A systematic review of permanent and semipermanent dermal fillers for HIV-associated facial lipoatrophy

Complications Following Non-Surgical Aesthetic Treatments in HIV+ Patients Receiving Antiretroviral Therapy: A 12-Years Experience

Since the advent of HIV antiretroviral therapies at the end of the 20th century, the morbidity and mortality rates associated with HIV infection have decreased dramatically. Unfortunately, these benefits are associated with substantial morphologic changes in the body, such as abnormal fat distribution with peripheral lipohypertrophy and facial lipoatrophy. Facial wasting is considered the major stigma for HIV–infected people and may result in reduced antiretroviral adherence. Patients suffering from the stigmata of HIV infection can benefit from non-surgical aesthetic treatments performed with fillers or lipolytic agents that provide a quick and reliable service for facial rejuvenation, with high patient satisfaction and a low risk of complications. In the present paper, a retrospective analysis of complications following non-surgical aesthetic treatments (calcium hydroxyapatite-based filler, hyaluronic acid filler, polyacrylamide hydrogel filler and dehoxycholic acid injections), in a cohort of 116 consecutive HIV+ patients, treated over a period of 12 years, was performed. With the exception of the tardive swelling reported after calcium hydroxyapatite injections, complications were recorded just after polyacrylamide hydrogel treatment as small, palpable, nonvisible nodules or aseptic abscess. Our experience is consistent with those already published in the literature and the complication rate seems to be comparable to non-infected patients.

The quality of online information regarding non-surgical aesthetic procedures

BACKGROUND

The rapid growth of non-surgical aesthetics has led to a scarcity of regulation that raises concerns for serious consequences to public health. Services are advertised primarily through websites which are not necessarily centrally monitored or maintained to a set gold standard. We quantitatively assess the quality of online information regarding non-surgical procedures in order to promote patient safety and informed decision making.

METHODS

Google and Bing, search engines that represent 95.27of global searches, were queried with the expanded search terms "facial filler" and "Botox". The top 100 results were sampled and two validated tools were used to assess the quality of healthcare information retrieved; the DISCERN instrument and the JAMA benchmark criteria.

RESULTS

Once duplicates were removed, a total of 77 unique websites were retrieved by the search. The majority of websites were published by private marketing firms. The median score for website quality across all included websites was 'fair' (42) when assessed according to the DISCERN instrument, and 'poor' (1) when assessed against the JAMA criteria. Private websites had the lowest quality of information online and institutional websites had the highest.

CONCLUSION

Non-surgical aesthetics are becoming increasingly popular with patients and clinicians due to their convenience, scope of treatment, and novel and strategic marketing. Online information available to patients, however, is often of poor quality, dominated by private clinics and commercial entities, and thus presents a significant risk of misinforming patients desiring to undertake these procedures. Significant reform and regulation of information is required in order to make this industry safer for patients.

A Case of Special Complication following a Large Amount of Polyacrylamide Hydrogel Injected into the Epicranial Aponeurosis: Leukocytopenia

Polyacrylamide hydrogel (PAAG) has been used as an injectable filler for soft tissue augmentation of different body parts, such as the face, breasts, and penis. However, this is the first report of leukocytopenia after injection of a large amount of PAAG in the epicranial aponeurosis. After receiving PAAG injection for craniofacial contouring, the female patient described herein experienced recurrent swelling, temporal pain (particularly with changes in ambient temperature and facial expression), and ultimately leukocytopenia due to widespread migration of the injected PAAG. We removed most of the PAAG from the affected tissues and the leukocytopenia disappeared 1 year after the operation. Based on this case, we hypothesize that injection of a large amount of PAAG into tissues that have ample blood supply, such as the epicranial aponeurosis, may induce leukocytopenia.

5-year study of a polyacrylamide hydrogel-based filler for rehabilitation of HIV-related facial lipoatrophy

BACKGROUND

Lipoatrophy of the face negatively impacts the quality of life and body image of individuals on antiretroviral therapy. Facial fillers can minimize the stigma associated with the human immonodeficiency virus (HIV).

OBJECTIVES

In this 5-year follow-up study, the author assessed the safety and efficacy of a permanent, non-biodegradable, polyacrylamide hydrogel for facial volume restoration, and compared the results with those of a previous 18-month follow-up study.

