Contemporary Surgical Management of HIV-Associated Facial Lipoatrophy

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.

Impact of antiretroviral therapy on growth, body composition and metabolism in pediatric HIV patients

Highly active antiretroviral therapy improves survival and growth in children with HIV infection. However, its use can be associated with adverse changes in body composition and metabolism. Bone mineral density can be adversely affected in HIV-positive children due to nutritional compromise or certain antiretrovirals. HIV-associated lipodystrophy, consisting of redistribution of adipose tissue, insulin resistance, and dyslipidemia, has also been described in children. Pediatric HIV patients may be at greater risk for these problems because of their longer potential lifetime exposure to these agents and because childhood is normally a period of rapid growth and tissue accretion. Healthcare providers for children with HIV infection must be aware of the potential complications associated with HIV antiretrovirals so that their antiviral efficacy can be balanced against their risk for side effects. In this review, we discuss the alterations in childhood growth and body composition that occur in HIV-infected children, and describe the impact of antiretroviral therapy on these outcomes. The problem of HIV-associated lipodystrophy syndrome in children is also discussed. Children with HIV should have their growth and body composition systematically monitored. Antiretroviral regimens should be tailored to optimize adherence and viral suppression while minimizing the potential for adverse side effects.

Sonographic assessment of facial HIV-related lypoatrophy

OBJECTIVE

To investigate the utility of ultrasonography (US) for assessing and grading facial lypoatrophy (FLA) in patients with HIV.

DESIGN

The social effect of FLA is huge and may reduce antiretroviral therapy adherence. Strategies for the early detection of FLA are crucial, because complete correction of FLA in late stages is unlikely.

METHODS

Fifty-two HIV-positive patients undergoing highly active antiretroviral therapy underwent US with nasogenian transversal scan using a high-frequency broadband transducer (5-17 MHz) to detect FLA. Intra- and interobserver variability were calculated to assess US reproducibility. Concerning FLA grading, patients were categorized in five clinical classes and four US classes.

RESULTS

Our results regarding inter- and intraobserver coefficients of variation permit the validation of US as a reproducible technique (p<.001), and a high correlation between US and clinical classification was obtained, with complete concordance for more advanced FLA classes.

CONCLUSIONS

The lack of a reference objective method to quantify subcutaneous fat is a major difficulty in measuring HIV-related FLA. Our results, in accordance with data from the literature, suggest that US is an ideal tool for assessing and grading FLA. Furthermore, US may be suitable for routine evaluation in HIV-infected patients for early detection of FLA and to select its optimal management.

Outcome measures in facial plastic surgery: patient-reported and clinical efficacy measures

OBJECTIVE

To survey the existing literature to identify, summarize, and evaluate procedure- and condition-specific outcome measures for use in facial plastic and reconstructive surgery.

METHODS

A review of the English-language literature was performed to identify outcomes instruments specific for targeted facial plastic surgery interventions and conditions. A search was performed using MEDLINE (1950 to September 2007), CINAHL (Cumulative Index to Nursing & Allied Health) (1982 to September 2007), and PsychINFO (1806 to September 2007). Outcomes instruments were categorized as patient-reported or clinical efficacy measures (observer-reported or objective measures). Instruments were then categorized to include relevant details on the intervention, degree of validation, and subsequent use.

RESULTS

Sixty-eight distinct instruments were identified (23 patient-reported, 35 observer-reported, and 10 objective measures), with some overlap among categories. Most patient-reported measures (76%) and half observer-reported instruments (51%) were developed in the past 10 years. The rigor of validation varied widely among measures, with formal validation being most common among the patient-reported outcome measures.

CONCLUSIONS

Validated outcomes measures are present for many common facial plastic surgery conditions and have become more prevalent during the past decade, especially for patient-reported outcomes. Challenges remain in harmonizing patient-reported, observer-based, and other objective measures to produce standardized clinically meaningful outcome measures.

HIV-associated facial lipoatrophy: establishment of a validated grading scale

OBJECTIVE

HIV-associated lipodystrophy is considered a sequela of highly active antiretroviral treatment. We describe the characteristics, possible etiology, and pathophysiology of HIV-associated lipodystrophy and facial lipoatrophy and establish a validated grading scale for HIV-associated facial lipoatrophy using evidence-based techniques.

