Reconstructive surgery is “a well tolerated, feasible tool to treat HIV-related face lipoatrophy”, according to an international team of investigators writing in the online edition of AIDS. Danish, Italian and Spanish researchers came to this conclusion after reviewing studies examining the safety and effectiveness of various surgical options for the treatment of fat loss.
They found that treatments were generally safe, but that their effectiveness depended on the severity of the fat loss that an individual had experienced.
Disturbances in the processing and distribution of fat in patients taking HIV treatment were recognised soon after the introduction of potent, multi-drug antiretroviral therapy in the late 1990s. This syndrome of side-effects is called lipodystrophy.
Body fat changes in patients receiving HIV treatment can include the accumulation of fat around the trunk and at the back of the neck, and loss of fat from the buttocks, limbs and face. Fat loss is usually described as lipoatrophy. When it occurs in the face, fat is lost from the fat pads in the cheeks and the temples.
A number of causes for lipodystrophy have been proposed. However, the biggest single cause of fat loss has been identified as treatment with d4T (stavudine, Zerit), and to a lesser extent AZT (zidovudine, Retrovir).
Neither of these drugs is now recommended for use in routine HIV care in resource-rich settings and modern anti-HIV drugs are thought to involve a low risk of lipodystrophy.
Slow restorations in body fat have been seen in patients who have switched from d4T or AZT to alternative anti-HIV drugs. However, facial fat loss usually remains extensive and drug therapies for body fat changes have proved elusive.
Facial fat loss can be highly stigmatising and confers an ill or aged appearance. Patients with facial atrophy have reported loss of self-esteem, poor overall quality of life and mental health problems such as depression.
Reconstructive surgery has become the mainstay of treatment for facial fat loss in patients with HIV.
The article’s authors wished to provide “an updated comprehensive knowledge of the surgical approaches for reconstruction of HIV-related facial lipoatrophy”. They therefore conducted a literature search to identify studies reporting on the criteria used to select patients for surgery; the reconstructive options used; outcomes; and side-effects.
A total of 27 studies were identified, but only two of the studies compared alternative therapeutic options.
Assessing eligibility
Two scales to assess facial lipoatrophy have been proposed. The first relies on photographic comparisons and the severity of patients’ fat loss is graded from 1 to 4. An alternative method of assessment used both photographic comparisons and CT scanning. Fat loss is then diagnosed as mild, moderate, or severe.
Surgical treatment of lipoatrophy can also be warranted because of its impact on emotional and psychological well-being.
An “Assessment of Body Change and Distress Questionnaire” has been developed and examines perceptions, attitudes, feelings, emotions, actions, and satisfaction related to appearance and body image. The investigators describe this as “an extremely useful tool”.
The perception of doctors and patients is the main criteria used to assess the success of reconstructive surgery for lipoatrophy. Ultrasound and CT scans have also been used. However, the investigators caution that “ultrasound evaluation of the cheek is a controversial end point”.
Reconstructive options
Three types of reconstructive surgery have been used: autologous fat transfer; biodegradable agents, for example polylactic acid; and non-biodegradable products.
All types of intervention can have short-term and chronic side-effects. They may also involve complications such as infections, or absorption or slippage of the filler.
The investigators note that: “it is surprising how very few studies have assessed safety, efficacy and durability of these interventions, and only two partially randomized studies have compared different treatment approaches.”
The first of these studies was conducted in Italy. Patients were randomised into three arms and were treated with either fat transfer, or the biodegradable polylactic acid, or the non-biodegrable polyacrylamide hydrogel.
Fat thickness was comparable between the three treatment arms at the end of the study. However, individuals who received fat transfer reported poorer satisfaction with their appearance. In addition, a small number of patients who were treated using the fat transfer technique developed a “hamster” appearance.
These three products were examined in the second study which had a non-randomised design. On entry to the study, 50% of patients were assessed as having moderate or severe fat loss. This fell to 8% after the completion of treatment. Patient satisfaction and quality of life improved significantly in all three groups.
Choosing a treatment
The investigators stress that corrective procedures should only be performed by expert healthcare staff. In particular, only plastic reconstructive surgeons should be allowed to undertake procedures involving fat transfer.
Possible improvements in facial appearance should not be the only criteria guiding a choice between biodegradable and degradable products, state the authors.
They explain, “biodegradable agents offer a greater safety profile, having a lower incidence of adverse effects compared to nonreabsorbable products.”
However, the effects of polylactic acid and similar treatments are often short, meaning that patients require subsequent courses of therapy.
Nevertheless, the investigators believe that biodegradable fillers “should be first choice in younger people suffering mild to moderate facial lipoatrophy”.
But the cost and “policy reimbursements” are likely to be a factor in the choice of therapy.
Regardless of this, the investigators comment: “Patients must be informed about the options that suit their necessities, and participate to the decision of what material will be used in his or her case.”
Conclusion
They conclude that “plastic surgery seems to be a well tolerated, feasible tool to treat HIV-related face lipoatrophy”, and that the choice of therapy will depend on severity of the condition.
The authors add that new controlled studies are needed “to define the long-term benefits and safety of the different surgical techniques”.
Guaraldi G et al. Surgical correction of HIV-associated facial lipoatrophy. AIDS, online edition: DOI: 10.1097/QAD.0b013e32833f1463, 2010.