The Use of Implants in Facial Augmentation for Hemifacial Atrophy Judy W. Lee, MD1, Richard A. Zoumalan, MD1, Samieh S. Rizk, MD2

1.Department of Otolaryngology, Lenox Hill/Manhattan Eye, Ear, and Throat Hospital; New York University Medical Center, New York, NY.2.Division of Facial Plastic Surgery, Lenox Hill/Manhattan Eye, Ear, and Throat Hospital, New York, NY.

ABSTRACTEducational Objective: Parry-Romberg Syndrome is a rare disorder which results in progressive hemifacial atrophy. Microsurgical reconstruction is considered the gold standard for volume replacement after the progression ends and the facial structure stabilizes. However, many patients opt for less invasive procedures for facial augmentation. We present a case report of such an option. This is a case report of a patient who underwent AlloDerm and silicone implantation and had an excellent result. The authors will provide information on Parry-Romberg Syndrome and its associated co-morbidities. It will provide information on various volume replacement options as well as recommendations on the appropriate timing of intervention. It will provide surgical technique of a less invasive/morbid surgical option.

Objective: We present a technique of volume replacement in patients with hemifacial atrophy due to Parry-Romberg Syndrome.

Study: Parry-Romberg syndrome is a rare disorder characterized by slowly progressive atrophy of the skin and soft tissues of half of the face (hemifacial atrophy). The onset of the disease begins between the ages of 5 and 15 years. The progression of the atrophy lasts a decade. Treatment for the atrophy is recommended after the quiescence of disease progression. Microsurgical reconstruction is considered the gold standard to restore facial symmetry. Given a free-flap's morbidity and risk of complications, some patients opt for less extensive procedures. We present the case of a 30 year old male with a history of Parry Romberg Syndrome with resultant left hemifacial atrophy. Consistent with the usual pattern of atrophy, the onset of the patient's disease began at the age of 10 years. The progression of the atrophy lasted 12 years. At presentation, his atrophy had been stable for the previous 8 years.

Methods: The senior author (SSR) used a combination of a stacked AlloDerm cheek implant and submalar silicone implanted intraorally to produce volume and symmetric contour on the affected side. He was discharged home from the recovery room without complication.

Results: The patient was followed for 7 years. He has had no complications and maintains excellent symmetric result. The patient is highly satisfied with his result and has not required any further surgery. Preoperative and postoperative photos at 6 years are presented.

Conclusions: Less invasive treatment options exist for hemifacial atrophy from Parry-Romberg syndrome.

PARRY ROMBERG HEMIFACIAL ATROPHYAlso known as progressive hemifacial atrophy (PHA), Parry Romberg hemifacial atrophy was first described by Parry in 1825. It was later described by Romberg in 1846.(1,2) Although many theories exist as to the actual etiology of this atrophy, no one has defined the true nature of this disease. While its true incidence is not known, hemifacial atrophy usually begins at age 5-15 and lasts for 2-10 years. Thereafter, the disease burns out. Romberg's disease tends to affect females more than males, with a ratio of 1.5:1. The atrophy is limited to one side of the face in 95% of patients, with equal side distribution amongst patients in a large study of 772 patients. In the early stages, atrophy involves the skin and subcutaneous tissue. Subsequently, it may involve the facial muscles and facial skeleton.(3)

Cases of Parry-Romberg syndrome are classified as mild, moderate, or severe in relation to atrophy of the skin, subcutaneous tissue, and bone involvement in territories of the trigeminal nerve as follows: (4)

• Mild: Atrophy of the skin and subcutaneous tissues is observable in the territory of just

one of the sensory branches of the trigeminal nerve; bone involvement is not observable.

• Moderate: Atrophy of the skin and subcutaneous tissues is observable in the territory of

two of the sensory branches of the trigeminal nerve, without the involvement of the

osseous orbital region or maxillary and mandibular growth.

• Severe: Atrophy of the skin and subcutaneous tissues is observable in all three of the

sensory branches of the trigeminal nerve or bone involvement.

There is no effective medical treatment which halts or slows the atrophy. At this time, the treatment of Romberg's disease is surgical. The treatment of Romberg's disease is focused on restoration of facial contour. There have been many different strategies used to create facial symmetry in patients with Romberg's disease. These consist of both autogenous grafts/flaps and alloplastic implants. One of the first grafts used, which is still used today, is autogenous fat.(5,6) Reduced survival of fat grafts gave rise to the use of silicone and other alloplastic implants.(7,8)

Other techniques used include bone and cartilage grafts, tissue expansion, myocutaneous flaps, and microvascular free omentum and myocutaneous flaps. (9,10) The variety of techniques used reflects a lack of consensus as to the optimal treatment strategy for facial contouring in patients with Romberg's syndrome.

