Correction of facial linear scleroderma ‘coup de sabre’ with BoneSource®

Adipose Tissue Grafting for the Treatment of Morphea En Coup De Sabre: A Simple Filler or an Emerging Cellular Therapy?

Linear scleroderma en coup de sabre is a rare chronic autoimmune disease. This form of localized scleroderma manifests through an inflammatory phenomenon of collagen overproduction and extracellular matrix destruction, affecting the skin and subcutaneous tissues of the face. This active pathological process is challenging to control and often goes unnoticed at its early stage. The sequelae manifest as an alopecic frontal scar lesion, causing the patient significant aesthetic and psychological damage. In this study, we report two clinical cases in which aesthetic sequelae were treated by autologous fat transplantation. We found encouraging results, with a global aesthetic improvement of 86.2% measured by a jury of medical specialists and outcome stability through a nine-year follow-up for one patient. Autologous fat transfer is excellent for treating stabilized en coup de sabre morphea, not only for its filling abilities but also for its regeneration activating and inflammation regulating abilities, which could open new prospects for curative treatment of this pathology.

Management Options for Linear Scleroderma ("En Coup de Sabre")

BACKGROUND

En coup de sabre (ECDS) is a form of linear-scleroderma, primarily affecting the face. Despite effectiveness of pharmacological interventions in the management of lesions, sequelae of cutaneous deformities are common.

OBJECTIVE

Review the existing surgical tools for the correction of "en coup de sabre" ECDS lesions and facial deformities.

MATERIALS AND METHODS

The authors conducted a literature search for reports on surgical interventions for ECDS deformations, in the electronic databases of PubMed, Scopus, and Cochrane Library Databases.

RESULTS

Twenty-six publications reporting 39 patients were found in the literature. The average age of patients was 25 ± 4.7 years. Thirty-one of the patients were females. Six methods were found in the literature for surgical correction of ECDS. Fat grafting was performed in 41% of patients, surgical reconstruction in 18%, injectable fillers in 15%, implants in 10%, botulinum toxin injections in 8%, and bone/cartilage grafts in 8%. Imaging studies of the skull and face were performed in 36% of patients. Bony defects were found in 64.3% of them.

CONCLUSION

Different surgical and minimally invasive options exist in the armamentarium of clinicians correcting ECDS deformities. Tailoring the method of correction to patient's needs and expectation is crucial in ensuring patient satisfaction.

Combination of Autologous Fat Grafting and Negative-Pressure Wound Therapy for the Treatment of Scalp Linear Scleroderma

ABSTRACT

Scalp linear scleroderma (LSc) is a subtype of localized scleroderma which typically affects young patients and which can be severely disfiguring. Traditional treatment options include bone grafting or tissue expansion. In this report, we present the case of a patient with scalp LSc successfully treated with scar release, autologous fat grafting, and negative-pressure wound therapy (NPWT). A 55-year-old female, with a history of craniectomy for a benign sellar tumor 10 years previously, developed LSc over the frontal scalp with exposure of titanium plates and screws. She was treated with removal of metalwork, scar release, autologous fat grafting from the abdominal wall and immediate application of NPWT. At 3-month postoperative follow-up, the appearance of the depressed lesion and of its margins had significantly improved. Our experience suggests that the combination of autologous fat grafting and NPWT is an effective treatment modality for scalp LSc.

Flap Reconstruction for Treatment of Pediatric Linear Scleroderma

BACKGROUND

Linear scleroderma is a rare connective tissue disease characterized by thickening of the skin due to excess collagen deposit. It is the most frequent type of localized scleroderma in the pediatric population (40%-70%), and it usually affects the extremities and head. Linear scleroderma can cause growth disturbances, extremity length discrepancy, and debilitating joint contractures. The aim of this study was to describe the surgical outcomes of microsurgical flap reconstruction of linear scleroderma in the pediatric population.

METHODS

A retrospective review of all children with linear scleroderma was performed at our institution. Patients less than 18 years of age with clinical diagnosis of linear scleroderma and who underwent microsurgical flap reconstruction for correction of their scleroderma were included. Fat grafting procedures were excluded. Patient demographics and surgical outcomes were collected.

RESULTS

A total 7 patients underwent microsurgical flap reconstruction for treatment of their linear scleroderma producing debilitating soft tissue contractures and preventing ambulation or elbow extension. Six patients had scleroderma involving the lower extremity and 1 involving the upper extremity. Three anterolateral thigh and 4 latissimus dorsi flaps were performed. The median age at surgery was 7 years (Q1-Q3, 5-11), and the median body mass index was 21.3 kg/m2 (Q1-Q3, 16.5-22.1). The median follow-up was 121.1 months (Q1-Q3, 43.2-187.4). All flaps survived, and no donor site complications were reported. Perioperative complications included wound infection that required debridement (n = 1), immediate postoperative bleeding requiring surgical intervention (n = 1), intraoperative venous congestion (n = 1), and scleroderma recurrence outside the flap (n = 2). When comparing anterolateral thigh and latissimus dorsi flaps, there was no statistically significant difference in the development of surgical complications, number of surgical revisions per patient [median, 4 (Q1-Q3, 4-7) vs 2.5 (Q1-Q3, 1.3, 3), P = 0.0916], or unplanned surgical interventions [median, 0 (Q1-Q3, 0-1) vs 1 (Q1-Q3, 0-1), P = 0.7228]. The reconstruction was successful in improving range of motion in 6 patients, 5 of which reached full weight-bearing. However, all patients had residual limb deformity, and 4 had remaining extremity length discrepancy.

