Hyaluronic Acid Treatment of Facial Fat Atrophy in HIV-positive Patients

H Bugge; A Negaard; L Skeie; B Bergersen

Disclosures

HIV Medicine. 2007;8(8):475-482. 

In This Article

Discussion

In our study using the temporary dermal filler Restylane SubQ, mean total cutaneous thickness increased from 6±1 mm at baseline to 15±3 mm at week 6 and declined to 10±2 mm at week 52. Response rate, defined as total cutaneous thickness >10 mm, was 100% at week 6, 85% at week 24 and 60% at week 52 (intention-to-treat analysis). Global Aesthetic Improvement Scale results showed improvement for about 90% of patients at week 52 despite the fact that all patients had a reduction in the degree of correction compared with week 6. Similarly, a significant increase in self-esteem scores and visual analogue scores, measuring patient satisfaction with their appearance, was found between baseline and week 52.

The major disadvantage of temporary fillers is the need for ongoing reapplication. However, in contrast to a previous study which reported that the hyaluronic acid product Restylane Perlane lasted for 3-6 months,[13] we found that with Restylane SubQ 60% of the patients had total cutaneous thickness >10 mm 52 weeks after the baseline treatment. No additional touch-up treatments were given between weeks 4 and 52. These results suggest that yearly reapplication of Restylane SubQ (in one or two sessions, 2-3 weeks apart) should be sufficient. Polylactic acid has probably been the material most often used in the treatment of HIV-related facial fat atrophy. The effect of polylactic acid has been reported to persist even longer, but this product needs multiple treatment sessions in order to obtain the desired effect.[1,14] It may take several months for the treatment results with polylactic acid to stabilize and for the full magnitude of the facial augmentation to become apparent.[15] In the study by Valantin et al.[14] the proportion of patients with total cutaneous thickness >10 mm was 19% at week 6, 41% at week 24, 61% at week 48, 52% at week 72 and 43% at week 96. In this study, most patients received four or five sets of injections of polylactic acid every 2 weeks.

(a) Clinical change following hyaluronic acid injections in one patient at baseline, weeks 6, 24 and 52. Notice the small lump at week 24(arrow). (b) Clinical change following hyaluronic acid injections in one patient at baseline, weeks 6, 24 and 52.

In our study, adverse events were confined to local injection-site reactions arising from the implant or the injection procedure, and the majority of these were mild. One patient had a facial swelling including the eyelids at the first and second injections. Exactly the same reactions to hyaluronic acid have not been described in detail previously, but 'redness and swelling' are frequently reported. Our patient was re-treated at week 52 without any reactions, and thus an allergic reaction seems unlikely.

Eight of the patients had palpable lumps after one or two treatments. Similar lumps have not been reported in other hyaluronic acid studies. However, the producers of Restylane SubQ were aware of this tendency to lump formation and advised against injecting more than 2 mL per treatment. It is also important that the gel is injected in small aliquots spread into the area to be augmented to avoid lump formation. This is, of course, particularly difficult in patients in whom lack of subcutaneous fat is a problem.

Polylactic acid can cause foreign-body granuloma reactions.[6,15] Case reports have also described granulomas and abscess-like nodule formations following hyaluronic acid treatment; however, most of the patients in these reports received facial injections before 2000.[5,16,17,18] A possible explanation for this is that after 2000 the amount of protein in hyaluronic acid was decreased.[8] No such changes were observed in our study at week 52; however, we acknowledge that the number of subjects may be insufficient to detect such rare complications.

In addition to hyaluronic acid and polylactic acid, fat transplantation[19] has also been used in the treatment of HIV-associated facial lipoatrophy. An important limitation to the use of fat transplantation in this patient group is the general lack of subcutaneous fat tissue in these patients, which leads to problems in obtaining enough donor fat.[19] Fat transplantation is a more complicated and time-consuming procedure than injection of synthetic fillers. In addition, some cases of disfiguring fat graft hypertrophy have been described.[20] Permanent fillers such as silicone may be ideal fillers when correctly placed, and no long-term side effects occur; the material is permanent and no reapplication is needed. However, there are some well-documented side effects of permanent fillers.[21] Granuloma formation typically occurs a couple of years after treatment.[22] In cases of infection, the permanent material must be extracted, and this may be difficult if it has been injected into soft tissue. Migration of permanent implants has also been described.[23]

The need for treatment of facial lipoatrophy in Norway is not very great. There are roughly 2500 people living with HIV in Norway, of whom about 5% are in need of treatment, and this number is likely to decrease, as current antiretroviral regimens do not appear to cause lipoatrophy to the same extent as previous regimens.[24]

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