Dr Patrick Treacy shares some of his most challenging cosmetic dermatology cases. This month, the he talks about a 71 year old socially isolated HIV+ patient with significant facial defects after undergoing treatment with antiretroviral drugs (HAART)

1. 63
CASE FILES
Aesthetic Medicine • July/August 2014
I N J E C TA B L E S
www.aestheticmed.co.uk
Dr Patrick Treacy shares some of his most challenging
cases. This month, the he talks about a 71 year old socially
isolated HIV+ patient with significant facial defects after
undergoing treatment with antiretroviral drugs (HAART)
Dr Treacy’s
CASEBOOK
DR PATRICK TREACY
is chairman of the Irish
Association of Cosmetic
Doctors and Irish regional
representative of the British
College of Aesthetic Medicine
(BCAM). He is European medical
advisor to Network Lipolysis
and Consulting Rooms and
holds higher qualifications in
dermatology, laser technology
and skin resurfacing. In 2012
and 2013 he won awards for
‘Best Innovative Techniques’
for his contributions to
facial aesthetics and hair
transplants. Dr Treacy also
sits on the editorial boards
of three international
journals and features regularly
on international television and
radio programmes. He was a
faculty member at IMCAS
Paris 2013, AMWC Monaco
2013, EAMWC Moscow 2013
and a keynote speaker for
the American Academy of
Anti-Ageing Medicine in
Mexico City this year.
>>
SPONSORED BY
A
n American patient with severe facial lipodystrophy secondary to HIV-
infection was referred to the Ailesbury Clinic. He was 71 years old and had
been suffering from HIV for 17 years. He had a full hematologic evaluation,
including a full blood count, biochemistry, liver function, lipids, glucose,
lactate, viral load and CD4 cell count. The subject had a CD4 of 632/µl with
a viral load below limit of detection. He had not received
any prior treatment for their HLS. He was been
treated by thymidine analogues stavudine
(d4T) and zidovudine (ZDV, previously
known as AZT). He was not receiving
anticoagulant therapy, steroids, or anti-
infective medications. The patient was
markedly socially isolated and had not
appeared outside his apartment for a
period of four years.
The patient was injected bilaterally
into the buccal, malar, and temporal
areas of his face with 23cc of the
polyalkylimide gel (BioAlcamid®,
Polymekon, Italy) in an attempt to
replace subcutaneous fat that had
atrophied as a result of severe facial
lipodystrophy. Regional injected anesthesia
was used in conjunction with topical anesthesia.
The treated area was sculptured to obtain
The patient was
injected bilaterally into the
buccal, malar, and temporal
areas of his face with 23cc of the
polyalkylimide gel (BioAlcamid®
,
Polymekon, Italy) in an attempt to
replace subcutaneous fat that had
atrophied as a result of severe
facial lipodystrophy

2. 64 Aesthetic Medicine • July/August 2014
I N J E C TA B L E S
CASE FILES SPONSORED BY
the best aesthetic appearance. At the end of the
treatment, the patient was put on prophylactic
Augmentin and Klacid for three days to
prevent infection.
DISCUSSION
The human immunodeficiency virus
(HIV)-lipodystrophy syndrome (HLS)
was a major problem for many HIV
patients undergoing long-term use of
highly active antiretroviral therapy
(HAART) within the past five years.
The condition was characterised by
a loss of subcutaneous fat, especially
in the cheeks, tempomanbidular and
periorbital areas1
. The psychological
effects of HLS included depression, anxiety,
social withdrawal, isolation and suicide
secondary to perceived social stigma caused
by the significant alteration in facial shape
that accompanies it2
. Facial lipoatrophy was the most obvious
and stigmatising manifestation of HIV-related lipoatrophy3
.
At the time this patient was treated, the etiology of the
condition was not yet understood. While some researchers
focus on a multifactorial phenomenon4
others consider either
primary HIV infection (CD4 cell counts, viral load) or the
use and duration of HAART as the most likely causes of the
pathology. Initially, protease inhibitors were implicated, but
many researchers believed that HLS is caused by nucleoside
analogues, particularly d4T and to a lesser extent AZT5
. The
author favoured the latter as did not see the condition amongst
HIV patients in Africa.
There was no pharmacological therapy to manage this
complex condition. Strategies compensating for facial fat loss,
including the use of HLA and bovine collagen were not helpful
as the effects declined after three to four months6
. Transferred
autologous fat was metabolised by the lipodystrophic process7
.
Poly-L-lactic acid (PLA) had found favor in HIV lipodystrophic
patients but it took many months to see the effect, requires
up to five sessions to administer and the resultant contouring
effect lasts only last two years8
. The author used BioAlcamid®
as the polyalkylimide became covered by a very thin collagen
capsule, completely surrounding the gel, isolating it from the
host tissues and making it a type of endogenous prosthesis. AM
REFERENCES
1. OetteM,JuretzkoP,KroidlA,SagirA,etal.Lipodystrophy
syndromeandself-assessmentofwell-beingandphysical
appearanceinHIV-positivepatients.AIDSPatientCareSTDS.
2002;16:413-417.
2. SekharRV,JahoorF,WhiteAC,PownallHJ,etal. Metabolicbasis
ofHIV-lipodystrophysyndrome.AmJPhysiolEndocrinolMetab.
2002;283;332-7.
3. GuaraldiG,OrlandoG,DeFazioD.Prospective,partially
randomized,24-weekstudytocomparetheefficacyand
durabilityofdifferentsurgicaltechniquesandinterventions
forthetreatmentofHIV-relatedfaciallipoatrophy.6th
LipodystrophyWorkshop(6thIWADRLH),Washington.Abstract
12.AntiviralTherapy2004;9:L9.
4. MaussS,CorzilliusM,WolfE,SchwenkA,etal..Riskfactorsfor
theHIV-associatedlipodystrophysyndromeinaclosedcohort
ofpatientsafter3yearsofantiretroviraltreatment.HIVMed.
2002;3:49-55.
5. CarrA,MillerJ,LawM,CooperDA. Asyndromeoflipoatrophy,
lacticacidaemiaandliverdysfunctionassociatedwithHIV
nucleosideanaloguetherapy:contributiontoproteaseinhibitor-
relatedlipodystrophysyndrome.AIDS;2000;18;25-32.
6. CoopermanS,MackinninV,BechlerG. Injectablecollagen:asix
yearclinicalinvestigation.AestheticPlasticSurg1985;9-145-151
7. TangL,EatonJW.Inflammatoryresponsestobiomaterials.AmJ
ClinPathol1995;103:466-471.
8. GogolewskiS,JovanovicM,PerrenSM,DillonJG,etal. Tissue
responseandvivodegradationofselectedpolyhydroxyacids
(PLA,PHB,PHB/VA).JBiomedMaterialRes1993;27:1135-1148
www.aestheticmed.co.uk
The condition was
characterised by a loss of
subcutaneous fat, especially in
the cheeks, tempomanbidular and
periorbital area. The psychological
effects of HLS included depression,
anxiety, social withdrawal,
isolation and suicide secondary
to perceived social stigma