Facial wasting is a very specific condition of the face in which specific areas of fat are resorbed and, in its severest form, is unique to the HIV patient taking retorviral medication. Nobody knows exactly why fat from the faces specifically goes away on people taking anti-HIV drugs, but a significant percentage of such patients will  experience it depending on their particular retroviral medication regimens. It seems to occur particularly in men of low body weight who are over the age of forty.

Facial wasting can present in a variety of appearances from subtle to very dramatic, based on the amount of fat under the skin that has been lost. Patients typically present with sunken-in cheeks, very prominent cheek bones not covered by the usual fat layer, and hollow temples. This also creates loose facial skin due to the lack of underlying fullness.

Facial wasting can be treated by a variety of plastic surgery methods. The most popularized is the injectable approach using Sculptra or other long-lasting fillers such as Radiesse. While injectable fillers definitely provide a benefit, I don’t find them to be the best value, given what they cost and the repeated treatment sessions necessary. In my experience, several surgical options are more effective with injectable fillers used to supplement them.

I find that cheek implants, specifically submalar implants, are the best first approach for facial improvement. These implants come in a wide variety of shapes and sizes so some customization of them can be done for each patient. These implants provide a good fill of the lost volume of the buccal fat pad and are easy to place through an incision inside the mouth. Once in the proper position, I prefer to place a screw through them to hold them permanently to the underlying cheek bone. There is some mild swelling after surgery but one can go back to work and resume all normal activities within just a few days. The advantage of an implant is that its volume will remain stable over time unlike injectable fillers. I have yet to experience any infections with cheek implants in the HIV patient nor do I think they are at any great increased infection rate from plastic surgery in general.

Injectable fillers can be used to fill in around the edges of the implants later. Often there can be a step-off or obvious demarcation from the implant to the surrounding skin in cases where the facial wasting is quite severe. In more mild cases, this is not necessary.

When the facial wasting is associated with loose skin, a modified facelift can also be very helpful. Changing the facelift to more of a jowl-neck tuck-up helps stretch out the loose cheek and facial skin. When done in combination with submalar cheek implants, some really nice facial improvements can be achieved.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

The official birthday (200^th) of Abraham Lincoln, our 16^th president from1861 to 1865, occurred on February 12, 2009.  Many states that had formerly observed Lincoln’s birthday have created a joint holiday to honor both Lincoln and our first president George Washington, known as Presidents Day. It coincides with the Federal holiday officially designated Washington’s Birthday, observed on the third Monday of February.

Abraham Lincoln had a very distinct face and it epitomizes the ‘gaunt look’. Based on photogtraphs, he had such a facial appearance since he was a young man but it became more pronounced as he got older. A story is told that at the age of 51, an eleven-year old child told him to grow a beard to make his face look fuller. He remained with a beard until his untimely death. Even with a beard, Lincoln’s face showed his sunken cheeks and a classic facial lipoatrophy appearance. Even a cursory look at his face on Mt. Rushmore shows how different his face appeared from the other presidents.

Facial lipoatrophy, sometimes referred to as facial wasting, is the loss of fat in the face usually in the cheek and temple areas. It is not necessarily loss of fat in all cases, in some it is simply that these fat areas never developed to any degree. It really represents a failure of adequate development of the buccal fat pad and all its extensions or a loss of this fat pad over time due to aging or certain medications. Facial lipoatrophy presents itself in five degrees of severity from the subtle type I, which usually represents as a mild congenital or natural gauntness to the face to the most severe type 5 which is best illustrated in the HIV patient where total loss of the buccal fat pad occurs due to the antiviral medications.

While a mild type 1 facial lipoatrophy appearance can be quite attractive when one is young (due to the appearance of high cheekbones), ongoing aging in one’s later years creates more of an unhealthy aged appearance. President Lincoln had  by the time of his presidency a type III or IV facial lipoatrophy condition. He had a very skeletonized face with completely sunken in submalar (below the cheekbones) areas that even his beard could not mask. His facial lipoatrophy condition was congenital or developmental in nature.

In severe facial lipoastrophy cases of the HIV patient, treatment of this facial appearance helps mask the stigmata of the disease. Various treatment options exist for the treatment of facial lipoatrophy and they can be tailored to how sunken the face appears. Most of the treatment approaches focus on the cheek or midface areas for enhancement or volume addition.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Facial lipoatrophy is a not uncommon facial condition that all of us have seen but didn’t know exactly what to call it. Some people call it ‘gaunt looking’, others may refer to it as ‘hollowing’ of the face. No matter what you call it, it is the result of loss of the buccal (cheek) fat pad that lies directly under the cheekbone (zygoma) prominence. The fatty layer immediately underneath the skin throughout the fat thins as well but the dominant feature is the sunken or dented in area immediately beneath the cheek.

