Poly-L-lactic acid for treating HIV-associated facial lipoatrophy: a review of the clinical studies

Injectable redox-polymerized methylcellulose hydrogels as potential soft tissue filler materials

There is a significant clinical need for long-lasting, injectable materials for soft tissue reconstruction. Methylcellulose (MC) is an FDA-approved polysaccharide derivative of cellulose that is inexpensive, renewable, and biocompatible, and may serve as an alternative to existing synthetic and natural fillers. In this study, MC was modified with functional methacrylate groups and polymerized using a redox-initiation system to produce hydrogels with tunable properties. By varying the percent methacrylation and macromer concentration, the equilibrium moduli of the hydrogels were found to range between 1.29 ± 0.46 and 12.8 ± 2.94 kPa, on par with human adipose tissue, and also displayed an inverse relationship to the swelling properties. Rheological analyses determined gelation onset and completion to be in accordance with the ISO standard for injectable materials. Cellulase enzymatic treatment resulted in complete degradation of the hydrogels by 48 h, presenting the possibility of minimally invasive removal of the materials in the event of malposition or host reaction. In addition, co-culture experiments with human dermal fibroblasts showed the gels to be cytocompatible based on DNA measurements and Live/Dead staining. Taken together, these redox-polymerized MC hydrogels may be of use for a wide range of clinical indications requiring soft tissue augmentation.

Understanding the experience of reconstructive treatments from the perspective of people who suffer from facial lipoatrophy: a qualitative study

BACKGROUND

Facial lipoatrophy has been described as the most distressing and stigmatizing expression of the lipodystrophy syndrome, a syndrome that is caused by antiretroviral combination therapy. In recent years, reconstructive treatments (such as poly-l-lactic acid and polyalkylimide) have been increasingly considered for this condition. These treatments allow for facial contours and facial fullness to be restored while being minimally invasive.

OBJECTIVE

The main objective of this qualitative research was to explore and describe the experience of people who suffer from facial lipoatrophy, specifically in regard to reconstructive treatments.

METHOD

A qualitative design, which incorporates explorative and descriptive attributes, was thought to be an appropriate choice for this research project. The data was collected using semi-structured interviews and was then analyzed following the principles of thematic analysis.

PARTICIPANTS

Over a period of three months, 11 men and 1 woman enrolled in the study which was conducted in Montreal (Quebec), Canada.

FINDINGS

Overall, participants explained that facial lipoatrophy had forced them into a situation of intense vulnerability by making them recognizable as persons living with HIV/AIDS and discreditable in the eyes of others. In this sense, they were willing to go to great lengths to restore their facial features and regain a sense of normalcy. Findings revealed that people who suffer from facial lipoatrophy engage in a process of reconstruction to reduce the visibility and disruptiveness of their condition but face many uncertainties along the way.

CONCLUSIONS

While the findings of this research corroborated what has been previously stated by other researchers about the impact of reconstructive treatments, they also shed light on the consequences of not making these treatments accessible as well as the undocumented realities of those who cannot afford the recommended course of dermal fillers.

Optimizing Injectable Poly-L-Lactic Acid Administration for Soft Tissue Augmentation: The Rationale for Three Treatment Sessions

BACKGROUND

The availability and variety of different injectable modalities has led to a dramatic increase in soft tissue augmentation procedures in recent years. Injectable poly-L-lactic acid (PLLA) is a synthetic, biodegradable polymer device approved in the United States for use in immunocompetent patients as a single regimen of up to four treatment sessions for correction of shallow to deep nasolabial fold contour deficiencies and other facial wrinkles. Injectable PLLA is also approved for restoration and/or correction of signs of facial fat loss (lipoatrophy) in individuals with HIV.

METHODS

The present article provides an overview of previous studies with injectable PLLA, and specifically focuses on the number of recommended treatment sessions and intervals between treatment sessions. The authors also provide two case studies to support their recommendations for an average of three treatment sessions.

RESULTS

Although the specific mechanisms remain hypothetical, injections of PLLA are believed to cause a cascade of cellular events that lead to collagen repair and subsequent restoration of facial volume. Because the development of a response to injectable PLLA is gradual and its duration of effect is long lasting, sufficient time between treatment sessions should be allocated to avoid overcorrection.

CONCLUSION

Studies of injectable PLLA support the hypothesized mode of operation, and the experience and clinical recommendations of the authors that suggest that three treatment sessions are an optimal regimen for use of injectable PLLA in the majority of patients.

The face of HIV and AIDS: can we erase the stigma?

