory (BICI), Self-rating Anxiety Scale (SAS), Self-rating Depression Scale (SDS) were performed preoperatively and postoperatively.

RESULTS

All the cases were cured with a good appearance with two kinds of operations. Free serratus anterior muscle-fascial composite tissue flap could correct face defects in one surgery and achieve good long time and short-time postoperative satisfaction in moderate-severe PHA. Fat transplantation could also enhance appearance in numerous operations for mild-moderate PHA. The volume of free-fat grafts decreased obviously after implantation in many cases. So, many patients (42.11%) accepted a series of operations to achieve satisfied postoperative effect. BICI, SAS, SDS score decreased a year later in all patients.

CONCLUSION

Free serratus anterior muscle-fascial composite tissue flap transplantation is an effective and safe treatment for moderate to severe PHA.

Reconstruction of the orbitozygomatic framework: State of the art and perspectives

The reconstruction of the whole orbitozygomatic framework (OZF) is complex and can be encountered in cases of congenital midface deformity, after tumor ablative surgery and in severe facial trauma. Nowadays, surgeon has a wide range of available techniques that have continually grown over the past years, optimizing the surgical management and the aesthetical outcomes. Among them, the autologous bone graft (ABG) remains one of the most suitable options : ABG is easy to harvest and has optimal biological properties for bone healing. It can be tailored to the patient anatomy thanks to the recent advances in computer-assisted surgery. However, substantial drawbacks remain such as the early resorption of the non-vascularized graft, the need of a donor site and its potential morbidity. Alloplastic reconstruction is another option that can resolve both the resorption issue and the donor site morbidity. Moreover, the 3D-printing technologies also allows the manufacturing of patient specific implants. However, alloplastic materials have a variable success, especially due to the high risk of infection or exposure. Consequently, regenerative medicine is a promising field that aims to find a procedure without the disadvantages of ABG or alloplastic based reconstructions, but displaying similar or even higher success rate. Indeed, recent tissue engineering strategies have demonstrated encouraging results for bone regeneration using natural or synthetic biomaterials, patient cells and synthetic bioactive substances. The objective of this review is to present the etiologies of OZF defect, the available reconstruction procedures as well as the current state of the research.

Measuring asymmetry in facial morphea via 3-dimensional stereophotogrammetry

BACKGROUND

Objectively determining tissue loss in craniofacial morphea is challenging. However, 3-dimensional (3D) stereophotogrammetry is a noninvasive modality that may be a useful adjunct.

OBJECTIVE

To prospectively evaluate 3D stereophotogrammetry in the assessment of craniofacial linear morphea.

METHODS

Participants underwent clinical, quality-of-life, and 3D-stereophotogrammetry assessments. Traditional photographs and 3D-stereophotogrammetry images were rated as mild, moderate, or severe by 2 experts and 2 nonexperts. In addition, interrater and intrarater reliability (on delayed rescoring) were calculated.

RESULTS

Of 23 patients with craniofacial morphea, 3D stereophotogrammetry detected pathologic asymmetry in 14 (20.6%) patients. Providers rated patients as more severely affected when using 3D stereophotogrammetry versus when using traditional photographs (19% severe on 3D stereophotogrammetry vs 0% severe on traditional photographs, P = .004). Qualitative ratings of both traditional and 3D images showed high inter- and intrarater reliability between experts and nonexperts alike. Physicians' Global Assessment of Damage scores correlated with mouth asymmetry (P = .0021), cheek asymmetry (P = .04), and 3D-stereophotogrammetry ratings (median, mild: 27.5 vs moderate: 46.5 vs severe: 64, P = .0152). Lower face asymmetry correlated with worse quality-of-life scores (P = .013).

LIMITATIONS

Small sample size and cross-sectional design.

CONCLUSION

3D stereophotogrammetry can reliably detect and quantify asymmetry in craniofacial morphea with greater sensitivity than that observed with traditional assessment alone. 3D stereophotogrammetry may be a useful adjunct to clinical examination.

"Soft Tissue Reconstruction in Progressive Hemifacial Atrophy: Current Evidence and Future Directions"

BACKGROUND

Progressive Hemifacial Atrophy (PHA) is a rare disorder characterized by gradual unilateral soft tissue atrophy in the face, which may also include clinically significant degeneration of underlying muscle and bone. In recent years, there has been a growing body of evidence regarding different soft-tissue reconstructive strategies in PHA, and the impact of intervention timing on disease progression. This article provides a comprehensive synthesis of the latest evidence in order to guide optimal management.

