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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 silicone prostheses and autologous fat transplant were not completely efficient. The treatment consisted of net-crossed injections, in the subcutaneous layer, of a 30% PMMA-microspheres solution on the atrophic areas of the buttock. One hundred and fifty-four patients were included. The amount of PMMA-microspheres used to treat buttock lipoatrophy depended on the degree of atrophy and size of the area to be treated. Patients were satisfied with this treatment and reported to be more comfortable to be seated for longer period of time. We demonstrated that soft tissue augmentation with PMMA-microspheres is safe and efficient for the treatment of buttock lipoatrophy associated with HIV lipodystrophy.
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International Journal of STD & AIDS
http://std.sagepub.com/content/early/2014/05/21/0956462414536878
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DOI: 10.1177/0956462414536878
published online 22 May 2014Int J STD AIDS
Marcio Soares Serra, Leonardo Zacharias Gonçalves and Marcia Ramos-e-Silva
lipodystrophy
Soft tissue augmentation with PMMA-microspheres for the treatment of HIV-associated buttock
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Original research article
Soft tissue augmentation with
PMMA-microspheres for the treatment
of HIV-associated buttock lipodystrophy
Marcio Soares Serra
1,2,3
, Leonardo Zacharias Gonc¸alves
1
and
Marcia Ramos-e-Silva
3
Summary
Background: 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 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 silicone prostheses and autologous fat transplant were not completely efficient.
Methods: The treatment consisted of net-crossed injections, in the subcutaneous layer, of a 30% PMMA-microspheres
solution on the atrophic areas of the buttock.
Results: One hundred and fifty-four patients were included. The amount of PMMA-microspheres used to treat buttock
lipoatrophy depended on the degree of atrophy and size of the area to be treated. Patients were satisfied with this
treatment and referred to be more comfortable to be seated for longer period of time.
Conclusion: We demonstrated that soft tissue augmentation with PMMA-microspheres is safe and efficient for the
treatment of buttock lipoatrophy associated with HIV lipodystrophy.
Keywords
Polymethyl methacrylate, HIV-associated lipodystrophy syndrome, lipodystrophy, buttocks
Date received: 21 August 2013; accepted: 26 March 2014
Introduction
Antiretroviral 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’ qual-
ity 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
1
Clinica Marcio Serra, Rio de Janeiro, Brazil
2
Sector of Dermatology – Gaffre
`e & Guinle University Hospital and
School of Medicine, Federal University of State of Rio de Janeiro
(UNIRIO), Rio de Janeiro, Brazil
3
Sector of Dermatology, Clementino Fraga Filho University Hospital and
School of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de
Janeiro, Brazil
Corresponding author:
Marcio Soares Serra, Sector of Dermatology, Clementino Fraga Filho
University Hospital and School of Medicine, Federal University of Rio de
Janeiro (UFRJ), Av. Nossa Senhora de Copacabana 540/1002, Rio de
Janeiro 22020-001, Brazil.
Email: mserra@terra.com.br
International Journal of STD & AIDS
0(0) 1–6
!The Author(s) 2014
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DOI: 10.1177/0956462414536878
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Int J STD AIDS OnlineFirst, published on May 22, 2014 as doi:10.1177/0956462414536878
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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.
Materials and methods
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 MetacrillÕ; it is produced by the company
Nutricell (Rio de Janeiro, Brazil) and it is certified
internationally by good practices. This treatment con-
sisted of net-crossed retrograde injections in the sub-
cutaneous 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.
Results
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
Figure 1. Female patient, 34 year old, with severe buttock
lipoatrophy.
Figure 2. Marked in blue area to be treated; black circles –
anaesthetic buttons.
Figure 3. Technique of net-crossed retrograde injections
showing the direction of the injections in the subcutaneous layer.
2International Journal of STD & AIDS 0(0)
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48.9 years old (34–69). Minimum amount of PMMA-
microspheres used in one session was 40 cc and max-
imum 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.
Discussion
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 treat-
ment 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
Figure 5. Severe buttock lipoatrophy treated with 650 cc of PMMA (a) before and (b) after 11 sessions.
