Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 946e949

CASE REPORT

Buffalo hump in HIV patients: surgicalmanagement with liposuction

Devesh Sharma*, Thomas J. Bitterly

Division of General and Plastic Surgery, Geisinger Medical Center, Danville, PA, USA

Received 22 August 2007; accepted 31 October 2007

KEYWORDSBuffalo hump;Liposuction;HIV

* Corresponding author. 2 Holly CouTel.: þ1 570 271 6363; fax: þ1 570 21

E-mail address: devesharma@hotm

1748-6815/$-seefrontmatterª2009Bridoi:10.1016/j.bjps.2007.10.086

Summary Although lipohypertrophy has been reported in as many as 41% of patients withHIV, buffalo hump or cervical lipomatosis has been reported in only 1e2% of patients. Thereis no definitive medical treatment for this disabling condition. Few case series describingthe role of liposuction in buffalo lump treatment have been published, with variable short-term and long-term results. We describe our experience in two patients, with a brief reviewof the literature.ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Publishedby Elsevier Ltd. All rights reserved.

Case reports

Two patients receiving treatment for HIV were referred tothe plastic surgery clinic at our institution for managementof buffalo hump. The first patient was a 48-year-oldfemale. She had been receiving non-nucleoside reversetranscriptase inhibitor and nucleoside reverse transcriptaseinhibitor antiretroviral medications for 2 years prior topresentation, and was evaluated in the plastic surgeryclinic for buffalo hump for 1 year (Figures 1 and 2). Thehump in the back of the neck was causing neck pain andheadaches off and on. The second patient was a 65-year-old male, who was on anti-retroviral medications for 11years prior to presentation at the plastic surgery clinic

rt, Danville, PA 17821, USA.4 9208.ail.com (D. Sharma).

tishAssociationofPlastic,Reconstruc

(Figures 5 and 6). He was on protease inhibitors for 8 yearsincluding nelfinavir (4 years) and Kaletra (lopinavir/ritona-vir; 4 years). He developed buffalo hump 4 years before hisvisit to our clinic. It was causing discomfort and affectingthe motion of his neck.

Suction-assisted lipectomy was performed on both thepatients. Tumescent solution was used. A no. 5 suctioncanula was used in the first case with a total aspirate of700 ml. In the second case, nos 5 and 6 suction canulaswere used with a total aspirate of 600 ml. At the end ofthe procedures, using no-touch technique, buried 4-0 mono-cryl dermal sutures were placed, followed by the applica-tion of dermabond and a pressure dressing.

No major or minor complications were encountered. Thepatients went home on the same day with good pain controlon oral pain medications in the postoperative period.

On follow-up visits, both patients were very satisfied withtheir postoperative results (Figures 3, 4, 7 and 8). Significant

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Figure 6 Patient 2, preoperative back view.Figure 3 Patient 2, preoperative profile view.

Figure 2 Patient 1, preoperative back view.

Figure 1 Patient 1, preoperative profile view.

Figure 5 Patient 1, postoperative profile view.

Figure 4 Patient 1, postoperative back view.

Liposuction for buffalo hump in HIV patients 947

Figure 8 Patient 2, postoperative back view.

Figure 7 Patient 2, postoperative profile view.

948 D. Sharma, T.J. Bitterly

aesthetic and functional improvement was seen. No recur-rence of the buffalo hump was seen in follow up after 7months.

Discussion

Since the introduction of highly active antiretroviral ther-apy, mortality in HIV patients has reduced significantly.With the increased life span of these patients and theprolonged therapy, new complications have been noticedover the last few years. One of these complications islipodystrophy, i.e. maldistribution of fat.1

Buffalo hump was among the first recognized manifes-tations of lipodystrophy (body fat changes) reported afterprotease inhibitors came into widespread use in the late1990s. Aetiology of buffalo hump was initially thought to be

Table 1 Literature review of management of ‘buffalo hump’ o

Authors No. of patients Procedure Complica

Ponce-de-Leon et al.3 1 SAL NoneWolfort et al.5 2 SAL NoneChastain et al.6 1 SAL NoneDeWeese et al.4 28 SAL/UAL Major, 5a

Minor, 9

Piliero et al.7 10 UAL Major ?2b

Rohrich (see ref. 7) 15 UAL/SAL NoneGervasoni et al.8 15c SAL NoneConnolly et al.9 6 SAL NoneGold and Annino10 5 UAL Minor, 1Hultman et al. 11 12 UAL/SAL Minor, 2Present authors 2 SAL None

SAL Z suction-assisted lipectomy or traditional liposuction with tumeUAL Z ultrasound-assisted liposuction.

a Major complications included infection, anaemia and pancreatitisb Two patients developed pneumococcal bacteraemia and pneumon

associated with the performance of UAL.c Performed surgical dermolipectomy in three patients, in additiond Two patients required multiple operative sessions but did not app

treatment with protease inhibitors. However, buffalo humphas been noticed even in untreated HIV-infected patients.The FRAM study, which is a large multicentre cross-sectional investigation, showed that buffalo hump isequally common in HIV-positive patients and the HIV-negative controls.2