 
There are numerous causes of facial lipoatrophy but the most common are aging in an alreadly thin person, advanced cancer or immune disease with significant weight loss, and loss of the buccal fat pad due to medications. (such as in the HIV patient who is on antiviral medication) The facial appearance is classic with the loss of roundness in the middle part of the face and an actual indentation where th cheek fat used to be. This gaunt look creates an unfavorable appearance that appears old or unhealthy.

 
There are two distinctly different methods in plastic surgery to treat facial lipoatrophy and rebuilt this area up andout, either using injectable fillers (including fat) or a special type of cheek implant. Both obviously attempt to fill the cheek void left by the vacated fat pad but approach it differently. Injectable fillers replace it either with a viscous liquid component which may or may not be permanent. Most injectable fillers are not permanent. Inject fat could be permanent but is unpredictable. I have not been a big fan of the injectable fillers for the cheek deficiency of facial lipoatrophy simply due to the volume of the filler needed and the subsequent cost. It doesn’t take long before one can approximate the cost of a surgery. For a more assured result, albeit a surgical one but it provides the best value, is the use of a submalar cheek implant.

 
Submalar cheek implants are a variation of the traditional cheek implant. They are not designed to build out the cheekbone prominence but fill out the submalar area where the buccal fat pad partially lies. They are surgically placed through a small incision underneath the upper lip. Different sizes are available dependent upon how much of a deficiency exists in the submalar area. Submalar cheek implants are placed on the underside of the cheek bone and are secured into position with s small screw to hold their precarious but important position. The effect of the submalar cheek implant is immediate. There is really no recovery other than mild soreness and some swelling for a few days.
The treatment of facial lipoatrophy with a submalar cheek implant is easy, satrightforward, and effective. While it only treats one component of facial lipoatrophy, the buccal fat pad area in the midface, this is often the most recognized and disfiguring component of the problem. The material that the submalar cheek implant is made out of is not of particular importance, whether it be silicone rubber, gore-tex, or other well-tolerated facial implant material. An artistic eye for proper cheek implant style and selection and accurate placement on the underside of the cheek bone are the keys to a pleasing outcome that can make the face appear more healthy and youthful.

 
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Facial lipoatrophy, sometimes referred to as facial wasting, is the loss of fat in the face usually in the cheek and temple areas. It is not necessarily loss of fat in all cases, in some it is simply that it was never there to start. It really represents a failure of adequate development of the buccal fat pad and all its extensions or a loss of this fat pad over time due to aging or certain medications. Facial lipoatrophy presents itself in five degrees of severity from the subtle type I, which usually represents as a mild congenital or natural gauntness to the face to the most severe type 5 which is best illustrated in the HIV patient where total loss of the buccal fat pad occurs due to the antiviral medications.

 
While a mild type 1 facial lipoatrophy appearance can be quite attractive when one is young (due to the appearance of high cheekbones), ongoing aging in one’s later years creates more of an unhealthy aged appearance. In severe facial lipoastrophy cases of the HIV patient, treatment of this facial appearance helps mask the stigmata of the disease. Various treatment options exist for the treatment of facial lipoatrophy and they can be tailored to how sunken the face appears. Most of the treatment approaches focus on the cheek or midface areas for enhancement or volume addition.
In miinor cases of submalar or cheek deficiency, many of the injectable fillers can be used. They are costly, require fairly large volumes, and are only temporary. Sculptra is the one injectable filler that has been specifically approved for facial lipoatrophy. It is essentially liquid ‘plastic’ and must be injected in layers over time. While it can be effective in the short-term, its development was based on its use in HIV patients who may not always be immunocompetent. Whether healthy patients with a normal imune system will adversely react to this filler more so than HIV patients remains to be seen. Such volumes of injectate for aesthetic applications make me a little nervous so I prefer other treatment approaches.

 
My preferred approach is the use of cheek, or to be more specific submalar, implants that sit below the cheek bone. This effectively pushes out the area where the buccal fat pad once was. The implants are placed through an incision inside the mouth and secured to the bone with screws. Additional implants can be placed over the upper jaw itself slightly in front of the submalar area. I have not seen any increase in infections or complications with the use of these implants, even in the HIV patient. Fat injections, using the patient’s own fat as a donor source, can then be done over the sides of the face where the implants do not create an effect. The entire facial enhancement could be done by fat injections alone but a lot of fat placed in not predictable in terms of survival in all cases.
While this combined implant and fat grafting approach does not treat all the areas of facial deficiency, it does focus on the most aesthetic area of the midface.

 
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis