We would like to thank Dr. Pavlidis and colleagues for their interest and comments regarding our article.1 Our experience with autologous fat in the treatment of human immunodeficiency virus–associated lipoatrophy is similar to theirs,2 with difficulties in obtaining the graft in these patients, who usually are very thin. Also, the variable and unpredictable resorption rates are an inconvenience when using this autologous filler. Related to this problem, we have read with great interest about the possibility of enhancing graft survival by adding platelet-rich-plasma or adipose-derived stem cells to the fat.3 Trials using this treatment have described enhanced fat survival and increased angiogenesis, and have resulted in fewer cysts4 because of growth factors contained in the platelet-rich-plasma. However, to date, the literature comparing these treatments has shown inconsistent results, with some finding no differences at all between enriched fat and graft fat alone.
In our opinion, the most important advantages of autologous fat are the long-lasting results and the low complication rates. Our study reveals that despite requiring general anesthesia and an operating room, it is the most cost-effective procedure. Other studies also support these findings.5 This is a point of great importance in our country, in which facial lipodystrophy is treated by the public health care system. Temporary fillers such as hyaluronic acid have shown good results for this indication6; however, because of the repeated injections needed and the elevated costs of the materials, this filler is not approved in our country. For this reason, if a synthetic filler is needed, we would choose a permanent filler such as polyacrylamide (Aquamid; Contura International, Søborg, Denmark) that in our hands has shown satisfactory and stable results over time.
In conclusion, our opinion is that permanent fillers are the best option to treat this chronic condition of human immunodeficiency virus patients, with autologous materials being the best option. Further studies are needed to improve resorption rates and stability of the graft, when possible by the addition of other autologous materials such as platelet-rich-plasma or adipose-derived stem cells.
The authors have no financial interests to disclose. No funding was received for this communication.
Alfonso Vallejo, M.D., Ph.D.Angela A. Garcia-Ruano, M.D., Ph.D.Department of Plastic SurgeryUniversity Hospital Gregorio MarañónMadrid, Spain
1. Vallejo A, Garcia-Ruano A, Pinilla C, Castellano M, Deleyto E, Perez-Cano R. Comparing efficacy and costs of four facial fillers in human immunodeficiency virus-associated lipodystrophy: A clinical trial. Plast Reconstr Surg. 2018;141:613623.
2. Pavlidis L, Sapountzis S, Spyropoulou GA, Demiri E. Fat grafting to the hand in patients with Raynaud phenomenon: A novel therapeutic modality. Plast Reconstr Surg. 2015;135:229e230e.
3. Xiong BJ, Tan QW, Chen YJ, et al. The effects of platelet-rich plasma and adipose-derived stem cells on neovascularization and fat graft survival. Aesthetic Plast Surg. 2018;42:18.
4. Jin R, Zhang L, Zhang YG. Does platelet-rich plasma enhance the survival of grafted fat? An update review. Int J Clin Exp Med. 2013;6:252258.
5. Shuck J, Iorio ML, Hung R, Davison SP. Autologous fat grafting and injectable dermal fillers for human immunodeficiency virus-associated facial lipodystrophy: A comparison of safety, efficacy, and long-term treatment outcomes. Plast Reconstr Surg. 2013;131:499506.
6. Ho D, Jagdeo J. Safety and efficacy of a volumizing hyaluronic acid filler for treatment of HIV-associated facial lipoatrophy. JAMA Dermatol. 2017;153:6165.