Treatment of human immunodeficiency virus-associated

Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 1209e1216
Treatment of human immunodeficiency
virus-associated facial lipoatrophy with
lipofilling and submalar silicone implants
A. Mori a,*, G. Lo Russo a, T. Agostini a, J. Pattarino a,
F. Vichi b, M. Dini a
a
Department of Plastic Surgery, University of Florence, Largo Palagi 1, 50134 Florence, Italy
Department of Infectious Diseases, S. Maria Annunziata Hospital, Via dell’Antella 58,
50011 Florence, Italy
b
Received 2 May 2005; accepted 9 December 2005
KEYWORDS
Facial lipoatrophy;
Lipofilling;
Silicone malar
implants;
Lipodystrophy;
HIV;
HAART
Summary In the absence of a current therapy to prevent facial lipoatrophy in
HIVþ patients treated with HAART, surgical correction of the defect still remains
the best option.
We evaluate two different surgical techniques for facial contour enhancing and
suggest the right choice related to the lipodystrophy severity.
Twelve HIVþ patients underwent surgical submalar correction: eight were
treated with lipofilling following Coleman’s technique and four had bilateral malar
silicone implants inserted after determining their positioning with the aid of a new
software.
Both techniques gave long lasting results in facial contour reshaping ranging from
good to very good. No complication was observed. In the mean follow-up period of 2
years no patient felt uncomfortable with his/her image.
Both techniques, lipofilling and silicone implant positioning, for managing facial
lipoatrophy in HIVþ patients treated with HAART had good results, but the right
choice has to be related to the severity of the lipodystrophy in the patient.
ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All
rights reserved.
* Corresponding author. Tel.: þ39 55 4278292; fax: þ39 55
4278099.
E-mail address: [email protected] (A. Mori).
Fat depots redistribution in the HIV-associated
lipodystrophy includes visceral fat accumulation in
the abdomen, subcutaneous fat accumulation in
breasts and in the cervical and dorsal area (buffalo
hump) with fat wasting in the legs, arms, buttocks
1748-6815/$ - see front matter ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2005.12.047
1210
and face. Many hypotheses have been proposed for
its aetiology: most of them focus on mitochondrial
toxic effects and altered adipocyte differentiation
induced by protease inhibitors and nucleoside reverse transcriptase inhibitors,1,2 but lipodystrophy
has also been represented as a selective neuropathy.3 Many authors have tried to define this syndrome based on the objective and/or self-assessed
features of patients fat distribution and searching
for a correlation between lipodystrophy, metabolic
abnormalities and antiretroviral therapy.4e6 In
some studies, the efficacy of switching antiretroviral therapy to improve lipoatrophy stigmata has
been proved,7 while in other cases the suspension
of the treatment in well monitored patients has
been attempted to stop the worsening of body
image.8 Today there is no treatment regimen which
definitely prevents the lipodystrophy development
over the years, hence these disfigured patients
seek plastic surgical correction. Facial lipoatrophy
secondary to the atrophy of the subcutaneous fat
is the most obvious and stigmatising manifestation
of the syndrome while the buccal fat pad is constantly present, as demonstrated in more than one
study.9,10 Following the consistent experience of
Coleman in facial lipofilling for aesthetic purposes,11,12 autologous fat injection has been chosen
as one of the most reliable treatments for facial
subcutaneous augmentation. Although not all
patients are candidates for this kind of treatment
because some do not present enough subcutaneous
tissue in the lower abdomen area, which is the fattiest in the body of these patients. Sufficient fat
tissue can be harvested if the cutaneous plica is
thicker than 1 cm measured by plicometer. Unfortunately, when at the end of the 1990s, the
HIV-related lipodystrophy patients started to be
recognised and sent to the plastic surgeon at our
Institution, most of them, if referred to the present
time, could be classified as belonging to the IV
degree of the facial lipoatrophy James scale,13 presenting a subtotal resorption of the subcutaneous
fat of the cheeks. They also showed an advanced
subcutaneous body fat atrophy. In these late presentation patients in whom the facial lipofilling
could not be attempted, it was decided to improve
the facial appearance using silicone implants for
cheek augmentation. Technical details and results
of these two approaches are discussed.