DESIGN/METHODS

A grading scale was designed based on the severity of each patient's facial lipoatrophy. Preoperative photographs of HIV-infected patients seeking treatment for facial lipoatrophy and control subjects were reviewed by physicians qualified in facial plastic surgery. With use of the devised grading scale, each patient was assigned a severity score. These scores were then compared for interrater variability, and the distribution of scores was analyzed.

RESULTS

Preoperative photographs of 39 HIV-infected individuals with facial lipoatrophy and 6 normal subjects were obtained and reviewed. All patients were males. A Cohen kappa of 0.73 was calculated, and there was a fairly equal distribution of all severity grades throughout the 39 patients.

CONCLUSION

HIV-associated facial lipoatrophy is a major stigma for HIV patients that can have dramatic effects on their self-esteem, social habits, and medication compliance. This current study introduces a validated evidence-based grading scale that can be implemented to categorize disease severity. Using this scale will hopefully generate improved treatment plans directed to each patient, which should produce enhanced postoperative results.

Surgical management of HIV-associated lipodystrophy: role of ultrasonic-assisted liposuction and suction-assisted lipectomy in the treatment of lipohypertrophy

PURPOSE

HIV-associated lipodystrophy is a frequent consequence of highly active antiretroviral therapy and has been associated with several metabolic disorders (increased triglycerides, hypercholesterolemia, insulin resistance) as well as altered fat distribution, including lipohypertrophy (neck, trunk, breasts) and lipoatrophy (nasolabial fold, cheek, extremities). Medical treatment of fat redistribution is usually ineffective. We evaluated the efficacy and safety of the surgical management of HIV lipodystrophy.

METHODS

We performed a retrospective review of 12 consecutive patients (3 female, 9 male; mean age, 44.4 years; mean CD4+ cell count, 554/mm3; mean body mass index, 28.9 kg/m2; mean triglycerides, 421 mg/dL; no active opportunistic infections; mean duration of HIV infection, 11.4 years) who underwent surgical management of HIV lipodystrophy at a university hospital from 2001 to 2006.

RESULTS

Surgical intervention included a combination of ultrasonic-assisted liposuction (UAL) and suction-assisted lipectomy (SAL) of the anterior neck (7 patients), posterior neck (10 patients), and trunk (2 patients); direct excision of mastoid fat pads (1 patient); direct excision of thigh lipomata (1 patient); facelift/necklift (1 patient); browlift (1 patient); fat injections (1 patient); and blepharoplasty (2 patients). Mean lipoaspirate volume was 701 mL (range, 270-1400 mL). Complications and sequelae included seroma (1 patient), ecchymosis (1 patient), need for revision (2 patients), and recurrence (3 patients) but did not include nerve injury, fat necrosis, skin loss, or infection. Although all patients reported improvement in form and function, UAL/SAL of the anterior neck had limited efficacy in 3 of 7 patients. UAL/SAL of the cervicodorsal fat pad was initially successful in 10 of 10 patients, but 3 patients developed partial late (>1 year) recurrence, all associated with weight gain. Mean follow up was 30 months (range, 1-66 months).

CONCLUSIONS

Despite the potential for recurrence, surgical management of HIV-associated lipodystrophy is efficacious with minimal morbidity. UAL/SAL is particularly beneficial in reducing the cervicodorsal fat pad, whereas facelift and necklift may be necessary to adequately address anterior neck lipohypertrophy.

Sculptra (Injectable Poly-L-Lactic Acid)

As contemporary antiviral therapy provides patients who have HIV effective long-term management of their disease, the prevalence of facial HIV-associated lipoatrophy is increasing. Sculptra (Dermik Laboratories, Berwyn, Pennsylvania) (injectable poly-L-lactic acid) is US Food and Drug Administration approved for the treatment of HIV-associated lipoatrophy and has been shown to increase skin thickness for up to 2 years. The number of treatment sessions depends on the volume of deficiency to be treated. As is true for any cosmetic treatment, expectations must be carefully managed, especially considering the frequent need for multiple Sculptra treatments. The few adverse events resulting from poly-L-lactic acid injections consist mainly of subcutaneous nodule formation and local bruising.