Gluteal Augmentation With Intramuscular Implants in Patients With Human Immunodeficiency Virus With Lipoatrophy Related to the Use of Antiretroviral Therapy.

INTRODUCTION: Lipodystrophy syndrome associated with highly active antiretroviral therapy (HAART) may lead to low self-esteem and poor compliance with the drug treatment on patients infected with human immunodeficiency virus (HIV), which is a matter of concern for the health system. The aim of this study was to evaluate patients with HIV submitted to gluteal augmentation with intramuscular silicone implants to correct gluteal lipoatrophy related to the use of HAART. METHODS: This is a retrospective evaluation of 10 patients submitted to gluteal augmentation with intramuscular silicone implant for correction of gluteal lipoatrophy related to the use of HAART, operated between 2012 and 2015. Postoperative complications and the degree of patient's satisfaction were analyzed. RESULTS: There were 3 postoperative complications including 1 case of surgical wound dehiscence and 2 cases of seroma. Six months after surgery, 8 patients had an excellent degree of satisfaction, and 2 patients had a good degree of satisfaction related to the procedure. Although this intervention does not offer functional advantages, it improves the body contour, increases patients' self-esteem, and helps them to accept their body image. These advantages can lead to higher compliance with prolonged HAART. CONCLUSIONS: Gluteal augmentation with intramuscular silicone implant can be a viable option to treat patients with HIV with gluteal lipoatrophy related to the use of HAART. The patients were satisfied with the outcomes of the procedure, and there were only minor self-limited postoperative complications.

Embodiment and biographical disruption in people living with HIV/AIDS (PLWHA).

This study attempts to provide a concrete understanding to the embodied experience of HIV/AIDS. PLWHA have to cope with physical changes, especially lipodystrophy, caused by HIV and its treatment. These clinical manifestations make the disease socially visible and form a potential source of stigmatization. Visibility seems to transform the personal experience of this particular illness into a collective one. The changing body image and the stigma, which is often internalized by individuals, along with other consequences of chronic illness, such as alteration of life plans and social relationships, constitute new elements that appear in their life after diagnosis. These new experiences can break one's biographical continuity, especially in cases like HIV/AIDS. Semi-structured and in-depth interviews were conducted with 18 HIV-positive individuals (13 men, 5 women) with lipodystrophy. Their ages ranged from 36 to 65 years. The analysis of data revealed three main themes: loss of control over the body, ambivalence about visibility of HIV/AIDS, attributing positive meaning to HIV/AIDS. Physical changes caused by lipodystrophy are a source of dysphoria for PLWHA. This dissatisfaction was closely associated with the absence of control over their own body, due to the virus and the side effects of medication. Furthermore, it became evident that there was ambivalence among participants about the visibility of HIV, as it was in parallel a source of stigmatization, but also a part of their identity and biography. Results indicate that individuals were in search of meaning and constitute strategies in order to "answer" to the disruptive aspects of HIV. These were the normalization of illness, the integration into personal identity and the recognition of positive effects of HIV in their lives (e.g., stopping drug and alcohol abuse). Further research is required to identify the factors that determine the selection of each "answer" by these particular individuals who belong to broader social groups.

Facelift in a patient with benign symmetric lipomatosis and HIV facial lipoatrophy: a case report.

Benign symmetric lipomatosis (BSL) is a rare condition characterized by deposition of unencapsulated adipose tissue at typical sites on the body. Although the pathogenesis is not clearly defined, the disease has been associated with male gender, alcoholism, Mediterranean descent, and highly active antiretroviral therapy. A case study is presented of a facelift performed on a human immunodeficiency virus-positive patient on a highly active antiretroviral therapy with facial lipoatrophy in the anterior cheek region in combination with BSL characterized by excess fat deposits in multiple areas including the posterior cheeks and neck. The resultant peculiar deformity was managed in this case with a modified facelift and fat excision without recurrence. There are few reports in the English literature describing surgical excision using the facelift pattern for treating BSL.

Labia majora labioplasty in HIV-related vaginal lipodystrophy: technique description and literature review.