Figure 4. Buttock lipoatrophy treated with 938 cc of PMMA (a) before and (b) after 11 sessions.
Figure 6. Bruising three days after the procedure.
Serra et al. 3
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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, espe-
cially 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 injec-
tions 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 com-
bination of silicone hard implants with PMMA treat-
ment could be considered the gold standard treatment
for these patients, minimising costs and number of ses-
sions. 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 tech-
nique contributes or directly improves the quality of
life, the pain and the self-esteem of these patients.
Conclusion
We consider that soft tissue augmentation with PMMA
is a reproducible technique and, with the recent
Figure 7. Lipoatrophy in the perianal area in a patient with
hypertrophic muscles.
Figure 8. Patient after autologous fat transplant: not enough fat
to fill the whole area.
Figure 9. Patient after silicone prostheses implants: lower butt
still atrophic and anus exposed.
4International Journal of STD & AIDS 0(0)
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scientific and technological knowledge, PMMA is one
of the few materials that is safe to be used in the peri-
anal area. Although long-term observations and results
need to be achieved, PMMA implants are a good ther-
apy option for buttock lipoatrophy due to HIV
lipodystrophy.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors
Conflict of interest
The authors declare no conflict of interest
Figure 11. Female patient with improvement of the hips and buttock shapes (a) before and (b) after three sessions of PMMA.
Figure 10. Patient before and after three sessions, with a total of 130 cc of PMMA (a and b) before and (c and d) after.
Serra et al. 5
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References
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ciated lipodystrophy: from fat injury to premature aging.
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2. Serra M, Gonc¸ alves LZ and Gontijo SG. Treatment of
HIV-related facial and body lipodystrophy with poly-
methylmethacrylate (PMMA): 10 years experience. In:
10th International Workshop on Adverse Drug Reactions
and Lipodystrophy in HIV, London, UK, November 2008
[Abstract P-72]. Antivir Ther 13(suppl 4): A75.
3. Carvalho Costa IM, Salaro CP and Costa MC.
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sonal experience in Brazil for more than 9 years.
Dermatol Surg 2009; 35: 1221–1227.
4. Serra MS, Oyafuso LK, Trope BM, et al. An index for
staging facial lipoatrophy and evaluation of the efficacy of
the treatment with polymethylmethacrylate in HIV/AIDS
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5. Abreu K, Ferreira C, Serra M, et al. Brazilian politics on
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and Lipodystrophy in HIV, London, UK, November 2008
[Abstract P-79]. Antivir Ther 13(suppl 4): A82.
6. Soares FMG and Costa IMC. Lipoatrofia associada ao
HIV/Aids: do advent aos conhecimentos atuais. An Bras
Deramatol 2011; 86: 843–864.
7. Orsi AT, Miranda AE, Souza AC, et al. Lipoatrophy in
patients with AIDS: treatment with polymethylmethacry-
late in Amazonas, Brazil. Int J Dermatol 2011; 50:
1255–1258.
8. Benito-Ruiz J, Fontdevila J, Manzano M, et al. Hip and
buttock implants to enhance the feminine contour for
patients with HIV. Aesth Plast Surg 2006; 30: 98–103.
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solid silicone implants. Aesth Plast Surg 2009; 33: 140–146.
6International Journal of STD & AIDS 0(0)
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... 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). ...
... 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. ...
... One of the options for facial filling is polymethylmethacrylate. (PMMA), also botulinum toxin (Botox®) and hyaluronic acid [1,[25][26][27][28][29]. ...
... 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). ...
Technical Report
Full-text available
Non-partisan analysis of the medical effectiveness, cost and utilization, and public health impacts of insurance coverage for HIV Associated Lipodystrophy
Article
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.
Chapter
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.
Chapter
Polymethyl methacrylate (PMMA) is a permanent filler used to correct furrows and deep depressions of the body and also for volume replacement. Among all permanent fillers available in the market, PMMA is the most regularly used. PMMA is demonstrated to be safe, effective, and long lasting with few adverse reactions when indicated correctly.
