Classification and Treatment of Facial Tissue Atrophy in Parry–Romberg Disease

Classification and Treatment of Facial Tissue Atrophy in Parry�Romberg Disease

Jose Guerrerosantos, M.D., Fernando Guerrerosantos, M.D., and Jessica Orozco, M.D.

From the Jalisco Plastic and Reconstructive Institute, Public Health System, Medical School, University of Guadalajara,Avenida Federalismo Norte #2022, Guadalajara, Jalisco, Mexico

Abstract.

Background: This report aims to show procedures that the

senior author has used for the rehabilitation of facialdeformities in Parry�Romberg disease since 1983. The au-thors also report the classification they use to plan the most

appropriate surgical procedure for these patients. Methods:For this study, 95 patients (67 females and 28 males) withdifferent types of facial tissue depression were classified

according to the depth of the defect so adequate treatmentcould be planned. The cases were classified into four types.For types 1 and 2, only fat grafts were used, whereas for types

3 and 4, a combined procedure was used according to thecase using cartilage and bone grafts, free dermis-fat grafts,and galeal flaps. Results: The results were successful, withfew or no complications. Objective examinations showed

excellent aesthetic improvement, with obvious deformityalleviated and the emotional status of the patients improved.Conclusions: The authors� practice frequently sees cases of

Parry�Romberg disease, which has allowed them to gainsignificant experience in this field. For depression types 1 and2, they recommend only fat infiltration, and for types 3 and 4,

they favor combined treatment with lipoinjection, galealflaps, free dermis-fat grafts, and bone and cartilage grafts.Occasionally, in areas of soft tissue with fibrosis, the authorsinfiltrated around 4 ml of fragmented fascia grafts instead of

fat grafts.

Key words: Facial deformities—Facial deformity rehabili-tation—Facial tissue depresion—Parry�Romberg disease

Improving the volume and contour of faces with tissueatrophy offers a great psychological and emotionalboost to patients. Plastic surgeons need to choose the

most appropriate surgical treatment for correction ofthese facial deformities. The use of autologous fatgrafts as a solitary procedure or together with othersurgical methods offers a very valuable solution forthese facial and cervical deformities.

Patients we have managed with this type of treat-ment include those with sequelae of Parry�Rombergdisease, craneomaxillo facial microsomia, sequels offacial paralysis, depressions after surgical proceduresand trauma, and the like. In this report, we referexclusively to patients with sequelae of Parry�Romberg disease.

To determine the most appropriate treatment foreach case, it is convenient first to classify the type oftissue atrophy exhibited by each patient. At the clin-ical examination, we classify the patients into one offour types. After this classification of the tissuedepression has been performed, we plan the treatmentfor the facial depression and loss of tissue volume.

Type 1 Tissue Depression

Type 1 depression is very mild, with a thinness of thesoft facial tissues. It occurs in patients with the acutephase of Parry-Romberg disease between the ages of10 and 20 years. The deformity is almost impercepti-ble to strangers, but noticeable to the patient, as wellto family and friends (Fig. 1A and B). This certainlycauses emotional pain for the affected patient.


Type 2 deformity is characterized by thinness of thesoft tissues, with no effect on bone or cartilage. Thedepression and loss of volume is more noticeable thantype 1 deformity, and recognized by anyone lookingat the patient (Fig. 2A and B).

Correspondence to J. Guerrerosantos, M.D.; email:[email protected]

Aesth. Plast. Surg. 31:424�434, 2007DOI: 10.1007/s00266-006-0215-4


With type 3 facial depression, the soft tissues arethinner than with type 2, and the bony and cartilag-inous tissues are also thinner. It is a very evidentdeformity (Fig. 9A and B). Facial depression types 3and 4 are experienced by patients who experienceParry�Romberg disease by the age of 10 years.


Type 4 deformity is the most severe facial tissuedepression. With type 4 tissue depression, the softtissues are so atrophied that in many cases, the skin ispractically next to the bones. The cartilages andbones are thinner than with type 3. Besides the aes-thetic deformities, the patients also have severefunctional problems, especially with the lips and thenose (Fig. 12A and B).

Treatment of Facial Tissue Atrophy Depressions

After classifying the facial depressions carefully, wemeticulously plan the treatment. Patients withdepression types 1 and 2 are treated with lipoinjectionsessions (Table 1) as isolated procedures. Patientswith type 3 depressions receive a combined treatmentthat could include galeal flaps, dermis-fat grafts,lipoinjection sessions, and cartilage and bone grafts.For patients with type 4 depressions, the treatment issimilar to that for type 3, except that the thickness ofthe flaps and grafts is thicker.

