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Facial Lipodistrofia In Patients Living with HIV/AIDS: From Diagnosis to The Necessary Interventions.

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


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AJBSR.MS.ID.000795


Department of Dentistry, Brazil University, Brazil
  Elcio Magdalena Giovani, Chairman, Professor, Integrated Clinic Discipline, Coordinator of Center for
Studies and Special Service for Patients, Professor, Postgraduate Dentistry Courses, UNIP, São Paulo, SP, Brazil.
To Cite This Article: Elcio Magdalena Giovani. Facial Lipodistrofia In Patients Living with HIV/AIDS: From Diagnosis to The Necessary
Interventions. Am J Biomed Sci & Res. 2019 - 4(3). AJBSR.MS.ID.000795. DOI: 10.34297/AJBSR.2019.04.000795
R : July 18, 2019 | : July 29, 2019
American Journal of
Biomedical Science & Research
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Literature Review
In HIV/AIDS patients using high-potency antiretroviral
therapy, from their Advent, in mid-1996, a series of new anatomical
and metabolic changes began to be observed, mainly in showing
atrophy of peripheral fat, as well as accumulation of central fat, and
simultaneously, it was noted that the redistribution of body fat was
accompanied by insulin resistance and several abnormalities in
serum lipids. These alterations were described and denominated
as lipodystrophy and/or lipodystrophy HIV syndrome (SLHIV).
At the time of the initial diagnosis of lipodystrophic syndrome,

2 years after the introduction of protease inhibitors (PI), however,
it coincides with the inclusion of a second nucleoside analog
reverse transcriptase inhibitor, stavudine. Initially, SLHIV was

were observed after the use of Crixivan® (indinavir), an IP class
medicine. Subsequently, the association between the use of
indinavir and the redistribution of body fat is observed, described
after the initial diagnosis of the syndrome, described in 1998,
where with the imagological resources, the utilization of computed
tomography was used, Demonstrating the increase in visceral fat in
these individuals. Following the chronological order of time, new PI
appear, and clinical and laboratory evidence was observed that the
redistribution of body fat was not an exclusive effect of indinavir,
and this denomination was abandoned. Nowadays, several
synonyms are used for SLHIV, such as body fat redistribution
syndrome, metabolic syndrome associated with antiretroviral
therapy, or, more recently, dyslipidemic lipodystrophy associated
with HIV/HAART [1-7].
  

them the moststriking were perceived in the face of the accumulation
of fat inthe abdominal region and in the posterior part of the neck,
called the Gibas. Other important anatomical alterations point
to the lipoatrophy of the face, the upper and lower limbs and a
      
fats in the region of the abdomen, cervical region and breasts. One
of the most used methods to determine a case of lipodystrophy
includes the subjective description of changes in body fat, and then

The advent of Aids has brought new challenges to the health area and the dentist surgeon plays an important role in the management of these
patients. Antiretroviral therapy has dramatically changed the morbidity and mortality associated with HIV/Aids infection but has contributed to
the emergence of other new situations that require proper approach. Lipodystrophic Syndrome Associated with HIV/AIDS is of multifactorial origin
but is strongly associated with the use of antiretrovirals. It comprises alterations in the distribution of body fat, accompanied or not by metabolic
alterations. The loss of facial fat, called facial lipoatrophy, is one of the most stigmatizing signs of the syndrome. This condition, often revealing the
disease, brought back the stigma of AIDS, leading patients to depression and total seclusion of their daily life activities. It is necessary that Dental Sur-
geons always share with the multidisciplinary team working with HIV/AIDS patients to identify these changes and seek effective and recommended
treatment options for the treatment of facial lipoatrophy associated with HIV/AIDS.
HIV/AIDS Patients; Lipodystrophic Syndrome; Lipodystrophy; Facial Lipoatrophy

