Treatment of 'en coup de sabre' Deformity with Porous Polyethylene Implant

"Treatment of En Coup de Sabre Deformity with Fat Grafting and Demineralized Bone Matrix: A Case Series"

En coup de sabre deformity (ECDS) is a form of localized scleroderma in the frontoparietal region caused by progressive subcutaneous tissue atrophy and bony defect. Although ECDS involves two layers, skin/subcutaneous tissue and bone, the existing literature mainly focuses only on treating the skin/subcutaneous tissue layer. In this case series, we aimed to propose a novel approach that includes the combined use of fat grafting and demineralized bone matrix (DBM). Four patients with ECDS deformity, operated between February 2016 and October 2018, were retrospectively evaluated. All the patients were treated with the novel approach. Patients were evaluated with localized scleroderma scale and computed tomography (CT) scan in the preoperative period and at the annual follow-up. We observed remarkable improvement in the localized scleroderma scale including appearance, palpation, and size scores in all patients at the annual follow-up. CT scans at the annual follow-up revealed new callus formation at the bony defect area in all patients. Reinforcing fat grafting with DBM could promote healing of the bony and skin/subcutaneous tissue defects associated with ECDS.

Aesthetic Restoration of Severe Hemifacial Atrophy With Free Adipofacial Antero Lateral Thigh Flap Followed by Autologous Fat Grafting; Optimizing Result and Long-Term Outcome

BACKGROUND

Hemifacial atrophy (Romberg disease) is characterized by progressive soft tissue and bone atrophy on 1 side of the face. The process of atrophy usually starts in the late first or early second decade of life. Romberg Patients usually require soft tissue augmentation for the correction of their defect. There are many reconstructive tools available to correct such facial asymmetry. In this study, we evaluate the outcome of the free adipofacial flap followed by autologous fat grafting in the treatment of Romberg disease, regarding aesthetics and longevity of the treatment.

PATIENTS AND METHODS

A retrospective review of 12 patients with moderate to severe hemifacial atrophy from April 2016 till March 2019. All patients received soft tissue augmentation with free adipofascial anterolateral thigh flaps, followed by autologous fat grafting 6 to 12 months later for correction of residual deformity. The average follow-up period was 18 months (range, 6-30).

RESULTS

There were 9 females and 3 males in this study. All flaps were survived, and the effect is long-lasting during follow-up. Patients were satisfied with the result especially after refinement of the result of free tissue transfer. The donor sites were closed directly and with no apparent morbidities nor dysfunctions.

CONCLUSIONS

Microsurgical free tissue transfer is considered a gold standard tool in the management of moderate and severe form of hemifacial atrophy. Among different flaps available, free adipofacial anterolateral thigh flap (ALT) works as a workhorse flap in the correction of a severe form of the disease. Autologous fat grafting is a versatile and reliable option to correct residual deformities. We believed that such a combination is a superb approach to optimize the outcome of the severe form of the progressive hemifacial atrophy.

Cosmetic treatment in patients with autoimmune connective tissue diseases: Best practices for patients with morphea/systemic sclerosis

Morphea and systemic sclerosis are inflammatory, sclerosing disorders. Morphea primarily affects the dermis and subcutaneous fat, while systemic sclerosis typically involves the skin and internal organs. Functional impairment and cosmetic disfigurement are common in both diseases. Treatment options to mitigate disease progression remain limited. Both functional impairment and cosmetic deficits negatively impact quality of life and psychological well-being in this patient population. While the number of cosmetic procedures performed in the United States continues to rise each year, limited data exist regarding best practices for correcting aesthetic deficits caused by autoimmune conditions. There is scarce information to guide safety decisions regarding laser parameters, soft tissue augmentation, treatment intervals, and the concurrent use of immune-modifying or immune-suppressing medications. Given the fears of disease reactivation and exacerbation from postprocedural inflammation along with limited data, it is difficult for clinicians to provide evidence-based cosmetic treatment with realistic expectations with regard to short- and long-term outcomes. In the first article in this continuing medical education series, we attempt to address this practice gap.

