Technique of net-crossed retrograde injections showing the direction of the injections in the subcutaneous layer. 

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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 ...