BACKGROUND: We present a rare case involving severe hypertrophy of the labia majora. This 39-year-old married woman developed a clinically noticeable bilateral lipodystrophy of her labia majora following the administration of chronic antiretroviral therapy. Different combination drug regimens that included drugs like Crixivan(®), Epivir(®), and Zerit(®) were administered to the patient from 1998 to 2005. The patient is currently on a single drug regimen of Atripla(®) with the disease under control and no other comorbidities. The severity of the pubic protuberance created an appearance resembling male genitalia, even when covered by underwear. This anatomical abnormality obviously impaired her social life and forced her to avoid wearing tight pants, swimming garments, and tight clothes in general. She also avoided any sexual activity. METHODS: Her pubic hair was shaved. Crural creases and vulvar mucosa were marked in order not to be violated. The estimated amount of skin and fat to be removed was marked. Intraoperative tailor-tacking suturing was used to mark the extent of the resection of the labia majora. Sutures were left in place to verify the accurate tension of the remaining skin. The procedure was performed with the patient under general anesthesia. Labial skin resection was performed by sharp dissection. Electrocautery was then used to excise the lobulated fat accumulation. Two layers of 3/0 Vicryl(®) sutures were used in the lax subcutaneous tissue. 4/0 Vicryl(®) rapide was used on the skin to approximate wound edges. Suction drains were left in place for 48 h to reduce the dead space and to manage postoperative bleeding. The patient was instructed to keep ice and compression pads on the area for the first 24 h and to keep the area clean. This was followed by the application of antibiotic ointment two times a day on the wounds to avoid blood crust formation and to keep the skin soft. RESULTS: Stitches were removed on POD 14 after an overall uneventful postoperative course. The sensitivity of the labia majora's interior aspect was preserved, even initially. With the legs slightly open, the labia majora just covered the entrance to the vagina. The clitoris and labia minora became visible again, restoring a normal anatomical appearance. Moderate edema was observed for 4 weeks after surgery. CONCLUSION: The surgical technique used provided an excellent result according to the patient, who regained her self-confidence and started having a normal sexual life again. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A facial marker in facial wasting rehabilitation.

BACKGROUND: Facial lipoatrophy is one of the most distressing manifestation for HIV patients. It can be stigmatizing, severely affecting quality of life and self-esteem, and it may result in reduced antiretroviral adherence. Several filling techniques have been proposed in facial wasting restoration, with different outcomes. The aim of this study is to present a triangular area that is useful to fill in facial wasting rehabilitation. METHODS: Twenty-eight HIV patients rehabilitated for facial wasting were enrolled in this study. Sixteen were rehabilitated with a non-resorbable filler and twelve with structural fat graft harvested from lipohypertrophied areas. A photographic pre-operative and post-operative evaluation was performed by the patients and by two plastic surgeons who were "blinded." The filled area, in both patients rehabilitated with structural fat grafts or non-resorbable filler, was a triangular area of depression identified between the nasolabial fold, the malar arch, and the line that connects these two anatomical landmarks. RESULTS: The cosmetic result was evaluated after three months after the last filling procedure in the non-resorbable filler group and after three months post-surgery in the structural fat graft group. The mean patient satisfaction score was 8.7 as assessed with a visual analogue scale. The mean score for blinded evaluators was 7.6. CONCLUSION: In this study the authors describe a triangular area of the face, between the nasolabial fold, the malar arch, and the line that connects these two anatomical landmarks, where a good aesthetic facial restoration in HIV patients with facial wasting may be achieved regardless of which filling technique is used.

[Treatment of facial lipoatrophy by lipofilling in HIV infected patients: retrospective study on 317 patients on 9 years]. / Traitement de la lipoatrophie faciale par lipofilling chez les patients infectés par le VIH: étude rétrospective de 317 patients sur neuf ans.