METHODS

A comprehensive multi-database search was performed through April 2020 using relevant search terms to identify clinical studies. Outcomes, complications, disease- and patient-related indications pertaining to different soft-tissue reconstructive strategies in PHA were collected and critically appraised.

RESULTS

35 articles reporting on a total of 824 PHA patients were evaluated; 503 (61%) were managed by microvascular free flaps, 302 patients (37%) were managed by autologous fat grafts, and 19 (2%) by pedicled flaps. A detailed synthesis of outcomes is presented herein, as well as a comparative evaluation of different microvascular free-flap options.

CONCLUSION

Soft-tissue reconstruction in PHA remains an evolving field. Operative decision-making is often multifaceted, and guided by specific volumetric, aesthetic and functional deficiencies. Serial fat grafting is the primary modality utilized for patients with mild soft-tissue atrophy, while microvascular free flaps widely remain the treatment of choice for reconstruction of large volume defects. There exists a growing role of graft supplementation to improve fat graft survival, while recent evidence demonstrates that early intervention may help curb disease progression.

Progressive hemifacial atrophy with characteristic ocular manifestations in a Chinese patient with a CRB1 mutation

Progressive hemifacial atrophy (PHA) is mainly characterized by asymmetrical atrophy of craniofacial tissue; however, 10% to 30% of patients with PHA exhibit ocular manifestations. Here, we describe abnormal ocular findings in a Chinese patient with PHA. The patient was a 29-year-old Chinese man. Characteristic ocular findings in his affected eye included keratic precipitate, corneal endothelial degeneration, fundus tessellation, pupillary dilation, direct light reflex loss, and visual evoked potential alteration. Whole exosome sequencing revealed that the patient harbored a mutation in the CRB1 gene; this gene has been associated with various retinal dystrophies. During 10 years of follow-up, the patient’s ocular status remained stable. To the best of our knowledge, this is the first report of ocular manifestations of PHA in a Chinese patient, and the first report of a CRB1 mutation in a patient with PHA; these findings may inform future research regarding PHA.

Frequency and Management of Craniofacial Syndromes

BACKGROUND

Craniofacial syndromes occur in approximately 1 in 5600 to 100,000 infants, often resulting in significant morbidity. Due to the heterogeneity of this patient population, no clear consensus consists on optimal treatment modalities and timing. The aim of this study was to analyze the craniofacial syndrome population that were treated at the University Hospital Leuven.

METHODS

A retrospective analysis of patients with a clinical diagnosis of a craniofacial syndrome was performed. Inclusion criteria were patients with a clinical diagnosis of a craniofacial syndrome and that received treatment between "2000-2005" and "2010-2015." Patients with nonsyndromic conditions were excluded. Data regarding patient characteristics, treatment modalities, and treatment outcomes were analyzed.

RESULTS

After matching the inclusion criteria, 98 eligible patients, affected by 40 different syndromes were included. In the period of "2000 to 2005," 48 patients were treated, as compared to 50 patients in the period of "2010 to 2015." A statistically significant decrease over time is seen for cleft surgery and orthodontic treatment (P = 0.0017 and P = 0.0015, respectively). No statistically significant differences were found concerning the age at which treatment was received (P = 0.42). Significant associations between treatment modalities were found for orthognathic surgery and distraction osteogenesis (P < 0.0001), orthognathic surgery and orthodontic treatment (P < 0.0001), and between orthodontic treatment and distraction osteogenesis (P = 0.03311).

CONCLUSION

A decline in cleft reconstruction surgery and orthodontic treatment for patients with craniofacial syndromes was seen over time. A significant association was found between distraction osteogenesis and orthognathic surgery, possibly due to higher reintervention rates for patients treated at a young age.

