Frontal lifting using a tissue expander in pachydermoperiost
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Pachydermoperiostosis, a rare condition, is characterized by pachydermia, finger clubbing, and periostosis.

A 25 year old hypertensive man presented with a history of skin thickening mainly on the face and scalp from the age of 14 years associated with prominent skin wrinkles and folds. He also presented with joint edema in the hands and knees and finger clubbing. His main complaint was premature aging of his face, specifically the wrinkles in the frontal region. He had previously received botulinum toxin injections with unsatisfactory results. Preoperative examinations did not reveal any changes. Placement of a rectangular tissue expander was proposed to thin the skin and reduce the depths of the skin wrinkles and folds that are characteristic of the syndrome.

Subperiosteal lifting was chosen, as the disease pathophysiologically manifests with thickened periosteum. In an attempt to thin the skin and decrease the prominent wrinkles and folds that are characteristic of the disease, as well as achieve greater and improved lengthening of the forehead skin over time compared with the punctual lengthening achieved via surgery, a rectangular expander measuring 8.5 × 5 cm with a 200 mL volume was initially placed on the forehead in a submuscular position. Slow and gradual expansion was then performed until the 200 mL volume was filled.

6 months after the placement of the expander, the patient underwent a subperiosteal frontal lift, wherein a precapillary incision was made, the expander and its capsule were removed, and multiple incisions were made in the forehead flap to improve stretching. Resection of the thickened periosteum, superior flap traction, and removal of the excess skin were also performed, maintaining the previous capillary line.

The patient presented significant improvements in the skin folds and wrinkles of the forehead, with this result being maintained 1 year after the surgical treatment. Slight scars were noted. The patient complained of hypoesthesia in the frontal region until the third month after the final surgery.