INTRODUCTION: HIV infection and antiretroviral therapy are responsible in 20 to 40% of cases of facial lipoatrophy. This one has an impact in an important way on the quality of life with a major social impact. Several treatments are available to correct facial lipoatrophy. We evaluate the efficiency of autologous fat transfer described by Coleman (Lipostructure®). PATIENTS AND METHODS: We recorded HIV-infected patients who had facial lipofilling between May 1999 and April 2008.Then, we estimated the severity of their lipoatrophy and the result of lipofilling after 1 month to 4 years follow-up. RESULTS: We have treated 317 patients by lipofilling. We have injected a mean of 8mL of fat on each side. There were no adverse events. Sixty-three percent had a good result on 1-year evaluation. CONCLUSION: Lipofilling is a safe and stable surgical procedure that makes the reference technique to correct facial lipoatrophy in HIV-infected patients. The use of facial fillers must be limited in case of impossibility to take fat tissue, which was exceptional in our study.

Open neck lipectomy for patients with HIV-related cervical lipohypertrophy.

BACKGROUND: The advent of effective antiviral medications has revolutionised the management of the HIV-infected patients. Although this has helped in achieving prolonged symptom control, high numbers of these patients are left with the stigmata of complications associated with the medication. Lipodystrophy, either as lipoatrophy or lipohypertrophy, is a known complication of long-term HIV infection and aggressive antiviral therapy, leading to significant physical and psychological morbidity in these patients. METHODS: Eleven patients demonstrating HIV-related anterolateral neck lipohypertrophy were offered the option of an open cervicoplasty involving pre- and subplatysma lipectomy, platysmaplasty, liposuction, and face-lift in selected patients. RESULTS: The amount of adipose tissue excised from each patient was higher than that normally achieved through liposuction, with the highest total of 140 g in one patient. The degree of cervical contouring was significant, with all patients reporting profound satisfaction in terms of restoration of a cosmetically acceptable neck contour. Complications included two hematomas and one seroma. There was no incidence of infection. CONCLUSION: Open anterior cervicoplasty with subplatysma contouring is a powerful tool for predictable and safe results and should be considered as one of the valuable treatment options for HIV-related anterolateral neck lipohypertrophy. Although the incidence of complications is higher than that for similar non-HIV patients, the degree of improvement it provided was perceived by patients as very rewarding.

A quantitative comparison of psychological and emotional health measures in 360 plastic surgery candidates: is there a difference between aesthetic and reconstructive patients?

This study examines the utility of the aesthetic and reconstructive categorization for making treatment decisions in patients seeking facial surgery. A total of 360 patients with aesthetic or combined functional aesthetic deficits were included. Validated psychological scales were used as outcome measures. All subjects showed clinically significant levels of appearance-related distress, with highest levels in the aesthetic and lowest levels in the functionally impaired group. Significant gender differences were not found on any psychological measures. A small negative correlation was found between age and distress. These findings challenge the validity of restricting treatment on the basis of an aesthetic distinction, since this is the group demonstrating the highest level of need. Neither age nor gender is a reliable discriminator. Subjective assessment of noticeability of disfigurement and associated psychological distress may be more useful in prioritizing treatment in systems with limited resources.

Nd:YAG laser-assisted liposuction for an HIV patient.

Active antiretroviral therapy has reduced the mortality of patients with acquired immune deficiency syndrome (AIDS) and increased both the quality of life and the longevity of patients infected with human immunodeficiency virus (HIV). The long-term effects of HIV infection are increasingly observed, particularly changes in fat distribution or "lipodystrophy." Strategies to prevent, mitigate, or reverse HIV-associated lipodystrophy have been difficult to develop. The medical management of fat redistribution usually is ineffective, and surgical approaches to HIV-associated lipodystrophy have already been described, but major drawbacks include recurrence of the fat accumulation. This report aims to describe the clinical outcomes for a man with buffalo hump who underwent lipolaser-assisted liposuction. This technique obtained a significant reduction in the size of the adiposity and an improvement in the neck's range of motion. At this writing, after 3 years, the patient is satisfied with his cosmetic and functional results. The authors believe that lipolaser-assisted liposuction using the Smartlipo Deka-Mela neodymium:yttrium-aluminum-garnet (Nd:YAG) 1,064-mm-long pulse is effective in reducing the cervicodorsal fat pad. The technique is performed using local anesthesia with low operative risks and minimal surgical trauma. The treated zone shows rapid healing, and the whole procedure requires a day-hospital recovery, thus reducing the costs.