METHODS

Thirty-one HIV-positive individuals, initially enrolled in the study between January 2008 and January 2009, received treatment of facial wasting by injection of the polyacrylamide gel until complete volume restoration was achieved. Asepsis rules were strictly observed before and during each injection session. Patients evaluated their aesthetic outcomes on a visual analog scale.

RESULTS

Patient satisfaction was high. There was no occurrence of local infection, foreign-body reaction, or product during the 5 years of follow-up. Small, palpable, nonvisible nodules were recorded in nine cases. It appears that these same nodules were present in the 18-month study. It is believed that the nodules were caused by overfilling in the same site.

CONCLUSIONS

As supported by the initial 18-month study, polyacrylamide hydrogel filler appears safe and effective for the treatment of HIV-related lipoatrophy. With strict observation of asepsis rules and patient adherence to posttreatment instructions, this filler can be ideal for treating facial wasting in patients with HIV.

LEVEL OF EVIDENCE

3 Therapeutic.

Safety of poly-L-lactic acid (New-Fill®) in the treatment of facial lipoatrophy: a large observational study among HIV-positive patients

BACKGROUND

Facial lipoatrophy is a frequently reported condition associated with use of antiretroviral (ARV) drugs. Poly-L-lactic acid (PLLA) acid has been used to correct facial lipoatrophy in people with HIV since 2004 both in Europe and the United States. The objective of this study was to establish, in real life conditions and in a large sample, the safety of PLLA (New Fill®, Valeant US, Sinclair Pharma Paris, France) to correct facial lipoatrophy among HIV-positive patients.

METHODS

A longitudinal study was conducted between 2005 and 2008 in France. Data from 4,112 treatment courses (n = 4,112 patients) and 15,665 injections sessions (1 to 5 injection sessions per treatment course) were gathered by 200 physicians trained in the use of PLLA.

RESULTS

The average age of patients (88.3% males) treated for lipoatrophy was 47.1 ± 8.1 years (Mean ± SD); 91.2% of patients had been receiving ARV treatment for 10.9 (±4.2) years; CD4 T-cell count was 535 ± 266 cells/mm3. The duration of facial lipoatrophy was 5 ± 2.8 years and the severity was such that 47.3% of patients required five injection sessions of PLLA and 81.9% of the sessions required two vials of the preparation. The final visit, scheduled two months after the last injection session, was attended by 66.0% of patients (n = 2,713). 48 treatment courses (2.8%) were discontinued due to adverse events (AEs). The overall incidence of AEs per course was 18.8%. Immediate AEs, bleeding (3.4%), bruising (2.3%), pain (2.0%), redness at injection site (1.6%), and swelling of the face (0.7%), occurred in 15.4% of courses and 7.0% of sessions (usually during the first session). Non-immediate AEs, mainly nodules (5.7%), inflammation (0.7%), granuloma (0.3%), discolouration (0.2%), and skin hypertrophy (0.1%), occurred in 6.7% of courses. Non-immediate AEs occurred within a time ranging from 21 days (inflammation) to 101 days (granuloma) and all but three of the 13 cases of granuloma resolved. Product efficacy was rated satisfactory by 95% of the patients and physicians.

CONCLUSIONS

This study demonstrated, in real-life conditions and on a large sample, that PLLA injections were feasible, efficient, and safe when performed by trained physicians.

Treatment of HIV-associated facial lipoatrophy: impact on infection progression assessed by viral load and CD4 count

BACKGROUND

HIV/AIDS-Associated Lipodystrophy Syndrome includes changes in body fat distribution, with or without metabolic changes. The loss of fat from the face, called facial lipoatrophy, is one of the most stigmatizing signs of the syndrome.

OBJECTIVES

To evaluate the effect of FL treatment using polymethylmethacrylate (PMMA) implants on disease progression, assessed by viral load and CD4 cell count.

METHODS

This was a prospective study of 44 patients treated from July 2009 to December 2010. Male and female patients, aged over 18 years, with clinically detectable FL and who had never been treated were included in the study. PMMA implantation was done to fill atrophic areas. Laboratory tests were conducted to measure viral load and CD4 count before and after treatment.

