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New and Successful Technique for the Management of Parry-Romberg

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New and Successful Technique for the Management of Parry-Romberg The Journal of Craniofacial Surgery Volume 26, Number 6, September 2015 Brief Clinical Studies Results: The patient was followed for 2 years. He has had no New and Successful Technique complications and maintains an excellent symmetric result. The patient is highly satisfied with his result and has not required any for the Management of further surgery. Preoperative and postoperative photos at year of follow up are presented. Parry-Romberg Syndrome’s Discussion: Less invasive treatment options exist for hemifacial Soft Tissue Atrophy atrophy from Parry-Romberg syndrome. Viviana Go´mez Ortega, MDÃ and Daniel Sastoque, MDy Key Words: Atrophy, enriched platelet plasma, Integra, Abstract: Parry-Romberg syndrome (PRS) is an infrequent, management, Parry-Romberg syndrome, soft tissues acquired disorder characterized by progressive hemiatrophy of the skin and soft tissue of the face and, in some patients, results arry-Romberg syndrome (PRS), also known as Romberg dis- in atrophy of muscles, cartilage, and the underlying bony structures. P ease, is a rare, acquired craniofacial disorder characterized by a The disease process exhibits varying speeds of development, slow progressive hemiatrophy, variably affecting the skin and subcutaneous tissue and, in some patients, muscles, cartilage, with onset occurring in early infancy or adolescence. Clinicians and underlying bony structures. First described by Parry in 1825 have classically reserved treatment until the end of the process. and Romberg in 1846, it was later named as progressive hemifacial Various treatment modalities have been attempted with differing atrophy (PHA) by Eulenberg in 1871.1–4 results. Described treatments include free tissue transfer (omentum, Through its slow progress, the disease commonly affects der- rectus, latissimus, serratus, diep, scapula, and parascapular), matomes of 1 or multiple branches of the trigeminal nerve. The pedicled flaps, autologous tissue (dermis-fat, bone and cartilage, onset of the disease begins between the ages of 5 and 15 years. The and fat), and biomaterials (silicone, polyethylene, and Alloderm). progression of the atrophy lasts a decade. Patients with PRS In this article, the authors present a patient of Parry-Romberg experience a progressive shrinking and deformation of 1 side of syndrome in a young boy who had undergone a free flap previously, the face followed by unilateral facial atrophy, ipsilateral enophthal- which failed to fill the atrophy of the right hemifacial soft tissues. mos, and deviation of the mouth and nose toward the affected side. Skin discoloration, cicatricial alopecia, and intraoral involvement The authors used Integra, which is a bilayer porous matrix of cross- with tongue hemiatrophy may associate as well. Bilateral atrophies linked bovine tendon collagen and glycosaminoglycan, and a were observed yet not common.5–8 It is typically restricted to one semipermeable polysiloxane (silicone layer) and fat grafts enriched half of the face but occasionally involves the arm, trunk, and leg. with Harvest PRP, to produce volume and symmetric contour on the The etiology of the disease is not well understood. Some affected side. The patient had a follow up of 2 years with excellent possible causes were proposed, including trauma, infection, cranial esthetic and functional results. vascular malformation, immune-mediated processes, disturbance of Objective: The authors present a technique of volume replacement fat metabolism, and sympathetic dysfunction. It appears to be more in patients with hemifacial atrophy because of Parry-Romberg common in the female gender. syndrome, which has never been reported before in the international Patients of Parry-Romberg syndrome are classified as mild, literature. moderate, or severe in relation to atrophy of the skin, subcutaneous tissue, and bone involvement in territories of the trigeminal nerve as Study: Microsurgical reconstruction is considered the gold stan- follows: dard to restore facial symmetry. Given a free flap morbidity and risk Mild: Atrophy of the skin and subcutaneous tissues is observable of complications, some patients opt for less extensive procedures. in the territory of just 1 of the sensory branches of the trigeminal The authors present the case of a 12-year-old boy with a history of nerve; bone involvement is not observable. Moderate: Atrophy Parry-Romberg syndrome with resultant right hemifacial atrophy. of the skin and subcutaneous tissues is observable in the territory Consistent with the usual pattern of atrophy, the onset of the of 2 of the sensory branches of the trigeminal nerve, without patient’s disease began at the age of 5 