The morcellized omentum is drawn up into heparinized 10-mL syringes for vertical gravitational decanting on the back table. After the material has separated into its aqueous and adipose components, the water layer is evacuated from the syringes. If present, an oil layer should also be eliminated before transfer. Once adequate graft volumes are obtained, all viable particulate fat is commingled in a single sterile cup (with several additional drops of heparin) to produce a tissue mass of confluent character and viability. The grafts are then drawn up into heparinized 3-mL syringes for transfer to the face.
A 1.5-mm single-eyed, gold-plated Tulip catheter (Tulip Medical Products, San Diego, Calif.) is attached to 3-mL syringes to deliver volume to the regions of the face that need to be addressed. A #11 blade is used to make nick incisions (1–1.5 mm in size) within the hair-bearing sideburns on each side of the face, in the oral commissures bilaterally, and within the brow, if needed. Hundreds of passes of the catheter are made to instill tiny trails of living fat graft as the cannula is withdrawn, without the application of significant pressure. A multiplanar cross-tunneling technique is employed to produce contours that are symmetrical, smooth, and natural in appearance. Photographs of the patient’s prewasted anatomic state are used for reference intraoperatively. Each wound is closed with a single interrupted 5-0 Blue Prolene suture, and bacitracin ointment is applied. Volumes instilled are carefully recorded by site to ensure symmetry.
For 2 weeks, patients are instructed to never apply ice to the face (preventing vasospasm that would block neovascularization of the graft particles), to avoid pressure or manipulation of any grafted region (preventing shape distortion), to maintain strict head elevation at 30-degrees or more (preventing excessive bruising and edema which compromise graft survival), and to refrain from lifting any object greater than 10 pounds (preventing micro- or macro-hematoma formation).
Outlining the Progression of Facial Wasting
The primary author documented anatomic findings that could easily be assessed both on physical examination and in standardized photographs to outline the consistent progression of wasting in patients with HIV facial atrophy. The schema was based on his 20-year observational experience with facial wasting in more than 600 consecutive patients. Wasting consistently occurred in an anatomically predictable manner.
Table 1 presents the progression of fat wasting from the face and the anatomic findings present on examination. Two independent observers analyzed the pre- and postoperative standardized frontal photographs of the subjects in this study for the presence of each anatomic feature and findings were tabulated.
Fourteen men with inadequate subcutaneous fat met criteria for reconstruction of facial lipoatrophy using morcellized omental fat. On examination, each patient had a protruding abdomen, suggesting that the omentum would be adequate for procurement and transfer. Table 2 outlines the clinical and surgical parameters and includes the mean values with standard deviations for age, estimated length of time from seroconversion, diameter of the umbilical incision, estimated intra-abdominal blood loss, amount of omentum harvested, and transferred volume. In all cases, the quantity of omentum was judged intraoperatively to be “adequate to abundant.” The average time required to harvest graft solely for facial transfer was estimated at less than 110 minutes, whereas mean procurement time for omental graft was 153 minutes because of additional fat harvested for secondary grafting procedures.
All patients were held for 23-hour observation except one who requested postrecovery room discharge. No patients required conversion to an open laparotomy, and no surgical sequelae required admission to the hospital. Complications included one occurrence of each of the following: transient ileus, bilateral arm pain due to positioning on the operating table, mild pressure injuries of the lower lip and buttocks (all healing within several days), and an allergic reaction to the nonabsorbable suture used for fascial closure in another case.
Patients had an average follow-up of 25 months. Before surgery, 13 of 14 patients exhibited the classic facies of HIV disease. The remaining patient (with an estimated 50% loss of facial volume based on evaluation of prewasting photographs) asked for proactive care before volume loss in the face became significant enough to disclose his status. Postoperatively, 10 of the 14 patients showed a major reduction in residual anatomic signs of the disease. Three of the remaining 4 showed noticeable improvement but continued to show anatomic signs of HIV wasting. One individual had no significant improvement as the onset of diabetes in the early postoperative period caused massive weight loss that likely compromised the omental fat grafts.
Figure 4 (case 5 in Table 2) is an example of the relative improvement seen after morcellized omental fat transfer. On preoperative examination, the maximal pinch thickness of the buccal fat was 2 mm, whereas postoperative pinch testing showed 1 cm of subcutaneous fullness.
Figure 5 documents the single patient who experienced overgrowth of the transferred graft 4 years post-op. Figure 5A shows a 2-year post-op view of the grafted face. Figure 5B shows volumetric hypertrophy in the medial and inferior buccal spaces 4 years postoperatively despite no significant change in body mass index. The patient requested and underwent microliposuction under local anesthesia to partially reduce the overgrown transferred omental adipocytes.