RESULTS

Of the 44 patients, 72.72% were male and 27.27% female, mean age of 44.38 years. Before treatment, 82% of patients had undetectable viral load, which increased to 88.6% after treatment, but without statistical significance (p = 0.67). CD4 count before treatment ranged from 209 to 1293, averaging 493.97. After treatment, the average increased to 548.61. The increase in CD4 count after treatment was statistically significant with p = 0.02.

CONCLUSION

The treatment of FL with PMMA implants showed a statistically significant increase in CD4 count after treatment, revealing the impact of FL treatment on disease progression. Viral load before and after treatment did not vary significantly.

From distress to illness: a critical analysis of medicalization and its effects in clinical practice

This paper is precisely aimed at exposing the limits of psychiatry's scientific claim-making and exploring how psychiatric diagnoses come to be utilized in practice and affect those who become pathologized. Drawing on research findings in the field of HIV/AIDS nursing, we portray the impact of psychiatric pathologization of women who see their bodies transformed by antiretroviral therapy and subsequently, must accept that their response to these changes become the target of psychiatric labelling and interventions. In this paper, we therefore engage with the reader in a critical analysis that exposes the tensions that exist between individual experiences of distress and psychiatric pathologization. The first section of the paper is dedicated to the presentation of a theoretical framework in which we explore the medicalization process and the ontological issues regarding psychiatric diagnoses. The second section seeks to present the results from a qualitative research study in the field of HIV/AIDS nursing and serves as a case example to foster discussions on the implications of psychiatric pathologization in clinical practice.

Treatment of facial lipoatrophy with polymethylmethacrylate among patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS): impact on the quality of life

BACKGROUND

The lipodystrophy syndrome is characterized by selective loss of subcutaneous fat on the face and extremities (lipoatrophy) and/or accumulation of fat around the neck, abdomen, and thorax (lipohypertrophy). The aim of this study has been to assess the impact of polymethylmethacrylate facial treatment on quality of life, self-perceived facial image, and the severity of depressive symptoms in patients living with HIV/AIDS.

METHODS

A non-randomized before and after interventional study was developed. Fifty-one patients underwent facial filling. The self-perceived quality of life, facial image, and degree of depressive symptoms were measured by the Short-Form 36 and HIV/AIDS--Targeted quality of life questionnaires, by a visual analogue scale and by the Beck depression inventory, respectively, before and three months after treatment.

RESULTS

Six of the eight domains of Short-Form 36 and eight of the nine dimensions of the HIV/AIDS--Targeted quality of life questionnaires, together with the visual analogue scale and by the Beck depression inventory scores, revealed a statistically significant improvement. The only adverse effects registered were edema and ecchymosis.

CONCLUSION

The treatment of facial lipoatrophy improved the self-perceived quality of life and facial image as well as any depressive symptoms among patients with HIV/AIDS.

Injectable redox-polymerized methylcellulose hydrogels as potential soft tissue filler materials

There is a significant clinical need for long-lasting, injectable materials for soft tissue reconstruction. Methylcellulose (MC) is an FDA-approved polysaccharide derivative of cellulose that is inexpensive, renewable, and biocompatible, and may serve as an alternative to existing synthetic and natural fillers. In this study, MC was modified with functional methacrylate groups and polymerized using a redox-initiation system to produce hydrogels with tunable properties. By varying the percent methacrylation and macromer concentration, the equilibrium moduli of the hydrogels were found to range between 1.29 ± 0.46 and 12.8 ± 2.94 kPa, on par with human adipose tissue, and also displayed an inverse relationship to the swelling properties. Rheological analyses determined gelation onset and completion to be in accordance with the ISO standard for injectable materials. Cellulase enzymatic treatment resulted in complete degradation of the hydrogels by 48 h, presenting the possibility of minimally invasive removal of the materials in the event of malposition or host reaction. In addition, co-culture experiments with human dermal fibroblasts showed the gels to be cytocompatible based on DNA measurements and Live/Dead staining. Taken together, these redox-polymerized MC hydrogels may be of use for a wide range of clinical indications requiring soft tissue augmentation.

