The Mirror Has Two Faces: A Personal Account of Using Facial Filler for Lipoatrophy
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If you have a bad case of facial wasting, you probably feel like you're willing to go through torture to get those cheeks back. Fortunately, you don't have to. Having a facial filler injected into your skin, when done correctly by an experienced plastic surgeon or dermatologist, is a not-too-uncomfortable procedure accomplished in a half-hour office visit. The most pain you're likely to feel is in your wallet, since even Sculptra (poly-L-lactic acid, New-Fill) and Radiesse (calcium hydroxylapatite, Radiance), the only treatments for lipo approved by the U.S. Food and Drug Administration (FDA), are rarely covered by private insurance. The challenge is choosing the right doc near you (see "Finding a Face-Filling Physician," below). We, of course, went to one of the best.
Meet Dr. Minas Constantinides, director of facial plastic and reconstructive surgery in the department of otolaryngology (aka ear, nose and throat) at New York University Medical Center. "I became interested in lipoatrophy patients about nine years ago because there didn't seem to be much that could be offered them. We tried all kinds of things, and all kinds of things failed," Constantinides says.
He ticks off some tried-and-untrue face-filling techniques, including fat transfer ("the problem with lipoatrophy is that there is a loss of subcutaneous fat throughout the body, so even patients with a little round belly or a buffalo hump don't have much fat"), implanting Gore-Tex sheets ("the microporous medical rubber -- the same stuff that makes your ski jacket waterproof -- would shift around") and standard face lifts ("it gave a tighter look when what was really needed was volume").
Back then Constantinides also had patients requesting injections with New-Fill, which was approved in Europe for cosmetic surgery but was still experimental in the United States. Yet Constantinides was skeptical.
"The volume required was so large that the results were never satisfactory over the long term," he says. "And my policy is not to inject non-FDA-approved materials into the face. So I never did."
Waiting was a wise move, as it turned out, because by the time New-Fill won the feds' OK in 2004 as Sculptra, the quality of the product had improved considerably.
"New-Fill went through a period where the dilution was wrong, and there would be lumps and growths and infections," says Constantinides. "But now Sculptra seems to be doing exactly what the company says it will do, which is to provide reliable, large-volume filling that can last two to three years and then needs a little touch-up." Now, without further ado, Constantinides will take you on a test drive.
In your initial consultation with the surgeon, it helps to bring in a photo of how you looked before the facial wasting. This way the surgeon knows what your expectations are and can tell you how realistic they are.
Before the first procedure, which is a series of injections of filler into the deep parts of your face, you should avoid aspirin and nonsteroidal anti-inflammatories, like ibuprofen, for a week or so, Constantinides says, because they can cause more bruising than is necessary.
The doctor will do his or her part the night before your injections by mixing the Sculptra, which comes as a freeze-dried powder of poly-L-lactic acid (PLLA), with water (plus needle-numbing lidocaine) until the consistency is just right.
The first injections are with nerve blockers to anesthetize your face, essentially what you get at a dentist before the drilling. "Most patients grade the procedure -- on a 0 to 10 scale, if 10 were the most severe pain that they had -- at a 3 or a 4," Constantinides says.
While you wait for the painkiller to kick in, your doctor is likely to discuss with you how he or she plans to "sculpt" the material under your skin. The process takes some artistry: Not only does the contour of the face vary, especially in the cheek area -- ranging from deep to superficial and requiring more or less amounts of filler. But each person's face is unique, and the goal is to get the reconstruction as close to the original as possible.
"It's very helpful to see pictures of what the patient looked like before they had the lipoatrophy," Constantinides says. "That way I can try to figure out with the patient if they are going to actually be able to look exactly like that. Or will they have to settle for less volume in their face than they had before."
The actual procedure of sticking that thin-gauge needle deep into your skin takes about 15 to 20 minutes to complete, with one vial of Sculptra for each side of the face. Expect some back-and-forth between you and your doctor of the "A little more here?" variety. And don't be afraid to ask questions.