Clinical management of HIV-associated lipodystrophy.

PURPOSE OF REVIEW: Lipodystrophy or fat re-distribution, and its associated metabolic abnormalities, are common in HIV patients. The pathogenesis is multifactorial. This article provides an update on the latest findings of the different clinical management strategies that have been utilized in patients with lipodystrophy. RECENT FINDINGS: Treatment strategies need to be different in those patients with lipoatrophy when compared with patients with central fat accumulation (lipohypertrophy). Most of the treatments studied have produced minimal or modest effects, which are not sustained when the therapy is discontinued. The treatment of associated metabolic abnormalities such as insulin resistance and hyperlipidemia should have similar goals to that in the non-HIV population, but is complicated by the fact that response may be worse and there is a need to consider drug-drug interactions with the antiretrovirals. SUMMARY: Multiple complex strategies will need to be utilized in these patients to treat the different features seen in lipodystrophy in order to reduce their long-term cardiovascular risk. Further research is also needed to evaluate combination therapies and to identify the underlying mechanisms in order to develop novel therapies for the future.

Correction of facial lipoatrophy using autologous fat transplants in HIV-infected adolescents.

OBJECTIVES: Antiretroviral therapy has dramatically improved the survival of HIV-infected children. Nevertheless, side effects comparable to those found in adults have been encountered, such as facial lipoatrophy, which can have a negative impact on the self-esteem of otherwise healthy adolescents. Cosmetic surgical procedures in adolescents raise psychological issues which need to be specifically addressed and which have never been previously reported in this population. We evaluated the patient satisfaction, safety and cosmetic results of HIV-infected adolescents who experienced autologous fat transplants for the correction of facial lipoatrophy. METHODS: We report the results of plastic surgery using autologous fat transplants (Coleman's Lipostructure) in six HIV-infected adolescents with facial lipoatrophy: three boys and three girls, aged 14-19 years. RESULTS: The quantity of reinjected fat on each side of the face varied from 5 to 12 mL within a single procedure. All the patients reported being satisfied or very satisfied with the cosmetic results and reported a positive impact on their daily life. CONCLUSIONS: With well-trained surgeons and carefully selected indications, corrective surgery of facial lipoatrophy in HIV-infected adolescents can provide immediate and long-lasting benefits in terms of physical appearance and psychological wellbeing, and should be considered as a component of comprehensive care.

Retreatment with injectable poly-l-lactic acid for HIV-associated facial lipoatrophy: 24-month extension of the Blue Pacific study.

BACKGROUND: Facial lipoatrophy occurs in HIV-positive patients taking highly active antiretroviral therapy and during natural aging. Injectable poly-l-lactic acid (PLLA) is a device approved internationally for restoration and correction of the signs of HIV-associated facial lipoatrophy. OBJECTIVE: To evaluate the long-term safety, duration of effect, and satisfaction with serial injections of PLLA for HIV-associated facial lipoatrophy. METHODS AND MATERIALS: In this single-site, open-label, retreatment study, 65 HIV-positive patients were treated with injectable PLLA every 5 weeks (until optimal recorrection). Presenting degree of lipoatrophy based on the James scale (1=mild, 4=severe) was reviewed. Skin thickness was measured at fixed points with calipers. Patients completed a post-retreatment satisfaction questionnaire. RESULTS: Nearly 10% of patients had persistent correction >36 months, based on patient report. Approximately 50% required three or fewer retreatments to maintain satisfactory correction (determined by patient and physician). Milder lipoatrophy on initial presentation required fewer retreatments and had more sustained correction. Time to first retreatment varied according to James scale score: 1 (21.4 months) and 4 (13.0 months). The mean patient satisfaction score was 4.9 (1=dissatisfied, 5=very satisfied) at study end. No serious adverse events were reported. CONCLUSION: Injectable PLLA is a safe and effective long-term treatment option for HIV-associated lipoatrophy.

[Treatment of HIV facial lipoatrophy with a submalar porous polyethylene implant (Medpor)]. / Traitement des lipoatrophies faciales utilisant des implants de Medpor en polyéthylène poreux.

