Plastic surgical options for HIV-associated lipodystrophy

A Systematic Review and Comparative Analysis of Reconstructive Rhytidectomy: Advantages, Disadvantages, and Patient Outcomes

Reconstructive rhytidectomy, commonly known as facelift surgery, is a prominent cosmetic procedure aimed at rejuvenating facial appearance by addressing signs of aging. This paper critically evaluates the advantages and disadvantages of various surgical techniques involved in rhytidectomy, including the superficial musculoaponeurotic system (SMAS), deep plane facelift, and subperiosteal approaches. This systematic review of recent literature highlights key outcomes such as scar quality, postoperative pain management, and patient satisfaction. While the techniques demonstrate significant improvements in aesthetic results and patient quality of life, they also present risks including complications, dissatisfaction with outcomes, and the financial burden of surgery. Future directions indicate a trend toward minimally invasive approaches, integration of regenerative medicine, and personalized surgical planning, aiming to optimize results and minimize risks.

Immune Checkpoint Inhibitors-Associated Generalized Lipodystrophy: Reconstructive Challenges of an Emerging and Distinct Form of Lipodystrophy

Total and permanent loss of facial and nonfacial fat is a rare side effect of immune checkpoint inhibitors (ICIs). Consequently, effective treatment modalities for patients remain undefined. Here, we discuss the surgical treatment of a patient with both ICI-related acquired generalized lipodystrophy (AGL). We additionally performed a comprehensive literature review (Cochrane, Embase, and MEDLINE) to summarize what is known about ICI-related lipodystrophy and available treatments for this rare complication. A 66-year-old female diagnosed with metastatic lung adenocarcinoma started ICI (pembrolizumab) treatment. She developed generalized lipodystrophy 13 months after her first cycle. Her primary concern was the loss of facial fat volume, which significantly aged her appearance. The patient underwent a 2-staged restoration of her facial fat compartments using dermal grafts from the lower abdomen and medial thighs. The patient recovered uneventfully and was satisfied with the aesthetic improvement at 18 months of follow-up. The authors identified 8 case reports with patients with ICI-AGL. The mean age was 53.63 years, and the mean BMI was 36.72 kg/m2. The average onset of symptoms was 7.44 months after ICI initiation. None of the studies described any sort of surgical or nonsurgical options to restore the volume of the facial fat compartments. The management of combined facial and nonfacial lipodystrophy remains challenging due to the lack of suitable autologous fat donor sites. In this report, the authors demonstrate that staged volume restoration can be achieved using autologous dermal grafts from the thigh, making it a viable reconstructive option in this subset of patients.

Lipodystrophy related to HIV-The Brazilian Public Health approach

BACKGROUND

Lipodystrophy associated with the human immunodeficiency virus (HIV) is an unpleasant disorder found in 6%-80% of patients infected with HIV. Brazil has a universal public health system, an effective program for patients diagnosed with HIV, providing lipodystrophy treatment since 2004. The objective of this article is to describe the Brazilian approach to this complication.

METHOD

A search in the Brazilian Health Care Legislation and the Brazilian Health System database was conducted to identify all the inclusion criteria and surgical treatment offered to HIV patients with lipodystrophy, identify all the facilities that offer this, and describe their geographic distribution. In addition, the number of procedures performed was obtained.

RESULTS

The inclusion criteria were the following:¹ diagnosis of HIV/AIDS and lipodystrophy due to the use of antiretroviral drugs for at least 12 months;² no response or the impossibility of changing ART;³ clinical stability for six months without clinical manifestations suggestive of immunodeficiency in the last 6 months;⁴ laboratory results showing CD4 cell count >250 cells/mm³ and viral load <10,000 copies/ml in the last 6 months; and⁵ stable clinical and laboratory parameters. A total of 4,760 procedures were performed, with the most common procedure being facial filler with polymethylmethacrylate. Eleven hospitals were registered to offer this treatment.

CONCLUSION

The Brazilian Health Care System approach to lipodystrophy has an organized plan with universal and integral coverage. All the procedures offered were safe and well-tolerated, according to the literature. However, regional distribution is the main issue and needs to be improved.

Direct Conversion of Human Fibroblasts into Adipocytes Using a Novel Small Molecular Compound: Implications for Regenerative Therapy for Adipose Tissue Defects

There is a need in plastic surgery to prepare autologous adipocytes that can be transplanted in patients to reconstruct soft tissue defects caused by tumor resection, including breast cancer, and by trauma and other diseases. Direct conversion of somatic cells into adipocytes may allow sufficient functional adipocytes to be obtained for use in regeneration therapy. Chemical libraries of 10,800 molecules were screened for the ability to induce lipid accumulation in human dermal fibroblasts (HDFs) in culture. Chemical compound-mediated directly converted adipocytes (CCCAs) were characterized by lipid staining, immunostaining, and qRT-PCR, and were also tested for adipokine secretion and glucose uptake. CCCAs were also implanted into mice to examine their distribution in vivo. STK287794 was identified as a small molecule that induced the accumulation of lipid droplets in HDFs. CCCAs expressed adipocyte-related genes, secreted adiponectin and leptin, and abundantly incorporated glucose. After implantation in mice, CCCAs resided in granulation tissue and remained adipose-like. HDFs were successfully converted into adipocytes by adding a single chemical compound, STK287794. C/EBPα and PPARγ were upregulated in STK287794-treated cells, which strongly suggests involvement of these adipocyte-related transcription factors in the chemical direct conversion. Our method may be useful for the preparation of autogenous adipocytes for transplantation therapy for soft tissue defects and fat tissue atrophy.

An ethics analysis of the rationale for publicly funded plastic surgery

Background

Healthcare systems are increasingly struggling with resource constraints, given demographic changes, technological development, and citizen expectations. The aim of this article is to normatively analyze different suggestions regarding how publicly financed plastic surgery should be delineated in order to identify a well-considered, normative rationale. The scope of the article is to discuss general principles and not define specific conditions or domains of plastic surgery that should be treated within the publicly financed system.

Methods

This analysis uses a reflective equilibrium approach, according to which considered normative judgements in one area should be logically and argumentatively coherent with considered normative judgements and background theories at large within a system.

Results and conclusions

In exploring functional versus non-function conditions, we argue that it is difficult to find a principled reason for an absolute priority of functional conditions over non-functional conditions. Nevertheless, functional conditions are relatively easier to establish objectively, and surgical intervention has a clear causal effect on treating a functional condition.

Considering non-functional conditions that require plastic surgery [i.e., those related to appearance or symptomatic conditions (not affecting function)], we argue that the patient needs to experience some degree of suffering (and not only a preference for plastic surgery), which must be ‘validated’ in some form by the healthcare system.

This validation is required for both functional and non-functional conditions. Functional conditions are validated by distinguishing between statistically normal and abnormal functioning. Similarly, for non-functional conditions, statistical normality represents a potential method for distinguishing between what should and should not be publicly funded. However, we acknowledge that such a concept requires further development.

End-of-Life Care and Bereavement Issues in Human Immunodeficiency Virus-AIDS

This review article addresses end-of-life care issues characterizing human immunodeficiency virus progression by delineating associated stages of medical and nursing care. The initial progression from primary medical and nursing care aimed at functional cure to palliative care is discussed. This transition is considered in accord with the major symptoms experienced, including fatigue, pain, insomnia; decreased libido, hypogonadism, memory, and concentration; depression; and distorted body image. From the stage of palliative care, progression is delineated onward through the stages of hospice care, death and dying, and the subsequent bereavement process.

Facial soft tissue volume decreases during metreleptin treatment in patients with partial and generalized lipodystrophy

PURPOSE

Lipodystrophy (LD) patients suffer from loss or maldistribution of subcutaneous adipose tissue accompanied by dysregulation of several adipocyte-secreted factors, e.g., leptin. The effect of recombinant leptin (metreleptin) therapy on facial soft tissue volume in patients with non-human immunodeficiency virus LD has not been quantified to date.

METHODS

Eight LD patients (six female, two male; six familial partial LD [FPLD], two generalized LD) were treated with metreleptin over 1 year. Anthropometric parameters and 3D stereophotogrammetric imaging of the patients´ faces were assessed at baseline and after 1 year of metreleptin treatment.

RESULTS

Median fat mass was significantly reduced during metreleptin treatment from 22.3 kg at baseline to 20.0 kg at 1 year (p = 0.031); however, body weight, body mass index, and waist-to-hip ratio were not significantly affected. Five of the six patients with FPLD lost between 4 and 114 cm³ of facial soft tissue volume in the pre-auricular, buccal, and submandibular area during metreleptin treatment whereas a slight volume gain was seen in one FPLD patient. The two patients with generalized LD developed a volume loss of 20 and 8 cm³ in the buccal region between baseline and 1 year of metreleptin therapy, respectively.

CONCLUSIONS

Metreleptin replacement leads to loss of facial soft tissue volume in FPLD and generalized LD. However, volume changes in most patients are not visible by the naked eye.

The successful use of lipectomy in the management of airway obstruction in a woman with HIV-associated lipodystrophy

Lipodystrophy is a common complication of highly active antiretroviral therapy and is associated with significant comorbidities. Altered fat distribution, particularly lipohypertrophy of the dorsal cervical fat pad is associated with reduced quality of life as well as medical complications. We report the rare case of a patient with airway obstruction secondary to HIV-associated lipodystrophy. Ultrasound-assisted liposuction was successfully performed to relieve her airway obstruction and to facilitate a tracheostomy. To the best of our knowledge, this is the first documented case of its kind. We also provide a brief review of the literature on the current management options for HIV-associated lipodystrophy.

Morcellized Omental Transfer for Severe HIV Facial Wasting

BACKGROUND

A novel surgical technique to reconstruct facial wasting was developed for patients with severe human immunodeficiency virus lipoatrophy and no source of subcutaneous fat for donor material. Fourteen patients underwent endoscopic harvest of omentum, extracorporeal morcellation, and autologous transfer to the face.

METHODS

Omental fat was harvested using a standard 3-port laparoscopic technique. A mechanical tissue processor created morsels suitable for transfer. Gold-plated, multi-holed catheters delivered living particulate fat to the subcutaneous planes of the buccal, malar, lateral cheek, and temporal regions. Results were evaluated using standardized pre- and postoperative photographs for specific anatomic criteria found along the typical progression of the disease process.

RESULTS

Electron microscopy confirmed that morcellized fat retained intact cell walls and was appropriate for autologous transfer. Complications were minor and transient. Patients were discharged home within 24 hours. No patient required open laparotomy. Survival of the adipose grafts was deemed good to excellent in 13 of the 14 cases.

CONCLUSIONS

Mechanically morcellized omental fat transfer provides a safe option to restore facial volume in those unusual patients with severe wasting and no available subcutaneous tissue for transfer. Consistent anatomic progression of facial wasting permits preoperative classification, counseling of patients, and postoperative evaluation of surgical improvement.

Biochemical Manifestation of HIV Lipodystrophy Syndrome

OBJECTIVES

Highly active anti-retroviral therapy (HAART), including protease inhibitors (PI) have led to dramatic improvements in the quality and quantity of life in patients with acquired immunodeficiency syndrome (AIDS). However, a significant number of AIDS patients on HAART develop characteristic changes in body fat redistribution referred to as lipodystrophy syndrome (LDS). Features of LDS include hypertrophy in the neck fat pad (buffalo hump), increased fat in the abdominal region (protease paunch), gynecomastia and loss of fat in the mid-face and extremities.

METHODS

The aim of this paper is to review the current knowledge regarding this syndrome. This article reviews the published investigations on biochemical manifestation of HIV lipodystrophy syndrome.

RESULTS

It is estimated that approximately 64% of patients treated with PI will experience this syndrome. Biochemically, these patients have increased triglycerides (Trig), total cholesterol (TC), low-density lipoprotein-cholesterol (LDL-C) and extremely low high-density lipoprotein-cholesterol (HDL-C).

CONCLUSIONS AND PUBLIC HEALTH IMPLICATIONS

It is hoped that awareness of this syndrome would aid in early diagnosis and better patient management, possibly leading to a lower incidence of cardiovascular complications among these patients.

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.

Disorders of fat partitioning in treated HIV-infection

HIV-associated lipodystrophy is clinically characterized by body fat changes including subcutaneous fat loss (lipoatrophy) with or without truncal fat accumulation (lipohypertrophy). Thymidine nucleoside reverse transcriptase inhibitors, stavudine and to a lesser extent zidovudine, are major contributors for lipoatrophy. Drug factors are not clear for lipohypertrophy. Restoration to health with effective viral suppression and weight gain may be factors playing significant roles in lipohypertrophy. Mitochondrial dysfunction and inflammation in subcutaneous adipose tissue are key factors in the pathogenesis of HIV-associated lipoatrophy. The pathogenesis of lipohypertrophy is less well understood. Switching from thymidine nucleoside reverse transcriptase inhibitors restores subcutaneous fat in patients with HIV-associated lipoatrophy, but improvement is slow and limited. Surgical filling cosmetically improves facial lipoatrophy. Exercise and diet may reduce increased visceral adipose tissue. Liposuction may be useful to remove superficial, localized fat accumuli.

Treatment options for HIV-associated central fat accumulation

Central fat accumulation is increasingly recognized as a problem for patients with HIV infection. The term "lipodystrophy" has been used to describe collectively a constellation of body habitus changes and metabolic abnormalities commonly observed in HIV-infected patients, particularly since the advent of highly active antiretroviral therapy. Visceral fat accumulation can place patients at increased risk of coronary artery disease.Furthermore, body shape changes are a source of distress to patients that may compromise treatment adherence.Reduction of abdominal obesity can therefore be considered part of therapy in HIV-positive patients with visceral adipose tissue (VAT) accumulation. Currently, there are no drugs approved by the Food and Drug Administration for the treatment of HIV-associated central fat accumulation. Lifestyle modifications such as diet and exercise and switching antiretroviral therapies appear to be of limited value in reducing VAT. Metformin has shown some benefit in reducing VAT but at the expense of accelerating peripheral fat loss, and the thiazolidinediones have no effect on VAT. Similarly, testosterone does not appear to reduce VAT in these patients,and there are no data on anabolic steroids. Two large, randomized controlled trials have demonstrated the efficacy of recombinant human growth hormone (rhGH) in reducing visceral adipose tissue. There are also promising data regarding treatment with growth hormone releasing hormone (GHRH).