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Progression of lipodystrophy syndrome is a big challenge in HIV treatment. Nowadays, fat loss at the lower part of buttocks has become another problem as patients have started to complain that it is painful to be seated for a long time and/or on hard surfaces. We developed a method for buttock lipoatrophy treatment with PMMA-microspheres, as silico...
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... therapy (ART) has completely changed the history of HIV, decreasing dramatically its morbid- ity and mortality. However, long-term use of ART leads to a fat redistribution syndrome, with peripheral fat loss and central adiposity, and metabolic abnorm- alities called, generally, lipodystrophy. 1 Of all the body changes, facial lipoatrophy is still the unaesthetic con- dition related to lipodystrophy that patients complain the most. We have been using PMMA-microspheres, a permanent filler, to treat facial lipoatrophy, for more than 10 years in Brazil. 2–4 This treatment is also offered by the Brazilian government through its public health system. 5–7 Nowadays, with aging and lipodystrophy progression, lipoatrophy of the buttock is becoming an additional problem. Fat loss on perianal area and lower part of the buttock severely affects patients’ quality of life, as it becomes painful, and sometimes impos- sible, to be seated for a long time and/or on hard surfaces ( Figure 1). Treatment options were autologous fat transplant or hard silicone implants, but not all patients have enough fat donor area and silicone implants have to be placed highly, at the area of the gluteus maximus, not helping the patients in their sitting problem. 8 In order to minimise buttock lipoatrophy, we develop a method to use PMMA-microspheres in these patients and we have been using it successfully for the last six years. The purpose of this study was to investigate the effect of the treatment of buttock lipoatrophy with PMMA-microspheres, its possible complications and the patient satisfaction with this therapy. All the procedures were performed by two of the authors (MSS and LZG) together. Areas to be treated were marked with the patient in an upright position, and then secondary markings for anaesthesia buttons were made (Figure 2). An anaesthetic solution of 0.2 cc of 2% lidocaine, with epinephrine, was diluted half and half with saline solution, limited to 12 ml of lidocaine diluted in 12 ml of saline solution. It was injected on each anaesthesia-marked button. Buttock lipoatrophy was treated with a 30% colloidal solution of PMMA in a vehicle containing carboxymethylcellulose. Its brand name is Metacrill Õ ; it is produced by the company Nutricell (Rio de Janeiro, Brazil) and it is certified internationally by good practices. This treatment consisted of net-crossed retrograde injections in the subcutaneous layer, starting from the perianal area to the lateral part of the hips and then towards the sacral area (Figure 3). Depending on patient ART combination, non-steroids anti-inflammatory and antibiotics, mostly azithromycin, were prescribed after the procedure for three to five days. Patients were advised to avoid sitting on the day of the surgery and avoid resistance exercises for seven days. Patients were photographed before and after treatment. New sessions were performed with a minimum of three months interval, and patients were questioned about improvement to seat. This study was approved by the Ethics Committee of the University Hospital of the Federal University of Rio de Janeiro and a written informed consent was obtained from all the treated patients. One hundred and fifty-four patients were included (145 men and 9 women) with a minimum follow-up of six months and maximum of 78 months. Median age was 48.9 years old (34–69). Minimum amount of PMMA- microspheres used in one session was 40 cc and maximum was 120 cc, with an average of 60 cc per session. The total maximum amount of PMMA-microspheres used in one patient was 938 cc, divided in 11 sessions, with a minimum of one and a maximum of 11, average being three sessions (Figure 4). The amount of PMMA- microspheres used to treat buttock lipoatrophy depended on the degree of atrophy and size of the area to be treated (Figure 5). The number of sessions and the amount of PMMA- microspheres used had two other factors that influ- enced both: patient satisfaction and financial issues. We just observed immediate side effects consisted of mild to moderate pain on the treatment day and bruis- ing on treated areas that disappeared in three to 10 days (Figure 6). No infection or immune granuloma was observed. Most of the patients (93%) were satisfied with the treatment and referred more comfort when seated and referred that they started to be able to be seated for longer periods of time. Pain due to fat loss on the buttock is the second major complaint for patients with lipodystrophy. One of our first recommendations, when we began treating