Human immunodeficiency virus associated facial lipoatrophy is becoming epidemic and is a distressing sign for patients. Non permanent fillers provide only temporary results and cannot be the solution for severe cases. Lipodystrophy makes the lipofilling difficult to perform with a fibrous low quality fat difficult to harvest. We propose another solution using porous polyethylene implants (Medpor). Eight patients underwent submalar augmentation through an upper gingivobuccal sulcus incision that allows a subperiosteal dissection. The implants are carved to provide the desired augmentation. Overall, eight patients had good or very good aesthetic postoperative outcomes as determined by the patient and the surgeon. No complications occurred and results remain natural. Porous polyethylene implant (Medpor) is our treatment of choice for mild to severe facial lipoatrophy. Besides these implants could be removed easily later if needed.

[Adipose tissue hypertrophy after Lipostructure in HIV patient with antiretroviral treatment. Case report and literature review]. / Hypertrophie du tissu adipeux après Lipostructure chez un sujet séropositif traité par antirétroviraux. Cas clinique et revue de littérature.

HIV-related facial atrophy is a common complication due to antiretroviral treatment. The social handicap due to this lipodystrophy increase the demand of surgical correction. The usual treatment is the Lipostructure described by Coleman. The hypertrophy is one of the complications which can occur after a correction by Lipostructure. This complication is different from the overcorrection by the free time before his appearance. The treatment by liposuction is possible but there is a high risk of recurrence. The best treatment, after the literature review, seems to be the direct excision.

Restorative interventions for HIV facial lipoatrophy.

Facial lipoatrophy is a common and distressing manifestation of HIV lipodystrophy. The changes in facial appearance can reduce quality of life, self esteem and antiretroviral adherence. Apart from the modest benefits of thymidine-based nucleoside analog cessation, there are no proven therapies for lipoatrophy. Management of established fat loss can be challenging as restoration of lost fat mass is extremely gradual. Plastic surgery and cosmetic procedures can restore lost facial volume. Both biodegradable and permanent filling agents have been investigated for HIV facial lipoatrophy. Biodegradable products offer a good safety profile, but maintenance of aesthetic benefits necessitates reinjection over time. Although permanent products offer longevity and lower treatment costs, adverse events should they occur can be serious and of long duration. Despite the substantial increase in options for soft-tissue augmentation in recent years, well-performed clinical studies in HIV-infected adults with facial lipoatrophy are scarce, and long-term clinical safety data are lacking. This review will summarize available efficacy and safety data of the biodegradable and permanent agents utilized for soft-tissue augmentation in this population. Difficulties associated with comparing treatment efficacy data, assessment of facial lipoatrophy presence and severity, and measurement of facial fat will be discussed. Available data indicate that in HIV-infected adults, most filling agents have short-term clinically safety, and can provide aesthetic improvement and improve well-being, social functioning and quality of life. However, well-designed studies with objectively assessed endpoints are needed to elucidate optimal treatments for this distressing condition.

Bio-Alcamid complications: A 10 year review.

This article is a follow up to "Early and late complications of polyalkimide gel (Bio-Alcamid)".1 It is a summary of late complications that have developed in patients treated with Bio-Alcamid for HIV lipoatrophy following extended follow up of 10 years.

Bilateral lipomastia in men: a side effect of highly active antiretroviral therapy.

Breast enlargement in men and women is a documented feature of the highly active antiretroviral therapy- associated human immunodeficiency virus lipodystrophy syndrome. The exact underlying histomorphological features of this condition are speculative because most cases are diagnosed on clinical grounds with or without radiographic confirmation. The main documented causes of breast enlargement in men on highly active antiretroviral therapy include gynecomastia and lipomastia; however, biopsy-confirmed lipomastia is a rarely described phenomenon, with only 1 such case being described to date. In documenting 2 patients who underwent bilateral mastectomy for clinical gynecomastia of unknown cause, we emphasize the need for a greater degree of clinicopathological awareness of highly active antiretroviral therapy-associated lipomastia and the role of the histopathologist in the informed management of patients afflicted with human immunodeficiency virus infection on highly active antiretroviral therapy.

Excisional lipectomy for HIV-associated cervicodorsal lipodystrophy.