Now, here's the tricky part: Your face immediately swells up with the Sculptra (plus some needle-related inflammation), and you're likely to love the result. But as lipoatrophy will no doubt already have taught you, appearances can be deceiving, so remember that the actual results of the Sculptra procedure -- your own body's production of natural collagen -- will take a full two months to materialize.
"Patients love the way they look immediately -- all swollen up," Constantinides says. "But it's important to realize that the five cc's of volume we're putting into each side doesn't translate to five cc's of actual volume of collagen response. It's more like two cc's -- about half of what patients see at the end of their session. But that's a nice base."
Within days, all the water in the Sculptra mixture is absorbed by your body -- and so all that swell swelling disappears. What a letdown that can be!
"Here you are, having spent a fair amount of money and gone through an uncomfortable procedure," Constantinides says, "and a week later you're back where you started. Just about every patient goes through it."
But face-filling with Sculptra is an object lesson in patience. Over the next month, your body will do its part by creating collagen in response to the many tiny particles of Sculptra, which act as irritants.
By week six, you should see 80 percent to 90 percent of the finished product. "You will feel it before you see it -- the tissues will feel fuller and more firm when you touch your face," Constantinides says.
And then it's time for more needles! "Typically, even with mild lipoatrophy, a patient needs at least two cycles of treatment, four vials altogether, eight weeks apart," Constantinides says. More severe cases require more treatments, with four sessions not atypical. "So it's a long process of gradual filling, but it is reliable. I have not had an unhappy Sculptra patient yet."
Why do you need touch-ups? As long as the Sculptra remains as an irritant, your body will be constantly depositing and absorbing and redepositing collagen. In fact, according to Constantinides, the studies the FDA reviewed before approving Sculptra showed that the volume of collagen continued to increase even two years after the procedures. But eventually the last of the Sculptra dissolves -- and so goes the collagen.
The total cost? With each vial of Sculptra costing about $500, a four-vial mild case of lipo will set you back $2,000 plus the plastic-surgeon price tag. But the effect lasts for two to three years, and as Constantinides says, "Most patients probably spend more on their hair than they do on Sculptra."
Unfortunately, trying to get your insurance company to cover Sculptra (or the other approved treatment for lipoatrophy, called Radiesse) can be hair-pull-out frustrating (see our article on "Health Insurance Tips") and even with a helpful doctor, you still may fail. Dermik Laboratories, the maker of Sculptra, has a patient assistance program that enables people who earn $40,000 or less a year to get their hands on those precious little vials at much-reduced rates. (BioForm Medical sponsors a similar program for people who can't afford Radiesse.) "It's a wonderful thing the company's doing," Constantinides says about the Sculptra program. "And every doctor who has had Sculptra training can supply the appropriate forms to their patients." So don't be shy about asking for a hand to save face.
America boasts an embarrassing number of board-certified plastic surgeons, but few with experience treating HIVers with lipo. The trick is finding a pro who will give you back your own face, not some cookie-cutter mug, so a doctor with a sculptor's caring eye is key.
If you're going the Sculptra route, Dermik Laboratories can steer you straight. Its Web site features a 411 on Sculptra, including a handy health care provider index -- just type in your zip code for a map with the offices of local docs. And since these folks are HIVer-friendly, they may also be versed in other face-filler procedures -- or at least be a useful place to start. BioForm Medical's Web site for Radiesse provides before and after photos of people who have had Radiesse injections and a "find a doctor" feature which can help you locate a doctor in your area with experience using Radiesse.
If you want to talk to other HIVers about their Sculptra experience -- or about Bio-Alcamid (poly-Alkyl-Imide), Silikon 1000 (polydimethylsiloxane) or other experimental products -- check out PWA activist Nelson Vergel's e-mail list, which offers an archive of practical advice from people who have been there, done that.
Want to try to convince your insurance company to cover your facial wasting fix? Here's a letter (in PDF format) that Nelson Vergel wrote with the help of Dr. Doug Mest that you can send to your health insurance company.
Get your questions answered at The Body's Ask the Experts forum on facial wasting!
Talk to others about lipoatrophy at The Body's Community Center.