Psychological morbidity and facial volume in HIV lipodystrophy: quantification of treatment outcome

Efficacy and Safety of Autologous Fat Transfer in Facial Reconstructive Surgery: A Systematic Review and Meta-analysis

Importance

The use of autologous fat transfer (AFT) or lipofilling for correcting contour deformities is seen as one of the major breakthroughs in reconstructive plastic surgery. Its applications in facial reconstructive surgery have been of particular interest owing to the prospect of achieving autologous reconstruction by a minimally invasive approach. However, its unpredictability and variable degree of resorption have limited its utility and much skepticism still exists regarding its efficacy. Furthermore, more than 2 decades of clinical research have produced a highly fragmented body of evidence that has not been able to provide definite answers.

Objective

To investigate the safety and efficacy of AFT in facial reconstruction through a systematic review and meta-analysis.

Data Sources

A literature search was performed in PubMed, Embase, and the Cochrane Library from inception to October 11, 2017.

Study Selection

All published studies investigating the efficacy and safety of AFT in facial reconstructive surgery.

Data Extraction and Synthesis

Two independent reviewers performed data extraction systematically, adhering to the PRISMA guidelines. Summary measures were pooled in a random-effects model meta-analysis.

Main Outcomes and Measures

The patient and surgeon satisfaction, graft survival, number of AFT sessions, and the incidence of AFT-related complications were the main outcomes of interest in this meta-analysis.

Results

This systematic review resulted in the inclusion 52 relevant studies consisting of 1568 unique patients. These included 4 randomized clinical trials, 11 cohort studies, and 37 case series. The overall follow-up averaged 1.3 years after AFT. Meta-analysis revealed a very high overall patient satisfaction rate of 91.1% (95% CI, 85.1%-94.8%) and overall surgeon satisfaction rate of 88.6% (95% CI, 83.4%-92.4%). The number of AFT sessions required to achieve the desired result was 1.5 (95% CI, 1.3-1.7) and 50% to 60% of the injected volume was retained at 1 year. Only 4.8% (95% CI, 3.3%-6.9%) of procedures resulted in clinical complications.

Conclusions and Relevance

To our knowledge, this study provides the first overview of the current knowledge about AFT in facial reconstructive surgery. Our results confirm that AFT is an effective technique for treating soft-tissue deformities in the head and neck, with low rate of minor complications.

Level of Evidence

NA.

Quality of life outcomes associated with treatment of human immunodeficiency virus (HIV) facial lipoatrophy

Facial lipoatrophy (FLA), characterized by a decrease in facial volume, has a high prevalence in patients with human immunodeficiency virus (HIV) infection treated with long-term highly active antiretroviral therapy (HAART). The social stigmatization that results from such changes in facial appearance has led some HIV patients to discontinue HAART. The use of fillers is one method of restoring facial volume. A critical outcome of treatment concerns the patient's quality of life (QoL). Although many studies have assessed patient satisfaction, as well as the social and psychological outcomes associated with the correction of HIV FLA, fewer studies have assessed QoL. We reviewed treatment options for HIV FLA with a specific focus on QoL outcomes. Our analysis revealed that the following treatments were associated with improvements in QoL: poly-l-lactic acid; calcium hydroxylapatite; hyaluronic acid; polyacrylamide gel; polyalkylamide gel; polymethylmethacrylate; silicone oil; and autologous fat transfer. The treatment of HIV FLA with these agents appears to improve QoL as assessed by various QoL instruments. Additional studies are required to identify a unifying QoL instrument to effectively assess longitudinal QoL outcomes and to compare treatment modalities.

Quantification of adipose volume reduction with a prospective study analyzing the application of external radiofrequency energy and high voltage ultrashort pulse duration electrical fields

To date, there have been no objective measurements of subcutaneous volume loss following treatments with a noninvasive radiofrequency (RF)-based device. Twenty female patients were treated with a suction-coupled bipolar RF device using external RF energy combined with pulsed electromagnetic RF energy for subcutaneous fat reduction. Parameters followed included weight, Vectra measurements of abdominal circumference and torso volume, and high-definition ultrasound measurements of fat thickness. Measurements were taken before treatment and three times following treatment. Analysis of the measured parameters showed that mean circumference reduction of 2.30 cm was noted at three months post-treatment. Independent volumetric analysis showed a mean subcutaneous volume reduction of 428 cc three months following RF treatment. High-resolution ultrasound fat thickness was reduced by a mean of 39.6% three months following the final BodyFX treatment. Independent and paired-sample t-tests showed a p value of < 0.05. Repeated measures of analysis of covariance (ANCOVA) adjusted for differences in age, as well as height and weight (proxy for body mass index) to minimize individual differences and control for extraneous variables that may affect the pre- and post-treatment results were analyzed. No confounding variables were found. All analyses were conducted using IBM SPSS 21.0.