these patients, was to prescribe weight resistance exercise for hypertrophy of the buttock muscles, but we realised that it would not be enough to compensate the absence of fat, especially around the perianal area (Figure 7). Fat transplant could be an option for buttock treatment but usually patients do not have a donor area or when they have there is not enough fat to fulfil the whole area that needs to be treated (Figure 8). Another option would be hard silicone prostheses, 8 but in order to place the prosthesis there is a necessity to surgically create a pocket in the middle of gluteus muscles, and these intramuscular implants have to be placed between upper buttock muscles 9 and not on perianal area and lower part of the buttock (Figure 9), main areas that we treat with PMMA. So the silicone prostheses would not help the patients’ main complaint as it is not possible to sit on them. Another problem with the prosthesis technique is that poor implant placement can result in complications as asymmetry, implant migration, capsu- lar contracture, infection and seroma. 8,9 Additional dis- advantage of fat transplant and silicone implants is that they need to be performed in a sterile surgical environ- ment compared with PMMA injections that can be done in an ambulatory as we do for facial fillers. The number of sessions and treatment costs are the negative points of PMMA implants, being potential limitations for the regular use of this treatment in HIV/AIDS patients with buttock lipoatrophy, especially when we need to enhance buttock volume. This present study was the major scientific support which helped to change the Brazilian government law and the guidelines to treat buttock lipoatrophy in HIV/ AIDS patients that nowadays includes PMMA injections in the perianal area plus silicone hard implants, but just for patients who do not have enough fat to transplant into this area. Maybe in the future this combination of silicone hard implants with PMMA treatment could be considered the gold standard treatment for these patients, minimising costs and number of sessions. Although we still do not know the ideal number of sessions and amount of PMMA-microspheres to be used for each patient, we have been observing that 120 cc to 140 cc of PMMA-microspheres, divided in two or three sessions, provide good and satisfactory results (Figure 10(a) to (d)), and can be used to enhance buttock volume and help to create a better shape (Figure 11(a) and (b)); but fundamentally, this technique contributes or directly improves the quality of life, the pain and the self-esteem of these patients. We consider that soft tissue augmentation with PMMA is a reproducible technique and, with the recent scientific and technological knowledge, PMMA is one of the few materials that is safe to be used in the perianal area. Although long-term observations and results need to be achieved, PMMA implants are a good therapy option for buttock lipoatrophy due to HIV ...
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Introduction: Human immunodeficiency virus (HIV)-associated lipodystrophy syndrome (LS) is defined as a redistribution of adipose tissue, metabolic and endocrine abnormalities, resulting from combined antiretroviral therapy (cART). Aim of this study was to evaluate LS in HIV-infected patients from Lower Silesia, Poland.
Material and methods: One hu...
Citations
... The results obtained in the filling of wrinkles and depressions in lipodystrophy resulting from the use of antiretroviral drugs in HIV confirm the safety and efficacy of the use of PMMA microspheres in the subcutaneous plane [11,12]. ...
Introduction: Polymethylmethacrylate (PMMA) is a synthetic, inert, biocompatible and nontoxic polymer, the applications in the medical field are numerous, and indications are increasingly broad. Objectives: To evaluate whether the fibrous response to injection of PMMA microspheres into striated muscles confers increased volume and resistance to muscle stretch. Methods: A total of 20 Wistar rats were injected with, 30% PMMA gel into the right rectus abdominis muscle, while the left rectus muscle received SHAM injections. After 4 weeks, all abdominal rectus muscles were measured and stretched on a bench dynamometer until rupture. The samples were analyzed histologically to verify the tissue response to PMMA. Results: The right rectus abdominis muscles of rats that received PMMA gel injection had increased volume and the breaking strength was greater than 100% compared to the left rectus muscles that received SHAM injections. There was a significant deposition of type I and III collagen fibers around the PMMA injection sites. Conclusion: PMMA microspheres implanted into the rectus abdominis muscle of Wistar rats promote neocollagenesis and significantly increase the breaking strength when subjected to stretch test. The mild and desired foreign body type tissue reaction around the PMMA is not objection to the augmentation of the rectus abdominis muscle.