Chapter
In 2015, over 2.4 million patients had treatments with soft tissue fillers, with the largest population between 40 and 54 years of age and ranging in age from teenagers to nonagenarians (ASPS, Plastic Surgery Statistics Report 2015, 2015) (4). This data is also representative of the patient population seeking treatment with temporary fillers of the trunk and extremities where the average age is around 60 years, with females significantly outweighing males. All skin types are represented in this demographic, but skin types II–IV are far more common than V–VI.
Article
Full-text available
Background Treatment of facial lipoatrophy of HIV/AIDS patients is mandatory by law in Brazil due to its negative impact on their quality of life. The index for facial lipoatrophy (ILA) is used as one of the inclusion criteria for patient treatment. Objectives To define a correct diagnosis and staging of facial lipoatrophy, by employing the ILA. Patients and methods This is an observational study of a series of case reports from patients submitted to facial lipoatrophy evaluation through ILA and treated with polymethylmethacrylate (PMMA) fillers. Facial lipoatrophy was classified in grades from I to IV, corresponding to mild, moderate, severe and very severe stage, according to ILA. Response to the treatment was defined as excellent (≥91%), good (71–90%), moderate (51–70%) and insufficient (≤50%). Results A total of 20 patients were included in this study: 18 men and two women. Median age was 49 years (35–61) and average ILA was 9.9 (7.2–16.8). Ten patients presented facial lipoatrophy grade II (moderate), 5 grade III (severe) and 5 grade IV (very severe). The average volume of PMMA used was 13 mL (5.5–22 mL). All patients showed good or excellent response, with a median of 86% (74–100%). The most typical adverse effect was local oedema but there were no late adverse effects. Conclusion The ILA is an excellent method for evaluation of facial lipoatrophy and also for the assessment of the response to therapy. Facial filling with PMMA showed efficacy and safety in the treatment of facial lipoatrophy in HIV/AIDS patients.
Article
Full-text available
The advent of AIDS has brought new challenges to Dermatology. Antiretroviral therapy dramatically changed the morbidity and mortality associated with HIV / AIDS, but contributed to the emergence of other new situations that require adequate approach by the dermatologist. The HIV / AIDS Associated Lipodystrophy Syndrome is multifactorial in origin, but it is strongly associated with the use of antiretroviral drugs. It includes changes in body fat distribution, with or without metabolic changes. The loss of facial fat, called facial lipoatrophy, is one of the most stigmatizing signs of the syndrome. This condition, often revealing of the disease, brought back the stigma of AIDS. It is necessary that the specialists working with patients with HIV / AIDS identify these changes and seek treatment options, amongst which stands out the implant with polymethylmethacrylate, which is available for the treatment of HIV / AIDS facial lipoatrophy in the Brazilian Public Health System.
Article
Full-text available
The antiretroviral therapy for patients with human immunodeficiency virus (HIV) causes lipodystrophy, or a change in the distribution of body. Treatment for the facial changes is well addressed and covered in the recent literature, but female patients also report changes in their buttocks and lower limbs. There is no treatment for the lower limb deformity, but plastic surgeons can do something for the buttock. The authors propose a classification for the deformities of these patients and a new solution to improve the contour of this area and to reduce the social impact of deformity on women with HIV. This consists of placing two silicone implants, in the buttock and on the hip, to give a rounder appearance. The authors think that hip implants may be indicated also for gender reassignment surgery and for women with masculine features.
Article
The use of antiretroviral therapy (ART) in AIDS has been associated with lipodystrophic syndrome, which is characterized by metabolic alterations and abnormal corporal fat distribution. Our goal was to describe and evaluate the use of polymethylmethacrylate (PMMA) to treat lipoatrophy in patients with AIDS from Amazonas, Brazil. Patients with AIDS undergoing ART and presenting with facial lipoatrophy were invited to participate in the study. A face-to-face interview was conducted, and patients were treated with applications of PMMA 30%. A total of 49 cases were included. The mean age was 45 (SD 6.1) years old, and the mean educational level (measured in schooling years) was 10.5 (SD 3.2) years of schooling. The median of CD4 cell count was 482.5 (interquartile range: 338-574.5) cells/mm(3) . Stavudine and zidovudine were the most frequently prescribed ART drugs. The total number of PMMA injections ranged from one to five times, and side effects were not frequent. A total of 42 (85.7%) patients reported satisfaction after a follow-up of more than 12 months, presenting good fullness of the deformity. Our data showed that patients with AIDS with lipoatrophy related to ART could safely benefit from PMMA-based treatment.
