ORIGINAL ARTICLE Surgical Management of HIV-Associated Lipodystrophy Role of Ultrasonic-Assisted Liposuction and Suction-Assisted Lipectomy in the Treatment of Lipohypertrophy C. Scott Hultman, MD,* Lindsee E. McPhail, MD,* Jeffrey H. Donaldson, MD,* and David A. Wohl, MD† Purpose: HIV-associated lipodystrophy is a frequent consequence of highly active antiretroviral therapy and has been associated with several metabolic disorders (increased triglycerides, hypercholester- olemia, insulin resistance) as well as altered fat distribution, includ- ing lipohypertrophy (neck, trunk, breasts) and lipoatrophy (nasola- bial fold, cheek, extremities). Medical treatment of fat redistribution is usually ineffective. We evaluated the efficacy and safety of the surgical management of HIV lipodystrophy. Methods: We performed a retrospective review of 12 consecutive patients (3 female, 9 male; mean age, 44.4 years; mean CD4 + cell count, 554/mm 3 ; mean body mass index, 28.9 kg/m 2 ; mean triglyc- erides, 421 mg/dL; no active opportunistic infections; mean duration of HIV infection, 11.4 years) who underwent surgical management of HIV lipodystrophy at a university hospital from 2001 to 2006. Results: Surgical intervention included a combination of ultrasonic- assisted liposuction (UAL) and suction-assisted lipectomy (SAL) of the anterior neck (7 patients), posterior neck (10 patients), and trunk (2 patients); direct excision of mastoid fat pads (1 patient); direct excision of thigh lipomata (1 patient); facelift/necklift (1 patient); browlift (1 patient); fat injections (1 patient); and blepharoplasty (2 patients). Mean lipoaspirate volume was 701 mL (range, 270 –1400 mL). Complications and sequelae included seroma (1 patient), ecchymosis (1 patient), need for revision (2 patients), and recurrence (3 patients) but did not include nerve injury, fat necrosis, skin loss, or infection. Although all patients reported improvement in form and function, UAL/SAL of the anterior neck had limited efficacy in 3 of 7 patients. UAL/SAL of the cervicodorsal fat pad was initially successful in 10 of 10 patients, but 3 patients developed partial late (1 year) recurrence, all associated with weight gain. Mean follow up was 30 months (range, 1– 66 months). Conclusions: Despite the potential for recurrence, surgical manage- ment of HIV-associated lipodystrophy is efficacious with minimal morbidity. UAL/SAL is particularly beneficial in reducing the cer- vicodorsal fat pad, whereas facelift and necklift may be necessary to adequately address anterior neck lipohypertrophy. Key Words: HIV lipodystrophy, HAART, lipoatrophy, lipohypertrophy, liposuction (Ann Plast Surg 2007;58: 255–263) F irst described by Carr in 1998, 1 HIV-associated lipodys- trophy syndrome is a frequent consequence of highly active antiretroviral therapy (HAART) and has been associ- ated with several metabolic disorders (increased triglycerides, hypercholesterolemia, insulin resistance, lactic acidosis) as well as altered fat redistribution, including lipohypertrophy (neck, trunk, breasts) and lipoatrophy (nasolabial fold, cheek, extremities). 2–11 In addition to causing such symptoms as headache, neck pain, impaired neck excursion, shoulder strain, altered posture, and possibly sleep apnea, 12 HIV lip- odystrophy also produces morphologic changes in facial features and body contour that are difficult to conceal can undermine self-esteem and confidence 13–16 and may threaten compliance with life-saving HAART regimens. 17 Because the exact mechanism for altered lipid and adipo- cyte metabolism has yet to be elucidated, strategies to prevent, mitigate, or reverse HIV-associated lipodystrophy have been difficult to develop. 2 Medical management of fat redistribution is usually ineffective, and treatment approaches have included antiretroviral substitution, initiation of metabolic agents such as thiazolidinediones or metformin, addition of growth hormone or testosterone, supplementation with antioxidants or mitochon- drial cofactors, nutrition, and exercise. 2 Surgical approaches to HIV-associated lipodystro- phy have recently been described. 18,19 Results are encour- aging and may offer considerable hope to carefully se- lected individuals who need to maintain an optimized HAART regimen. In the setting of lipoatrophy, soft tissue defects of the face can be replaced with fat autotransplan- tation, 20 –22 dermal fat grafts, 23,24 permanent malar im- plants, 25–29 or semipermanent soft tissue fillers 30 –32 such Received September 15, 2006 and accepted for publication September 18, 2006. From the Divisions of *Plastic and Reconstructive Surgery and †Infectious Disease, University of North Carolina, Chapel Hill, North Carolina. Presented at the Annual Meeting of the Southeastern Society of Plastic and Reconstructive Surgeons, The Cloisters, Sea Island, GA, June 3–7, 2006. Reprints: C. Scott Hultman, MD, FACS, Chief and Program Director, Associate Professor of Surgery, Division of Plastic and Reconstructive Surgery, Suite 7038 Burnett-Womack Building, CB#7195, University of North Carolina, Chapel Hill, NC 27599-7195. E-mail: cshult@med.unc.edu. Copyright © 2007 by Lippincott Williams & Wilkins ISSN: 0148-7043/07/5803-0255 DOI: 10.1097/01.sap.0000248128.33465.83 Annals of Plastic Surgery • Volume 58, Number 3, March 2007 255