Most people with lipoatrophy concentrate on trying to fix the wasting in their face. There are many options, but only two products approved in the United States specifically for HIV-related lipoatrophy, Sculptra (aka poly-L-lactic acid or New-Fill) and Radiesse (calcium hydroxylapatite or Radiance). Sculptra must be injected by a trained doctor into a specific layer of skin where fat has been lost. The active ingredient in Sculptra stimulates the body's natural production of collagen, the protein that is the main component in cartilage, teeth and bones. The injections are usually done in several sessions over the course of a few weeks or months, allowing the doctor to "sculpt" the collagen, building up the thickness of the skin for a more natural facial appearance.
The pros: Although the injections can be painful and cause some swelling at first, Sculptra appears not to cause any notable side effects if injected by a trained physician and if the proper facial massage technique is used after the procedure to avoid granules.
The cons: Since the filler is made largely of water, it is slowly absorbed by the body, and your body may not produce enough long-lasting collagen to fill out your face. As a result, additional "touch-up" sessions may be necessary, usually after 18 months or so. Also, some people develop tiny bumps in their skin at the injection sites. Although invisible, these bumps can be felt; massaging daily may make them disappear.
The cost: Sculptra ain't cheap. Few insurance policies will cover it without a fight, and Medicare and Medicaid won't cover it at all. Fortunately, Dermik Laboratories, the company that sells Sculptra, has set up a patient-assistance program (call 1-866-310-7551) that will provide free or reduced-cost Sculptra to people whose annual income is less than $40,000 a year (with no dependents). There is a sliding scale for those with incomes between $40,000 and $80,000. You still have to pay a doctor to give you the injections, however, which generally run about $250 to $500 per session. (For more on Sculptra injections, see the interview with Dr. Minas Constantinides.)
Radiesse (calcium hydroxylapatite or Radiance) was approved for facial wasting in people with HIV by the U.S. Food and Drug Administration in 2006. Like Sculptra, Radiesse is injected directly into the face by a health care professional, and the filler makes the body produce collagen, which gives the face a fuller appearance.
The pros: There is strong evidence that Radiesse works. Controlled clinical trials have proved that Radiesse is effective for people with HIV who experienced facial wasting. The drug is considered relatively long-lasting, so fewer treatments with Radiesse may be necessary.
The cons: The effect is not permanent. Typically, it will last from a few months to several years. With time, the results will fade, but booster injections can keep cheeks plump longer. Because the injections can irritate the face, people sometimes experience bruising, swelling or pain after it is applied.
The cost: Radiesse is pricey. Depending on what the doctor charges, treatment with Radiesse can cost hundreds to thousands of dollars. Insurance companies may refuse to cover it on the grounds that the treatment is "cosmetic." In the United States, the maker of Radiesse will provide up to six injections at reduced cost to people who earn less than $80,000 a year and don't have prescription drug coverage through a private insurance company or a government program. To learn more about their patient assistance program, you can call 1-866-862-1211.
Bio-Alcamid (poly-Alkyl-Imide) is not approved for use in the United States, but has been approved in Canada and is widely available in Europe and Mexico. This synthetic gel is injected under the skin, then pressed and molded by a professional to fit the contours of your face. A thin collagen capsule then forms around it. Although it is very pricey (about $4,500) and hard to access (no longer available in Tijuana), Bio-Alcamid is not only permanent but can be injected in large volumes in a single procedure. It is extremely stable -- unlikely to obey the law of gravity and droooooooop, leaving you with a big jowl rather than an apple cheek. The manufacturer claims that it can be removed if the doctor over-injects or if lipoatrophy improves with time. Long-term data are lacking on this product, however.
This highly refined silicone oil is not approved for lipoatrophy, but doctors in the United States have been using it as an effective facial filler for lipoatrophy. Silikon 1000 (polydimethylsiloxane) is administered using a "microdroplet technique" in which tiny drops of the oil are injected into the skin. The cost is around $600 per session, and four to eight sessions may be needed, depending on the severity of your facial wasting. A word of warning: There's a lucrative black market in silicone implants in the United States, and the facial lipoatrophy supply-and-demand is no exception. Advertised as cheap and safe, these procedures often use silicone oil more like grainy brake fluid than pristine facial filler, often resulting in bumps, lumps and worse. This product cannot be removed after being injected. Buyer, beware!
Also known as Articol, Artefill, Metacrill and polymethyl-methacrylate, this product contains small amounts of PMMA surrounded by bovine collagen. Three months after an injection, the collagen breaks down, stimulating, like Sculptra, your body to produce its own natural collagen, which fills out the space under the skin. This procedure is not approved for lipoatrophy, but many people swear by it -- especially when done by an artful surgeon such as the popular dermatologist Marcio Serra, in Rio de Janeiro (his PMMA -- Metacrill -- is a nonanimal collagen, minimizing the risk of an allergic reaction). The cost per treatment is between $250 and $500, with two sessions usually required. Artefill will most likely be approved in the United States in 2006, but no HIV data are available. This product cannot be removed after being injected.
There are many other, lesser-known treatments available for lipoatrophy. To repeat, though, only Sculptra and Radiesse are approved in the United States for lipoatrophy; Sculptra has the most research to back up its use. Bio-Alcamid, Silikon 1000 and PMMA all are believed to be safe and effective, but there is little info on most other procedures, so consult with your doctor before deciding which to use.
The following chart describes the 10 most popular treatments for facial lipoatrophy, how each works and the comparative benefits and risks. The first six are temporary; the last four are permanent. Only two, Sculptra and Radiesse are approved by the U.S. Food and Drug Administration (FDA) for facial lipoatrophy, but all are used, to better or worse effect. Comparing costs is tricky because cheaper materials tend to require more procedures and more touch-ups; the priciest, Bio-Alcamid ($4,500), can be injected in one session and is permanent -- yet is generally unavailable in the United States. Don't forget to include the cost of travel expenses when figuring out how much products not approved in the United States will cost.
|Type||Product||How It Works||Pros||Cons|
|Semi-permanent & permanent||Silicone (Silikon 1000)||Highly refined silicone oil mixed with water is injected into the face using "microdroplet technique"||Safe and effective in small amounts||Numerous injections for volume; cannot be removed; can migrate causing jowls; swelling and nodules|
|Polymethyl-methacrylate (PMMA; Articol, Artefill, Metacrill)||Material (small amounts of PMMA surrounded by bovine or synthetic collagen) is injected into the face, causing body's own production of collagen; the PMMA does not break down||Safe and effective; can be removed||Numerous injections for volume; allergic reactions; requires three months for full effects; sometimes visible under skin|
|Poly-Alkyl-Imide (Bio-Alcamid)||Synthetic material is injected into the face, then molded and pressed into precise shape; a thin collagen capsule forms around it||A single procedure can inject large volume; can be removed; extremely stable||Not available in the U.S.; little data on efficacy and safety|
|ePTFE implants (Gore-Tex, Gore SAM, SoftForm)||Solid implants are surgically inserted into the face through a small incision||Fills large, sunken areas||Post-op swelling and infection; possible fibrosis around implant; tends to be unstable|
We'd like to thank Nelson Vergel of facialwasting.org, who helped significantly with this chart.
Get your questions answered at The Body's Ask the Experts forum on facial wasting!