- Fat wasting, also known as lipoatrophy -- In this form fat is lost from particular areas of the body:
- face (sunken cheeks, temples, and eyes)
- arms and legs (veins may become more visible; this is called "roping")
- Fat accumulation, also known as lipohypertrophy -- In this form, fat builds up in particular parts of the body :
- back of the neck and upper shoulders (often described as "buffalo hump")
- abdomen (also called "protease paunch" or "Crixivan potbelly") This abdominal fat gained is underneath the muscle wall (visceral fat) and feels firm to the touch.
- breasts (in both men and women)
- lipomas (fatty growths in different parts of the body)
- The third type is known as hyperlipidemia or dyslipidemia. It has been linked to higher rates of heart disease and diabetes-like symptoms. Before the availability and use of anti-HIV drugs, HIV disease progression was associated with decreases in cholesterol levels, particularly "good" cholesterol. An increase in this blood fat is uniquely associated with using certain anti-HIV drugs.
From the plastic surgeons viewpoint, these patients present wanting to regain a more "normal" face/body.
- Diet and Exercise--Diet and exercise are essential to maintaining muscle mass and lean body mass, but will do nothing to address the substantial atrophy of the face or remove the "buffalo hump".
- Anabolic Steroids hormones, the synthetic derivatives of testosterone, are thought to prevent catabolism and help preserve lean body mass. At this time, the only approved indications for these drugs are anemia, hereditary angioedema, and metastatic breast cancer, so their use in HIV-related wasting or lipodystrophy is considered “off-label.” Many products are currently available, including nandrolone and oxymetholone. Inherent in the use of anabolic steroids are the risks of hypertension, which may be treated with antihypertensive medications, and liver toxicity. Liver function tests should be monitored closely.
- Growth Hormone is a naturally occurring product of the anterior pituitary. Growth hormone directly causes lipolysis of adipocytes and has indirect anabolic effects by the action of insulin-like growth factor I. Baseline growth hormone concentrations were found to be decreased in patients with lipodystrophy when compared with concentrations in unaffected HIV patients. There are reports by Torres et al. and Wanke et al. using recombinant growth hormone in HIV patients with truncal obesity and buffalo hump. Improvements in visceral adipose tissue and buffalo hump were noted in all patients. In addition, Torres et al. found that those patients who discontinued treatment experienced a recurrence of their dystrophic fat. Adverse effects of growth hormone included arthralgias, myalgias, carpal tunnel syndrome, and impaired glucose tolerance and hyperglycemia. Although growth hormone therapy is probably the safest and easiest way of increasing lean body mass, its utility is limited because it is prohibitively expensive for these patients, who are already taking a multidrug regimen presumably for the rest of their lives.
- Metformin is an oral hypoglycemic used in the treatment of type II diabetes. Metformin decreases gluconeogenesis, improves insulin sensitivity, and decreases intestinal absorption of glucose. HIV patients treated with metformin have been shown to have significant decreases in weight and waist circumference, along with greater decreases in visceral adiposity. Although metformin may have minimal effects on HIV lipodystrophy–associated body composition, no study to date has mentioned the effects of metformin on buffalo hump, and it has no effect on the lipoatrophy aspects of the syndrome. Metformin is generally well tolerated in this population. However, lactic acidosis is a persistent and
serious risk and there has been one fatal case reported in a man being treated with a nucleoside reverse transcriptase inhibitor and metformin.
- Experimental Medications -- Several newer medications have been investigated in the treatment of HIV-associated lipodystrophy. Studies of the thiazolidinediones, a class of drugs that decrease insulin resistance and gluconeogenesis, have reported conflicting results. Ultimately, no drug therapy exists to fully ameliorate or correct the cosmetic changes of HIVassociated lipodystrophy. Studies of human growth hormone, however, have produced the most substantial results. If it is cost effective, human growth hormone may be the pharmacologic treatment of choice for certain patients with HIV lipodystrophy.
Three problems that can be treated with reconstructive surgery are the abnormal areas of fat deposition in the cervicodorsal fat pad (buffalo hump), gynecomastia, and facial wasting. The options include
- suction-assisted lipectomy for anatomic areas that show abnormal fat deposition
- injection of natural substances, such as collagen, as well as synthetic substances, such as New-Fill (Ashford Aesthetics, Inc., Belgium, Germany) and Sculptra (Aventis Pharmaceuticals, Bridgewater, N.J.), to treat facial wasting;
- surgical injection of autogenous fat
- a combination of lipoaspiration of the buffalo hump and use of the aspirate as a donor graft
- fat/dermal grafting
- alternative tissue grafting, using material from donor sites with concurrent deformities, such as gynecomastia tissue and cystic parotid gland.
Autologous Free Fat
Lipodystrophy and Women--March 2005 Article at TheBody.com
Update on Lipodystrophy...Or Is It Just Lipoatrophy? by Donald P. Kotler, MD -- MedScape Article, 2002
Lipodystrophy, Generalized by Robert A Gabbay, MD & others --eMedicine Article, July 17, 2007
Lipodystrophy, HIV by Ali Hendi, MD & others -- eMedicine Article, January 18, 2006
Lipodystrophy -- DermNet NZ, updated 12-25-2007
Surgical Algorithm for Management of HIV Lipodystrophy; Plastic & Reconstructive Surgery, Vol 120(7):1843-1858, December 2007; Davison, Steven P. M.D., D.D.S.; Timpone, Joseph Jr M.D.; Hannan, Catherine M. M.D.
Cosmetic Interventions for HIV-Associated Lipoatrophy by Graeme J. Moyle, MD, MBBS -- MedScape Article