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180
some diagnostic criteria are proposed, among them the clinicians
described as face-back, temples Depressed, clotted eyes, prominent
zygomatic arch, slimed aspect, prominent non-varicose veins
in arms and legs, loss of skinfolds, loss of contour and fat of the
gluteal region. The accumulation of fat is categorized into 5 areas,
such as: increased abdominal circumference, pectoral enlargement,
buildup of dorsal-cervical fat, accumulating facial fat, and the
presence of lipomas. The methods for evaluation and monitoring of
fat include patient complaint, clinical assessments, anthropometric
measurements and imaging exams.
The lack of standardized values in relation to fat in the general
population and the heterogeneity of the clinical manifestations of
        
methods that have been used are effective and recommended, such
as Anthropometry, bio impedance, DEXA, computed tomography,
magnetic resonance imaging and ultrasonography. Anthropometry
and Impedanciometry are not able to measure regional fat, but the
use of Ultrasound becomes important and promising, in the face of
its simplicity of not being invasive, and low cost. Epidemiologically

lipodystrophy is extremely variable among HIV patients, using
antiretroviral therapy (ART) for at least one year [1,3,6,8-10].
The metabolic alterations are detected and among them are
understood the lipid alterations and abnormalities in glucose
homeostasis, and they can still be associated or not the anatomical
alterations and the lipid alterations found in the SLHIV, which
Are the increase in serum triglyceride levels (GCT) and/or total
cholesterol. Hypertriglyceridemia is mainly due to the high rates of
new lipogenesis and delayed clearance of GCS in the postprandial
    
IP, have increased serum levels of Fasting of Apoliproteins B and E,
possibly by increased synthesis of the same, which could be related
to the manifestation of hyperlipidemia.
Glucose abnormalities may manifest as glucose intolerance,
peripheral insulin resistance or diabetes mellitus (DM), and
the mechanisms of action by which ARVS, such as protease
inhibitors, cause insulin resistance, are the Reduction of insulin-
mediated glucose uptake in skeletal musculature and adipocytes,
affecting glucose metabolism by producing imperfect peroxisome
proliferator-activated gamma receptor (PPAR-gamma) expressions.
Nucleoside analogous reverse transcriptase inhibitors mainly
cause lactic acidosis occurring in the syndrome. Moreover,
secondary to mitochondrial dysfunction due to the inhibition of
the deoxyribonucleic acid (DNA) Mitochondrial polymerase by this
class of drugs. The establishment of lactic acidosis is slow and the

Metabolic alterations are associated with increased risk of
cardiovascular events. Hyperinsulinemia associated with insulin
resistance and a recognized risk factor in HIV-infected patients
and may contribute to the increased risk of acute myocardial
infarction in patients receiving ARV. Thus, HIV-positive patients,
         
glycemia and triglycerides and low levels of HDL cholesterol, have
an increased risk of atherosclerosis, coronary disease and diabetes
mellitus, which is evident as an expressive pathology associated
with lipodystrophic syndrome in patients living with HIV/Aids
[1,3-6, 11-13].
There are proposals for adequate interventions for patients
with facial lipoatrophy to be established and shared by the
multidisciplinary team (dentist, clinical physician, infectologist,
endocrinologist, dermatologist, plastic surgeon, Nutritionist,
physical educator), being:
a) Change the medication: in a patient receiving HIV
treatment with ARVs such as Zidovudine or stavudine, it is
recommended to exchange for a nucleoside analogue such as
Abacavir, and in patients using PROTEASE inhibitor to evaluate
its substitution by an Integrase inhibitor as Dolutegravir.
b) Dietary changes: food restructuring replacing all excesses
by low fat and carbohydrate diet.
c) Drug treatment with metformin, glyazones and or human
recombinant leptin.
d) Hormonal treatment: Use of supplements and hormones
should be evaluated with caution due to the risk of drug
interaction and increased risk of hepatitis.
e) Physical activities: Implement physical activity routines
preferably at least 3 times a week.
f) Cosmetic Treatments: Facial reconstruction with free



or even the edentulous, show considerably improvements in the
conditions of deformities caused by facial lipoatrophy, alleviating
the losses, Patient’s facial region [14-19].
Facial Lipoatrophy
Among the areas affected by lipoatrophy, one of the most
frequent components of the syndrome, the face is the region in
which fat loss is more evident and impactful. Facial lipoatrophy is

malar fat called Bichat ball and temporal fat, consequently implying
the emergence of new skin grooves and the accentuated increase of
Expression Grooves, In addition to areas of depression and evidence
of bone structure, which is why it leads to a wrinkle of the face and
gives the individual an aspect of premature aging and, in women,
the loss of facial fat leads to a loss of the femininity of the face, and
the aspect of the face in A “disease facies”, returning the stigma
of the “face of Aids”, in addition to the fear of the unintentional
revelation of the diagnosis [3,20-23].
        