Demonstrative Clinical Cases

Case 1

A 30-year-old man presented with sequelae ofParry�Romberg disease involving type 1 facial

atrophies located in the left half of the upper lip, thelabial commissure, the left external part of the lowerlip, and the mental superior region, which showedtwo depressions (Fig. 1A). He was treated in a singlesession with 12 ml of lipoinjection. At 6 months afterthe treatment, the contour and volume of the affectedareas were increased, with better aesthetic appearance(Fig. 1B).

Case 2

A 35-year-old woman presented with deeper depres-sions than in case 1, with type 2 tissue depressionsaffecting the right temporal region, the right cheek,and the right zygomatic area (Fig. 2A and B). Shewas treated with four sessions of lipoinfiltration every12 months. In the first session, 40 ml of fat wasinfiltrated, followed by 30 ml in the second session,25 ml in the third session, and 20 ml in the last ses-sion. The evolution of the patient was highly satis-factory, and we observed improvement 2 years afterthe first two lipoinjections (Fig. 2C and D), and 6years after four lipoinjections (Fig. 2E and F).

Case 3

A 38-year-old woman with sequelae of Parry-Rom-berg disease presented to our practice in 1981 showingfive depressed areas (Fig. 3A�D) located on the leftside of the face and neck, in the frontal region, thetemporal region, the cheek, the mental region, and theinframandibular neck (Fig. 3B�D). When she wasseen in our institution, we were undertaking a studywith the collagen Zyplast III (Palo Alto, CA) (Fig. 3E)for the correction of facial depressed areas, and wetreated her with three sessions of collagen infiltration.After 1½ years of these infiltrations, the patient didnot show any improvement in volume or contour(Fig. 3F and G).

In 1983, when beginning the use of autologous fatgrafts, we decided to adopt this method for thispatient. In the first session, we placed 60 ml oflipoinfiltration (Fig. 3H). After 6months, we observedimprovement in the face and neck of this patient(Fig. 3I�J). In the first lipoinjection session, it wasalready our routine to infiltrate the fat into the mus-cular tissue of the neck, or at least below the submu-cosal aponeurotic system (SMAS), because weobserved long-lasting survival results with these

Fig. 1. Case 1. (A) Male patient with labial type 1 tissuedepressions before treatment. (B) Patient 6 months aftertreatment with microfat grafts showing good volume andcontour of the lips.

Table 1. Average amount of fat infiltrated per half face

Type of depression. Amount (ml)

1 252 953 404 60

J. Guerrerosantos et al. 425

tissues. We infiltrated fat in the subcutaneous layer ofthe depressed area, and 6 months later, the volumeaugmentation was slightly noticeable (Fig. 3K). Oneyear later, the bulges disappeared because of absorp-tion.The second session with 30 ml of lipoinfiltration

was performed 6 months after the first session. Weobserved very satisfactory cervicofacial improvement6 months after the second infiltration. One year later,we performed the third infiltration, placing only 15ml of fat. The aesthetic improvement 6 months afterthe infiltration was significant (Fig. 3L�N). The pa-tient returned to the clinic, 8 years after the last in-filtration, and we observed with satisfaction that thedepressions had disappeared totally (Fig. 3O and P).This case, along with others, confirmed the long-lasting survival of the fat grafts placed in the mus-cular layer.

Case 4

A 20-year-old man presented with sequelae ofParry�Romberg disease including facial asymmetry,with depressions on the left hemifacial side and facialtissue atrophy types 1 and 2 (Fig. 4A) in the malar,cheek, and mandibular regions (Fig. 4B�D). As atreatment, we performed only one lipoinjection sessionof 25 ml (Fig. 4E). One year later, the patient showedgreat facial aesthetic improvement (Fig. 4F�H).

Comment

In these three cases of facial tissue atrophy types 1and 2, for which treatment with lipoinjection alonewas sufficient, we obtained very satisfactory resultsover the long term. For successful fat transplantation,we recommend infiltrating fat grafts into the muscle(Fig. 5).

Patients with Facial Tissue Atrophy Types 3 and 4

Patients with facial tissue depression types 3 and 4require complex treatment. These patients requirecombined treatment carried out in various surgicalsteps. The surgical methods we used were lipoinfil-tration, free transplantation of flaps with microsur-gery, galeal flaps, dermis-fat grafts, and cartilage andbone grafts. Having used various techniques, we fa-vor one that includes infiltration of microfat grafts,galeal flaps that can include either fascia alone orfascia and muscle, free dermis-fat grafts 3 mm thick[17], and cartilage and bone grafts.