... 53,54 LD can be classified into primary (idiopathic or familial) versus secondary depending on the underlying etiology (HIV, panniculitis, autoimmune, medication, trauma), or general versus partial depending on the extent of involvement. [55][56][57] More than 70% of patients with LD suffer from chronic pain, most commonly neuropathic pain, followed by arthralgia and muscle pain amongst others. Peripheral sensory-motor neuropathy is found in more than 60% of patients with LD and diabetes. ...
Description Adipose tissue (AT) has diverse and important functions in body insulation, mechanical protection, energy metabolism and the endocrine system. Despite its relative abundance in the human body, the clinical significance of AT in musculoskeletal (MSK) medicine, particularly its role in painful MSK conditions, is under-recognized. Pain associated with AT can be divided into intrinsic (AT as a primary pain generator), extrinsic (AT as a secondary pain generator) or mixed origin. Understanding AT as an MSK pain generator, both by mechanism and its specific role in pain generation by body region, enhances the clinical decision-making process and guides therapeutic strategies in patients with AT-related MSK disorders. This article reviews the existing literature of AT in the context of pain generation in the lower back and lower extremity to increase clinician awareness and stimulate further investigation into AT in MSK medicine.
... One of the options for facial filling is polymethylmethacrylate. (PMMA), also botulinum toxin (Botox®) and hyaluronic acid [1,[25][26][27][28][29]. ...
... Generally, we use 40-60 ml per session, but a maximum amount of 120 ml has been used. Subcutaneous retroinjections, using the "in network" technique, should be performed in all areas, with a 3-month interval between sessions (Serra et al. 2015). ...
... For both regions, most patients Fig. 4 (a, b) Visible and palpable nodules required two to three sessions to achieve good results. This is in contrast with our experience, in which the largest amount we used to treat buttock lipoatrophy in a HIV-patient was 938 ml in total, divided into 11 sessions (Fig. 8) (Serra et al. 2015). ...
... The mean mental health score on the Medical Outcomes Study-HIV questionnaire increased significantly from baseline to 9 months. Scores were not significantly different from baseline at One observational study of 156 patients who received PMMA fillers for lipoatrophy of the buttocks found that most of the patients (93%) were satisfied with the treatment and reported more comfort when seated and that they had been able to be seated for longer periods of time (Serra et al., 2015). ...
Non-partisan analysis of the medical effectiveness, cost and utilization, and public health impacts of insurance coverage for HIV Associated Lipodystrophy
... Generally, we use 40-60 ml per session, but a maximum amount of 120 ml has been used. Subcutaneous retroinjections, using the "in network" technique, should be performed in all areas, with a 3-month interval between sessions (Serra et al. 2015). ...
... For both regions, most patients Fig. 4 (a, b) Visible and palpable nodules required two to three sessions to achieve good results. This is in contrast with our experience, in which the largest amount we used to treat buttock lipoatrophy in a HIV-patient was 938 ml in total, divided into 11 sessions (Fig. 8) (Serra et al. 2015). ...
Permanent fillers are mainly used in the correction of furrows and deep depressions of the skin that are beyond the normal facial wrinkles that appear with aging. They can be an excellent option in facial rejuvenation, especially when there is need for facial and body volume restoration, such as in HIV lipodystrophy. Of the permanent fillers currently available, polymethyl methacrylate (PMMA) is the most commonly used, and has been shown to be safe, effective, and long lasting.
... Similar fillers have been used as "volumizing agents" in Europe and the United States for facial augmentation 21,22 and in Brazil for muscle augmentation since 1998. 23,24 The purpose of this study is to report the safety and efficacy of PMMA microspheres suspended in carboxymethyl-cellulose (Metacrill, Nutricel, Guapimirim, Rio de Janeiro, Brazil) for cosmetic or corrective girth enhancement of the penile shaft. ...
Introduction:
An unknown percentage of men will take every risk to develop a larger penis. Thus far, most injectables have caused serious problems. Polymethylmethacrylate (PMMA) microspheres have been injected as a wrinkle filler and volumizer with increasing safety since 1989.