resulting from aging caused by alterations in the soft tissues and
fat loss occurring in HIV-associated lipoatrophy, suggest that it
is lower in aging than that observed in people With Lipoatrophy.
However, with advances in the treatment of Aids and the reduction

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of morbidity and mortality, consequently there was an increase in
life expectancy and, increasingly, we will have the combination of
these two factors (aging and lipoatrophy) interfering directly in the
contour Patients living with HIV/Aids.
Another worrying and currently detected factor is the loss of
bone mineral density that is part of the same syndrome, and is
        
maintaining special care for dental surgical procedures Avoiding
intimely conducts exerting the proposed activities with lightness
and safety avoiding fractures and other traumas to the patient,
besides the same for the success of the surgical indication of the
placement of dental implants, which may be associated with
avascular necrosis, it also has to be considered as an important
complication of SLHIV, since hyperlipidemia and the infection itself
by HIV are known risk factors for osteonecrosis of the femoral head
and in mandibles [1,4,20,24].
In the present moment, it evidences a certain tendency of Aids
       
the administration of antiretroviral drugs, its use can accelerate
        
life in those who Develops. To improve the quality of life of the
patient, when the dentist and or the multidisciplinary team itself
point to the aforementioned diagnosis of these patients with
facial lipoatrophy, it is necessary for the patient to be welcomed,
forming an important bond with him in order to receive a look,
and special attention and multidisciplinary preference, and ensure
the dental treatment, replacing the losses of the dental elements, a
factor that decreases the Flattening and or even the sinking caused
by lipoatrophy, rescuing the aesthetics, chewing and phonetics,
considerably improving the appearance and the posterior when
necessary and with indication for each case as a complementary

completing and correcting the marks of facial lipoatrophy. One of
       
also botulinum toxin (Botox®) and hyaluronic acid [1,25-29].
The Facial lipoatrophy Index (ILA) was developed an
instrument that aims to measure the degree of atrophy and the
degree of improvement with the treatment, in an objective way. The
ILA evaluates 3 regions of the face, which are:
1) Malar region that corresponds to the areas of the
zygomatic and buccal regions, having as limits the infraorbital
border and the lower edge of the mandible; The zygomatic
bone, the projection of the mandible body, the major zygomatic
muscle, the canine fossa and the maxilla.
2) Temporal region corresponds to the anterior portion of
the temporal fossa, limited by the temporal line of the frontal
bone and the zygomatic arch.
3) The Preauricular region corresponds to the Masseterin
region, between the zygomatic arch and the angle and the lower
edge of the mandible.
The depth and extent of the affected area in the malar, temporal
and pre-auricular regions are evaluated separately. The depth of the
atrophic areas is scored from 0 to 4, being 0 as absence of atrophy,
1 mild depth, 2 moderates, 3 being severe and 4 very severe. The
extent of the affected area is scored from 0 to 5, being 0 as absence
of impairment, 1 impairment less than 20% of the evaluated region,
2 from 21 to 50%, 3 from 51 to 70%, 4 from 71 to 90% and 5 from
91 to 100%. A partial number is calculated for each area evaluated,
multiplying the score relative to the depth by the score relative
to the affected area and still by a correction factor. Since fat loss
is not symmetrical, it is considered the most affected side in the
evaluation.
      
lipoatrophy in grades I to IV, from the application of the ILA. Being
grade I, or mild facial lipoatrophy, and in these cases, there is a
slight depression, but there is no evidence of anatomical accidents
in the region or loss of facial contour. Grade II, or moderate,
is characterized by depression, and is more visible with the
onset of the visualization of anatomical accidents, especially the
zygomatic arch and the increase of the nasolabial sulcus. Grade III,
or severe, where the Malar region’s accidents are observed, such
as the zygomatic bone, visualization of the canine fossa, partial
visualization of the major zygomatic muscle, and mild or moderate
depression of the lower edge of the mandible. Loss of facial contour
and jaw projection may occur. The degree IV, or very severe, and
there is almost complete visualization of the anatomical contours,
revealing the bone and muscular framework of the face. There is
loss of facial contour, with visualization of the upper and lower faces
of the zygomatic arch in the temporal and preauricular regions.
       