Galeal Flaps

The technique we use is based on the procedurepublished by Avelar and Psillakis [1], which uses amonopedicle galeal flap, including the portion sup-

Fig. 2. Case 2. Preoperative condition offemale patient with type 2 tissue depres-sions in the temporal (A) and cheek (B)regions. (C,D) Patient 2 years after twoinfiltrations. (E,F) Patient 6 years aftertreatment with four sessions of fat infil-trations.

426 Classification and Treatment of Facial Tissue Atrophy

plied by the superficial temporal artery and vein.When we need a bipedicle flap, it also is necessary totake into account galea supplied by the occipital andposterior auricular arteries. To prepare the recipientarea for placement of the galeal flap, a preauricularrhytidoplasty fashion incision is made that continuesin the scalp following an inverted Y line. To allow thesurgeon to visualize the donor area of the galeal flapperfectly, we perform and lift a well-vascularizedscalp flap. The undermining of the scalp should beperformed atraumatically to avoid damage to thepilous follicles and the superficial temporal vessels.

Then, according to the dimensions and shape of thedepression to be corrected and augmented, the inci-sions around the galeal flap are drawn to get a suffi-cient and appropriate flap, which is undermined,raised, and rotated to the recipient deformed facialarea (Fig. 6B).

In the cheek, the skin flap is undermined as in arhytidoplasty to receive the galeal flap, which is placedbelow the facial cutaneous flap (Fig. 6D and E). Thegaleal flap has two purposes. The first purpose is toprovide volume and contour for correction of the fa-cial depression, and also to provide revascularization

Fig. 3. Case 3. Femalepatient with type 2 tissuedepressions. (A) The fivedepressed areas aredrawn. (B�D) Patient in3=4 and front views beforetreatment. (E) Over 1½years, the patientreceived collagen infil-trations. (F,G) Patientwithout contourimprovement after threecollagen infiltrations.(H) Infiltration of fatgrafts in the affectedareas. (I�K) Patient 6months after the secondsessions of fat infiltra-tion. (L�N) Patient6 months after the thirdinfiltration with greataesthetic improvementin volume and contour.(O,P) Patient 8 yearsafter the last infiltration,without depressions.


with both fat grafts and galeal flaps. Simultaneously,another surgical team harvests a dermis-fat graft fromthe inguinal region, which is placed over the SMAS ofthe deformed area, with the dermal surface facing thegaleal flap, and sutured carefully. The galeal flap isplaced over the dermis-fat graft. Lipoinjection is per-formed using micrografts infiltrated into the galealflap. Then a careful suture of the galeal flap is per-formed inside the cavity and also outwardly withpullout sutures to avoid retraction of the galeal flapand development of a deformity in the reconstructedarea. This flap retraction can lead to the formation ofvisible steps, which can be felt at the borders of thegaleal flap. Finally, the cutaneous cheek flap is suturedin the preauricular incision, and the scalp also is su-tured similar to that for rhytidoplasty incision (Fig. 6F).

Free Dermis-Fat Graft

In the great majority of cases, we obtain free dermis-fat grafts from the inguinal region with the patientunder general anesthesia or under intravenous seda-

tion. According to the size and shape of the defect, apattern of the graft is drawn. The graft size should bea little larger than the size of the defect (Fig. 7A).because free grafts have a tendency to retract imme-diately.

After drawing the flap, we infiltrate local anesthesiawith lidocaine and epinephrine to diminish bleeding(Table 2). We wait 10 min to get vasoconstriction,then deepithelialize the area of the future graft, withrenoval of the epidermis (Fig. 7B). After that, a 3-mm-thick graft is harvested. The donor area is closedin three layers after careful hemostasia, and a dress-ing is placed under light pressure.