Patients with severe lipoatrophy display a unique disease-related facial deformity, which may be severe enough to disclose the patient’s serostatus. This archetypal facial appearance has been referred to as the “Face of HIV” or the “modern scarlet letter,”33 with all the stigma that each term carries.2,3,10,11
Because treated HIV-infected patients now have near-normal life expectancies, the need to provide facial reconstruction is real and rational. It restores self-confidence, improves quality of life,9,29 and is now considered “medically necessary” by many insurance providers, including Medicare, on a case-by-case basis. Because of the progressive nature and severity of the disfigurement, the reconstructive process is by no means “cosmetic” and should never be referred to as such. The anatomic defects are real, reconstructive options are effective, and Federal codes exist to classify both the deformity (ICD-9 codes: 738.19 acquired deformity of the face, 272.6 disease-related LD, and 042 symptomatic HIV) and the procedures performed to restore normal anatomy (bilateral autologous fat grafting of the face 20926-22 and 20926-22,50,59).
Numerous publications discuss the use of injectable fillers to minimize the deformity associated with facial lipoatrophy.2,27–29,34,35 However, these are costly, require ongoing procedures, have inconsistent long-term results,6,27,36 and only partially restore volume. Furthermore, repeated injection of fillers may cause subcutaneous scar formation (characterized as “collagen in-growth” in promotional literature from the pharmaceutical companies and in the lay-press), which hardens the cheeks and prevents more natural autologous restoration.26 Numerous studies report that AFT is a more favorable, long-term solution for restoring significant volume to the face,2,4,18,21,22,24,25 but none mentions that traditional AFT is of no value in the small subset of HIV patients who lack subcutaneous fat stores.
As an alternative for these latter individuals, the laparoscopic approach to omental procurement and extracorporeal morcellation is safe, provides adequate tissue, adds minimal morbidity to the traditional AFT procedure, and permits significant diminution of deformity. Post transfer, tissues are stable and cells remain intact. The data described above support the contention that morcellized omentum is an excellent source of fat that can be safely utilized for facial augmentation. To our knowledge, this is the first article reporting the use of morcellized omental fat transfer for restoration of volume. This technique improves facial contours in the majority of patients to minimize the “Face of HIV” and its societal implications.
Three important practical issues must be considered and discussed with patients preoperatively. First, before grafting, patients must be informed that the total volume lost from the face is greater than the volume that can safely be transferred so that appropriate expectations may be set. Approximately 45 cm3 of particulate fat can be transferred per side before overwhelming the process of neovascularization. This makes complete correction in one stage nearly impossible because most individuals with severe wasting have lost more than 60 cm3 of adipose per side. If patients desire secondary harvest, such procedures are possible. This was accomplished in 1 individual from this patient set who underwent secondary harvest and morcellization of the omentum for autologous transfer to the face 6 years after the initial omental transfer without difficulty or complications. Second, it is important that patients maintain body fat content at or above preoperative levels to experience the volumetric benefits of transplanted cells because transferred fat behaves as it would in its native location. Lastly, patients must be cognizant that, although rare, continued growth of the omentum in the postoperative period can result in excess facial fullness requiring surgical reduction.
Although biopsies of the transferred omentum have not been performed, several clinical observations provide support for long-term graft survival and the maintenance of physiologic integrity. One patient exhibited graft hypertrophy that was significant enough to require subsequent microliposuction. Against advice, 2 additional patients chose to lose weight postoperatively through diet and exercise, dropping both fat content and thickness of the grafts. One of the two regained 8 pounds, remained wasted in other areas of lipoatrophy, but experienced hypertrophy of grafted omental fat as his abdominal girth increased, showing that the transferred adipocytes maintain the physiologic properties inherent to the donor tissue.
A novel description for facial wasting using anatomic criteria allows for mapping of disease progression of facial fat that has wasted away in HIV lipoatrophy patients. This clinical tool could track disease progression and also allow for comparison of the outcomes of the various options available for facial restoration.
As patients with HIV approach normal life expectancies, the extended disease course ultimately means a growing number of individuals will experience LD and the associated deformities. Traditional AFT is the gold standard for restoration of facial form, but the use of morcellized omental fat provides an important reconstructive option for patients with no subcutaneous donor tissue. In an ideal world, studies comparing the benefits of morcellized omental fat with those of traditional fat transfer should be considered, but this is impossible in this patient population, given the absence of subcutaneous adipose tissue.
HIV routinely wastes traditional subcutaneous adipocytes and, in many cases, compensatory enlargement of a mammary ridge subpopulation of fat almost always occurs to some degree, providing a rich source for harvesting autologous fat for reconstruction. However, in rare individuals, this lipohypertrophy does not occur, and inadequate subcutaneous fat is available for reconstruction of the well-described severely wasted “face of HIV.” Mechanically morcellized omental fat transfer provides a safe and effective tool to restore facial volume in HIV lipoatrophy. This unique subpopulation of transferred omental adipocytes remains viable over time, appears to maintain volume, and has been seen to undergo post-transfer hypertrophy in at least one patient.
The primary author (D.T.) acknowledges Selene Forkes, Kathe Stennis, and Lynda Davis for dedicated operative assistance, along with many members of the administrative staff of Saint Joseph Hospital for their support of this project. Lincoln Park Anesthesia provides ongoing, compassionate, and dedicated care to this patient population. All authors thank Dr. Louis Keith for providing critical editorial insights.
All patients provided written consent for the use of their images.
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