Autologous Fat Graft for Soft Tissue Camouflage in Craniofacial Microsomia

INTRODUCTION

In India, a large majority of patients with craniofacial microsomia are unable to undergo complex reconstructions owing to unaffordability, lack of access to good craniofacial centers, or reluctance of parents to accept the surgical risk. There is also considerable social stigma attached to the resultant facial scars of surgery, especially in a girl child. Hence, we have explored autologous fat graft transfer as a "stand-alone" reconstructive option for soft tissue camouflage and aesthetic correction of facial deformity in unilateral craniofacial microsomia of Pruzansky-Kaban Grades I and II.

MATERIALS AND METHODS

Twelve patients who were seeking aesthetic correction of facial deformity in unilateral craniofacial microsomia of Pruzansky-Kaban Grades I and II, and who had adequate fat in the preferred donor sites of lower abdomen and antero-medial thighs, were selected. Patients with Grade III deformity, facial palsy, and previous skeletal surgeries were excluded. Autologous fat harvesting was done with the standardized Coleman's technique and injected after decantation. Volumetric augmentation was assessed by clinical comparison with normal side for facial symmetry, skin pinch thickness at four reference points, and by two-dimensional analysis of pre- and postoperative standardized photographs at periodic intervals.

RESULTS AND ANALYSIS

Eleven of our patients were female and one was a male (N = 12). In each session, 20-40mL (mean 28.75 ± standard deviation [SD] 5.69) fat was aspirated and 12-35mL (mean 23.67 ± SD 6.07) fat was injected. The average operating time was 35min (mean 32.91 ± SD 4.05). Majority of our patients needed three sessions (mean 2.8 ± SD 1.03) of serial fat injections to achieve bilateral facial symmetry. Increase in skin pinch thickness was 6.4167 ± 1.31 mm. The mean patient satisfaction score was 8.83 ± SD .717.

CONCLUSION

Based on our results, we conclude that autologous fat transfer, when used for soft tissue camouflage, is a versatile, easy, effective, and inexpensive method for obtaining consistent long-term aesthetic goals in mild to moderate cases of craniofacial microsomia.

Parry-Romberg syndrome treatment with fat transfer and a new bleaching formula

Parry-Romberg syndrome is a hemifacial atrophy which can be complicated by melasma. We present two cases of Parry-Romberg syndrome, treated by fat transfer and bleaching of the skin using a modified "Kligman's formula." The atrophy, as well as the skin dyschromia, improved, and the results were stable.

Dermal-Fat Graft for Facial Contouring in Patients With Craniofacial Microsomia

Craniofacial microsomia (CFM) is a variable craniofacial malformation, related to the development of the structures originated from the first and second brachial arches, affecting skeletal tissue, soft tissue, and neuromuscular components. In the situation of subcutaneous tissue and chewing muscles hypoplasia, free tissue transfer is a treatment option. Dermal-fat graft allows easy modeling during surgery, volumetric gain and improvement of asymmetry. The aim of this study was to evaluate the facial contour and the percentage of symmetry after the use of dermal-fat graft in patients with CFM, who had already submitted to osteotomies, attended at the Associate Center for Cleft Lip and Palate (CAIF) during 2001 to 2018. For analysis, the authors selected 17 patients who fulfilled the above prerequisites. The symmetry study was done by the analysis of preoperative and postoperative photographs in the Image J software. Two standard points were used: nasal base and upper lip limit. On the nasal base, the preoperative analysis showed a hypoplastic side with a median of 93.00% of the normal side size, rising to 97.78% in the postoperative period. On the upper lip limit, the preoperative analysis showed a median of 87.80% and, in the postoperative period, 98.15%. Analysis of the interaction between the operative moments and the modified Pruzansky classification showed that there were no significant differences between grades. Long-term evaluation demonstrated that the use of a dermal-fat graft for correction of facial symmetry was effective and close to 100%, regardless of the degree of hypoplasia of the patient.

Surgical Management of Progressive Hemifacial Atrophy With De-Epithelialized Profunda Artery Perforator Flap: A Case Report

Progressive hemifacial atrophy (PHA) is a rare disorder characterized by slow, unilateral atrophy of the soft tissues and bones of the craniofacial region. The defect becomes more pronounced with age, leading to esthetic and functional deficits. However, the proper timing and method of surgical reconstruction are still debated. The correction of this defect markedly influencing the quality of life of the patient can be achieved with less invasive to more invasive surgical approaches. A 21-year-old female patient with hemifacial atrophy and extensive alopecia presented to our clinic. Considering the body type and the expectations of the patient, a profunda artery perforator flap was applied for the reconstruction and esthetic improvement of the facial region. The facial asymmetry attenuated after the reconvalescence period. This case shows that in the up-to-date surgical treatment of severe PHA, the use of microvascular free flaps may provide a better approach when trying to achieve an acceptable esthetic result. This is the first time that a profunda artery perforator flap was used to restore facial asymmetry caused by PHA.