all with a degree of subjectivity for being evaluator dependent
[14,17,23,28,30-33].
Final Considerations
With the introduction of high-potency antiretroviral treatment
(HAART), in people living with HIV/Aids (PVHA) important and
determinant factors such as the decrease in morbidity and mortality
and increased life expectancy, with higher quality, began to make
Some of the achievements acquired in these years, but on the other
hand, a series of adverse events related to the use of medications
have been reported. Several clinical signs and symptoms have been
described since then and grouped as Lipodystrophic syndrome,
which is characterized by anatomical and metabolic alterations,
and may occur in isolation or associated form. Metabolic
alterations comprise a serum increase in lipids (cholesterol and
triglycerides), increased peripheral resistance to insulin, changes
in bone trabeculate, type I diabetes mellitus, associated or not with
anatomical alterations. These, in turn, derive from the redistribution
of body fat, which may result in loss (lipoatrophy) or accumulation
(lipohypertrophy).
Lipoatrophy occurs in the region of the face, upper and
lower limbs and buttocks. Lipohypertrophy occurs in the
abdomen, cervical region and breasts. Dentists together with the
multidisciplinary team reveal an important role in this context,
as they achieve within their area of knowledge to mitigate these
adverse effects of lipoatrophy, as they perform an effective treatment

Am J Biomed Sci & Res Copyright@ Ewa Filip
181
Dentistry, mainly by replacing the loss of dental elements that
automatically associated with lipoatrophy, somatize irreparable
damage. But the placement of oral prostheses replenishing the
dental losses, rescuing the loss of the vertical dimension, the
phonetics, the aesthetics, and carefully adjusting the prostheses
         

toxin, polymethacrylate and other available options that jointly
mitigate all procedures the deleterious effects of facial lipoatrophy.
These alterations in the body contour negatively affect mainly the
psychosocial health of people living with HIV/Aids, who may have
their seropositivity revealed by these remarkable characteristics,
which intensify the stigma in relation To the disease, strengthening
prejudice, impacting social and affective relationships, directly

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Lipodystrophy is a term used to describe a metabolic complication of fat loss, fat gain, or a combination of fat loss and gain, which is associated with some antiretroviral (ARV) therapies given to HIV-infected individuals. There is limited research on lipodystrophy in low- and middle-income countries, despite accounting for more than 95% of the burden of HIV/AIDS. The objective of this review was to evaluate the prevalence, pathogenesis and prognosis of HIV-related lipoatrophy, lipohypertrophy and mixed syndrome, to inform clinical management in resource-limited settings. We conducted a structured literature search using MEDLINE electronic databases. Relevant MeSH terms were used to identify published human studies on HIV and lipoatrophy, lipohypertrophy, or mixed syndrome in low-, low-middle- and upper-middle-income countries through 31 March 2014. The search resulted in 5296 articles; after 1599 studies were excluded (958 reviews, 641 non-human), 3697 studies were extracted for further review. After excluding studies conducted in high-income settings (n=2808), and studies that did not meet inclusion criteria (n=799), 90 studies were included in this review. Of the 90 studies included in this review, only six were from low-income countries and eight were from lower middle-income economies. These studies focused on lipodystrophy prevalence, risk factors and side effects of antiretroviral therapy (ART). In most studies, lipodystrophy developed after the first six months of therapy, particularly with the use of stavudine. Lipodystrophy is associated with increased risk of cardiometabolic complications. This is disconcerting and anticipated to increase, given the rapid scale-up of ART worldwide, the increasing number and lifespan of HIV-infected patients on long-term therapy, and the emergence of obesity and non-communicable diseases in settings with extensive HIV burden. Lipodystrophy is common in resource-limited settings, and has considerable implications for risk of metabolic diseases, quality of life and adherence. Comprehensive evidence-based interventions are urgently needed to reduce the burden of HIV and lipodystrophy, and inform clinical management in resource-limited settings.
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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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