final program.qxd - Parallels Plesk Panel

SS 5.2
HIV-associated facial lipoatrophy and therapeutic approaches : therapeutic
strategies to treatment of HIV-Facial Lipoatrophies
Christophe Compagnon, Marseille - FRANCE
Lipoatrophy prevalence: Many cross studies outline lipodystrophy prevalence from 18 to
80%. In the "Aproco" cohort, 62% of the patients treated in first intention with HAART
including an IP show at least one lipodystrophy sign and 25% show facial atrophy.
Nevertheless, number of lipodystrophies seems to decline thanks to new HAART.
Therapeutic alternatives: There are 3 main treatments for lipodystrophy: medical means
by less toxical HAART, addition of adjuvant treatments like uridine and pioglitazone, those
being at an experimental stage. On a surgical basis, there are two therapeutic approaches
for facial lipoatrophy: autologuous fat tissue transplantation with Coleman technique
(lipo-filling) and fillers. Main adverse effects of the Coleman technique are: "hamster"
syndrome 16%, re-operation 37%, facial oedema 50% [Guaraldi G et al.], more rarely, fat
accumulation may need a re-modeling by liposuction. Biodegradable fillers: 1. Collagen:
Allergic risk is one of the most important side effects. A test must be done prior to
injection, particularly for bovine collagen. FDA has approved human collagen, less
allergenic, in March 2003. Effects of this kind of treatment remain 3 to 6 months.
2. Hyaluronic acids: Different kinds of hyaluronic acids exist depending on their viscosity,
they are easy to use. Although effects are immediate, they remain only few months (3 to
9). 3. New-Fill (L-polylactic acid): This biodegradable injectable medical device is the most
used in treatment of facial lipoatrophy in HIV-infected patients. It is the only product
reimbursed by social security (France) in this indication and FDA has approved it in 2004
in this indication too. Restoration of volume in depressed areas of the face by stimulating
neocollagenesis is progressive and effects remain about 2 years. 4. Eutrophill ® (Outline)
is a polyacrylamide hydrogel obtained by polymerization of acrylamide monomers with an
official half-life of 5 years. Under evaluation. There are also non biodegradable implants
like Bio-Alcamid ® (polymeric material composed of alkylimide-amide groups) Bio-Alcamid
can be defined a sort of "endoprosthetis". Adverse events: Most of the adverse events
encountered with fillers are depending on their re-absorption lasting and their mechanism
of action. Short re-absorption products are of short lasting effect. Longer lasting products
may occasion micronodules, induration areas, reactive fibrosis and granulomas.
Infections and casts may occur with non-biodegradable product. Adverse events are more
often subject to re-absorption lasting of the product. Therapeutic strategy: Patients should
be informed of benefits and drawbacks of each technique. The selection of the technique
and the product will be related to the lipodystrophy grade (moderate, intermediate,
severe). Autologous graft (Coleman technique) will be proposed to patients with areas
amenable to liposuction, in that case, a temporary social exclusion should be necessary
Moderate lipoatrophy
Therapeutic adjustment
Long lasting or short lasting biodegradable product
Pioglitazone (research in progress)
Moderate lipoatrophy
Therapeutic adjustment
Autologous grafs when possible
Long lasting biodegradable product in first intention or non-biodegradable implant
Severe lipoatrophy
Therapeutic adjustment
Long lasting biodegradable product in first intention or non-biodegradable implant
Clinical Cases: examples of facial lipoatrophy treatment will be shown.
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