Bilateral Parry-Romberg Syndrome Associated with Retinal Vasculitis

PURPOSE

To describe an unusual case of bilateral progressive facial hemiatrophy (Parry-Romberg syndrome (PRS)) associated with retinal vasculitis.

METHODS

In a 37-year-old man with bilateral PRS, retinal vasculitis of the right eye was evident on fundus examination and fluorescein angiography. Right temporalis muscle biopsy and needle electromyography of the masseter muscles were performed. The patient underwent immunosuppressive therapy and retinal laser photocoagulation.

RESULTS

Biopsy specimens showed large fibrosis with focal lymphohistiocytic infiltration of the muscle fibers. Electromyographic findings are consistent with a primary muscle disease. Visual acuity improved from 20/25 to 20/20 in the right eye with a follow-up of one year.

CONCLUSIONS

The evidence of retinal vasculitis and the histologic findings of facial changes observed in this PRS case could support the pathogenetic model of a chronic inflammatory process as a plausible explanation for progressive facial hemiatrophy.

Management of Craniofacial Development in the Parry-Romberg Syndrome: Report of Two Patients

Objective

The aim of this article is to describe the orthodontic therapy for Parry-Romberg syndrome. The therapeutic goal is to minimize the wasting effects of progressive atrophy on facial development of a part of the face.

Design

To correct problems affecting craniofacial development of these patients, occurring during puberty, an orthodontic appliance was employed, which helps maintain parallelism of the facial planes, in particular the mandibular plane.

Setting

Orthodontic care was carried out in the Dental Clinic of the Catholic University of the Sacred Heart of Rome.

Intervention

Two patients underwent orthodontic therapy for 6 years. Appliances were checked every month and modified periodically so as to adapt to facial bone growth.

Results

At the end of craniofacial growth, the mandible was almost symmetric and the problem relating to atrophy remained confined to the initial area. Cephalometric analyses demonstrated that the occlusal plane and the mandibular plane maintained a straight orientation in relation to the bizygomatic plane. The ratio between the left and right side of the ramus and condyle, in the mandible, improved.

Conclusions

The use of orthodontic therapy allows patients affected by hemifacial progressive atrophy to present a more harmonic face at the end of puberty when final reconstruction can be planned. These results provide for a limitation of surgical intervention to the sclerodermic area alone.

Injectable hyaluronic acid for the correction of HIV-associated facial lipoatrophy

Objective

To evaluate the use of Perlane, an injectable form of hyaluronic acid, for the correction of HIV-associated facial lipoatrophy.

Study Design And Setting

A prospective, observational study in a consecutive series of 18 HIV-positive males with facial lipoatrophy injected with Perlane. Fourteen patients were available for final analysis.

Results

Mean follow-up time was 12 months. Based on photographic analysis, there was a significant early improvement ( P = 0.0035). This difference remained significant after 12 months ( P = 0.04666); no significant difference in grade was shown between 1 and 12 months ( P = 0.3693). Office assessments of improvement showed an early marked improvement in 85.8% of patients, and 78.6% of subjects demonstrated at least moderate improvement at 12 months.

Conclusion/Significance

Patient satisfaction was high, with only minor side effects and no late complications. Our findings support Perlane to be a feasible option for the provisional correction of mild to moderate facial lipoatrophy.

[Facial asymmetry: the benefits of cone beam computerized tomography]

Treatment planning in facial asymmetry is complex and requires precise diagnosis and planning. In the case of a fourteen year old boy with Parry Romberg syndrome, cone beam computerized tomography scanning was used to analyse the asymmetry. Linear, angular and volumetric measurements helped to make clear the extent of the asymmetry, giving the orthodontist and surgeon as well as the patient insight into the possibilities and expectations of treatment. Also the mirror image of the unaffected side superimposed on the affected side was very helpful in this respect. The latter may offer new possibilities for fabrication of individualized alloplastic onlays to further correct asymmetry in the future.

Minimally invasive combined treatment for Parry-Romberg syndrome

BACKGROUND

Facial hemiatrophy, a typical manifestation of Parry-Romberg syndrome, produces massive face asymmetry, causing marked aesthetic damage and severe psychological discomfort, with repercussions to the psychophysical status of the patient. This article presents a successful combined treatment that results in resolution of symptoms and patient satisfaction.