Aim:
To report on a safe and permanently effective method to enhance penile girth and length with an approved dermal filler (ie, PMMA).
Methods:
Since 2007, the senior author has performed penile augmentation in 752 men mainly with Metacrill, a suspension of PMMA microspheres in carboxymethyl-cellulose.
Main outcome measures:
The data of 729 patients and 203 completed questionnaires were evaluated statistically.
Results:
The overall satisfaction rate was 8.7 on a scale of 1 to 10. After one to three injection sessions, average girth increased by 3.5 cm, or 134% (10.2 to 13.7 cm = 134.31%). Penile length also increased by weight and stretching force of the implant from an average of 9.8 to 10.5 cm. Approximately half the patients perceived some irregularities of the implant, which caused no problems. Complications occurred in 0.4%, when PMMA nodules had to be surgically removed in three of the 24% of patients who had a non-circumcised penis.
Conclusion:
After 5 years of development, penile augmentation with PMMA microspheres appears to be a natural, safe, and permanently effective method. The only complication of nodule formation and other irregularities can be overcome by an improved injection technique and better postimplantation care.
Background
Volume restoration and enhancement of the gluteal region appearance has become nowadays a popular concern in particular for many women. Several options are available, none however are without complications and side effects. Volume enhancement with soft tissue fillers of the gluteal region is emerging as a highly attractive minimally invasive modality. It has led unfortunately to more unlicensed, nonmedical practitioners administering illicitly injections for buttock augmentation at relatively low costs.
Materials and Methods
To determine safety, efficacy, and cost effectiveness of mostly used soft-tissue fillers for buttock augmentation, a systematic literature search of PubMed, Medline, and Embase was conducted to identify the mostly used fillers for gluteal augmentation. It was complemented by searching for each of the identified filler material separately to retrieve any missed reports. References of clinical studies and trials, reviews, and consensus reports were reviewed as well for the same objective.ResultsIn the final analysis 12, mostly strongly biased clinical reports providing a low level of evidence, were identified for inclusion in the review. Two studies involved Polymethylmethacrylate (PMMA), 5 Poly-L-lactic acid, 1 Calcium hydroxyapatite and 4 hyaluronic acid filler injection. No studies were identified involving liquid silicone or Polyacrylamide hydrogel. The little available evidence provided by this review indicates that a specific brand of PMMA in Brazil has a demonstrable relatively good safety, efficiency, and cost-effectiveness record superior to surgical alloplastic gluteal augmentation or to lipofilling only when injected by experts.Conclusion
Gluteal augmentation with soft tissue fillers is not as simple and innocuous as advertised. Serious complications may occur. Moreover, optimal buttock contouring entails not only volume augmentation but also volume removal; thus, volume augmentation with soft tissue fillers may not be ideal. Popularizing this modality must also be approached with great care. Serious complications do occur; they become inevitable when performed illegally by non-specialized, non-authorized, and unscrupulous practitioners in non-accredited facilities. Patients must be warned that adherence to regulations is critical and that only well-trained certified experts practicing legally in accredited facilities can address safely and efficiently their concerns.Level of Evidence IIIThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
With the introduction of effective antiretroviral therapy for the treatment of human immunodeficiency virus infection in 1996, there has been a surge of patients with body contour abnormalities that present with central fat accumulation and peripheral fat loss. Fortunately, there are many surgical approaches to help patients with these deformities. Loss of volume and projection, hip narrowing, widening of the intergluteal cleft, persistent dermatitis and ulcers characterize the gluteal deformities seen in these patients. A classification of gluteal lipoatrophy is presented in this chapter in order to adequately manage these patients. Silicone implants, autologous fat grafting and polymethyl methacrylate injections are among the most common procedures performed for these patients. There are several benefits for treating HIV-associated lipodystrophy beyond pure aesthetics. Changes in body morphology can be associated with psychological stress that can affect patients’ self-esteem and adherence to the medications. Therefore, plastic surgery procedures are highly indicated for patients presenting lipodystrophy caused by antiretroviral therapy.