Lower limb onset Parry-Romberg syndrome: an unusual presentation of a rare disease

Parry–Romberg syndrome (PRS) is characterized by progressive degeneration and atrophy of the cutaneous, subcutaneous connective tissues, muscles and bones. Classically, PRS is restricted to unilateral face but in 20% of patients may extend to other parts of the body including ipsilateral or contralateral arms, trunk and legs. We report a case of 24-year-old male who presented with insidious onset, gradually progressive deformity and muscle wasting of right lower limb followed by right side of face and chest for 8 years. The right side of the face showed hemiatrophy, coup de sabre and deviation of nose and chin toward the same side. The magnetic resonance imaging showed atrophy of right lower limb. Computed tomography with 3D facial reconstruction revealed atrophy of facial bones on right side. He was managed with physiotherapy and symptomatic treatment and planned for facial and ankle reconstructive surgery on follow-up.

Parry-Romberg reconstruction: beneficial results despite poorer fat take

OBJECTIVE

For the treatment of Parry-Romberg syndrome or progressive hemifacial atrophy, we studied the volume retention and skin changes after autologous fat grafts within diseased regions.

SUMMARY BACKGROUND DATA

The long-term survival and volume retention of fat grafts used in soft tissue reconstruction of Parry-Romberg syndrome is still unknown, as are skin changes after fat grafting.

METHODS

Sex, age, severity of deformity, number of procedures, operative times, and augmentation volumes were recorded. Preoperative/postoperative 3-dimensional computed tomographic scans were also reviewed. A digital 3-dimensional photogrammetry system was used to determine "final fat take" and symmetry. Romberg fat grafting volumes were compared to nonaffected, cosmetic fat-grafted patients. For skin changes, a spectrophotometer was used to quantify percent improvement in melanin index. Physician and patient satisfaction surveys (5-point scale) were elicited, including overall outcome and skin color/texture.

RESULTS

The mean number of procedures correlated to the severity of deformity: mild, 1.8 procedures; moderate, 3.4; and severe, 5.2. With Romberg patients, fat grafting injected: per case, 48 mL; total, 188 mL; and final measured volume, 101 mL. Romberg patients had less "fat take" than nonaffected grafted patients (final take, 41% vs 81%). Skin color/texture showed 3-fold improvement after fat grafting procedures. The mean melanin index improvement seen in the diseased regions of Romberg patients after fat grafting was 42% (+3%). Skin color and texture improvement was also shown in patient surveys (preoperative = 2.4 + 0.06 to follow-up = 3.4 + 0.09) and physician (preoperatively = 2.1 + 0.1 to follow-up = 3.6 + 0.1).

CONCLUSIONS

Despite poorer fat graft take within the disease region of Romberg patients, fat grafting resulted in long-term improvement in hypoplasia and skin hyperpigmentation.

Localized scleroderma: clinical spectrum and therapeutic update

Scleroderma is a rare connective tissue disease that is manifested by cutaneous sclerosis and variable systemic involvement. Two categories of scleroderma are known: systemic sclerosis, characterized by cutaneous sclerosis and visceral involvement, and localized scleroderma or morphea which classically presents benign and self-limited evolution and is confined to the skin and/or underlying tissues. Localized scleroderma is a rare disease of unknown etiology. Recent studies show that the localized form may affect internal organs and have variable morbidity. Treatment should be started very early, before complications occur due to the high morbidity of localized scleroderma. In this review, we report the most important aspects and particularities in the treatment of patients diagnosed with localized scleroderma.

Combined maxillary and mandibular distraction osteogenesis in patients with hemifacial microsomia

INTRODUCTION

Hemifacial microsomia is a deformity of variable expressivity with unilateral hypoplasia of the mandible and the ear. In this study, we evaluated skeletal soft tissue changes after bimaxillary unilateral vertical distraction.

METHODS

Eight patients (4 preadolescents 4 adolescents) each with a grade II mandibular deformity underwent a LeFort I osteotomy and an ipsilateral horizontal mandibular ramus osteotomy. A semiburied distraction device was placed over the ramus, and intermaxillary fixation was applied. Anteroposterior cephalometric and frontal photographic analyses were conducted before and after distraction. Statistics were used to analyze the preoperative and postoperative changes.

RESULTS

Cephalometrically, the nasal floor and the occlusal and gonial plane angles decreased. The ratios of affected-unaffected ramus and gonial angle heights improved by 15% and 20%, respectively. The position of menton moved toward the midline. The photographic analysis showed a decrease of the nasal and commissure plane angles, and the chin moved to the unaffected side. The parallelism between the horizontal skeletal and soft tissue planes improved, with an increase in the affected side ramus height and correction of the chin point toward the midline.

CONCLUSIONS

Simultaneous maxillary and mandibular distraction improved facial balance and symmetry. Patients in the permanent dentition with fixed orthodontic appliances and well-aligned dental arches responded well to this intervention.

Parry-romberg syndrome: a linear variant of scleroderma with discoid lupus erythematosus on scalp - an association

Parry-Romberg syndrome is a rare neurocutaneous syndrome characterized by progressive shrinkage and degeneration of the tissues beneath the skin, usually on one side of the face. It is associated with neurological disorders such as trigeminal neuralgia, facial paresthesia, headache, and focal epilepsy. Concomitant occurrence of discoid lupus erythematosus (DLE) and morphea in the same skin lesion is exceptional, defined as overlap syndrome with two or more different connective tissue disease concurrently or consecutively. A 32-year-old female developed DLE on a long-standing lesion of scleroderma over left temporal area with characteristics histopathological changes. She was treated with oral antimalarials and steroids which halted the progress of the disease.

Total mandibular subapical osteotomy and Le Fort I osteotomy using piezosurgery and computer-aided designed and manufactured surgical splints: a favorable combination of three techniques in the management of severe mouth asymmetry in Parry-Romberg syndrome

Although its pathogenesis remains obscure, Parry-Romberg syndrome (PRS) has been associated with the linear scleroderma en coup de sabre. PRS is characterized by unilateral facial atrophy of the skin, subcutaneous tissue, muscles, and bones with at least 1 dermatome supplied by the trigeminal nerve. Facial asymmetry represents the most common sequela and can involve the soft tissues, craniomaxillofacial skeleton, dentoalveolar area, and temporomandibular joint. Although orthognathic procedures have been reported for skeletal reconstruction, treatment of facial asymmetry has been directed to augmentation of the soft tissue volume on the atrophic side using different recontouring or volumetric augmentation techniques. Total mandibular subapical osteotomy has been used in the management of dentofacial deformities, such as open bite and mandibular dentoalveolar retrusion or protrusion associated with an imbalance between the lower lip and the chin. Management of orthognathic procedures has been improved by the recent introduction of stereolithographic surgical splints using computer-aided design (CAD) and computer-aided manufacturing (CAM) technology and piezosurgery. Piezosurgery has increased security during surgery, especially for delicate procedures associated with a high risk of nerve injury. The present report describes a combined total mandibular subapical osteotomy and Le Fort I osteotomy using piezosurgery and surgical splints fabricated using CAD and CAM for the correction of severe mouth asymmetry related to vertical dentoalveolar disharmony in a patient with PRS.

Surgical techniques for smile restoration in patients with Möbius syndrome

Möbius syndrome is a congenital condition, the etiology when is not associated with misoprostol is not well defined. Signs and symptoms include difficulty swallowing, speech problems, drooling, strabismus, limitation of eye movement and more importantly, the facial blankness that these individuals have, result of the facial paralysis, due to atrophy of the cranial nerves that are involved in this condition. The ability to express emotions is affected and are considered “children without a smile.” There is currently no treatment to solvent the birth defects, the treatment options for reduce these alterations is the surgical option that has as main objective to restore muscle function through various techniques, used as required, the possibilities of applying them, is taking into consideration the outcome of the procedure to execute. Among the surgical techniques used mainly: the lengthening myoplasty of the temporal muscle,muscle transfers, cross-facial grafting, neurorrhaphy and nerve transposition, of which latter are the best performers, giving the patient a more natural, in as far as regards expression and function.

