SANTA BARBARA, Calif. - Fat transfer for lipoatrophy is safe and cost effective, and provides excellent long-term results, lasting over a year in some cases, said Dr. Ilya Reyter.

Dr. Reyter, along with Dr. David Sawcer, launched a lipodystrophy clinic in the department of dermatology at the University of Southern California's Keck School of Medicine in early 2007. The clinic is dedicated to treating HIV-associated lipodystrophy and lipoatrophy using tumescent liposuction and fat transfer.

Dr. Reyter, an assistant clinical professor of dermatology at the university, also has extensive experience with fat transfer and liposuction for non-HIV cosmetic improvement, and performs the procedure in his private practice in Beverly Hills, Calif.

Lipodystrophy is marked by central fat deposition on the abdomen, dorsocervical area, salivary glands, breasts, face, and neck. "Before we started this clinic, a lot of our patients were being sent to plastic surgeons, especially for excision of lipodystrophy, particularly in the dorsocervical area," Dr. Reyter said. The dystrophic fat accumulations can be removed more simply using local anesthesia with tumescent liposuction, thereby avoiding the risks of surgery with general anesthesia, he said.

Patients are referred to the HIV lipodystrophy clinic by the HIV dermatology clinic and by other physicians working with HIV patients at the medical school. Dr. Reyter has treated numerous patients for non-HIV cosmetic fat transfer, "but in the HIV clinic, we have treated a few dozen patients," he said. "We select the patients carefully, to make sure that they are appropriate candidates. Not everyone with facial atrophy is a candidate for fat transfer, or fillers, for that matter."

He went on to describe his methods for treating lipoatrophy using fat transfer. Lipoatrophy, also know as fat wasting, particularly affects the face, and is marked by prominent zygomata, reduction of Bichat’s fat pads, sunken eyeballs, and a cachectic appearance.

HIV-associated lipoatrophy was recognized shortly after the first protease inhibitors were approved in 1995. "You can see some of these features in patients who are HIV positive but not on any medication, but it's a really small subset, only about 3% of them," said Dr. Reyter.

He said that lipoatrophy has replaced Kaposi’s sarcoma as the "scarlet letter" of HIV disease, "and it can lead to noncompliance with therapy. It has been shown that correction of the problem can lead to physical and psychological improvement. Lipoatrophy is increasing in prevalence, because HIV is becoming a chronic disease. The longer patients are on medications for their disease, the more of this we will see. The patients have nowhere else to go. As dermatologists we are the experts of skin and subcutaneous fat. If we don't treat it, who will?"

The exact causes of lipoatrophy and lipodystrophy remain unclear, but they are most likely related to multiple factors, he said, including a decrease in retinoic acid receptors, a decrease in triglyceride uptake, inhibition of mitochondrial DNA, inhibition of lipid metabolism, and prevention of adenocyte development.

A patient with lipoatrophy is shown before undergoing fat transfer.

For small volume areas that need treatment, Dr. Reyter prefers hyaluronic acid fillers such as Restylane and Juvéderm, but for large volume areas such as the cheeks, fillers "don't last a very long time, and they cost a lot. To me, those are prohibitive features for being widely used in HIV. It was not a cost-effective model to be doing this about every 6 months, using 10-14 syringes per side on a patient's face. It just made no sense," he said.

The same patient is shown 6 months after the fat transfer procedure.

Other filler options include poly-L-lactic acid (Sculptra) and calcium hydroxylapatite (Radiesse), but Dr. Reyter said that he has seen patients with and without HIV develop complications including granulomas after being treated with these agents. "I don't feel as comfortable offering these particular fillers," he said, even though they are Food and Drug Administration approved. "I think it's up to physicians to evaluate whether or not a filler is something they would want to use on their own patients."

Fat transfer wins out for larger volumes, he said, if donor fat is available. "Fat is very cheap to harvest; most patients have adequate fat reserves, and it can be done safely."

