Consumer's Guide to Lipo Surgery
Those Sunken Cheeks
Index of Treatment Options
All of which relates to those sunken cheeks frequently seen in people with HIV on antiviral medications. Of all the body changes being seen with the drugs, none are as distressing as the loss of fat in the temples and cheeks, giving a sickly look to an otherwise healthy person and sucking out the youth and beauty of their face. At the same time, this condition is the most difficult to treat with plastic surgery.
"I called it the Buchenwald (concentration camp) look," says one PWA (person with AIDS). "My doctor called it the Dachau dimple (after the name of a specific Nazi concentration camp). I appreciate the alliteration."
Because most of Bob's surgery was picked up by his insurance company and he doesn't want them to have a change of heart, he had to speak anonymously about his experience. "It hits you hard. One day you wake up and it's there (the sunken look). You don't notice your cheeks slowly going away. I think when people feel, 'Oh, I only have one or two or three years to live,' it doesn't matter as much. It was when I started feeling better and not being so sick that it bothered me more. It became a mark of AIDS, or of being sicker than I was." Bob was out on disability at that time and has since returned to his satisfying work, despite getting almost as much money on disability as he did while working.
Bob had slices of Alloderm inserted into his cheeks. He described Alloderm as a "human skin product that is like human collagen, which is deeper skin." You can also call it "purified cadaver skin tissue without cells," or tissue from dead bodies. The Alloderm treatment came out lumpy and he had to go in for a second surgery. This time his surgeon used finely cut (scalpeled) pieces of Alloderm. Still, his face did not become quite as full as he had expected.
Bob paid $3,000 out-of-pocket for both surgeries. The total cost was $10,000. Because Alloderm is used in skin grafts, his surgery was coded as a skin graft and his insurance covered most of the bill. Collagen would not have been paid for by the company, Bob says. Other wording used by his primary doctor and by the surgeon to ensure insurance coverage: "acquired deformity of face" and "patient's condition is terminal." The stark language startled him.
As for his okay results, he says he's come to realize that while others had made him aware of how he looked, he learned that ultimately he's much more sensitive about his appearance than other people are (a realization shared by other PWAs). After his surgery, many people told him they didn't think he had looked so bad before. Final word of advice: "Someone going into this should be aware that this may not be a one-shot deal."
That's true of all the facial reconstruction options, although some surgeons say they have found a permanent solution.
Goretex and Alloderm come in flat sheets. Alloderm is organic. It's sterilized cadaver (dead body) tissue. Either material may move out of the location where they were placed. Goretex is easier to remove, if need be. Insertion of Goretex and Alloderm is an out-patient procedure.
People whose health is compromised can expect greater complications from surgery, especially if they're on medications. Beware of blood thinning products, such as aspirin, vitamin E and gingko biloba. Unless stopped for about two weeks before surgery, they can lead to excess bleeding. (Note that Agenerase contains a lot of vitamin E.)
Summarizing a workshop on surgery for lipodystrophy-related body changes held in San Francisco last summer, Dr. Harvey Bartnof wrote for HIVandHepatitis.com: "Any of the surgery procedures for fat loss in the cheek may not completely reverse the total fat loss appearance, but would be expected to improve it. The best improvement in one procedure is the implants. However, even that may not completely reverse the fat loss apppearance.
"Dr. (Michael) Echavez (of San Francisco) summarized the surgical approaches for fat redistribution by indicating that:
The goal is complete restoration.
The likely outcome is improvement, not complete restoration.
No surgical procedure is ideal.
Sometimes a combination of procedures works best."
(Sources include HIVandHepatitis.com and POZ magazine, January 1998 and June 2000.)
But there are a lot of problems with the options for facial reconstruction of sunken cheeks. "The more choices you have, the more it means none of them are perfect," he says. "You want to replace tissue with as like tissue as possible, ideally fat, but fat is notoriously unreliable." On the other hand, he says he's seen "wonderful results" with using fat, but it's frequently difficult to find enough elsewhere on the body of HIV patients to conduct the surgery. Also, he says he finds that many people opt for injections of fat or collagen because they're less expensive, but then opt for surgery when the results fade after a few months and the costs of more injections start adding up. Then they sometimes opt for surgery.
As for insertion of Goretex or Alloderm sheets, Dr. Tiller says these are not thick enough for what's needed by many people with HIV. That's not all. "I've taken out more Goretex than I put in. They harden." Silicone implants are thicker and firm, but he says he finds that they just don't look good in men, but do look good in women.