METHODS

The authors proposed a clinic-therapeutic management comprising a customized program of bio-lipo-intense pulsed light (IPL) remodeling.

RESULTS

In 2007, at a 1-year follow-up visit, the patient presented a stable result. She is satisfied with the augmentation treatment, the new volume and contours of the face, and the resolution of the sclerosis and ochrodermia.

CONCLUSION

The authors have succeeded with a minimally invasive reconstructive technique for Romberg disease using a customized therapeutic program of poly-L-lactic acid, lipofilling, and IPL therapy. They report a case of good healing without recurrences and complications, with a good cosmetic result, and with satisfaction of the patient.

Progressive Hemifacial Atrophy--case report

Progressive Hemifacial Atrophy, also known as Parry-Romberg Syndrome, is an uncommon degenerative and poorly understood condition. It is characterized by a slow and progressive atrophy affecting one side of the face. The incidence and the cause of this alteration is unknown. A cerebral disturbance of fat metabolism has been proposed as a primary cause. This can be the result of a trophic malformation of Cervical Sympathetic Nervous System. Possible factors that are involved in the pathogenesis include trauma, viral infections, heredity, endocrine disturbances and auto-immunity, among others. The most common complications that appear in association to this health disorder are: trigeminal neuritis, facial paresthesia, severe headache and epilepsy, being this last one the most frequent complication of the Central Nervous System. Characteristically, the atrophy progresses slowly for several years and, soon after, it become stable. Now, plastic surgery with graft of autogenous fat can be performed, after stabilization of the disease, to correct the deformity. Orthodontic treatment can help in the correction of any associated malformation. The objective of this work is, through the presentation of a clinical case, to accomplish a literature review concerning general characteristics, etiology, physiopathology, differential diagnosis and treatment of progressive hemifacial atrophy.

Parry-Romberg syndrome: a global survey of 205 patients using the Internet

Parry-Romberg syndrome (PRS) is a rare neurocutaneous disorder characterized by progressive facial hemiatrophy. In this study, 205 patients with PRS were surveyed using the Internet. Estimates of the frequency of limb involvement (19%), epilepsy (11%), and other clinical and etiologic features were obtained. There was a wide range of age at onset and considerable diagnostic overlap with scleroderma "en coup de sabre."

Hemiatrophy

The authors present a series of seven patients who have a diagnosis fitting that of combined ipsilateral facial and somatic hemiatrophy. Diagnostic features include facial, tongue, and ear asymmetry and associated decreases in length and size of the ipsilateral limbs. The symptomatic problems related to leg length discrepancy can be addressed in the usual fashion, and this condition does not appear to progress to large leg length discrepancies. The cosmetic side of this disorder is often concerning: it is the most reliable identification of the existence of this condition and is present from birth. Facial hemiatrophy is mild and does not appear to be progressive. The hemiatrophies probably have a multifactorial pathogenesis that most likely has at its basis a genetic cause.

[Progressive hemifacial atrophy in the young patient: physiopathologic hypotheses, diagnosis and therapy]

Parry-Romberg syndrome is characterized by a limited progressive hemifacial atrophy. Since its first description in 1825, this syndrome has aroused interrogation and reflection about is pathophysiology, its variable clinical expression and its progression. The first part of this focuses on the different hypotheses advanced to date to explain this type of atrophy. We then recall the different steps for clinical diagnosis and treatment. Management of such an unpredictable disorder is particularly difficult. Because of the uncertain pathophysiology, medical therapy has not been very successful. Palliative reconstruction surgery remains the only possibility. We present three cases illustrating this review of progressive hemifacial atrophy.

[A case of progressive hemifacial atrophy with Pourfour de Petit syndrome which was successfully treated by stellate ganglion block]

We herein report a 31-year-old woman with progressive hemifacial atrophy. The atrophy at her left face began about ten years ago. She had been in a traffic accident one year before the onset of her facial atrophy. Neurological examination revealed anisocoria (right < left) and retraction of the left eyelid, which thus suggested the presence of Pourfour de Petit syndrome. The pupillary reaction to both cocaine and tyramine were reduced bilaterally. Thermography of the face showed slightly lower surface temperature on the left side. A facial thermal sweat test was normal. These findings indicated local hyperactivity of the sympathetic nervous system at the Th 1-Th2 levels on the left side. A left stellate ganglion block effectively induced an accumulation of the subcutaneus tissue of her face on the left side. This is a very rare case in which local sympathetic hyperactivity is present and has caused progressive hemifacial atrophy.