A. Mori et al.
1999 to May 2004. All patients were treated with
HAART regiments including NRTI and IP over a mean
period of 7 years and nine of them were receiving
D4T treatment. All of them had a CD4 T lymphocyte
count over 100 cells/mm3 at the time of operation.
Perioperative antibiotics were given in each case.
Submalar augmentation by autologous fat injection
was performed in eight patients, who had a cutaneous infraumbilical plica thicker than 1 cm measured
by plicometer. In the remaining patients, silicone
implants to enhance the facial contour were
placed. All patients treated by fat injection were
operated on under general anaesthesia, the others
had the infraorbital and the mental nerves of both
sides blocked by an anaesthetic solution of 0.8% lidocaine and 1:200 000 adrenaline. For the lipofilling
procedure, it rigorously followed Coleman’s technique12 of fat harvesting by a 3 mm blunt cannula
connected to a 10 cc luer-lock syringe for vacuum,
fat graft centrifugation for 5 min at 3000 rpm and
graft placement by a 17-gauge blunt cannula. Fat
graft injections were always performed through
three incisions: one at the most lateral aspect of
the malar bones and the other two at the distal
and proximal part of the nasolabial folds, respectively. The fat grafts, ranging from 5 cc to 12 cc in
Patients and methods
Twelve patients (eight men and four women)
ranging in age from 32 to 55 years underwent
surgical correction of malar atrophy from January
Figure 1 Implants resting on the skin of the submalar
area of the patient in the programming time.
Treatment of HIV-associated facial lipoatrophy
Figure 2
1211
(a, b) Preoperative view of a patient treated with lipofilling.
quantity for each hemifacial treatment, were distributed in multiple levels along crossing tunnels.
The facial incisions were closed by steri-strips.
The four patients, who presented an infraumbilical
plica thinner than 1 cm measured by plicometer,
underwent silicone implant positioning via an intraoral approach through a 1.5 cm incision at the
first premolar level on the labial side of the upper
buccal sulcus. The position of the silicone implant
was planned before the surgery. The Alterimage
software (Alterimage Seattle Software design,
1416 N., 54th Street, Seattle, WA 98103, USA) was
used to create a virtual enhancement of the submalar area bilaterally in the front view digital photo
and in the oblique view digital photo of the patients. The unmodified and the modified photos
were printed to evaluate the correct position of
the implant and the front view photo and the oblique view photo of the patients were taken with
the implant just resting on the skin of the right
submalar area (Fig. 1). Then, with the information
obtained by comparing these photos, the correct
position of the implants was drawn on the patients’
skin. A subperiosteal pocket was dissected lateral
to the maxillary canine to avoid the main branch
of the infraorbital nerve. In two cases, in which
we considered it proper to place the implants
more medially, they were split partially so as to
avoid nerve injury. After position and symmetry of
the implants were assessed, they were always
secured in place by one medial and one lateral
pull-out stitch, removed after 6 days (Figs. 2e7).
Results
Submalar augmentation with lipofilling resulted in
a notable improvement of the facial contour in all
eight patients treated with this technique. The
results were graded by patients from good to
excellent and produced a consistent enhancement
in psychological well-being, getting back to everyday life. No infection has been recorded. Though
patients continued their therapy regimen, the
results appeared stable during the follow-up period ranging from 10 months to 4 years. Since the
facial lipoatrophy corrected by silicone implants
belonged to the IV degree of the lipoatrophy James
scale, the results in the four patients treated with
this technique were considered as very good by
patients, but left the surgeon not completely
satisfied. No infections, haematomas, seromas or
displacements occurred. Results were not influenced by therapy regimen in these cases either.
1212
A. Mori et al.
Figure 3
(a, b) Twenty-four months postoperative view of the same patient.
