By Dr. Patrick McNamara
HIV infection and its treatment have been associated with fat redistribution in the face and body. Lipodystrophy, as it is known, includes patients with a build-up of fat (usually in the torso) as well as those with a loss of fat (usually in the face, buttocks, and limbs). We don’t know precisely what causes fat redistribution. It may be due to some of the medications used to treat HIV, or even the virus itself. Changing HIV medications can be helpful in reversing the abnormal distribution of fat. Fortunately, the newer HIV treatments are much less likely to result in lipodystrophy. If fat redistribution does occur, there are a number of options such as facial fillers for fat loss and liposuction, growth hormone, and tesamorelin (Egrifta) for fat build-up.
Lipodystrophy can manifest itself as fat build-up (lipohypertrophy) or fat loss (lipoatrophy), or a mixture of both. Fat build-up may result in an increase in neck circumference, an accumulation of firm, fibrous fat across the neck and upper shoulders, breast enlargement, and an increase of fat within the abdominal cavity. Fat loss tends to occur in the subcutaneous spaces of the face, arms, legs, and buttocks. There is no blood test for lipodystrophy. The diagnosis is made based upon the body changes described above.
Lipodystrophy can reduce the quality of life of patients with HIV in a variety of ways. Patients with fat accumulation around the neck and shoulders may not be able to turn their heads and frequently have difficulty finding a comfortable position in which to sleep. Increased amount of breast tissue can be painful as well as disfiguring. The changes caused by lipodystrophy can be profound both physically and mentally by affecting a person’s self-esteem. Lipodystrophy is also associated with “metabolic syndrome,” which includes elevations of blood sugar, insulin, and fats in the blood.
There are a number of ways to manage lipodystrophy and improve the quality of life for those affected. For some patients, changing their HIV mediation can be helpful. Some of the use of drugs developed years ago, such as AZT, indinavir (Crixivan), ritonivir (Norvir), and D4T (Zerit) have been statistically linked to the occurrence of lipodystrophy. With more than 25 drugs available to treat HIV, physicians can prescribe alternative combinations of drugs with less likelihood of fat redistribution. Increased fat in the abdominal cavity may be reduced by synthetic growth hormone or by increasing the body’s production of growth hormone through the use of tesamorelin. The accumulation of fat in the breast area, the upper back, shoulder, and flanks is best treated with liposuction. The loss of subcutaneous fat is best treated with fillers.
The treatment of patients with fillers for facial fat loss is very rewarding for both the physician and the patient. I participated in a study of a filler called Sculptra (polylactic acid) that looked at quality of life and indicators of self-esteem before and after treatment. Two different analytic questionnaires were used to evaluate these parameters. Every patient showed marked improvement in their scores. Other dermal fillers have also shown similar improvement.
I use four different fillers to treat facial fat loss. They are Sculptra (L-polylactic acid), Radiesse (calcium hydroxylapatite), Bellafill (polymethyl methacrylate), and fat transfer. Each filler has unique properties and method of administration. There is no “best” filler. Every patient has a unique set of needs and situations that need to be discussed in detail with the physician before a particular filler is selected for treatment.
Sculptra was the first filler approved by the FDA for treatment of HIV facial wasting. When Sculptra is injected into the skin, it produces volume by stimulating cells to produce collagen. Sculptra is packaged in a vial in powder form. The powder is mixed with sterile water to form a suspension that is injected into the skin. When the water is eventually absorbed by the skin—a process that takes four to five days—Sculptra remains in the tissue stimulating collagen production. During this five-day period it is important that the patient press firmly on the treated area for five minutes five times daily. Sculptra as a suspension can shift position due to the motion of the facial muscles with eating, talking, and smiling. Firmly pressing the skin prevents the filler from bunching up.
Side effects of all the fillers are the same. Bruising, irregular contours, or nodules occur infrequently and are easily managed. Multiple treatments with Sculptra are needed to create the volume necessary for aesthetic improvement. Depending on the amount of initial volume loss, three to five treatments spaced one month apart may be required. Most patients with lipodystrophy will require an additional treatment one year following their last monthly injection. For patients with limited financial resources, Galderma, the manufacturer of Sculptra, has a patient assistance program. Their phone number is 866.310.7551. Applications for this program can also be obtained from your treating physician.
Radiesse (calcium hydroxylapatite) is also FDA-approved for the treatment of HIV-associated lipoatrophy of the face. Radiesse is comprised of a calcium complex suspended in a paste of methylcellulose. Radiesse can appear as flecks of white on dental and facial X-rays. This is not harmful, but good information to be shared if an X-ray is to be taken. Both Sculptra and Radiesse stimulate collagen production and will provide volume for similar periods of time. Depending on the degree of facial volume loss, Radiesse can be administered in one or two sessions. Radiesse has a patient assistance program as well. Applications can be obtained by calling 866.862.1211, as well as at most treating physicians’ offices.
Bellafill (polymethyl methacrylate) is an excellent filler that will last at least five years (and probably longer). Bellafill consists of polymethyl methacrylate (PMMA) microspheres that are evenly dispersed through bovine collagen. Because of the rare occurrence of sensitivity to bovine collagen in the general population, a skin test on a forearm precedes the treatment of the face. Bellafill does not have FDA approval for the treatment of HIV-associated fat loss, and, as a result, there is no patient assistance program available. Bellafill will be more expensive upfront, but actually save money overall due to its long duration of action. Treatment of Bellafill is usually divided into two treatments, occasionally more. As with most fillers, Bellafill can cause swelling that adds to the appearance of fullness. I like to let Bellafill “settle in” and then re-assess the patient four weeks later.
Lastly, fat transfer from one area of the body to the face has been utilized as a “permanent” filler. Fat is harvested through liposuction, washed twice, and then injected into the face with a thin tube. Platelet-enriched plasma and calcium are added to the fat to provide growth factors, which increase the survival of the transplanted fat. Adequate volume repletion requires “overfilling” the face to compensate for those fat cells that don’t survive the move. Because of the significant facial swelling and the unpredictable outcome, I rarely utilize fat transfer to correct facial lipodystrophy. If a patient wants a permanent filler, I find Bellafill to be the better, more predictable choice.
When a patient experiences fat build-up around the front of the neck, the use of growth hormone has been very helpful in reversing this. Tesamorelin stimulates the production of growth hormone and has been helpful in reducing intra-abdominal fat. These drugs are given by daily injection over a period of several months. Most physicians who are managing the treatment of HIV are familiar with both of these and may prescribe one or the other to reverse the fat build-up in the neck or abdomen. Fat build-up on the back of the neck rarely responds to these medications and is best treated with ultra-sound assisted liposuction.
Correction of the fat redistribution associated with HIV and its treatment has significantly improved the lives of those affected. With anesthesia of the skin, facial injections are easily tolerated, and make a world of difference. With the assistance of ultrasound to liquefy fat, liposuction has become more effective with less disruption of other tissues. Patients will see the results immediately and fully recover within several days. For patients with limited income, the patient assistance programs have put treatment within their reach.