[Polylactic acid injections: usefullness for the treatment of facial lipoatrophy in HIV+ patients under tritherapy].
BACKGROUND
The aim of the study was to evaluate the mean-term efficacy and tolerance of the polylactic acid injections (New-Fill) for the correction of facial lipoatrophy occurring in HIV-positive patients under tri-therapy.


METHODS
The patients were managed at the University Hospitals of Besançon and Strasbourg (France) from January 2002 to December 2005 for a prospective study. The patients were consecutively included in this study once their consent was obtained. Patients not stabilized by their antiretroviral treatment were excluded. Facial lipoatrophy was classified in four clinical stages (stage I: mild, stage II: moderate, stage III: important, stage IV: severe) after a clinical examination. The polylactic acid solution was prepared according to the manufacturer's recommendations, and injected in a retrotracing manner in the hypoderm at the rate of one 5 ml flask per side, with an interval of one month. The number of sessions varied according to the severity of the stage. Treatment efficacy, assessed after a minimal follow-up of one year, was established clinically by comparing the initial and final photographs (changes in the clinical stage) and by the patient's and surgeon's satisfaction rate (from zero to ten). Treatment tolerance was established on the painfulness of injections and on socioprofessional constraints reported by the patients and made on a visual analogical scale. The occurrence of adverse-effects was checked. Finally, we compared the cost of the treatment with that of lipostructure.


RESULTS
Twenty-five patients were included (mean age: 44, sex-ratio: 23 male/2 female patients). The mean body mass index was 21. The mean CD4 cell count was 600/mm(3). The mean HIV-1 RNA was 276 copies/ml. The severity of the lipoatrophy was stage one in two patients (8%), stage two in 12 patients (48%), stage three in nine patients (36%), and stage four in two patients (8%). The mean number of sessions was 5.2. The mean follow-up time was 26 months. In 76% of the cases we observed a complete correction of lipoatrophy (100% of stages I, 92% of stages II, 66% of stages III, 0% of stages IV). However, among stages II, III, and IV that were incompletely corrected, an improvement was noticed in all patients (grading to an inferior stage, at least). The mean satisfaction rate was 8/10 by patients and 7.2/10 by surgeons. In six patients (24%) a renewal of the treatment was proposed because of inadequate results. The painfulness of injections was rated at 3.3/10 and constraints at 3/10 by patients. One single case of visible and palpable sub-cutaneous granuloma was noticed in a patient at the end of the follow-up period (18 months).


CONCLUSIONS
The use of polylactic acid is a safe and efficient procedure for the treatment of facial lipo-atrophy in HIV-infected patients, however severe the clinical stage may be, after a two-year follow-up period. We recommend hypodermic (and not dermic) injections to prevent adverse effects. This treatment is not more expensive then lipo-structure and the progressive correction is considered as an important advantage by patients. Considering our results, the simplicity of the procedure, and the low rate of complications observed, the injection of poly-lactic acid has become our first intention treatment for this condition.
Piquet
M
M
Service de chirurgie maxillofaciale et stomatologie, CHU de Jean-Minjoz, boulevard Fleming, 25030 Besançon cedex, France. mathieupiquet@mac.com
Brignol
L
L
Chatelain
B
B
Rey
D
D
Ricbourg
B
B
Meyer
C
C
D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D000998:Antiviral Agents / Q000627:therapeutic use; D001672:Biocompatible Materials / Q000627:therapeutic use*; D015992:Body Mass Index; D002482:Cellulose / Q000627:therapeutic use*; D003357:Cosmetic Techniques; D004954:Esthetics; D005145:Face; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy; D039682:HIV-Associated Lipodystrophy Syndrome / Q000145:classification / Q000628:therapy*; D006801:Humans; D007279:Injections, Subcutaneous; D019344:Lactic Acid / Q000627:therapeutic use*; D008297:Male; D008353:Mannitol / Q000627:therapeutic use*; D008875:Middle Aged; D017060:Patient Satisfaction; D011108:Polymers / Q000627:therapeutic use*; D011446:Prospective Studies; D016896:Treatment Outcome
D000998:Antiviral Agents; D001672:Biocompatible Materials; C482305:New-Fill; D011108:Polymers; D019344:Lactic Acid; D008353:Mannitol; D002482:Cellulose