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