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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Posts Tagged ‘HIV’

A Facial Implant Approach To Volume Restoration in Facial Wasting (Severe Lipoatrophy)

Sunday, June 29th, 2014


Fat loss in the face is referred to as facial lipoatrophy. While some people have it occur naturally with aging or weight loss, for others it is a medication side effect. While retroviral drugs have extended the lives of patients with human immunodeficiency virus (HIV), one of its well know side effects is the loss of the facial fat compartments. This has become known as facial wasting since it is an abnormal and active process. In facial lipoatrophy terms, there are various degrees of it classified as I through V. Many HIV positive patients have advanced type IV and V facial lipoatrophy appearances.

While facial wasting affects all fat layers in the face, its biggest impact is on the buccal fat pad. With its numerous fingers of fat that extend throughout the face and up into the temple region, loss of the buccal fat pad creates a skeletonized and hollow facial appearance. In its fullest extent, it makes one look ill and unhealthy and carries the social stigmata of someone who has the disease.

It has been shown that thymidine analogue drugs are the cause of this facial lipoatrophy effect. Recovery of some of the lost fat can be achieved with a switch to nucleoside reverse transcriptase inhibitor-sparing therapies but it is slow and never complete.Various forms of plastic surgery are needed to create a more dramatic and immediate facial change.

Facial rejuvenation procedures for facial wasting is focused on volume restoration around  the periorbital region (eyes), specifically that of the cheeks and temple regions. The temple hollowing is a pure soft tissue deficit while that of the cheek area is a combined bone and soft tissue deficit. This is not to say that the cheek has lost bone but that it has become very skeletonized adn looks withered, thus cheek (malar = bone) and the area below the cheek (submalar = soft tissue) needs building back up.

While there are injectable treatments available to treat facial wasting, synthetic (Sculptra) and natural (fat), they have favorable degrees of effectiveness. Sculptra injections are for those patients who are definitely opposed to surgery and have the patience to wait until their fill effect is seen…and then have it repeated 18 to 24 months later. Fat injections are problematic both in harvest and persistence. Many facial wasting have little fat to harvest and its ability to survive in tissue beds with very little subcutaneous fat is precarious at best.

Temple Implants in Facial Wasting result front view Dr Barry Eppley Indianapolis_edited-1A facial implant approach can be very successful and create an immediate volume restoration with long-term stability. The temple hollowing is treated with new soft silicone elastomer temple implants that are placed below the fascia but on top of the muscle. This camouflages the implant edges and is a remarkably simple procedure to insert them with no postoperative pain, little swelling and a very quick recovery. They are far superior to any injectable filler because they are so effective. They key in using them is to not pout in a size that is too big which is very easy to do in a very skeletonized temporal region.

Cheek Implants for Facial Wasting Dr Barry Eppley IndianapolisThe cheek area requires a very broad-based implant, part of which is placed below the cheek bone on the masseter muscle. Proper implant placement actually puts at least half if not more of the implant below the bone. While once submalar cheek implants were exclusively used, I have found that larger combined malar-submalar shell implants do a better job of midface volume restoration. Because these type of cheek implants are substantative in size, screw fixation is useful to keep them in the desired location as they heal.

One area that is left out with temple and malar-submalar shell implants is the intervening area over the zygomatic arch and immediately beneath it into the lower face. A complete facial wasting surgery includes implantation of this area as well but has to be done with either fat injections or preferably a dermal-fat graft placed through a limited facelift approach. Without filling in this area there can be a step-off in the face behind where the malar-submalar shell implant ends.

Facial wasting treatment is one specialized form of facial reshaping surgery. These procedures allowing for volume restoration of the face hopefully to a level that is close to what they looked like before starting their anti-viral drugs. With a more ‘plump’ face, one self-confidence is improved, they look healthier and they will be encouraged to stick with their long-term drug therapy.

Dr. Barry Eppley

Indianapolis, Indiana

Risks of Plastic Surgery in the HIV/AIDS Patient

Friday, May 16th, 2008

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 the May 2008 issue of the journal Plastic and Reconstructive Surgery, these basic issues were reviewed. 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 or laser-assisted 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

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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