Demonstrative Clinical Cases

Case 5

A 19-year-old girl presented with type 3 facial tissueatrophy as a sequela of Parry�Romberg disease, withobvious depressions in the left zygomatic and cheekareas and dark ochrodermia in the affected areas(Fig. 8A�C). Treatment was performed using a ga-leal flap with fascia and muscle, obtained from theleft temporoparietal region (Fig. 8D and E). We thenundermined a cheek cutaneous flap with a preauric-ular incision as in rhytidoplasty, then rotated thegaleal flap to the deformed area (Fig. 8F). This flapwas fixed with internal and external pullout stitches(Fig. 8G) to avoid retraction as well as secondarydepression and lack of volume and contour of thecheek. Then 6 months after the surgical procedure, 20

Fig. 4. Case 4. Malepatient with tissuedepression types 1 and 2.(A) The depressed areas.(B�D) Patient beforetreatment. (E) Infiltra-tion. (F�H) Patient 1½years after lipoinfiltra-tion with improvementto his facial asymmetry.

Fig. 5. Fat transplantation should be infiltrated into themuscle.


ml of microfat grafts was infiltrated, with a secondinfiltration of 10 ml applied 6 months later. Exami-nation showed obvious aesthetic improvement 2years after the primary operation, 1½ years after thefirst infiltration, and 1 year after the second infiltra-tion. At this writing, 2 years after the last infiltration,we see a normal volume and contour on the left

Fig. 6. (A) A preauricular rhytidoplasty incision is made, which continues on the scalp following the Y line. (B) After thescalp flap is undermined carefully, the shape of the galeal flap is drawn, which is dissected subperiostically (C). (D) The skinflap in the cheek is undermined in the areas of the depression. (E) Subsequently, the galeal flap is rotated to the cheek andapplied over the dermis-fat graft. (F) Finally, the cheek and scalp flaps are sutured.

Fig. 7. (A) Free dermis-fat graft theappropriate size of the defect is takenfrom the inguinal region. (B) The epi-dermis is removed, and the graft iscarved to a thickness of no more than3 cm.

Table 2. Complication summary

Amount %

Hematoma 9 9.47Undercorrection 7 7.36Prolonged edema 2 2.10Induration 4 4.21


zygoma area and cheek, and a very diminished darkochrodermia (Fig. 8H�J).

Case 6

A 27-year-old patient presented with sequelae ofParry�Romberg disease and type 3 facial tissuedepressions on the left cheek, mandibular, and chinareas (Fig. 9A�C). For this patient, we combinedvarious flaps and grafts. This patient improvedgradually. After the first surgical session, in which weused a galeal flap, cartilage grafts, free dermis-fatgraft, and lipoinjection, we observed aestheticimprovement. Later, we performed two infiltrationsof fat and two sessions of intramuscular applicationof fragmented fascia [12]. We observed a veryfavorable result 4 years after the first surgery and 6months after the last infiltration of fat and fascia. Thechin was improved with fragmented fascia grafts(Fig. 9D�F).

Case 7

A 31-year-old woman presented with facial tissueatrophy types 3 and 4 as sequelae of Parry�Rombergdisease located in the left zygomatic region, thecheek, and the mandibular region (Fig. 10A�C). Inthe first surgical stage of treatment, we used a galealflap with fascia and muscle, which was sutured to

the recipient deformed area with pullout sutures(Fig. 10D). A dermis-fat graft from the inguinalregion and the first lipoinfiltration with 60 ml ofmicro grafts also were performed. Months later, weperformed another two sessions with 30- and 15-mllipoinjection. The patient showed a good aestheticresult 1 year and 4 months after the last lipoinjection,with improved facial volume and contour (Fig. 10E�G).

Case 8

A 24-year-old woman with type 4 facial tissue atro-phy presented with severely deformed depressions inleft hemifacial area (Fig. 11A�D). Treatment in thefirst surgical stage included a galeal flap with fasciaand muscle, cartilage grafts, and the first 40-mlinfiltration of macrofat grafts. Later, three sessions oflipoinjection were performed every 12 months. At 1year after the last infiltration of fat, we could see avery satisfactory aesthetic result. We also saw thispatient 4 years after the main surgical procedure and6 months after the fourth lipoinjection (Fig. 11E�G).

Case 9

An 18-year-old boy with type 4 facial tissue depres-sions on the left hemiface presented with affectedtemporal region, cigomatic region, cheek, mandibular

Fig. 8. Case 5. Female patient with type 3 depressions in the left cheek. (A�C) Patient before treatment. (D,E) A galeal flapfrom the temporal region was used. (F) The galeal flap was rotated to the depressed area. (G) Through a subcutaneous tunnel,the flap was introduced. (H�J) Patient 2 years after treatment with improvement in contour and volume and decreasedochrodermia.


Fig. 9. Case 6. Female patient with type 3tissue depressions in the left hemiface.(A�C) Preoperative condition. (D�F)Result 4 years after treatment with agaleal flap and infiltration of fat andfascia grafts.