Instead, he says he's pioneering an old plastic surgery technique that he believes will give permanent results for HIV facial reconstruction. He inserts dermis, a layer of skin between the top layer of skin (epidermis) and layers of fat underneath. For this "dermal/fat graft," he uses dermis from the butt. "A lot of people want a buttock lift, so I use this material. It's placed under the facial dermis, where it fuses." (The buttock lift is not surprising, considering how often the butt disappears as part of HIV lipodystrophy syndrome. Even in the old days before combination therapy, there was so-called "AZT butt.") He says that in the past two and a half years, he has performed about 60 of these surgeries.
"It gives good augmentation and very natural-looking results," Dr. Tiller says. "The biggest complaints I've gotten are about scars at the site of harvesting (butt area). It is more surgery -- it's not like going into the fridge for a syringe of injectible." The cost is about $3,000 and includes general anesthesia. He reports seeing more cases of excess bleeding and more hemotomas (blood clots at the site of the surgery) in any surgery on people with HIV. (This can be expected in people with medical conditions.) Like Dr. Brande, he likes fat harvesting as well, and finds it can also give permanent results if harvested very gently.
www.plasticsurgery.org. Ask your surgeon for financing options, including bank loans.
By Enid VázquezLes went under Dr. Harvey Abrams knife on a Tuesday and was enjoying a cruise of the Greek Isles by the weekend. His mom, whom he treated to the cruise, quickly and painlessly removed the stitches out of his back. He felt great.
You would think that because his buffalo hump came back within four months of his liposuction that he would be an unhappy customer. But he's not.
"Before, it was right on the back of my neck and more pointed, like a buffalo hump," says Les. "Now it's like a pad, and it's lower and more spread out. I feel that it's not normal, but it's not hideous like the old days before the surgery." It also used to be extremely hard, which made him feel like something horrible was in store for him. Now it's soft like normal fat.
It also helped that he was not expecting a cure, since his HIV specialist had pointed out before the surgery that until the reason for the hump is understood, it would probably come back since you can't treat something until you know what's going on.
Another big difference is his use of testosterone cream and gel to rub on his back. On an internet e-mail list for the discussion of HIV medications, PI Treatment, complementary treatment guru Michael Mooney talked about someone who found that his buffalo hump went away after rubbing testosterone cream on it.
Another member of the internet list did Les one better. He skipped the surgery and went straight to the cream. It went down by about 85 percent within two months. According to his partner, HIV treatment advocate Bob Munk (who's written for Positively Aware), "Our (HIV) doctor says maybe it would have gone away by itself naturally. But I don't know of anyone whose hump went away by itself, do you?"
As someone who follows medical developments, Munk understands that individual reports are different from scientific proof. Says Munk, "There's no way to know if it's the testosterone cream. It isn't proof, but its an interesting anecdote."
There was a different experience for yet another member of the PI Treatment list. Paul says he developed a buffalo hump after two years on a Norvir (ritonavir) protease inhibitor combination. "I pretty much took myself off the dating list at that point," he says. Paul tried a common tactic being explored in research and in the real world for the metabolic and body shape changes being seen with HIV medications: switching drugs. He also tried testosterone.
"Partially I did switch because of the hump. The other reason was the temptation of only having to take three pills once a day with Sustiva (efavirenz) and none of the eating/not eating requirements. I think the hump was the big motivator.
"I started Sustiva and the testosterone cream pretty close to simultaneously. I was on a lipodystrophy e-mail list and heard about the testosterone cream through them. It was purely anecdotal, but I was willing to give it a shot. Initially I was using the patches instead of the cream, and was definitely on Sustiva by the time I started with the cream. I think the testosterone helped control the growth of the hump more than anything. It is really hard to say. My neck size is down to about 17.5 (from 18.5, normally my size is 16.5), and the hump itself seems somewhat reduced."
As for his treatment experiment, he says, "My viral load has been undetectable since I started the ritonavir and has stayed that way with Sustiva thus far, about four years all together."
When considering surgery, smaller humps can be liposuctioned, while larger ones need surgery to be cut out. Some humps do not return. Humps are easier to get insurance coverage for, since they often disrupt the neck's mobility.
This article was provided by Test Positive Aware Network. It is a part of the publication Positively Aware. Visit TPAN's website to find out more about their activities, publications and services.