One of the manifestations of the lipodystrophy syndrome is the Buffalo Hump deformity. While it occurs mostly in patients with HIV on antiviral medications, it can also be associated with chronic steroid use, such as in asthma patients. Occurring in both men and women, its predominant feature is the fat accumulation at the back of the neck and upper back. Fat accumulation can extend around the neck to the jawline and even around the ears. While unsightly, it also causes functional issues such as neck stiffness and pain and difficulty with the fitting of clothes around the neck.

Why this fat accumulation occurs is not precisely known, but it is a thickening of the subcutaneous fat layer between the skin and the underlying muscle or bone. This fat is unique in that it is very fibrous in quality, meaning it is a mixture of fat and scar tissue that makes it more difficult to remove than many other fat sites in the body.

Liposuction is the preferred method in many cases for removal of the buffalo hump as the scarring is minimal which is an important consideration around the neck and face. Liposuction avoids the need for a long incision on the neck and upper back, has a lower risk of postoperative fluid collections, and does not require the use of drains. This fat is surprisingly gritty and tough to remove and traditional liposuction methods can be quite disappointing. Or at the least, requires a lot of work to get much out. For these reasons, ultrasonic liposuction is my preferred technique. This does better than traditional cannula methods in this type of fat. I have not yet used laser liposuction methods but I would expect them to be effective, but am unsure if they would be more effective than an ultrasonic method.

Ultrasonic liposuction can provide significant improvement but can not get all of the excessive fatty tissue. Expect improvement but not a complete cure of the problem. No long-term studies have ever been done that can substantiate how permanent the results from liposuction reduction of the buffalo hump are.

Fat around the front part of neck up into the face can be part of the buffalo hump or can also occur in Madelung’s disease. Open excisions of fatty tissue around the face, jawline, and ears works better than liposuction in my experience. The facial areas and front part of the neck are more difficult to treat with liposuction and usually less satisfying. Unlike liposuction, however, open excisions are associated with postoperative fluid collections (seromas) and the use of drains is needed. Open excision is done through a facelift type approach, placing the scars in the most favorable location.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

I have seen numerous patients over the years who are positive with the HIV virus, otherwise known as the acquired immunodeficiency syndrome (AIDS) and probably some that had the virus but it was unknown to them or they did not disclose it. Thesd patients fall into two categories of procedural requests; those patients seeking typical cosmetic procedures and those patients who have the adverse effects of antiretroviral therapies known as the lipodystrophy syndrome. In either case, there is always the question of the adviseability of performing elective plastic surgery. Are the patients healthy enough so that they are not at increased infection and complication risks?….and….What is the real risk to the operative team in terms of potential disease transmission?

 
In an excellent article in Plastic and Reconstructive Surgery (May 2008), Dr. Steve Davison of Georgetown University reviews these basic issues. In HIV positive patients, they can safely undergo elective plastic surgery provided that a thorough preoperative workup has been performed. Patients with CD4 counts greater than 200 and low viral loads have surgical risks that are similar to the general population. There is no evidence to support the historic contention that they have poor or compromised wound healing. Increased surgical risks are in those patients whose CD4 counts are less than 200 or have viral loads greater than 10,000. The risk of disease transmission to the surgical team is not precisely known but is estimated to be around 0.3% for penetrating injuries from surgical sharps, a rate that is less than 10% that of hepatitic C exposure which is far more dangerous.

 
In my practice, I generally see known HIV-positive patients for facial lipoatrophy of the cheek and temple areas and fat accumulation of the back of the neck (buffalo hump). Both of these can be managed by non-surgical options although I find the surgical alternatives to give superior results. Injectable fillers, such as Scuptra, Radiesse, and ArteFill can be used to correct the typical patterns of facial wasting but they do require large volumes of injectate and numerous sessions. They quickly become as costly as surgery. A surgical alternative are submalar implants and fat grafting which I have found quite satisfying even if 100% of the fat does not survive. Buffalo hump reduction (dorsocervical fat accumulation) can be treated by LipoDissolve injections if the area is not too large but it usually takes at least 3 sessions over a greater number of months to get a reasonable result. Ultrasonic liposuction is far more efficient and can take away a larger amount of excess fat in an obviously shorter time.

 
I have found performing plastic surgery on HIV positive patients to be rewarding and well appreciated. They often suffer the stigmata of their disease and wish its improvement to improve their self-esteem and improved social acceptance. I have seen no greater incidence of complications in this patients than any other types of patients.

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