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Aesthetic Medicine • July/August 2014

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Dr Patrick Treacy shares some of his most challenging cases. This month, the he talks about a 71 year old socially isolated HIV+ patient with significant facial defects after undergoing treatment with antiretroviral drugs (HAART)

Dr Treacy’sCASEBOOK

DR PATRICK TREACYis chairman of the Irish Association of Cosmetic Doctors and Irish regional representative of the British College of Aesthetic Medicine (BCAM). He is European medical advisor to Network Lipolysis and Consulting Rooms and holds higher qualifications in dermatology, laser technology and skin resurfacing. In 2012 and 2013 he won awards for ‘Best Innovative Techniques’ for his contributions to facial aesthetics and hair transplants. Dr Treacy also sits on the editorial boards of three international journals and features regularly on international television and radio programmes. He was a faculty member at IMCAS Paris 2013, AMWC Monaco 2013, EAMWC Moscow 2013 and a keynote speaker for the American Academy of Anti-Ageing Medicine in Mexico City this year.

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An American patient with severe facial lipodystrophy secondary to HIV-infection was referred to the Ailesbury Clinic. He was 71 years old and had been suffering from HIV for 17 years. He had a full hematologic evaluation, including a full blood count, biochemistry, liver function, lipids, glucose, lactate, viral load and CD4 cell count. The subject had a CD4 of 632/µl with

a viral load below limit of detection. He had not received any prior treatment for their HLS. He was been treated by thymidine analogues stavudine (d4T) and zidovudine (ZDV, previously known as AZT). He was not receiving anticoagulant therapy, steroids, or anti-infective medications. The patient was markedly socially isolated and had not appeared outside his apartment for a period of four years.

The patient was injected bilaterally into the buccal, malar, and temporal areas of his face with 23cc of the polyalkylimide gel (BioAlcamid®, Polymekon, Italy) in an attempt to replace subcutaneous fat that had atrophied as a result of severe facial lipodystrophy. Regional injected anesthesia was used in conjunction with topical anesthesia. The treated area was sculptured to obtain

The patient was injected bilaterally into the buccal, malar, and temporal

areas of his face with 23cc of the polyalkylimide gel (BioAlcamid®, Polymekon, Italy) in an attempt to replace subcutaneous fat that had

atrophied as a result of severe facial lipodystrophy

64 Aesthetic Medicine • July/August 2014

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the best aesthetic appearance. At the end of the treatment, the patient was put on prophylactic Augmentin and Klacid for three days to prevent infection.

DISCUSSIONThe human immunodeficiency virus (HIV)-lipodystrophy syndrome (HLS) was a major problem for many HIV patients undergoing long-term use of highly active antiretroviral therapy (HAART) within the past five years. The condition was characterised by a loss of subcutaneous fat, especially in the cheeks, tempomanbidular and periorbital areas1. The psychological effects of HLS included depression, anxiety, social withdrawal, isolation and suicide secondary to perceived social stigma caused by the significant alteration in facial shape that accompanies it2. Facial lipoatrophy was the most obvious and stigmatising manifestation of HIV-related lipoatrophy3. At the time this patient was treated, the etiology of the condition was not yet understood. While some researchers focus on a multifactorial phenomenon4 others consider either primary HIV infection (CD4 cell counts, viral load) or the use and duration of HAART as the most likely causes of the pathology. Initially, protease inhibitors were implicated, but many researchers believed that HLS is caused by nucleoside analogues, particularly d4T and to a lesser extent AZT5. The author favoured the latter as did not see the condition amongst HIV patients in Africa.

There was no pharmacological therapy to manage this complex condition. Strategies compensating for facial fat loss, including the use of HLA and bovine collagen were not helpful as the effects declined after three to four months6. Transferred autologous fat was metabolised by the lipodystrophic process7. Poly-L-lactic acid (PLA) had found favor in HIV lipodystrophic patients but it took many months to see the effect, requires up to five sessions to administer and the resultant contouring effect lasts only last two years8. The author used BioAlcamid® as the polyalkylimide became covered by a very thin collagen capsule, completely surrounding the gel, isolating it from the host tissues and making it a type of endogenous prosthesis. AM

REFERENCES 1. Oette M, Juretzko P, Kroidl A, Sagir A, et al . Lipodystrophy

syndrome and self-assessment of well-being and physical appearance in HIV-positive patients. AIDS Patient Care STDS. 2002;16:413-417.

2. Sekhar RV, Jahoor F, White AC, Pownall HJ, et al. Metabolic basis of HIV-lipodystrophy syndrome. Am J Physiol Endocrinol Metab. 2002;283; 332-7.

3. Guaraldi G, Orlando G, De Fazio D. Prospective, partially randomized, 24-week study to compare the efficacy and durability of different surgical techniques and interventions for the treatment of HIV-related facial lipoatrophy. 6th Lipodystrophy Workshop (6th IWADRLH), Washington. Abstract 12. Antiviral Therapy 2004; 9:L9.

4. Mauss S, Corzillius M, Wolf E, Schwenk A, et al.. Risk factors for the HIV-associated lipodystrophy syndrome in a closed cohort of patients after 3 years of antiretroviral treatment. HIV Med. 2002;3:49-55.

5. Carr A, Miller J, Law M, Cooper DA. A syndrome of lipoatrophy, lactic acidaemia and liver dysfunction associated with HIV nucleoside analogue therapy: contribution to protease inhibitor-related lipodystrophy syndrome. AIDS; 2000;18;25-32.

6. Cooperman S, Mackinnin V, Bechler G. Injectable collagen: a six year clinical investigation. Aesthetic Plastic Surg 1985; 9-145-151

7. Tang L, Eaton JW. Inflammatory responses to biomaterials. Am J Clin Pathol 1995; 103: 466-471.

8. Gogolewski S, Jovanovic M, Perren SM, Dillon JG, et al. Tissue response and vivo degradation of selected polyhydroxyacids (PLA, PHB, PHB/VA). J Biomed Material Res 1993;27: 1135-1148

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The condition was characterised by a loss of

subcutaneous fat, especially in the cheeks, tempomanbidular and periorbital area. The psychological

effects of HLS included depression, anxiety, social withdrawal,

isolation and suicide secondary to perceived social stigma