Antonio Pedone

Multidisciplinary Approach to the Treatment of Metabolic and Morphologic Alterations of HIV-Related Lipodystrophy

Abstract Background: Treatment for metabolic and morphologic alterations in HIV-related lipodystrophy include medical therapy, physical exercise, and surgical interventions. Method: We assessed the efficacy and safety of a comprehensive multidisciplinary approach for treating morphological and metabolic alterations of the lipodystrophy syndrome in consecutive patients attending the Metabolic Clinic (MC) of the University of Modena and Reggio Emilia who had at least 2 evaluations over a 48-week period. 245 patients were evaluated: 143 (62.4%) were men, 74 (36.1%) presented with lipoatrophy, 10 (4.9%) with fat accumulation, 93 (45%) with mixed forms, 24 (11.3%) had hypercholesterolemia (LDL >160 mg/dL), 87 (38%) had hypertriglyceridemia (TG >150 mg/dL), 13 (5.7%) had diabetes (glucose >126 mg/dL), and 78 (44%) had insulin resistance (HOMA-IR >4). Results: At follow-up, a significant improvement was observed in both objective and subjective variables. Anthropometric improvement was observed in waist to hip ratio, waist circumference, and right and left cheek dermal thickness measurements. A nonsignificant improvement was observed in fat and lean regional mass by DEXA; CT showed improvement in visceral and subcutaneous adipose tissue. Glucose, HOMA-IR, total cholesterol, and APO B improved. Subjective variables improved in aesthetic satisfaction. Conclusion: We conclude that the medical and surgical interventions proposed in this multidisciplinary therapeutic approach are efficacious and safe in the management of lipodystrophy.

Polyacrylamide hydrogel injection in the management of human immunodeficiency virus-related facial lipoatrophy: a 2-year clinical experience.

Background: Facial lipoatrophy is defined as the reduction in buccal and orbital fat pads along with a more global loss of fat within the subcutaneous tissue. It is the most common and distressing sign of human immunodeficiency virus–associated lipodystrophy. Injectable polyacrylamide hydrogel (Aquamid) is a synthetic nonbiodegradable polymer consisting of a minor backbone of 2.5 percent cross-linked polyacrylamide and 97.5 percent nonpyrogenic water and is used for cosmetic facial contour correction. Favorable results with maximum aesthetic gains with the use of polyacrylamide hydrogel for reconstruction of facial lipoatrophy on the face in significantly immunocompromised individuals are being reported. These results are attributable to its use in limited volume injected at multiple sites and in multiple sittings. Methods: Aquamid has been used for the correction of severe nasolabial folds and mid and lower facial volume loss in patients affected by human immunodeficiency virus–associated lipodystrophy. Fifty patients were enrolled and treated, with a mean follow-up of 13.1 months. Results were evaluated clinically, by standardized ultrasonography, and by psychological tests (visual analogue scale, Beck Depression Inventory, and Assessment of Body Change and Distress questionnaire) to quantify patient satisfaction. Results: No significant side effects or issues such as swelling, infections, allergies, or nodule formation were noted over the follow-up period. Conclusion: Aquamid has provided a minimally invasive, effective, long-lasting facial contour correction that significantly improves the quality of life in human immunodeficiency virus–infected patients.

Surgical correction of HIV-associated facial lipoatrophy.

Lipodystrophy was first described in HIV-1-infected patients in 1998 [1–5]. The main clinical feature is subcutaneous fat loss or lipoatrophy of the face, limbs, and buttocks [6,7]. Patients can also experience fat accumulation within the abdomen, neck or breasts [8,9]. The pathogenesis of lipoatrophy appears to be multifactorial. Contributing factors are CD4þ lymphocyte cell count, HIV clinical stage, race, sex, exercise level, age at start of antiretroviral therapy [8], and the rapidity of its onset may depend on the individual total fat mass. The driving force behind lipoatrophy is undoubtedly the cumulative exposure to thymidine analogue drugs. These drugs, in particular stavudine and to a lesser extent zidovudine, block mitochondrial DNA polymerase function producing apoptosis of fat cells [9,10]. Earlier detection and treatment of HIV infection [11], as well as the use of antiretroviral drugs with less deleterious effects on body fat, make it reasonable to hypothesize a decrease in prevalence of lipodystrophy in the coming years.

Merkel cell carcinoma of the upper eyelid: presentation and management

Merkel cell carcinoma (MCC) is a rare and potentially aggressive neuroendocrine tumour. The authors describe a unique presentation of a 4.5 cm wide MCC of the upper lid in a 73-year-old female. After total upper lid resection, immediate reconstruction was achieved by a full-thickness lower-lid transposition flap based on the lower lateral palpebral artery. At the 3 year follow-up the patient is free from disease and the reconstructive result is satisfactory both functionally and aesthetically.