years. the involvement of the osseous orbital region or maxillary and Methods: The senior authors used a combination of a stacked mandibular growth. Integra cheek implant and fat grafts enriched with Harvest PRP to Severe: Atrophy of the skin and subcutaneous tissues is obser- produce volume and symmetric contour on the affected side. vable in all 3 of the sensory branches of the trigeminal nerve or bone involvement. The patient was discharged home the next day after the surgical Treatment for the atrophy is recommended after the quiescence procedure from the recovery room, without complications. of disease progression. Multiple surgical procedures have been used to improve the facial volume and contours of patients with this disease, including alloplastic, silicone, or collagen implants; From the ÃPlastic and Reconstructive Surgery Department of the Hospital Simo´n Bolivar and La Fundacio´n Santa Fe´ de Bogota´ and Hospital de la lipofilling; and pedicled or free-flap transplants. Policia; and yPlastic and Reconstructive Surgery Department of the The most appropriate treatment modality for these patients can Hospital Simo´n Bolivar, Bogota, Columbia. be determined based upon the observations noted during their 9 Received January 15, 2015. clinical examination. Regardless of the specific modality chosen, Accepted for publication June 28, 2015. treatment involves augmentation of the atrophied region and restor- Address correspondence and reprint requests to Viviana Go´mez Ortega, ation of facial symmetry to provide great psychologic and MD, Hospital Simo´n Bolivar, Fundacio´n Santa Fe´ de Bogota´, Hospital a emotional benefits to the patient. The use of autologous fat grafts, de la Policia, Cra 7 No 121-33, Bogota´, Colombia; alone or in combination with other surgical methods, offers a E-mail: [email protected] practical treatment of the condition. Alternatively, the injection The authors report no conflicts of interests. Copyright # 2015 by Mutaz B. Habal, MD of biomaterials, such as alloplastic materials, silicone, or collagen, ISSN: 1049-2275 also provides practical solutions. Other treatment methods include DOI: 10.1097/SCS.0000000000002023 pedicled or free flap grafts. # 2015 Mutaz B. Habal, MD e507 Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Brief Clinical Studies The Journal of Craniofacial Surgery Volume 26, Number 6, September 2015 Various treatment modalities have been attempted with differing results. Described treatments include free tissue transfer (omen- tum,10 rectus,11 latissimus,12 serratus,13 diep,14 scapula,15 and parascapular16), pedicled flaps,17 autologous tissue (dermis-fat,18 bone and cartilage, and fat19), and biomaterials (silicone,20 poly- ethylene,21 and Alloderm22). PATIENT AND METHODS A 12-year-old boy presented with a history of PRS, characterized by FIGURE 2. A, Integra which is a bilayer matrix used for wound dressing right facial atrophy of the subcutaneous tissues that began when he composed of a porous matrix of cross-linked bovine tendon collagen and was 5 years old. The objective of clinical examination indicated glycosaminoglycan and a semipermeable polysiloxane (silicone layer). The moderate to severe soft tissue deficits affecting the zygomatic, buccal, photo shows when we removed the silicone layer of the Integra, to use the mental, cheek, and orbital regions of his right face without significant collagen matrix only as the filler. B, Harvest autologous platelet concentrate. alteration of the skin pigmentation. The patient was treated in other institution until he was 9 years old. When he was 8 years old he underwent a latissimus dorsi free flap surgery to treat his right facial atrophy. The free flap was originally presented as the best solution for soft tissue augmentation in this patient. The free flap was performed but after some time it suffered a retraction placing itself in the right preauricular regio´n, the assymetry of the face persisted after this procedure as it is shown in the Fig. 1A-G. We decided to perform another surgical procedure in which we used Integra as a filler to improve his face contour (Fig. 2A) and fat grafts enriched with FIGURE 3. The patient’s bone involvement was mild. Harvest PRP to produce volume and symmetric contour on the affected side (Fig. 2B). The patient?s bone involvement was mild with a 3 mm blunt cannula. After the supernatant was removed, fat whereas the atrophy of the skin and subcutaneous tissues was pre- was transferred into syringes and immediately injected into the sented in all 3 of the sensory branches of the trigeminal nerve (Fig. 3). affected regions of the face. Multiple access sites for injection and a ‘‘fanning-out’’ technique were used to transfer small aliquots of fat Operative Technique into various depths of the soft tissue and hypoplastic regions. The With the patient under
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