Editorial     Comité Editorial     Enlaces     Instituto de Cirugia Estetica  



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.


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.


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).


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.


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


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.

medicina estetica · cirugia estetica · cátedra de cirugía plástica, estética y reparadora · nota legal
  Diseño web: Nitium