Surgical Process Developed to Treat Side Effects of Antiretroviral Therapy

Newswise — The introduction of highly active antiretroviral therapy (HAART) has drastically improved the clinical prognosis of patients with HIV and has contributed to a significant reduction in disease associated morbidity and mortality. However, HAART has also led to undesirable consequences such as HIV-associated lipodystrophy, or defective metabolism of fat. First described in 1998, the main clinical features of this condition include lipoatrophy, the loss of subcutaneous fat of the face, limbs, and buttocks and central fat accumulation in the abdomen, breasts, and neck. Metabolic features include hyperlipidemia, insulin resistance, and in some cases type II diabetes mellitus.

Although the exact mechanism of HIV-associated lipodsytrophy is unclear it's development appears to be temporally associated with the introduction of protease inhibitors in 1997. Additionally, patients taking only nucleoside reverse transcriptase inhibitors (NRTIs) have also experienced HIV-associated lipodystrophy. It is believed that protease inhibitors and NRTIs may work synergistically in the development of this problem.

The various signs associated with HIV-associated facial lipoatrophy are most prominent in the midface affecting the cheeks, and surrounding areas to varying degrees. More severe signs of facial lipoatrophy include significant volume loss around the eyes and near the temples.

Facial lipoatrophy is a frequent and distressing sign for patients receiving HAART and may reveal the individual's health problem to the public. The stigmatization of this syndrome has led to low patient self-esteem, social withdrawal, depression, and at times, forced disclosure of one's HIV status. Thus, resulting in non-compliance with these medications and in some cases refusal to initiate HAART

To date, attempts to remedy the signs associated with HIV-associated lipodystrophy using medical therapy have been unsuccessful. As a result, numerous methods have been described to improve these patients' facial appearance and include silastic malar implantation, dermal-fat grafts, and injection of fat and facial fillers.

A validated grading scale for HIV-associated facial lipoatrophy using evidence-based techniques has been previously established. This grading scale can determine the severity of facial lipoatrophy prior to treatment, help determine the most effective therapy, assess improvement postoperatively, and permit clinicians to communicate more effectively. A new study utilizes the grading scale in order to construct an effective step-by-step management process for treatment of HIV-associated facial lipoatrophy.

The authors of "Contemporary Surgical Management of HIV-Associated Facial Lipoatrophy," are Etai Funk MD, and A.E. Brissett MD, at the Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine; and Fred J. Bressler MD, from the Bressler Facial Plastic Surgery Center, all in Houston, TX. Their findings are to be presented at the 109th Annual Meeting & OTO EXPO of the American Academy of Otolaryngology—Head and Neck Surgery Foundation, being held September 25-28, 2005, at the Los Angeles Convention Center, Los Angeles, CA.

Methodology: Patients who sought treatment for HIV-associated facial lipoatrophy received Terino malar shell® or Binder submalar® silastic implantation. Selected patients later received adjuvant facial filler injection using Radiesse™, Restylane®, or Sculptra® in specific fat deficient locations which the implants did not address. Pre and post treatment photographs were compiled and organized into two separate albums. Each patient had one frontal and two lateral photographs. Patient demographics were recorded. Assessment of photos was completed in a blinded fashion by two experienced facial plastic surgeons using a postoperative visual analog scale. Once the scores were assigned, a comparative analysis was performed between each patient's severity grade and their visual analog score.

Results: Thirty-six patients received Terino malar shell® implants while three received Binder submalar® silastic implants. Seven patients requried postoperative adjuvant filler injection. Ages ranged from 34-60 years old. At the time of implantation, 24 (61.54 percent) patients were receiving protease inhibitors, 11 (28.21 percent) were on NRTIs only, and 23 (58.97 percent) were on both.Post-operative photographs of 34 patients after implantation were obtained for evaluation. All severity grade I patients received a visual analog score of I (excellent result) after implantation alone. The majority of patients with severity grade II-IV received visual analog scores of II-III.

Photographs of two patients were evaluated after injection of facial fillers. Their visual analog scores improved from a III after implantation to a II after facial filler injection. There were four complications after malar implantation. One patient's implant fell out of position, which was easily corrected by revision surgery. Three patients developed infections associated with the implants at one, three, and five years post-operatively. These were all temporally associated with preceding dental procedures. There were no complications from facial filler injection. A treatment algorithm related to the severity grading scale.was constructed utilizing implantation and facial filler injection.

Conclusions: All of the patients in this study underwent silastic malar implantation. These synthetic implants provide a durable and permanent foundation, which can later be augmented with facial fillers if necessary. Malar silastic implantation involves a single operative procedure at a single site and would reduce the frequency and volume of postoperative injection for augmentation. This would not only reduce cost, time, and discomfort to the patient, but would also minimize exposure risk.

The postoperative results based on the visual analog scale demonstrate that an excellent cosmetic result is reached for grade I disease with malar implants alone. However, adjuvant facial filler injection is necessary after implantation to achieve acceptable aesthetic results in patients with grade II-IV disease.

HIV-associated facial lipoatrophy is a disfiguring and stigmatizing feature of HIV-associated lipodystrophy syndrome that appears to be related to the use of HAART. Using their validated grading scale, these researchers have developed a treatment process that has proven to provide the most effective, long-lasting, and aesthetically pleasing results.