Article
Combination antiretroviral therapy (cART) against HIV infection dramatically reduces AIDS-related morbidity. However, many patients under cART display HIV-associated lipodystrophy. Moreover, some develop early age-related comorbidities. Thymidine analog reverse transcriptase inhibitors (tRNTIs) are mainly responsible for peripheral lipoatrophy, and protease inhibitors (PIs) for fat hypertrophy and metabolic complications. Long-term HIV infection probably also causes fat alterations. Severe mitochondrial toxicity and oxidative stress cause lipoatrophy, whereas the hypertrophy of upper body fat depots could result from mild oxidative stress, cortisol activation and inflammation. The metabolic complications associated with lipodystrophy are responsible for increased cardiovascular and hepatic risks and could also participate in premature aging. We propose that adipose tissue injury by HIV and cART induces fat hypertrophy or atrophy and contributes to premature aging.
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Synthetic permanent fillers for soft-tissue augmentation have acquired an important role in cosmetic improvement of patients with facial aging, facial atrophic scars, or lipoatrophy leading to facial defects. Polymethylmethacrylate (PMMA) is a filler introduced to the market as one option for long-lasting treatment. PMMA microspheres are purified, and the particles are larger than 20 microm. The product used as a filler has proven to be safe, effective, and long lasting. To determine the efficacy and safety of PMMA as a facial filler. Two hundred sixty-six patients (aged 17-72; 154 women) received injections of PMMA to correct facial defects. The number of sessions ranged from one to four, with an interval of 40 to 60 days between applications. Seventy-nine subjects (30%) had facial atrophy related to HIV infection, 159 (60%) had photoaging signs with deep wrinkles and atrophic areas, 25 (9%) had depressive scars from acne process, and three (1%) had residual depressions from lupus profundus. The results were satisfactory and long lasting. Side effects were transient. No late complications were observed. PMMA used for the treatment of atrophy, depressions, and facial wrinkles has been shown to be effective, long lasting, safe, and gratifying to patients and physicians.
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Body-contouring implants are becoming increasingly popular and more accepted and requested for aesthetic purposes. These implants must be placed in a safe and reproducible plane of anatomic dissection for a successful long-term outcome. Poor implant placement techniques result in greater complications such as asymmetry, implant migration, capsular contracture, and infection. This article discusses (1) the history and the evolution of body-contouring implants, (2) the different techniques and dissection planes in which to put the implants in the calf, gluteal, pectoral, and triceps/biceps areas, and (3) the complications associated with the different implantation techniques. The different anatomical areas that have been treated with solid silicone implants are the gluteus, pectoral, calf, deltoids, biceps, triceps, and trapezium. Determining the ideal plane for implant placement is the most important surgical goal for satisfactory aesthetic results. Aesthetic contouring of the chest, back, arms, buttocks, and calf can be done safely with solid silicone implants. Proper pocket dissection and location are paramount to successful implant placement and decreased complications.
Brazilian politics on lipodystrophy treatment in the public health system
  • K Abreu
  • C Ferreira
  • M Serra
Abreu K, Ferreira C, Serra M, et al. Brazilian politics on lipodystrophy treatment in the public health system. In: 10th International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV, London, UK, November 2008 [Abstract P-79].
Lipoatrofia associada ao HIV/Aids: do advent aos conhecimentos atuais
  • Fmg Soares
  • Imc Costa
Soares FMG and Costa IMC. Lipoatrofia associada ao HIV/Aids: do advent aos conhecimentos atuais. An Bras Deramatol 2011; 86: 843-864.