A review of Parry-Romberg syndrome

Parry-Romberg syndrome, also known as progressive hemifacial atrophy, is a rare disorder characterized by unilateral facial atrophy affecting the skin, subcutaneous tissue, muscles, and sometimes extending to the osteocartilaginous structures. It has been associated with various systemic manifestations, particularly neurologic, ophthalmologic and maxillofacial. In this article, we review Parry-Romberg syndrome with its associated findings (neurologic, ophthalmologic, cardiac, rheumatologic, endocrinologic, infectious, orthodontic and maxillofacial, and autoimmune), underlying cause, differential diagnoses (en coup de sabre, scleroderma, and Rasmussen encephalitis), and therapeutic options.

Progressive facial hemiatrophy - a case series

Six female patients diagnosed with Progressive Facial Hemiatrophy are presented here. The clinical and serological features are highlighted, and treatment options for the condition are discussed. We would like to highlight the need to differentiate the condition from localized scleroderma and the with limitation of its medical management.

Acquired partial lipodystrophy with C3 hypocomplementemia and antiphospholipid and anticardiolipin antibodies

Acquired partial lipodystrophy is an extremely rare condition of unknown etiology characterized by progressive loss of fat of the face, neck, trunk, and upper extremities. It usually begins during childhood and is more common in girls. C(3) hypocomplementemia is seen in 70% of patients with acquired partial lipodystrophy. Unlike generalized forms of the disease, no insulin resistance occurs. We present three boys with acquired partial lipodystrophy having C(3) hypocomplementemia. In addition, one of them had antiphospholipid and anticardiolipin antibodies.

Volumetric correction using poly-L-lactic acid in facial asymmetry: Parry Romberg syndrome and scleroderma

BACKGROUND

Linear scleroderma and Parry-Romberg Syndrome (PRS) are chronic diseases that can affect the face, with patients therefore requiring facial volumetric correction.

OBJECTIVE

We have used poly-L-lactic acid (PLLA) to treat facial asymmetry in patients with linear scleroderma and PRS, because it can restore volumetric defects and has been proven to be safe.

MATERIALS AND METHODS

Since February 2004, we have treated six patients: four with linear scleroderma and two with PRS. The patients were treated every 4 weeks for three to five sessions. Photographic documentation was taken at the beginning and at the completion of every treatment and 12 and 18 months later.

RESULTS

In patients with PRS and linear scleroderma of the face, we noticed good restoration of facial volume and symmetry and improvement in skin quality. The results were found to be permanent at 18 months in patients with PRS and 12 months in patients with linear scleroderma.

CONCLUSIONS

PLLA has been shown to be a useful material for the correction of small volumetric defects caused by linear scleroderma and PRS. The authors have indicated no significant interest with commercial supporters.

Secondary cicatricial and other permanent alopecias

Various nonfollicular scalp conditions can cause secondary scarring or permanent alopecia. Possible causes are congenital defects, trauma, inflammatory conditions, infections, and neoplasms (rarely drugs). Associated signs and symptoms and other diagnostic procedures such as histopathology may aid in the diagnosis. Detection of the underlying disorder may be difficult in end-stage lesions. Treatment is specific for active conditions. Surgery and hair transplantation are options for localized scars.

Operative Korrektur einer Sklerodermie en coup de sabre durch En-bloc-Resektion

A 15-year-old patient developed scleroderma en coup de sabre on right temple at 5 years of age. Multiple treatments (3 cycles of intravenous penicillin, topical glucocorticosteroids, topical calcipotriol, and cream PUVA phototherapy combined with topical calcipotriol) produced no improvement. The patient suffered greatly from the psychosocial stigmatization, so that the entire lesion was resected at 14 years of age. One year after the operation a thin non-sclerotic scar was present; tiny lateral areas of sclerosis not included in the operative field were unchanged. The operation greatly improved the patient's daily life. The surgical therapy of scleroderma en coup de sabre offers an interesting therapeutic alternative.