Discussion
The lipodystrophy syndrome in HIVþ patients has
been studied by many authors since the late
1990s.14 Besides many efforts made to best define
the syndrome from a physical and a metabolic point
of view,15e18 research for new antiviral drugs and
therapy regimens has continued.19,20 The adipocyte
apoptosis that has been shown to be up-regulated in
the lipoatrophic areas of the patients treated with
highly active retroviral therapy (HAART)21 seems
not to be influenced or just partially influenced by
therapy changes,22 although it has been demonstrated that the number of apoptotic adipocytes decreases in the adipose tissue treated by coenzyme
Q10 in vitro.23 Today life expectancy is quite long
for these patients. Improving the quality of their
life becomes the main aim in the treatment of the
HIV-1 infection, considered a chronic illness. Recently, in many cases, the physician, who manages
the therapy of these patients, has informed them
of the possibility of a plastic surgery treatment for
their facial lipoatrophy. This strategy makes the
patients adhere to their therapy more readily.
The increasing demand for facial augmentation
in the aesthetic plastic surgery field has led to the
development of several safe and durable materials
and new operative techniques. Hinderer and Spadafora et al.24,25 pioneered malar augmentation by
silicone implants, stressing the importance of the
planning for prosthesis positioning.26 Today silicone implants, even if different from those used
by Hinderer, are still amongst the most reliable
devices for malar enhancing. High-density polyethylene (Medpor, Newman, GA) implants and expanded polytetrafluoroethylene implants (Goretex,
Flagstaff, AZ) are possible alternatives to the silicone implants in the cheek area.27 The first ones
have a very high biocompatibility due to their porosity and they are quite resistant to infections, but
they are more rigid than silicone and their high tissue integration causes a decreased exchangeability.
This is an important disadvantage for HIVþ patients
whose facial features are prone to variability. The
second ones have optimal biocompatibility, conformability, softness, high resistance to infections
and they are easy exchangeable, but they are quite
expensive compared to the silicone implants. Many
injectable materials have also been used for facial
contouring in these patients. Permanent ones have
been preferred in these cases and injectable silicone, illegal in our country for these purposes, has
Treatment of HIV-associated facial lipoatrophy
Figure 4
1213
(a, b) Preoperative view of a patient treated with lipofilling.
also been implanted.28 Recently, the polylactic acid
injectable implants (New-Fill and Sculptra,
Bridgewater, NJ) have been experimented with
and then introduced for the treatment of facial
lipoatrophy in these patients. The progressive
increase of dermal thickness is due to a local reaction induced by this material during its resorption.
No serious adverse effect was observed in these
studies,29,30 but with this technique several series
of injections are necessary to get a final result
and sometimes palpable micronodules can result
from the resorption process.
Surgical correction of facial lipoatrophy of these
patients with autologous tissue is mainly represented by dermafat grafts and fat injections. Both
techniques need the presence of a fat pannicule
thick enough for harvesting.
Following the rules given by Coleman in facial
lipofilling for aesthetic purpose,12 we performed
facial enhancement in the eight patients in whom
the infraumbilical adipose tissue layer was thicker
than 1 cm, measured by plicometer, as suggested
by N. Caye et al.31 This technique has the advantages of the filling injection method, namely, the
accuracy in treating the specific areas that have
to be augmented, the inconsistency of scars and
the technical easiness compared to other techniques like the dermafat graft implantation. This
latter procedure has good results but the more invasive technique is not justified by a longer lasting
result, as even dermafat grafts are prone to a
consistent resorption.32,33 It has been widely demonstrated that autologous fat injection, following
Coleman’s technique of harvesting and implantation, has good and long lasting results with very
few drawbacks11,34 and in our small series these
findings were confirmed. The absence of atrophy
in the implanted fat in HIVþ patients is also well
known but remains unexplained. Gueraldi et al.35
revealed fat hypertrophy in the face of some
HIVþ patients in whom lipofilling was performed
using buffalo hump brown fat. This finding prompted the hypothesis that adipocyte specific receptors are transferred with the intervention.