Semipermanent filler treatment of HIV-positive patients with facial lipoatrophy: long-term follow-up evaluating MR imaging and quality of life

BACKGROUND

Injectable fillers such as poly-L-lactic acid (PLLA) and calcium hydroxylapatite (CaHA) have shown promising results in the treatment of combination antiretroviral therapy (cART)-induced facial lipoatrophy (FLA). However, the effects of these substances on magnetic resonance imaging (MRI) have not yet been described.

OBJECTIVE

The authors analyze the association between the effects of treatment with semipermanent fillers on MRI and changes in quality of life (QOL).

METHODS

Eighty-two human immunodeficiency virus (HIV)-positive patients with cART-induced FLA (grades 2-4) were enrolled in this prospective study. A mean volume of 58.2 mL (range, 12-105 mL) of PLLA (n = 41 patients) and 9.1 mL (range, 3-23 mL) of CaHA (n = 41) was injected in multiple sessions. The MRI examinations were performed prior to treatment and again 12 months after. The self-reported severity of FLA as well as QOL was measured using questionnaires based on Short Form 36, Medical Outcomes Study HIV Health Survey, and Center for Epidemiologic Studies Depression Scale formats.

RESULTS

Significant increases in total subcutaneous thickness (TST) of the injected regions could be identified on MRI in nearly all patients 1 year posttreatment. Patients reported that mental health and social and role functioning improved; depressive symptoms decreased after treatment. In addition, the increase in TST was positively associated with improvement of QOL.

CONCLUSIONS

This study confirms that treatment with both PLLA and CaHA not only increases TST but also is associated with improved QOL for HIV-infected patients. Furthermore, the study also demonstrates that MRI can show filler-induced neocollagenesis and quantify FLA treatment effects.

Oral lesions associated with human immunodeficiency virus disease

Human immunodeficiency virus (HIV)-associated oral disease among people living with HIV infection includes oral candidiasis, oral hairy leukoplakia, Kaposi sarcoma, oral warts, herpes simplex virus ulcers, major aphthous ulcers or ulcers not otherwise specified, HIV salivary gland disease, and atypical gingival and periodontal diseases. Diagnosis of some oral lesions is based on clinical appearance and behavior, whereas others require biopsy, culture, or imaging for definitive diagnosis. Management strategies including pharmacologic and nonpharmacologic approaches are discussed in this article. Dentists also need to be cognizant of the potential oral side effects of HIV antiretroviral medications.

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.

Polyacrylamide gel for facial wasting rehabilitation: how many milliliters per session?

BACKGROUND

Facial lipoatrophy is most distressing for HIV patients in pharmacologic treatment. Nonabsorbable fillers are widely used to restore facial features in these patients. We evaluated the safety and aesthetic outcomes of two samples of HIV+ patients affected by facial wasting who received different filling protocols of the nonabsorbable filler Aquamid® to restore facial wasting.

METHODS

Thirty-one HIV+ patients affected by facial wasting received injections of the nonabsorbable filler Aquamid for facial wasting rehabilitation. Patients were randomly divided into two groups: A and B. In group A, the facial defect was corrected by injecting up to 8 ml of product in the first session; patients were retreated after every 8th week with touch-up procedures until full correction was observed. In group B, facial defects were corrected by injecting 2 ml of product per session; patients were retreated after every 8th week until full correction was observed.

RESULTS

Patients of group A noted a great improvement after the first filling procedure. Patients in group B noted improvement of their face after four filling procedures on average. Local infection, foreign-body reaction, and migration of the product were not observed in either group during follow-up.

CONCLUSION

The rehabilitation obtained with a megafilling session and further touch-up procedures and that with a gradual build-up of the localized soft-tissue loss seem not to have differences in terms of safety for the patients. However, with a megafilling session satisfaction is achieved earlier and it is possible to reduce hospital costs in terms of gauze, gloves, and other items.

Understanding the experience of reconstructive treatments from the perspective of people who suffer from facial lipoatrophy: a qualitative study

BACKGROUND

Facial lipoatrophy has been described as the most distressing and stigmatizing expression of the lipodystrophy syndrome, a syndrome that is caused by antiretroviral combination therapy. In recent years, reconstructive treatments (such as poly-l-lactic acid and polyalkylimide) have been increasingly considered for this condition. These treatments allow for facial contours and facial fullness to be restored while being minimally invasive.