CONCLUSIONS

Microsurgical flaps are a good option for functional improvement of severe pediatric linear scleroderma affecting the extremities. However, residual limb deformity is common, and patients are often required to undergo additional surgical revisions.

Nasal and Oral Subunits Reconstruction of Localized Scleroderma Deformities

ABSTRACT

Localized scleroderma is a rare soft tissue disorder characterized by a thickening of the skin from excessive collagen deposits. For patients with face involved, soft tissue depression and atrophy could cause serious facial contour deformity and adversely affect the patients' quality of social life. However, localized scleroderma cases with delicate facial aesthetic subunits defects were rarely reported to be surgically reconstructed. In this study, we present 2 patients with nasal subunits and oral subunit deformities caused by localized scleroderma respectively. The first patient with a right-side alar defect and nasal dorsum depression, forehead depression and eyebrow depression were treated through a 2-stage surgical approach, with microvascular preauricular and helical rim flap and dermofat graft transplantation. The lower lip and mandible defects of the second patient were reconstructed with a combination of submental flap and fat grafting. The transplanted dermofat graft, fat graft, the microvascular free flap, and the submental flap survived completely and maintained adequate tissue volume and facial contour during the follow-up time of 2 years. Both patients were satisfied with the overall aesthetic results. This clinical report supports the use of microsurgical flap and tissue grafts on the treatment of localized scleroderma (LS) caused facial aesthetic subunits deformities.

Treatment of linear scleroderma "En coup de Sabre" with single-stage autologous fat grafting: A case report and review of the literature

BACKGROUND

Linear scleroderma "en coups de sabre" is a disease that causes scar-like lesions in the forehead and the scalp, and atrophy of the underlying structures. The result is an acute facial asymmetry that can be distressing to affected young adults. Several surgical treatments are available such as free tissue transfer and synthetic fillers.

AIMS

In this report, we present a rare case of linear scleroderma "en coups de sabre," which was successfully managed with single-stage autologous fat grafting.

PATIENTS/METHODS

The patient was a 17-year-old male who presented with a soft-tissue defect in the left forehead region. Treatment consisted of transferring autologous fat into the defect in a retrograde fashion, as described by Coleman, and overcorrecting the defect to account for fat resorption.

RESULTS

At 6 mo postoperatively, the patient had maintained a satisfactory correction of his left forehead and scalp regions with minimal resorption of fat.

CONCLUSION

Autologous fat grafting provides a safe and easy approach for the treatment of linear scleroderma "en coups de sabre". With minimal manipulation of the aspirated fat, combined with overcorrection of the defect, long-term clinically satisfactory results can be obtained.

A surgical approach to linear scleroderma using Medpor and dermal fat graft

Linear scleroderma en coup de sabre (LScs) is a variant of localized scleroderma. This disease typically occurs in patients in their 20s or younger individuals and predominantly occurs in the forehead area. A 26-year-old man with linear scleroderma was surgically treated at our center with Medpor (porous polyethylene) and dermal fat graft for the forehead lesion. After 26 months of postoperative follow-up, the depressed lesion that appeared scarred as well as the margins improved significantly. The surgical treatment of LScs using Medpor and dermal fat graft is an effective treatment modality that can increase patient satisfaction.

Surgical Management of Localized Scleroderma

Background

Localized scleroderma is characterized by a thickening of the skin from excessive collagen deposits. It is not a fatal disease, but quality of life can be adversely affected due to changes in skin appearance, joint contractures, and, rarely, serious deformities of the face and extremities. We present six cases of localized scleroderma in face from our surgical practice.

Methods

We reviewed six localized scleroderma cases that were initially treated with medication and then received follow-up surgery between April 2003 and February 2015. Six patients had facial lesions. These cases presented with linear dermal sclerosis on the forehead, oval subcutaneous and dermal depression in the cheek.

Results

En coup de sabre (n=4), and oval-shaped lesion of the face (n=2) were successfully treated. Surgical methods included resection with or without Z-plasty (n=3), fat graft (n=1), dermofat graft (n=1), and adipofascial free flap (n=1). Deformities of the affected parts were surgically corrected without reoccurrence.

Conclusion

We retrospectively reviewed six cases of localized scleroderma that were successfully treated with surgery. And we propose an algorithm for selecting the best surgical approach for individual localized scleroderma cases. Although our cases were limited in number and long-term follow-up will be necessary, we suggest that surgical management should be considered as an option for treating scleroderma patients.