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Consumer's Guide to Lipo Surgery

Those Sunken Cheeks

July/August 2000

Index of Treatment Options

"It's not surprising that some patients are disappointed and depressed at first." So warns the American Society of Plastic Surgeons in its factsheet on facelifts. After all, as the association also says in that document, "A facelift can make you look younger and fresher, and it may enhance your self-confidence in the process. But it can't give you a totally different look, nor can it restore the health and vitality of your youth. Before you decide to have surgery, think carefully about your expectations and discuss them with your surgeon."

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.

Facial Options

To renew those sunken cheeks, you have basically four options: fat transfer; injections; insertion; and implants.

Fat Transfer

The surgeon removes fat from your abdomen, groin or butt and injects it into your face. The procedure takes a few hours and you'll be home that night. One problem is that whatever is causing the fat loss in the face seems to be causing the fat loss in the areas best used for harvesting, so that many people with HIV don't have any or much fat to transfer. Also, fat seems to have a tendency to get re-absorbed by the body. There is concern that what caused your cheeks to become sunken in the first place will cause them to deflate again. However, Dr. Jeffrey Brande in Manhattan says that wasting has not reoccurred in patients who had fat transplants more than two years ago. However, he stresses that he harvests fat very, very gently and then injects tiny particles slowly and carefully using many passes.


Collagen comes from cows (it's not pleasant to think of). Collagen injections tend to last for less time than do fat injections (about three to nine months for either material). Like fat transfer, this is an out-patient procedure (in the doctor's office). Cost is about $800 to $1,200 per treatment. One customer reports, "I have been doing collagen for two years. It is not a permanent correction, but looks great while it lasts. It depends on how fast your body metabolizes the collagen. Up side is it's fast, safe and looks totally natural. Down side is the expense, $700 each visit, and my body metabolizes it in about six months, so that's twice a year." Newer injection materials are Dermalogen and Fascian, both from cadaver tissue that's been sterilized (again, not a pleasant thought).

Other Materials

You can also get Softform, Goretex or Alloderm inserted. Softform and Goretex are made of polyethylene, the synthetic material used in raincoats. This material has been used in surgery for years. Softform consists of hollow tubes and may be more stable than Goretex because there's a tendency for facial tissue to bind to the inside of the tubes. You usually need more than one surgery to progressively increase the fullness of the cheeks.

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.

Silicone Implants

Unlike the other options, which can be performed as an office procedure, silicone cheek implants represent major surgery. However, the results last much longer.

Potential Problems

Any injected material can end up looking lumpy. You'll need another surgery to smooth it out -- which costs more money, as well. In addition, repeated surgeries for new injections, if fat loss continues, also adds more expense.

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 "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 and POZ magazine, January 1998 and June 2000.)

Old and Improved?

Dr. Howell Tiller's plastic surgery practice in Miami Beach began seeing lots of HIV patients three years ago. "This is more than cosmetic," he says. "It's psychological. This is reconstruction. Most of my patients are insistent about it: the sunken face is a stigma of AIDS."

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.

Doctor, Doctor

The following physicians have experience treating HIV drug-related body changes. To find a board certified plastic surgeon in your area or to learn more about reconstructive surgery, call toll free at 1-888-4PLASTIC or visit the American Society of Plastic Surgeons at Ask your surgeon for financing options, including bank loans.

Dr. Harold J. Brody (404) 525-7409

Dr. David Teplica (773) 296-9900

Los Angeles
Dr. Harvey Abrams, Dr. Robin Schaffran (323) 936-1245

Dr. Howell Tiller (305) 534-9054

New York
Dr. Jeffery Brande (212) 873-7302
Dr. Michael Lorin Reed (212) 888-2260

San Francisco
Dr. Jeffrey DeWeese (415) 397-1210
Dr. Michael Echavez (415) 558-8200

Where the Buffalo Roam

By Enid Vázquez

Les 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.

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This article was provided by Positively Aware. It is a part of the publication Positively Aware. Visit Positively Aware's website to find out more about the publication.