OBJECTIVE

The main objective of this qualitative research was to explore and describe the experience of people who suffer from facial lipoatrophy, specifically in regard to reconstructive treatments.

METHOD

A qualitative design, which incorporates explorative and descriptive attributes, was thought to be an appropriate choice for this research project. The data was collected using semi-structured interviews and was then analyzed following the principles of thematic analysis.

PARTICIPANTS

Over a period of three months, 11 men and 1 woman enrolled in the study which was conducted in Montreal (Quebec), Canada.

FINDINGS

Overall, participants explained that facial lipoatrophy had forced them into a situation of intense vulnerability by making them recognizable as persons living with HIV/AIDS and discreditable in the eyes of others. In this sense, they were willing to go to great lengths to restore their facial features and regain a sense of normalcy. Findings revealed that people who suffer from facial lipoatrophy engage in a process of reconstruction to reduce the visibility and disruptiveness of their condition but face many uncertainties along the way.

CONCLUSIONS

While the findings of this research corroborated what has been previously stated by other researchers about the impact of reconstructive treatments, they also shed light on the consequences of not making these treatments accessible as well as the undocumented realities of those who cannot afford the recommended course of dermal fillers.

Lipoatrofia facial associada ao HIV/AIDS: do advento aosconhecimentos atuais

O advento da AIDS trouxe novos desafios para a Dermatologia. A terapia antirretroviral mudou drasticamente a morbimortalidade associada à infecção pelo HIV/AIDS, mas contribuiu para o surgimento de outras novas situações que exigem abordagem adequada do dermatologista. A Síndrome Lipodistrófica Associada ao HIV/AIDS tem origem multifatorial, mas está fortemente associada ao uso dos antirretrovirais. Compreende alterações na distribuição da gordura corporal, acompanhada ou não de alterações metabólicas. A perda da gordura da face, chamada lipoatrofia facial, é dos sinais mais estigmatizantes da síndrome. Esta condição, muitas vezes reveladora da doença, trouxe de volta o estigma da AIDS. É necessário que os especialistas que atuam com pacientes com HIV/AIDS identifiquem estas alterações e busquem opções de tratamento, dentre as quais se destaca o implante com polimetilmetacrilato, que é disponibilizado para tratamento da lipoatrofia facial associada ao HIV/AIDS no Sistema Único de Saúde

Coinfections associated with human immunodeficiency virus infection: workshop 1A

The importance of opportunistic pathogens in HIV disease has been demonstrated from the onset of the epidemic. This workshop aimed to review the evidence for the role of oral microorganisms in HIV-related periodontal disease and HIV transmission and the effect of HIV therapy on periodontal disease. Despite being a common copathogen, tuberculosis seems to have limited oral presentation. The oral manifestations seem to have little impact on the individual and, once diagnosed, are responsive to chemotherapy. The participants debated the available evidence on the role of microorganisms and whether further research was warranted and justified. Although the effects of lipodystrophy on facial aesthetics may be profound and may markedly affect quality of life, there is no evidence to suggest a direct effect on the oral cavity. Though of interest to oral health care workers, lipodystrophy and associated metabolic syndromes were thought to be further investigated by other, more appropriate groups.

New and emerging agents in the management of lipodystrophy in HIV-infected patients

Lipodystrophy remains a major long-term complication in human immunodeficiency virus-infected patients under antiretroviral (ARV) therapy. Patients may present with lipoatrophy or lipohypertrophy or both. The choice of treatments to improve fat redistribution depends on the form of lipodystrophy and its duration. Measures known to improve lipoatrophy are switches in ARV therapy (stavudine or zidovudine to abacavir or tenofovir) and filling interventions. Pioglitazone may be added to these measures, although any benefits appear small. Uridine and leptin were found to be disappointing so far. Regarding lipohypertrophy, diet and exercise, recombinant human growth hormone, and metformin may reduce visceral fat, but may worsen subcutaneous lipoatrophy. Surgical therapy may be required. Attractive pharmacologic treatments include growth hormone-releasing factor and leptin. Adiponectin and adiponectin receptors are promising therapeutic targets to explore.