A systemic review of autologous fat grafting survival rate and related severe complications

OBJECTIVE

Clinical application of autologous fat grafting (AFG) is quickly expanding. Despite the widely acceptance, long-term survival rate (SR) of AFG remains a question not yet solved. Meanwhile, although rare, severe complications related to AFG including vision loss, stroke even death could be seen in the literature.

DATA SOURCES

A comprehensive research of PubMed database to June 2013 was performed according to guidelines of the American Society of Plastic Surgeons Fat Graft Task Force Assessment Methodology. Articles were screened using predetermined inclusion and exclusion criteria.

STUDY SELECTION

Data collected included patient characteristics, surgical technique, donor site, recipient site, graft amount, and quantified measurement methods. Patient cohorts were pooled, and SR was calculated. All the severe complications were also summarized according to the different clinical characteristics.

RESULTS

Of 550 articles, 16 clinical articles and 10 animal studies met the inclusion criteria and provided quantified measurement methods. Totally, 596 patients were included. SR varied from 34% to 82% in breast and 30-83% in the facial area. Nude mice were applied to investigate human fat grafting SR (38.3-52.5% after 15 weeks). Rabbits were commonly used to study animal AFG SR (14.00-14.56% after 1-year). Totally, 21 severe complications were reported, including death (2), stroke (10), vision loss (11, 8 of which accompanied with stroke), sepsis (3), multiple abscess (1) and giant fat necrotic cyst (2). Ten of these complications happened within 10 years.

CONCLUSIONS

There is no unified measurement method to evaluate fat graft SR until now and no clinical evidence to show better SR according to different donor and recipient cite. Body mass index change between pre- and postoperation may be the bias factor in evaluating fat SR. Fat embolisms of the ophthalmic artery and the middle cerebral artery are the most severe complication of AFG and still lack of effective treatment.

Injectable carboxymethylcellulose hydrogels for soft tissue filler applications

Disease, trauma and aging all lead to deficits in soft tissue. As a result, there is a need to develop materials that safely and effectively restore areas of deficiency. While autogenous fat is the current gold standard, hyaluronic acid (HA) fillers are commonly used. However, the animal and bacterial origin of HA-based materials can induce adverse reactions in patients. With the aim of developing a safer and more affordable alternative, this study characterized the properties of a plant-derived, injectable carboxymethylcellulose (CMC) soft tissue filler. Specifically, methacrylated CMC was synthesized and crosslinked to form stable hydrogels at varying macromer concentrations (2-4% w/v) using an ammonium persulfate and ascorbic acid redox initiation system. The equilibrium Young's modulus was shown to vary with macromer concentration (ranging from ∼2 to 9.25kPa), comparable to values of native soft tissue and current surgical fillers. The swelling properties were similarly affected by macromer concentration, with 4% gels exhibiting the lowest swelling ratio and mesh size, and highest crosslinking density. Rheological analysis was performed to determine gelation onset and completion, and was measured to be within the ISO standard for injectable materials. In addition, hydrolytic degradation of these gels was sensitive to macromer concentration, while selective removal using enzymatic treatment was also demonstrated. Moreover, favorable cytocompatibility of the CMC hydrogels was exhibited by co-culture with human dermal fibroblasts. Taken together, these findings demonstrate the tunability of redox-crosslinked CMC hydrogels by varying fabrication parameters, making them a versatile platform for soft tissue filler applications.

Current treatment methods for combination antiretroviral therapy-induced lipoatrophy of the face

Summary

Combination antiretroviral therapy (CART) reduces the mortality and morbidity in HIV-infected patients. However, facial lipoatrophy (FLA) is one of the well-known side-effects of this treatment and subsequently imposes major problems for HIV-infected patients. In the last decade, ample experience has been obtained with both local therapeutic options as well as possible systemic treatment options. Soft tissue fillers are a relatively simple and efficient treatment option for FLA. Especially, the biodegradable semi-permanent fillers combine a good effect with durability and an acceptable safety profile. The best way to prevent or restrict the development of FLA remains the exclusion of thymidine analogue nucleoside reverse-transcriptase inhibitors from the CART schedule.