PUBLICACIONES
EN REVISTAS CIENTIFICAS DE CIRUGIA ESTETICA Y
PLASTICA
LIPOFILLING. INYECCION DE GRASA CON LA TECNICA
DE COLEMAN DE LIPOESCULTURA.
Treatment of Facial Fat Atrophy Related to Treatment
with Protease Inhibitors by
Autologous Fat Injection in Patients with Human
Immunodeficiency Virus Infection
José-María Serra-Renom, M.D., Ph.D.,
and Joan Fontdevila, M.D.
Barcelona, Spain
A parallel effect of the use of protease inhibitors
in human immunodeficiency virus–positive
patients is the appearance of facial fat atrophy.
To correct this, the authors propose lipoinjection
of autologous fat into the areas of facial atrophy
by a technique based on the atraumatic procurement
of fat and posterior treatment with decantation,
centrifugation, and cleaning of other material
obtained by aspiration. The method of fat injection
is also important and is performed by means of
interlaced tunnels and the introduction of a small
volume of fat into each tunnel as a graft. In
30 percent of the cases, reinjection of fat was
required during the first postoperative months.
The results obtained after the experience of 2
years were very satisfactory. (Plast. Reconstr.
Surg. 114: 551, 2004.) The use of protease inhibitors
in human
immunodeficiency virus therapy has led to the
appearance of a series of syndromes associated
with alterations in the distribution of body fat
and lipid metabolism.1–3 At a peripheral
level, these alterations are found as fat atrophy
with thin extremities and a loss of facial fat,
with a sunken appearance of the cheeks and in
the temporal region at the
upper edge of the zygomatic arch.
From an anatomical point of view of the temporal
region, atrophy is found in the three areas of
facial fat: superficial fat, delimited by the
dermis on the surface and the superficial
temporal aponeurosis; intermediate fat, between
the surface layer and the deep layer of
the deep temporal aponeurosis; and the deep fat
level, which is shaped as a sack of fat
below the deep temporal aponeurosis. This deep
facial fat sack is the Bichat fat sack,
which has three branches: temporal, buccinator,
and retromandibular.
This appearance is perceived as a stigma because
it identifies the patient as human immunodeficiency
virus–positive. To correct this deformity,
we inject previously treated autologous fat into
the sunken area. Not all patients are candidates
for treatment with this technique because some
do not present enough subcutaneous fat to allow
procurement of sufficient tissue to correct the
problem.
TECHNIQUE
Six hours before surgery, the patient is given
prophylactic antibiotics with an initial dose
of 500 mg of levofloxacin, which is continued
every 12 hours for 5 days. Half an hour before
surgery, the surgical area is covered with anesthetic
cream and the infraorbital and mental nerves of
both sides of the face and the sensitive temporomalar
branches are blocked with 1% mepivacaine.
The area of fat procurement is also anesthetized
with a solution of 1% mepivacaine. The
area we prefer for procuring fat is the infraumbilical
region, where subcutaneous fat
is normally abundant. To obtain the fat, we use
cannulas designed by Coleman4; and aspiration
is performed with a 10-cc syringe, achieving a
vacuum by aspiration. To perform fat aspiration,
we make a vacuum with a 10-cc syringe. The aspirated
material is deposited vertically to decant at
the level of the three strata: the upper stratum
where the fat is in the form of oil, which is
lysed by the extraction process; the intermediate
stratum, with the adipocytes; and the lower stratum,
where the erythrocyte detritus is concentrated.
The upper stratum is absorbed with surgical patties
and the lower stratum is extracted on withdrawal
of the inferior plug of the syringe and pushed
with the plunger. The stratum containing the adipocytes
is transferred to 1-cc syringes for injection.
When the injection material is prepared, we make
two pointed incisions, one at the malar level
and the other at the level of the nasolabial sulcus,
in both cheeks, where fat is injected in multiple
tunnels at different levels, crossing over the
tunnels made from one incision to another. It
is very important to avoid fat accumulation, and
the fat should be distributed in thin longitudinal
tunnels to facilitate revascularization. In cases
including the upper region of the zygomatic arch,
it is sometimes convenient to make an incision
at the hairline.
The facial incisions are closed with skin closure
strips, which are withdrawn after 3 days.
The incision in the area of fat donation in the
abdomen is sutured with 5-0 nylon. It is recommended
that the patient avoid facial gesticulation, especially
smiling, for a 48-hour period. Antibiotic prophylaxis
is administered for 5 days.
