Soft tissue augmentation with PMMA-microspheres for the treatment of HIV-associated buttock lipodystrophy

Abstract

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
The online version of this article can be found at:
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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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.
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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.
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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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