Although buffalo hump was initially considered asa cosmetic deformity, it can be associated with neckpain, dysaesthesia, restricted neck movement, abnormalposture, sleep apnoea and insomnia. It can contribute tonon-compliance with anti-retroviral therapy. In view ofuncertain aetiology and possibly multi-factorial aetiology,preventive measures are lacking. Medical options are alsolimited for the same reasons. Surgical options includetraditional surgical dermolipectomy and liposuction. Bothtraditional liposuction and ultrasound-assisted liposuctionhave been used for the treatment of buffalo hump. Ponce-de-leon et al. first described the use of liposuction forprotease-inhibitor-associated lipodystrophy.3 Poor to

r cervicodorsal lipodystrophy with liposuction

tions Immediate results Follow up Late recurrence

Acceptable Not reported Not reportedGood Not reported Not reportedGood Not reported NoneExcellent, 21 >6 months 2 (7.1%)Good, 5Poor, 2Satisfactory Not reported 5 (50%)Good Not reported 1 (6.7%)Good 19 months 1 (6.7%)Good 12 months NoneSatisfactory Not reported Noned

Excellent 30 months 3 (25%)Excellent 7 months None

scent technique.

.ia 1 and 3 months after undergoing UAL. Not clear if these were

to 15 SAL.ear to represent recurrence.

Liposuction for buffalo hump in HIV patients 949

excellent results have been described in the largest (28patients) case series by DeWeese et al.4 Relapse rates of0%e50% have been described over a follow up of 12e30months (Table 1).

In conclusion, buffalo hump (cervical lipomatosis) isa well recognized outcome of prolonged HIV infection.Exact aetiology of this condition is not known. Affectedpatients have both aesthetic and functional concerns.No medical therapy has been shown to be consistentlyeffective to treat this medical condition. Surgical therapyin the form of traditional liposuction or suction-assistedliposuction has been shown to provide good results in mostof the patients treated. Although recurrence rate has beenreported up to 33% in some studies, the procedure can berepeated without significant morbidity. The main hurdle intreating these patients with liposuction is poor insurerreimbursement. Liposuction not only helps to improve theaesthetic appearance of these patients but also signifi-cantly reduces functional disability. We hope that thegrowing evidence in the literature, supporting the role ofliposuction in the treatment of buffalo hump in HIVpatients, will make this treatment more easily accessibleto patients.

References

1. Lichtenstein K, Balasubramanyam A, Sekhar R, et al. HIV-associated adipose redistribution syndrome (HARS): etiologyand pathophysiological mechanisms. AIDS Res Ther 2007;4:14.

2. Grunfeld C. Basic science and metabolic disturbances. Posterpresented at 14th International AIDS Conference, Barcelona,Spain, 2002. [abstract TuOr158].

3. Ponce-de-Leon S, Iglesias M, Ceballos J, et al. Liposuction forprotease-inhibitor-associated lipodystrophy. Lancet 1999;353:1244.

4. DeWeese. J, DeLaney. A, Klein. D, et al. Surgical treatment ofHIV lipohypertrophy of head and neck. 10th Conference on Ret-roviruses and Opportunistic Infections (CROI), Boston, 2003.[abstract 721].

5. Wolfort FG, Cetrulo Jr CL, Nevarre DR. Suction-assisted lipec-tomy for lipodystrophy syndromes attributed to HIV-proteaseinhibitor use. Plast Reconstr Surg 1999;104:1814e20.

6. Chastain MA, Chastain JB, Coleman WP. HIV lipodystrophy: re-view of the syndrome and report of a case treated with liposuc-tion. Dermatol Surg 2001;27:497e500.

7. Piliero PJ, Hubbard M, King J, et al. Use of ultrasonography-assisted liposuction for the treatment of human immunodefi-ciency virus-associated enlargement of the dorsocervical fatpad. Clin Infect Dis 2003;37:1374e7.

8. Gervasoni C, Ridolfo AL, Vaccarezza M, et al. Long-term effi-cacy of the surgical treatment of buffalo hump in patientscontinuing antiretroviral therapy. AIDS 2004;18:574e6.

9. Connolly N, Manders E, Riddler S. Suction-assisted lipectomyfor lipodystrophy. AIDS Res Hum Retroviruses 2004;20:813e5.

10. Gold DR, Annino Jr DJ. HIV-associated cervicodorsal lipodystro-phy: etiology and management. Laryngoscope 2005;115:791e5.

11. Hultman CS, McPhail LE, Donaldson JH, et al. Surgical manage-ment of HIV-associated lipodystrophy: role of ultrasonic-assisted liposuction and suction-assisted lipectomy in thetreatment of lipohypertrophy. Ann Plast Surg 2007;58:255e63.