RESULTS
Thirty-eight patients (12 women and 26 men) ranging
in age from 28 to 56 years underwent surgery from
February of 1999 to September of 2001. Twenty-five
of these patients were receiving the protease
inhibitor indinavir, whereas 13 were undergoing
treatment with nelfinavir. Ten patients presented
hepatitis B or C virus infection and six were
active smokers.
The patients underwent monthly controls, with
no case of infection being presented. At 6
months, symmetry and volume were evaluated. On
12 occasions, a new injection of fat was made
to improve symmetry and the cases of reabsorption.
The cosmetic result was objectively evaluated
1 year after surgery. The patient, the clinic
nurse, and the surgeon graded the result on a
scale from 1 to 4 (1 = poor, 2 = fair, 3 = good,
and 4 = excellent) for shape and symmetry. The
mean value was 3.7 as judged by the patients,
3.5 as judged by the nurse, and 3.2 as judged
by the surgeon (Figs. 1 through 3).
DISCUSSION
To fill in the sunken areas, we prefer to use
fat because of its advantages over synthetic materials.
In cases of infection, synthetic material must
be extracted, and this may be difficult if it
is injected into soft tissue. Moreover, fat presents
good characteristics for injection because it
is very manageable and moldable, in addition to
being of no cost to the patient.
The disadvantages found include reabsorption within
the first month, requiring reinjection
in a high percentage of patients. Moreover, there
is an important limitation to take
into account, namely, the quantity of fat that
may be obtained from the subcutaneous fat in
this type of patient, as sometimes they do not
have a good area of donor fat because of their
thinness resulting from the disease. In these
cases, fat injection must be discarded.
The procurement of fat is performed with the vacuum
created by the 10-cc syringe to
avoid lesions to the fat tissue by aspiration
pressure. 4 The fat retrieved in the 10-cc syringe
is transferred to a 1-cc syringe to thereby make
smoother and more precise longitudinal, tunnel-
like injections, avoiding the formation of fat
accumulation. The injection is made from two points
in the inferior and external vertices of the sunken
zone in the shape of a triangle so that a net-like
crossing over of the tunnels is performed.
In summary, the fat should be obtained with the
least trauma possible and should be injected as
whole and as clean as possible without blood or
detritus. It is also important to make the tunnels
with the least trauma to avoid hematoma formation,
and the injections should be longitudinal, with
little quantities of fat in each tunnel.5 The
fat should be introduced homogeneously, and thus
two incisions are made, and crossing over of the
tunnels is performed at several levels. To better
control the quantity of fat, the intervention
is regulated and systematic, counting the tunnels
made on each incision and the number of 1-cc syringes
used to thereby have rigorous control of the volume
and distribution of the fat. We prefer not to
centrifuge the fat, because the first cases in
which the technique was used showed greater reabsorption
than the later cases, in which the fat was obtained
with the decantation technique and as little trauma
as possible.
CONCLUSIONS
Human immunodeficiency virus–positive patients
who present with facial atrophy and
good control of the viral load are treated by
means of autologous fat injection, in those
who have sufficient fat in any region of the body.
The fat is obtained by atraumatic methods and
injected by means of tunnels. The procedure gives
very satisfactory results, and we prefer it to
the injection of synthetic materials.
In 30 percent of cases, it was necessary to administer
a new fat injection within
the first months. Once the fat is completely integrated,
the results remain satisfactory at
2-year follow-up.
José Serra-Renom, M.D.
Hospital Clinic
C/ Villarroel 170
08036 Barcelona, Spain
drserra@cirugiaestetica.org
REFERENCES
1. Viraben, R., and Aquilina, C. Indinavir-associated
lipodystrophy. A.I.D.S. 12: 37, 1998.
2. Carr, A., Samaras, K., Burton, S., et al. A
syndrome of peripheral lipodystrophy, hyperlipidemia
and insulin resistance in patients receiving HIV
protease inhibitors.
A.I.D.S. 12: 51, 1998.
3. Carr, A., Samaras, K., Chisholm, D. J., and
Cooper, D. A. Abnormal fat distribution and use
of protease inhibitors. Lancet 351: 1736, 1998.
4. Coleman, S. R. Facial recontouring with lipostructure.
Clin. Plast. Surg. 24: 347, 1997.
5. Coleman, S. R. Structural fat grafts: The ideal
filler? Clin. Plast. Surg. 28: 111, 2001.
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