Key words:Möbius syndrome, surgery, smile, facial nerve, muscle transfer, transfer nerve, temporalis muscle.

Fat grafts supplemented with adipose-derived stromal cells in the rehabilitation of patients with craniofacial microsomia

BACKGROUND

Although first reports of the clinical use of adipose-derived stromal cells suggest that this approach may be feasible and effective for soft-tissue augmentation, there is a lack of randomized, controlled clinical trials in the literature. Thus, this study aimed to investigate whether a faster protocol for isolation of adipose-derived stromal cells and their use in combination with fat tissue improve the long-term retention of the grafts in patients with craniofacial microsomia.

METHODS

Patients with craniofacial microsomia (n = 14) were grafted either with supplementation of adipose-derived stromal cells (experimental group) or without supplementation of adipose-derived stromal cells (control group). The number of viable cells isolated before and after the supplementation of the grafts was calculated, and these cells were examined for mesenchymal cell surface markers using flow cytometry. Computed tomography was performed to assess both hemifaces preoperatively and at 6 months postoperatively.

RESULTS

The average number of viable cells isolated before and after the supplementation of the grafts was 5.6 × 10 and 9.9 × 10 cells/ml of fat tissue (p = 0.015). Flow cytometric analysis revealed that the adipose-derived stromal cells were positive for mesenchymal cell markers (>95 percent for CD73 and CD105). Surviving fat volume at 6 months was 88 percent for the experimental group and 54 percent for the control group (p = 0.003).

CONCLUSION

These results suggest that this strategy for isolation and supplementation of adipose-derived stromal cells is effective, safe, and superior to conventional lipoinjection for facial recontouring in patients with craniofacial microsomia.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Frontal linear scleroderma en coup de sabre associated with epileptic seizure

Linear scleroderma is a rare variant of localised scleroderma, which is usually seen in childhood and during the adolescent period, and can cause severe functional morbidity as well as cosmetic and psychological problems. Although its ethiopathogenesis is yet obscure, autoimmunity, local ischaemia and injuries, vaccination, irradiation, vitamin K injections, Borrelia burgdorferi and Varicella infections have been incriminated. A 4-year-old girl who had been followed up for about 18&emsp14;months with diagnosis of epilepsy had a colour discolouration and depression that first appeared 1&emsp14;year ago and then progressed on her left frontal region. Her CT scan showed a thinning in the frontal bone and depression in the frontal region. These findings are described as 'en coup de sabre' a rare form of linear scleroderma localised at the frontal region of the scalp. In this paper, we present clinical and radiological findings of a 4-year-old girl with epileptic seizures that started 1&emsp14;year before the onset of the lesion of linear scleroderma.

Cell-assisted lipotransfer for the treatment of parry-romberg syndrome

Progressive facial hemiatrophy, also known as Parry-Romberg syndrome, is a progressive and self-limited deformation of the subcutaneous tissue volume on one side of the face that creates craniofacial asymmetry. We present the case of a patient with a five-year history of progressive right facial hemiatrophy, who underwent facial volumetric restoration using cell-assisted lipotransfer (CAL), which consists of an autologous fat graft enriched with adipose-derived stem cells (ASCs) extracted from the same patient. ASCs have the capacity to differentiate into adipocytes. They also promote angiogenesis, release angiogenic growth factors, and some can survive as stem cells. The use of autologous fat as a filler in soft tissue atrophy has been satisfactory in patients with mild and moderate Parry-Romberg syndrome. Currently, CAL has showed promising results in the long term by decreasing the rate of fat reabsorption. The permanence and stability of the graft in all the injected areas has showed that autologous fat grafts enriched with stem cells could be a promising technique for the correction of defects caused by this syndrome.

Rhytidectomy associated with autologous fat transplantation in Parry-Romberg syndrome

Progressive hemifacial atrophy or Parry-Romberg syndrome is an uncommon degenerative and poorly understood condition characterized by progressive atrophy of 1 side of the face. It may involve several layers of tissue manifesting itself in a more or less aggressive form (mild, moderate, and severe). Generally, the restoration of contour and symmetry are the goals of the therapy in patients affected by this syndrome. In this article, we present the technique and the 6-year postsurgery result of a case of Parry-Romberg syndrome treated with 1-stage anterior lifting, removal of superficial muscular aponeurotic system, and autologous fat transplantation because the patient requested to recover more than atrophy and also 20 years of lost youth.

