September 30, 2002
Dealing with the metabolic problems often associated with HIV infection and antiretroviral therapy (ART) is a challenge for patients and their doctors. While insulin resistance and hyperlipidemia have potentially serious health consequences, changes in physical appearance can be particularly distressing. Patients with greatly improved immune systems may appear chronically ill due to lipodystrophy, especially facial lipoatrophy or fat loss. The psychological stress of facial wasting cannot be underestimated. Switching ART to a new regimen may improve cholesterol and triglycerides, but changes in fat loss in the face seem less likely to return to normal.
A growing number of doctors, mainly dermatologists and plastic surgeons, are taking interest in this problem and developing new techniques to improve appearance. Injections of a number of different substances that fill the area of the lost fat have been studied in small trials. These include silicone-based products and collagens, and they have had variable success and some problems, notably movement of the injected material from the intended position. Fat taken from other parts of the body may be the best solution, but patients with severe facial fat loss may not have adequate amounts of fat in other areas of the body, and this approach requires two separate procedures, the harvest and the injection. Dr. Moyle and colleagues in London report favorable results of a small study of 30 patients (28 men and 2 women) treated with a different injected material, polylactate (NewFill).
Polylactate is different from the other substances in that the main goal is not to "fill" the space under the skin, but instead to trigger a reaction that causes the patient's own muscle and collagen (but not fat) to grow, improving appearance in the areas with fat wasting. Immediately after injecting 4-5 ml of polylactate under the skin of the cheeks, there is a filling out of the hollowness that disappears after a day or so. The increase in facial tissue takes weeks to months to become fully apparent, and the effect may last more than two years. The injections must be performed at least three times, with each session separated by about one to two weeks. The injections were well tolerated overall, with one patient experiencing bruising and one experiencing skin redness that didn't require any specific treatment. Polylactate is reported to be immunologically inert and biodegradable.
Patients in Dr. Moyle's study were noted to have improved facial appearance when photos were assessed by a panel of independent physicians and an increase in facial skin tissue thickness when assessed by ultrasound. The patients' scores on a survey of anxiety and depression also improved after polylactate injections, a result that has not been previously reported.
As these techniques to improve appearance after facial wasting are optimized, the next major hurdle for patients will be the cost. Currently, most insurers consider these procedures "cosmetic" and will not cover the cost. Until the psychological impact of facial wasting is appreciated by insurance companies, this type of treatment will unfortunately be an out-of-pocket expense. Hopefully larger studies like this will establish their importance and effectiveness.