In one patient we also tried to use the adipose
tissue harvested from the buffalo hump and centrifuged as usual but its high fibrous consistency made
us once again rely on the infraumbilical fat.
1214
A. Mori et al.
Figure 5
(a, b, c) Thirty months postoperative view of the same patient.
All the four patients presenting an insufficient
fat pannicule in the infraumbilical region could be
classified as belonging to the IV degree of the
facial lipoatrophy James scale, hence lack of
subcutaneous trunk fat has always been related
to the most serious facial lipoatrophy in our
patients. These had been treated by antiretroviral
therapy longer than the others. Submalar augmentation by silicone implants seemed to us to be the
Figure 6
most reliable and effective procedure for them.
Since the subcutaneous fat defected in these
patients is conspicuous, the Implantech Terino
facial implants (Implantech Associates Inc., 2064
Eastman Avenue, Ventura, CA 930003, USA) (wider
than those used in aesthetic surgery for lesser
corrections) were inserted. Technical details have
been widely discussed by many authors and the
transoral approach has been chosen as the least
(a, b) Preoperative view of a patient treated with submalar silicone implants.
Treatment of HIV-associated facial lipoatrophy
Figure 7
1215
(a, b) Eleven months postoperative view of the same patient.
invasive or traumatic in most cases.26,36e40 Research for programming of the best way to define
the correct position for the implants brought
many authors, over many years, to standardise
facial features by drawing intricate lines on the
faces of their patients, although the necessity of
fitting those lines to the unique facial traits has
been universally accepted.26,38,39,41e44 We exploited Alterimage software to create a virtual
correction of the submalar area as a guide for implants positioning. We found this planning method
easy and giving good results even if it is not precise
and is quite time consuming.
HIVþ patients treated with antiretroviral therapy have a long life expectancy. Today no drugs or
particular therapy regimens are able to stop lipodystrophy progression. Plastic surgery treatment
is essential for them to ameliorate lipoatrophy
facial stigmata, giving back fullness to their faces.
We prefer using autologous tissue for facial enhancing when possible, strictly following Coleman’s lipofilling technique. Otherwise, we opted
for submalar silicone implants positioning for its
technical simplicity and few drawbacks. Results of
both techniques are encouraging and leave the
patients well satisfied.
References
1. Carr A, Samaras K, Chisholm DJ, et al. Pathogenesis of HIV-1
protease inhibitor-associated peripheral lipodystrophy,
hyperlipidaemia, and insulin resistance. Lancet 1998;351:
1881e3.
2. Brinkman K, Smeitink JA, Romijn JA, et al. Mitochondrial toxicity induced by nucleoside-analogue-reverse-transcriptase
inhibitors is a key factor in the pathogenesis of antiretroviral-therapy-related lipodystrophy. Lancet 1999;354:1112e5.
3. Fliers E, Sauerwein HP, Romijn JA, et al. HIV-associated
adipose redistribution syndrome as a selective autonomic
neuropathy. Lancet 2003;362:1758e60.
4. Tershakovec MA, Frank I, Rader D. HIV-related lipodystrophy and related factors. Atherosclerosis 2004;174:1e10.
5. Tien PC, Grunfeld C. What is HIV-associated lipodystrophy?
Defining fat distribution changes in HIV infection. Curr Opin
Infect Dis 2004;17:27e32.
6. Carr A, Emery S, Law M, et al. An objective case definition
of lipodystrophy in HIV-infected adults: a case control
study. Lancet 2003;361:726e35.
7. McComsey GA, Ward DJ, Hessenthaler SM, et al. Improvement in lipoatrophy associated with highly active antiretroviral therapy in human immunodeficiency virus-infected
patients switched from Stavudine to Abacavir or Zidovudine: the result of the TARHEEL study. Clin Infect Dis
2004;38:263e70.
8. Wohl DA. Diagnosis and management of body morphology
changes and lipid abnormalities associated with HIV infection and its therapies. Top HIV Med 2004;12:89e93.