BACKGROUND: The development of effective antiretroviral therapy for the treatment of human immunodeficiency virus (HIV) has allowed for prolonged and healthier lives for affected patients. However, significant side effects from the drugs have been well documented, including syndromes of abnormal fat distribution. Cervicodorsal lipodystrophy, or "buffalo hump" deformity, is a common presentation of lipodystrophy syndrome and can cause significant disfigurement to the patient. Surgical correction has been the mainstay of treatment. OBJECTIVE: The authors report on the use of excisional lipectomy to correct cervicodorsal lipodystrophy. METHODS: Six male patients and one female patient (mean age, 47.2 years) underwent excisional lipectomy for buffalo hump deformity caused by HIV protease inhibitor use. Common complaints on presentation included disfigurement, neck pain, and difficulty sleeping. Deformity had first been observed an average of 4.75 years before presentation (range 2 to 7 years). At the time of consultation all patients were on antiretroviral regimens that included protease inhibitors. RESULTS: Excisional lipectomy of the hypertrophied cervicodorsal fat pad was performed on all patients, with suction-assisted lipoplasty (SAL) additionally to optimally contour the nondystrophic fat at the periphery of the resection. One patient also underwent simultaneous abdominoplasty, another underwent rhytidectomy with autologous fat transfer, and one patient received malar autologous fat injections. The average operative time for all procedures was 2.7 hours (range 1.0 to 5.8 hours). Complications included seroma in three cases and wound dehiscence in one patient, none of which required reoperation. At an average of 26.6 months of follow-up, all patients report satisfaction with their results, and there have been no recurrences. CONCLUSIONS: Cervicodorsal lipodystrophy is a well-described complication of extended use of HIV protease inhibitor therapy. Patients may seek consultation with plastic and reconstructive surgeons for correction of the aesthetic and functional morbidity associated with the deformity. Because of the fibrous nature of the hypertrophied cervicodorsal fat and the high rate of recurrence after SAL alone, an approach with excisional lipectomy (with or without SAL) may provide improved results and superior long-term outcomes.

Assessing the long-term viability of facial fat grafts: an objective measure using computed tomography.

BACKGROUND: Autologous fat transplantation for soft tissue augmentation is a commonly used technique without a universally accepted approach. The literature includes a variety of reports describing varying degrees of success or failure. OBJECTIVE: To evaluate the behavior of facial fat grafts in humans with the use of an objective measuring tool. METHODS: A prospective randomized study, comparing patients pre- and postoperatively, was designed to evaluate the long-term viability of fat grafting. Participants were 18 men and 8 women between 34 and 59 years of age (mean, 45.07 yrs; standard deviation, 6.54 yrs). A total of 52 hemifaces in 26 patients diagnosed with HIV and demonstrating facial lipoatrophy were treated with fat transplantation using Coleman's technique. HIV-positive patients were chosen as study participants because their nearly total lack of subcutaneous fat diminishes the bias in the evaluation of fat volume. Fat graft viability was evaluated by measuring the volume of adipose tissue evolution via computed tomography scan before fat grafting, at the second month after fat grafting, and 1 year after fat grafting. Descriptive statistical analysis was performed. RESULTS: The mean volume on the right and left cheeks before fat grafting was 1.57 cc. The mean volume 2 months after the procedure was 2.93 cc with a statistically significant mean increase of 1.36 cc (P < .001) between baseline and the second month after the procedure. The mean volume after 12 months was 3.29 cc (P < .001), with a mean increase compared with the baseline of 1.72 cc, and of 0.36 cc between months 2 and 12. The statistically significant posttreatment improvement (P < .001) was maintained until month 12 of the follow-up period. CONCLUSIONS: Using objective measurement, this study demonstrates that with one fat grafting procedure a durable result can be achieved, persisting for a minimum of 12 months without any trend towards reabsorption.

Treatment of facial lipoatrophy in HIV-infected patients.

Standard management for facial lipoatrophy caused by antiretroviral drugs includes switching drugs and surgical autografting of adipose tissue. Local injections of polylactic acid have not been compared with surgery. Benefits usually seem to outweigh adverse effects in the short term but few long-term results are available.