Three-dimensional photogrammetry for surgical planning of tissue expansion in hemifacial microsomia

BACKGROUND

We aim to illustrate the applications of 3-dimensional (3-D) photogrammetry for surgical planning and longitudinal assessment of the volumetric changes in hemifacial microsomia.

METHODS

A 3-D photogrammetric system was employed for planning soft tissue expansion and transplantation of a vascularized scapular flap for a patient with hemifacial microsomia. The facial deficiency was calculated by superimposing a mirror of the normal side on the preoperative image. Postsurgical volumetric changes were monitored by serial superimposition of 3-D images.

RESULTS

A total of 31 cm(3) of tissue expansion was achieved within a period of 4 weeks. A scapular free flap measuring 8 cm × 5 cm was transplanted to augment the facial deficiency. Postsurgical shrinkage of the flap was observed mainly in the first 3 months and it was minimal thereafter.

CONCLUSION

3-D photogrammetry can be used as a noninvasive objective tool for assessing facial deformity, planning, and postoperative follow-up of surgical correction of facial asymmetry.

Parry-romberg syndrome: a rare entity

Parry-Romberg syndrome or progressive hemifacial atrophy is vary rare, uncommon, degenerative, poorly understood condition characterized by a slow and progressive atrophy affecting one side of the face. The incidence and the causes of this alteration are unknown. Possible factors that are involved in the pathogenesis include disturbance of fat metabolism, trauma, viral infections, heredity, endocrine disturbances and auto-immunity. The most common complications are: trigeminal neuritis, facial paresthesia, severe headache and epilepsy. Characteristically, the atrophy progresses slowly for several years and become stable after certain time period. After stabilization of the disease multi specialty approach including physician, orthodontic treatment and reconstructive surgery with autogenous fat graft can be performed to correct the deformity. The objective of this article is to accomplish a literature review concerning general characteristics, etiology, physiopathology, differential diagnosis and treatment of progressive hemifacial atrophy.

En Coup de Sabre Scleroderma and Parry-Romberg Syndrome in Adolescents: Surgical Options and Patient-related Outcomes

Objective.

There is little information regarding surgical options and outcomes in patients with facial localized scleroderma. We evaluated the surgical outcomes of procedures performed for linear scleroderma of the face in the pediatric age group; and assessed psychosocial effects of surgical interventions on the affected children.

Methods.

A retrospective chart review was performed of children with en coup de sabre scleroderma (ECDS) and Parry-Romberg syndrome (PRS) who underwent surgical intervention; this included demographic data, clinical features, and type of surgical interventions. A questionnaire of 13 questions covering 4 domains (physical, emotional, social, and symptoms) was sent to patients who consented to take part in the survey. Surgical treatments and outcomes were analyzed retrospectively.

Results.

Seventeen patients underwent surgical intervention (autologous fat injections, Medpor implants, bone paste cranioplasty, and free groin flap) to correct facial asymmetry. Ten patients answered the questionnaire (58.8% response rate). Unhappiness with their appearance, loss of confidence, and bullying were cited as reasons for surgery. The appearance subscale of the survey demonstrated the lowest standardized scores and greatest negative effect on the patients’ quality of life compared to the 3 other subscales. All subjects would consider another surgery and would recommend surgery to other patients with ECDS and PRS.

Conclusion.

Surgical treatment is a potential useful intervention in children with facial disfigurement. Prospective data are needed.

Parry-Romberg Syndrome Associated with Localized Scleroderma

Parry-Romberg syndrome is a rare neurocutaneous disorder of unknown origin. It is characterized by progressive facial hemiatrophy and frequently overlaps with a condition known as linear scleroderma ‘en coup de sabre’. Neurological involvement is frequently described in these patients, including migraine, facial pain and epilepsy, which represent the commonest neurological conditions, sometimes associated with brain abnormalities ipsilaterally to the skin lesions. We present a case of Parry-Romberg syndrome with neurological involvement in a patient with diagnosed localized scleroderma (morphea).

