Please introduce yourself and tell us how you got involved in treating lipoatrophy.
My name is Minas Constantinides, and I am the director of facial plastic and reconstructive surgery for the Department of Otolaryngology, which is the ear, nose and throat department at New York University School of Medicine. I have been here in that capacity for the last 12 years.
About eight years ago or so, I became interested in lipoatrophy patients, only because there didn't seem to be much that could be offered to them. I tried to make myself an expert as to what the various options for them were. At that time, the options were really minimal.
Of course, the problem with lipoatrophy is that there is a loss of fat throughout the body -- really a loss of subcutaneous fat throughout the body, as well. So even patients with a little round belly, because there's some fat redistribution, don't have much fat there to use. The only real fat that we could use reliably in severe cases was buffalo hump fat -- the fat from the back that developed as a hump in patients.
So we tried fat transfer from all kinds of sources, including other parts of the patients and from buffalo humps, and rapidly learned that that fat suffered the same fate as facial fat, in the sense that it would atrophy just like facial fat would. There was no good long-term improvement whatsoever. Initially, patients looked great, but about six to eight months later, they were back to where they started. So that was unsatisfactory.
Was this before the cause of lipoatrophy was connected to HIV drugs?
I don't know. I don't have any real knowledge of that, of what the dynamic is, actually. So, we tried other things. We tried implanting Gore-Tex sheets. Those are sort of microporous medical rubber -- really, sheets made out of Gore-Tex -- the same stuff that's in your ski jacket that makes it waterproof. Well, medical grade Gore-Tex can be stacked and implanted, and we tried that. The stuff would shift around a little bit and it was just not satisfactory, either.
We tried directly excising [cutting out] parts of the nasolabial folds, those folds between the nose and the side of the mouth, that would get redundant and fall forward [as a complication of lipoatrophy]. And that made the fold go away [closing it so the scar would lie in the natural line of the face]; but it didn't really fix the lipoatrophy problem. We even tried different face lifting techniques to try to lift what was there to try to give a tighter look to the face. That was unsatisfactory, because what really was needed was volume.
Were you struck by how severe the cases were, and by the psychological impact that was having on people?
Yes. The severity of the cases ranged from the relatively mild, where a patient might just look a little bit gaunt or a little bit more defined, in terms of cheekbone area. Most people who would see that patient on the street wouldn't think twice about their appearance. Yet, that same mildly-affected patient would bring in a picture of themselves before lipoatrophy and they would have full, round faces. It would still be a dramatic change for them. This was extremely debilitating to them, in terms of their being able to deal in their day-to-day world with society, both with their friends and also in their professional lives.
They felt -- and the echo that resounded throughout every patient's tale was -- I feel like I have a mask on my face that has labeled me as a patient with AIDS. That's very stigmatizing and depressing, especially when treatment has so advanced and viral counts are undetectable, and CD4 levels are nearly back to normal. To still have that label is a very psychologically difficult thing for most patients to handle.
Along with the saga goes the efforts to try to get insurance companies to pay for some treatment for lipoatrophy. That has, pretty much across the board, failed, except for some very sort of rare policies that might allow for some treatment, based on the psychological impact of the disease. But it's striking that insurance coverage is relatively rare for this pretty prevalent problem related to a medical problem, not to anything other than that.
Why is it so difficult to get coverage?
Well, I think insurance companies view this as a cosmetic problem. Just like they won't pay for your face lift, they won't pay for lipoatrophy treatment. Of course, the two things are completely different.
Especially in the sense that a treatment for lipoatrophy is really reconstructing the face to what it was, whereas a face lift could be said to be enhancing.
Well, you can play semantics all you want, and I could probably make an argument that face lifting was rebuilding the face to a younger age. But the truth is that I don't believe that face lifting should be paid for by insurance, but I do believe that lipoatrophy should because it is a disease that is a result of a disease process and/or a series of medications.
So that's sort of the history behind lipoatrophy and my own personal struggles with treating these patients. When Sculptra [poly-L-lactic acid, New-Fill] came along as a possible treatment choice, I was a little skeptical, because I had tried other fillers for lipoatrophy patients. The volume required was always extraordinarily large and it didn't seem that other fillers really were satisfactory, in terms of long-term goals for these patients.
Having said that, I have personally not tried silicone, liquid silicone, for lipoatrophy. I know that there are some doctors that are using it. I have not tried it.