[Parry-Romberg syndrome. Summary and new knowledge based on an unusual case]

A 52 year old female with Parry-Romberg syndrome presented with gradual atrophy of the subcutaneous fat and muscle on her chest and back. The disease process was limited to the C3 to T2 dermatomes on the right side. In addition, there was muscle atrophy of the right arm and extending down the back to T10, als well as right sided paralysis of the diaphragm. Sympathetic nerve blockage reduced pain and hyperesthesia; no progression was seen over several months using NMR to monitor the patient. The Parry-Romberg syndrome has been defined in many ways; in view of this unusual case, we review the literature, attempting to provide a more accurate case definition.

Progressive hemifacial atrophy: ten-year observation of a case

The authors describe the case of a 14-year-old girl who experienced progressive hemifacial atrophy at the age of three-and-a-half years. The patient's early age at appearance of the condition resulted not only in atrophy of skin, subcutaneous tissue, and muscles, but also in very severe deformation of the right side of the face due to disorders in growth of cartilaginous and osseous tissue. Changes in her brain case and craniofacial skeleton included enophthalmos, underdevelopment of the eyelids, nose, hard plate, and dental process of the jaw including the premolar teeth, and a lack of the second molar. These changes caused an irregular line of bite. The differential diagnosis excluded hemifacial microsomy and sclerodermal hemifacial atrophy.

[Stellate ganglion block therapy against progressive facial hemiatrophy]

A typical case with progressive facial hemiatrophy was treated with a new therapeutic trial, stellate ganglion block. The present case, a Japanese girl, suffered from progressive atrophy involving the soft tissue of the left buccal region, with onset at the age of 6 following a minor local trauma. She visited our hospital at the age of 9, and as soon as the diagnosis was made, left stellate ganglion block was initiated. Local injection of lidocaine was performed 53 times over the period of 1 year and 4 months. During this period of therapy and the subsequent follow-up period of 4 years, the state of atrophy remained unchanged and nonprogressive. Stellate ganglion block as a therapy against progressive facial hemiatrophy was considered to be worth further evaluation, although it was impossible to judge, based solely on our experience, whether the arrest of progression was attributable to the therapy. The rationale of this therapy was also discussed. It was based upon the assumption that atrophy may result from irritation of the cervical sympathetic nerve, one of the most popular theories regarding the pathomechanism of progressive facial hemiatrophy.

Free-fat injections for the correction of hemifacial atrophy

Three adult patients with long-standing hemifacial atrophy were treated with repeated free-fat injections at 4- to 8-week intervals. The longest follow-up study to date is 18 months, and following the expected postoperative resorption, no further loss of bulk of injected fat has been observed. On palpation, the feel of the fat is normal, and facial expression is also good. The relative ease of this procedure, which does not entail any scarring, appears to justify more widespread use of free-fat injections to restore facial soft-tissue depressions.

Massive injection of liquid silicone for hemifacial atrophy

Liquid silicone injection for soft-tissue augmentation remains a controversial procedure despite 30 years of clinical use which has demonstrated exceptional results in patients with severe facial atrophies. This article describes a case in which massive silicone injection was used to treat hemifacial atrophy. Over a 9-year period, 11 injections totaling 97 ml of liquid silicone were administered to the patient, representing the largest volume of silicone ever injected into the face. In the 16 years following the first injection, there have been no major complications and the patient has experienced a greatly enhanced body image and improved self-esteem. Although liquid silicone for injection remains under investigation, its use in patients with hemifacial atrophy may produce dramatic results with minimal complications.

Ocular manifestations and treatment of hemifacial atrophy

Enophthalmos, flattening of the maxilla that may progress to inferior orbital rim and floor defects, eyelid atrophy, and slight relative hypotony occurred in patients with hemifacial atrophy. Less common manifestations included pupillary and iris abnormalities, vertical muscle imbalances, and retinal changes. The prognosis for vision was good. Fluid silicone injection was the major modality in treatment and the results were generally excellent.