While the choice of technique used is varied, there are certain aspects of the disease which must be understood by the reconstructive surgeon. Some patients, while appearing have a progression which has "burned out," begin to atrophy again. This has been documented to occur after 2 years, and it seems to recur at a later interval if the initial disease initiated at a later age. (11) Therefore, it is essential for the surgeon to wait 2 years after the atrophy has halted before performing any procedure. This is especially important if the patient had a late disease onset.

TECHNIQUEThe entire operation was performed by the senior author involved in this poster (Samieh S. Rizk). For access to the face, a combined unilateral facelift approach was used. Various sheets of AlloDerm consisting of varying thickness were utilized. This AlloDerm was placed and sutured in positions of the soft tissue deficit. A gingivobuccal incision was used to access the malar region. Malar/submalar implants were placed on bone and secured using screws. The implants were composed of silicone. The AlloDerm was placed strategically over the implants to provide soft tissue over the implants. This would serve to create a soft tissue cushion which mimicked the contralateral aspect of the face. It was felt that volume augmentation without this cushion would have made the contour and induration of the implants seem too un-natural. For periorbital region, an upper blepharoplasty and lower external subciliary approaches were used for AlloDerm placement. A decision was made by the surgeon (SSR) to not place any hard implants around the eye.

AlloDerm was placed in aggressive fashion. The surgeon’s (SSR) experience with AlloDerm gave him the impression that in the long term, AlloDerm provides only about half the volume that one achieves immediately postoperatively. This overcorrection was important in maintaining fullness on the operated side.

The patient had decided against a local flap or microvascular free flap. He desired a limited procedure without donor site morbidity. While fat is commonly used for filling such facial defects, it was decided to not use fat. This decision was made due to a combination of lack of faith in the fat persisting. The surgeon’s previous experiment with fat gave unpredictable longevity. In addition, the patient had defined facial architecture on the contralateral side. Fat injections on the left side of the face would have lacked definition necessary to produce a symmetric appearance.

Now 7 years out from surgery, this patient is very pleased with his result. The surgeon uses injectable fillers to augment certain aspects of the face at two-year intervals. He has had no infections or any other complications related to the implants or surgery.

CONCLUSION

Parry Romberg can be managed with a variety of techniques. This poster describes a successful cosmetic outcome for a patient with progressive hemifacial atrophy.

REFERENCES

1. Parry, C.H. Collections from the Unpublished Medical Writings of the late Caleb Hillier Parry. London: Underwoods, 1825.

2. Romberg, M.H. Klinische Ergebnisse. Berlin: A. Forstner, 1846.

3. Rogers, B.O. Progressive Facial Hemiatrophy: Romberg's Disease, A Review of 772 Cases. In Transactions of the Third International Congress of Plastic Surgery. msterdam: Excerpta Medica, 1964.

4. Inigo, F., Rojo, P., and Ysunza, A. Aesthetic treatment of Romberg's disease: Experience with 35 cases. Br. J. Plast. Surg. 46: 194, 1993.

5. Peer, L. A. : The neglected free fat graft. Plast. Reconstr. Surg. 18 (1956) 233-250

6. Sokolova, L. A.. Free adipo-dermal grafts in the surgical treatment of progressive lipodystrophy. Acta Chir. Plast. 14 (1972) 157-165

7. Kiskadden, W. S., M. W. McGregor." Report of a case of progressive facial hemiatrophy with pathological changes and surgical treatment. Plast. Reconstr. Surg. 1 (1946) 187-192.

8. Ashley, F. L., T. D. Rees, D. L. Ballantyne et al.: An injection technique for the treatment of facial hemiatrophy. Plast. Reconstr. Surg. 35 (1965) 640-648

9. Schuller, D.E., Bardach, J., and Krause, C.J. Irradiated homologous costal cartilage for facial contour restoration. Arch. Otolaryngol. 103: 12, 1977.

10. Tweed, A.E., Manktelow, R.T., and Zuker, R.M. Facial contour reconstruction with free flaps. Ann. Plast. Surg. 12: 313, 1984.

11. Longaker MT, Siebert JW. Microvascular free-flap correction of severe hemifacial atrophy. Plast Reconstr Surg. 1995 Sep;96(4):800-9.

Pre-Op 6 years Post-Op