Fig. 10. Case 7. Female patient with type 3 tissue depressions on her left hemiface. (A�C) Patient before treatment. (D) In thedepressed area, a free dermis-fat graft was placed over the submucosal aponeurotic system (SMAS). A galeal flap was placedover the dermis-fat graft and sutured with pullout sutures. (E�G) The patient�s improvement is shown 3 years later.


border, and upper lip (Fig. 12A and B). For treat-ment, four surgical sessions were used. In the firstsurgical stage, cartilage grafts were applied to thezygomatic region, bone grafts to the body and ramusof the mandible (Fig. 12C), and a free dermis-fatgraft from the inguinal region to the SMAS of thecheek. We also applied a bipedicle galeal flap withfascia and muscle over the dermis-fat grafts (Fig. 12D�G). Lipoinfiltration of 10 ml of macrofat graftswas applied on the galeal flap to make it thick(Fig. 12H and I). Later, every year for 3 years, fatgrafts were applied, with placement of 60 ml, 30 ml,and finally 15 ml. The patient showed an appropriateincrease in volume and good facial contour 5 yearsafter the first surgical stage and 6 months after thelast lipoinjection (Fig. 12J and K).

Discussion

Multiple procedures have been used through theyears to repair sequelae of Parry�Romberg disease.Surgeons have used various implants and autologousgrafts and flaps, the descriptions of which have beenreported and discussed widely in the medical andsurgical literature previously and are not be repeatedhere.In our institution, we believe it is very important to

classify the patient by depression type to select themost appropriate treatment. For facial tissuedepression types 1 and 2, we find it very useful andsufficient to treat with lipoinfiltration, placing the fat

grafts preferably either below the SMAS, into themuscles, and/or over the periostium because theselayers are well vascularized. Fat grafts have been usedfor correction of this condition in the past[1,6,14,15,17,18], and recently to correct this condi-tion and also for aesthetic surgery [2�5,8�11,16]. Forfacial tissue depression types 3 and 4, we use infil-tration of fat in addition to other tissues to improveblood supply and aesthetic facial volume and con-tour.

In our practice, besides galeal flaps, we have usedmicrosurgical flaps [13] that included dermis and fat,and in selected cases, we also have added musculartissue. The aesthetic outcome with these microsurgi-cal flaps has been satisfactory initially, but later, thesetransplanted tissues have become hard and palpableexternally. For that reason, we prefer to use galealflaps because we get good facial volume, smoothcontour, and soft palpation [1,7]. We also note that inthe reconstructed areas of all tissue depression types,regardless of our treatment, the blood supply hasimproved notably and the dark ochrodermia hasdiminished, even disappearing in some cases.

We also note that these patients are examined inthe clinic periodically to review the status of thevolume and contour of the affected area because it ispossible that a limitation to the blood supply coulddevelop, leading to presentation of mild depressions.For this reason, we recommend that patients beexamined every 3 to 5 years after treatment. In somecases, it may be necessary to perform additionalinfiltrations of small amounts of microfat grafts.

Fig. 11. Case 8. Femalepatient with type 4 tissuedepressions on her lefthemiface. To improvethe vermillion border ofthe upper and lower lips,she was treated with atongue flap bone andcartilage grafts, a der-mis-fat graft, and agaleal flap. (A�D)Preoperative condition.(E�G) Result 4 yearslater.


Conclusion

For successful correction of facial tissue atrophy as asequela of the Parry�Romberg disease, it is impor-tant first to classify the depression type. This aids inthe planning and performance of the most appro-priate surgical technique, and thereby provides thebest aesthetic result.In our hands, cases of depression types 1 and 2 are

treated solely with fat infiltration because thedepressions are mild or moderate. For types 3 and 4,in which tissue depression and thinness are severe, wecombine fat infiltration, dermis-fat grafts, galealflaps, and bone and cartilage grafts. Grafts and flaps

are selected according to the features of the deformityto obtain the best rehabilitation and aestheticimprovement. Surgical technique and some demon-strative cases are presented.

References

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Fig. 12. Case 9. Male patient with type 4 depressions on his left hemiface. (A,B) Preoperative condition. (C,D,F,G)In thetreatment, we include bone and cartilage grafts, dermis-fat graft, and galeal flap. (H,I) Inflitration on the galeal flap. (J,K)Patient 5 years after treatment.


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Classification and Treatment of Facial Tissue Atrophy in Parry–Romberg Disease

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