In one study of 38 HIV patients who were treated with fat transfer, researchers graded the results at 1 year on a scale from 1 to 4, with 4 being excellent. The mean score reported by the patients was 3.7 and the mean score reported by the surgeon who performed the procedure was 3.2 (Plast. Reconstr. Surg. 2004;114:551-5). No serious adverse effects were observed.

In a separate study of 33 HIV patients who were treated with fat transfer and surveyed 1 year later, 93% of patients reported being satisfied (14 reported being very satisfied and 17 reported being partly satisfied). Furthermore, 81% (27 patients) reported an improved quality of life.

Three independent evaluators reported a 52% improvement in the area treated at 1 year (Arch. Dermatol. 2005;141:1220-4). No significant complications were observed.

In Dr. Reyter's clinical experience, some patients might need another fat transfer at 1 year, "but even so, a year is a significant improvement, especially for a procedure that didn't entail a lot of risk, didn’t have a lot of cost of consumables, and resulted in a benefit for a person."

In another study, researchers used computed tomography analysis and volume calculating software to evaluate the effects of fat transfer in 26 patients (18 men and 8 women aged 34-59 years) with HIV (Aesthetic Surg. J. 2008;28:380-6). The investigators observed increasing volumes of fat after 1 year, leading some to speculate that fat transfer may involve the transfer of stem cells.

"Are stem cells somehow influencing this result?" Dr. Reyter asked, adding that the data on stem cells in fat transfer are inconclusive. "Stem cells have been shown to be present in fat, and they have been shown to be transferred."

According to Dr. Reyter, his pretreatment protocol is the same as for tumescent liposuction: a CBC test; CD4 measurement; a viral load test; confirmation serum transaminases levels are not elevated; and clearance from the primary care physician.

"An important step is marking," he added. "I like to view the sites of deficit as triangles on the face. I make a topographical overlay. After we numb up the area, a lot of that numbing will distort the facial architecture. So if youdidn’t do a good marking job beforehand, your landmarks will be distorted."

For the fat transfer procedure Dr. Reyter uses small, blunt microcannulas. To harvest donor fat, he uses a straight Coleman harvesting cannula connected to a 10-cc syringe.

"I harvest on manual pressure, and then I let the fat sit to allow it to separate" he said. "There's a lot of debate as to whether or not you should spin the fat. I prefer to do nothing that would introduce trauma to the fat or to expose the fat to contamination."

He uses a 1-cc syringe attached to a blunt-tipped 18-gauge cannula to re-inject the fat, injecting 0.1-0.2 cc per pass on withdrawal.

The donor harvesting of fat takes about 20-30 minutes, allowing the fat to sit takes about 10-12 minutes, and reinjecting the fat takes about 30 minutes. "The whole procedure can take an hour to an hour and 15 minutes to do 20-30 ccs of fat per side, which I think is pretty efficient," he remarked.

Typical filling volumes are 10-20 cc for each cheek, 5-8 ccs for the temple, and 5-10 ccs for nasolabial folds. "Edema during and after fat transfer is common," said Dr. Reyter. "Because of this you have to overfill by 25%-50%. That’s where the skill comes in."

The procedures appear to change the overlying skin texture, "producing a global rejuvenation effect," he said. "It brings people back to speculating what the role of stem cells is."

To date there have been no serious complications since the lipodystrophy clinic opened its doors, said Dr. Reyter, who estimated that 25%-50% of his current clinical work involves fat transfer.

"There is a high degree of patient satisfaction at 6-12 months, and very few touch-ups are necessary," he said.

The responses from patients who have gone through the fat transfer procedure "have been overwhelmingly positive," he added. "So many patients tell us that their lives have been transformed."

For example, one patient with severe facial atrophy and longstanding unemployment was able to finally find employment after the fat transfer – "because he no longer looked so ill," Dr. Reyter said. "Another patient just wrote 'thank you for my new face. ... I look so healthy!' The doctors in the clinic regularly receive thank you notes and tokens of appreciation from the patients – in my experience, much more than we typically get in the course of providing any other medical care."

Dr. Reyter said that he had no relevant financial disclosures to make.

Fat Transfer Boosts HIV Patients' Quality of Life