Facial reconstruction with vascularised serratus anterior muscle flap in patients with Parry-Romberg syndrome

OBJECTIVE

Parry-Romberg syndrome, popularly known as progressive hemifacial atrophy, is a rare and complicated craniofacial deformity characterized by idiopathic and progressive atrophy of patient's face with compromised facial aesthetics and functions. In the present study, we performed a retrospective review on the vascularised serratus anterior muscle flap transfer for the treatment of the hemifacial atrophy in 4 consecutive Chinese patients with Parry-Romberg syndrome.

METHODS

The serratus anterior muscle flaps were harvested and transferred to correct the facial defects together with simultaneous nerve anastomosis between the long thoracic nerve and the ipsilateral cervical branch of facial nerve in the patients with Parry-Romberg syndrome. The postoperative results from patients' own perception of improvement of facial profile and symmetry were also evaluated.

RESULTS

In this patient series, both of the vessels and nerves of all flaps were anastomosed successfully in the recipient facial regions without any microvascular failures. Satisfactory facial contour and favorable symmetry were achieved with minimal donor-site morbidity, complications, recurrence and little resorption in surgical reconstruction of hemifacial atrophy during our follow-up period.

CONCLUSIONS

Our results suggested that vascularised serratus anterior muscle flap transfer combined with simultaneous nerve anastomosis is a reliable and effective treatment of choice that offers satisfactory results in the surgical correction of facial atrophy associated with Parry-Romberg syndrome.

Correction of hemifacial atrophy with autologous fat transplantation

BACKGROUND

Autologous fat transplantation has frequently been used by many surgeons for facial recontouring in esthetic patients, with good long-term results. However, this technique has not been used primarily in treating patients with hemifacial atrophy, and its efficacy and long-term outcome remain unknown.

METHODS

In a 7-year period, 31 patients with hemifacial atrophy were treated with autologous fat transplantation in our institution. All patients had been in their stable phase of the disease for at least 1 year. Autologous fat grafts were harvested from the lower abdomen or thigh with our preferred low-pressure syringe technique and then spun at the lower speed. The fat grafts were injected into multiple areas in multiple tissue planes and tunnels to the diseased side of the face. The same procedure was repeated once or twice as necessary after each injection in at least 3 months. All patients were followed up to 5 years, and their outcomes were evaluated by the patients, plastic surgeons, and laypersons separately.

RESULTS

Obviously improved facial contour was evident in most patients after autologous fat transplantations. More than 65% of the patients in this series were assessed as satisfactory by all 3 groups. Between 10% and 30% of the patients were mostly satisfactory. Only less than 7% of the patients were unsatisfactory. No complications were seen in either donor sites or recipient sites in this series.

CONCLUSIONS

Autologous fat transplantation can be a good treatment of choice for patients with hemifacial atrophy.

Free latissimus dorsi perforator flap for reconstruction of hemifacial atrophy: Case report

Progressive hemifacial atrophy (PHA) is characterized by slow and progressive atrophy usually of one side of the face. PHA affects primarily the subcutaneous fat and muscle tissues, but may involve the bone. The cause is unknown. The treatment is symptomatic and directed at augmentation of the deficient soft-tissue volume. The reconstructive procedures may combine fat grafts, dermis fat grafts, pedicle flaps, bone grafts, microvascular free flaps, and alloplastic implants. We report a patient with of PHA whose condition was treated with a free latissimus dorsi (LD) perforator flap. The LD perforator flap was suitable for the large defect of the patient. It could easily be tailored and thinned to follow the facial contour. Minor revisions were needed for esthetic reasons. There was neither significant downward gravitation nor wasting of the flap. 23 months later, the natural appearance of the face was maintained.

Vascularized Fat Transfer

The use of free tissue transfers has dramatically improved the outcomes of soft tissue reconstructions of the face. This is particularly true when large volumes of soft tissue are needed or when the recipient bed has a compromised local blood supply. Although traditional fat grafting procedures often allow for satisfactory results in some patients, the use of scapular and parascapular free tissue transfers has markedly improved the predictability of these reconstructions, often in a single stage. As perforator flap reconstructions evolve over time, these types of flaps may eventually supplant the available fasciocutaneous free flaps as the flap of choice in these reconstructions primarily because of improved donor site scarring and morbidity.