Facial lipoatrophy can be obvious and stigmatising. Poly-L-lactic acid (PLLA) has been used widely for the correction of HIV-associated facial lipoatrophy. Analysis of the PLLA treatment protocols of 441 consecutive patients was undertaken. Product dilution, product volume per session, number of sessions, time between sessions, facial areas treated, plane of injection and incidence of injection-site nodules were recorded. Assessments included the Hospital Anxiety and Depression Scale and the Appearance Satisfaction Questionnaire. During the learning curve 30 patients were treated every 2 weeks for a minimum of three sessions. A 3-ml dilution was used and a total of 5 ml was injected in the deep dermis of the buccal areas. The incidence of nodule formation was 31% and 52% of patients did not achieve resolution of their facial disfigurement. A total of 411 patients were treated every 4 weeks for a minimum of four sessions. A minimum 5-ml dilution was used and a minimum total of 10-ml was injected subcutaneously in the temporal, infraorbital and buccal areas. The incidence of nodule formation was 2.9% and 10% of patients did not achieve resolution of their facial disfigurement. Patient anxiety and depression scores and appearance satisfaction scores improved significantly with treatment.

Treatment of facial asymmetry with poly-L-lactic Acid: a case study

Poly-L-lactic acid (PLLA) (Sculptra, Dermik Laboratories, Bridgewater, NJ, a business of sanofi-aventis US, LLC) is a novel biocompatible and biodegradable injectable device currently under review by the Food and Drug Administration for a cosmetic indication. When implanted into soft tissues, PLLA is thought to elicit a foreign body reaction, resulting in fibroplasia and subsequent collagen formation. This process leads to a gradual thickening of the dermis and long-lasting augmentation of facial contours. In the reported case, PLLA was used to treat a 69-year-old African-American woman who had undergone numerous unsuccessful procedures for correction of prominent facial asymmetry. One vial of PLLA (5-ml dilution) was injected into the dermal-subcutaneous plane using a lattice distribution in the right upper cheek and malar regions, followed by massage. The procedure was repeated 6 weeks later. Several months after the two separate PLLA treatment sessions, the contours of the right upper cheek and malar regions were visibly and cumulatively enhanced, and facial symmetry was gradually restored, to the patient's full satisfaction. The treatment was well tolerated on both occasions, and the benefits of treatment have been sustained 18 months after the last procedure. The author concludes that injectable PLLA is a safe and effective minimally invasive treatment for facial contour defects.

Long-term psychometric outcomes of facial lipoatrophy therapy: forty-eight-week observational, nonrandomized study

The aim of this observational, prospective, nonrandomized study was to assess long-term psychometric outcomes of surgical treatment of HIV-related facial lipoatrophy. Two hundred ninety-nine participants (70.8% male) consecutively attending the Metabolic Clinic of Modena and Reggio Emilia University from November 2005 to July 2006, undergoing surgical interventions for HIV-related facial lipoatrophy were enrolled. Fifty-four (18.1%) underwent facial lipofilling, which consists of the harvesting of a small, intact parcel of fatty tissue with processing that removes the nonviable components and of the transport of fatty parcels through a small cannula to implant the graft in a manner that provides nutrition and anchors the fat to the host tissue. After an initial lipofilling, 24 (8%) needed polylactic acid injections to correct cheek asymmetry, 91 (30.4%) received only polylactic acid infiltrations, and 130 (43.5%) polyacrylamide infiltrations only. Subjective outcome measures were face aesthetic satisfaction, body image perception, depression evaluated by a visual analogue scale (VAS), the Assessment of Body Change and Distress questionnaire (ABCD), and by the Beck Depression Inventory questionnaire, respectively. Objective measure was cheek thickness evaluated by a 7.5-MHz frequency ultrasound probe perpendicular to the skin surface at the nasolabial fold, the corner of the mouth, the zygomatic arch, and centrally between these points in the buccal fat pad area. Both subjective and objective variables were evaluated at baseline and 48 weeks after end of surgical treatment. All 299 participants had significant improvement of the aesthetic satisfaction for the face (VAS from 2.9 +/- 2.1 to 6.2 +/- 2.1, p < 0.0001), of body image satisfaction (ABCD question 7 from 3.8 +/- 1 to 3.1 +/- 1 p < 0.0001 and ABCD question 8 from 70.7 +/- 16.7 to 77.2 +/- 17.2 p < 0.0001), of depression score (Beck score from 11.4 +/- 8.3 to 9.4 +/- 7.8 p = 0.001). Participants experienced a significant augmentation of both cheeks' thickness (right cheek from 4.3 +/- 1.9 mm to 9.5 +/- 3 mm p < 0.0001, left cheek from 4.4 +/- 2 mm to 9.6 +/- 3.1 mm, p < 0.0001). Our data suggest that facial surgery is an important option in the treatment of HIV-related lipoatrophy as an integral part of the management of HIV infection, because of the important and lasting psychological benefits.