Psychological morbidity and facial volume in HIV lipodystrophy: quantification of treatment outcome

INTRODUCTION HIV-associated facial lipoatrophy is a stigmatizing condition associated with significant psychological morbidity. The condition may be treated with soft tissue fillers, although quantification of objective and patient- reported outcomes is lacking. The primary aim of this study was to evaluate change in facial volume and psychological morbidity following treatment for HIV lipodystrophy with autologous fat transfer, Newfill and Bio-alcamid. An additional aim of the study was to compare psychological characteristics between HIV seropositive patients with lipodystrophy (HIV LD) and without lipodystrophy (HIV non -LD) and HIV seronegative men who have sex with men (MSM).METHODS HIV LD patients were treated with autologous fat, Newfill or Bio- alcamid based on a clinical assessment in a prospective, observational study. The Colemnan technique of fat transfer was utilised. Newfill injections were carried out at monthly intervals using 1 vial per cheek. Bio- alcamid was injected subcutaneously under aseptic technique to achieve the desired cheek augmentation. 3 -D images were obtained pre- operatively then at 2, 6 and 12 months post -operatively using the DI3D system. Volume changes in treated areas were measured using DI3D software. The DAS -24 and HADS were used to assess psychological morbidity at similar time intervals. An additional case -control study was conducted to measure psychological morbidity in HIV LD, HIV non -LD and MSM groups utilising the Derriford Appearance Scale (DAS -24) and Hospital Anxiety and Depression Scale (HADS). Data was analyzed using appropriate statistical tests.RESULTS ANOVA tests demonstrated significantly higher DAS -24 scores in the HIV -LD group compared to the HIV non -LD and MSM groups. No difference in HADS -A scores was seen between groups. 48 patients with HIV LD were treated: 16 patients had Bio- alcamid augmentation, 20 patients received Newfill injections and 12 patients underwent fat transfer. The mean injected volume of Bio- alcamid was 25.5cc The Wilcoxin test demonstrated no significant difference in mean volume change relative to zero at 2, 6 and 12 months. The mean injected volume of fat was 20.1cc, which did not differ from the measured volumes at 2 months (1)= 0.15). There was a mean reduction in measured volume of 7.3cc at 6 months and 9cc at 12 months (p <0.001). For Newfill, the mean volume change compared to baseline was 8.7cc at 2months, increasing to 12.6cc at 6 months and 12.3cc at 12 months. ANOVA tests demonstrated no difference in psychological outcomes between groups. There was a significant improvement in DAS -24 scores compared too baseline for all 3 groups throughout follow -up. For Bio- alcamid, a significant improvement in HADS -A and HADS -D scores were seen at 2 months but mean scores increased at 6 and 12 months. In the fat group, some improvement in HADS -A and HADS -D scores were seen at follow -up, although values only reached significance at 6 months. In the Newfill group, small improvements in both HADS -A and HADS -D were demonstrated in the post -treatment scores, although these did not reach significance. No correlation between change in facial volume and psychological measures was demonstrated.CONCLUSIONS The case control study demonstrated that patients with HIV lipodystrophy have greater distress relating to body image and depression compared to HIV-seropositive patients without lipodstrophy and HIV-seronegative MSM control groups. The prospective study of the HIV LD treatment cohort demonstrated a change in 3 -D measured facial volume for all 3 groups. Bio-alcamid produced the greatest, permanent volume change but was associated with the most complications. Newfill was associated with a moderate, delayed volume augmentation but was insufficient for some patients with severe lipoatrophy. Volume enhancement with autologous fat was good immediately post-operatively but variable degrees of fat resorption occurred. Treatment was associated with improved body image perception. However, initial improvements in anxiety and depression symptoms were not maintained in the long term

Application of the liposuction techniques and principles in specific body areas and pathologies

The buttocks have been a symbol of attraction, sexuality and eroticism since ancient times and therefore, they have an important role in defining the posterior body contour. More and more people are talking about and understand the meaning and the role that buttocks play in modeling and physical beauty. The three dimensional gluteoplasty (3-DGP) is an innovative technique that allows us to change volume, shape and firmness, not only in the buttocks but also in the adjacent regions such as the thighs and trochanters, becoming an ideal tool to answer the frequent reasons of consultation of our patients about this particular area of the body: ..

Evaluation of methods for measurement of facial fat in HIV infected patients with lipoatrophy

Ph.DDOCTOR OF PHILOSOPH

Features of Marfan syndrome not listed in the Ghent nosology : the dark side of the disease

Introduction: The revised Ghent nosology presents the classical features of Marfan syndrome. However, behind its familiar face, Marfan syndrome hides less well-known features. Areas covered: The German Marfan Organization listed unusual symptoms and clinical experts reviewed the literature on clinical features of Marfan syndrome not listed in the Ghent nosology. Thereby we identified the following features: (1) bicuspid aortic valve, mitral valve prolapse, pulmonary valve prolapse, tricuspid valve prolapse, (2) heart failure and cardiomyopathy, (3) supraventricular arrhythmia, ventricular arrhythmia, and abnormal repolarization, (4) spontaneous coronary artery dissection, anomalous coronary arteries, and atherosclerotic coronary artery disease, tortuosity-, aneurysm-, and dissection of large and medium-sized arteries, (5) restrictive lung disease, parenchymal lung disease, and airway disorders, (6) obstructive- and central sleep apnea, (7) liver and kidney cysts, biliary tract disease, diaphragmatic hernia, and adiposity, (8) premature labor, and urinary incontinence, (9) myopathy, reduced bone mineral density, and craniofacial manifestations, (10) atrophic scars, (11) caries, and craniomandibular dysfunction, (12) headache from migraine and spontaneous cerebrospinal fluid leakage, (13) cognitive dysfunction, schizophrenia, depression, fatigue, and pain, (14) and activated fibrinolysis, thrombin, platelets, acquired von Willebrand disease, and platelet dysfunction. Expert commentary: Future research, nosologies, and guidelines may consider less well-known features of Marfan syndrome

Facial contour deformity correction by fat injection.

INTRODUCTION: Having face most expressive part of body and becoming the need of the hour for both men and women. It instills sense of pride among individuals by not only enhancing the personality but also by boosting the confidence level of an individual. Aesthetic surgery is one of the most effective ways of improving and enhancing the facial look of an individual. Unlike earlier days, where people were skeptic undergoing cosmetic surgery, there is an increase in the number of people in India undergoing them. People‟s ifestyle, socio economic status, awareness, professional need, self -image, phases of life, globalization has motivated people towards cosmetic surgery. WHO defines health as “a state of complete physical, mental and social wellbeing and not merely the absence of disease and infirmity”. This harmony of wellbeing is lost when a person feel he is physically less attractive. The goal of aesthetic facial contour surgery is to eradicate physical characteristics that impede the free interaction of individuals. By undergoing surgery, these individuals wanted not to disavow their ethnic backgrounds or cultures but to escape being rejected by the people with whom they come in to daily contact and who decline to associate with them. AIM AND OBJECTIVES: AIM : To study the aesthetic outcome of facial contour correction surgery. OBJECTIVES: Primary Objective: To study the Aesthetic outcome of Facial contour deformity correction by Autologous fat injection, and includes ; 1. To study the patient selection factors for facial, 2. To describe operative approaches for comprehensive spectrum of facial Contouring surgical procedure. Secondary Objective: To improve the quality of life in Facial contour deformity patients by giving better aesthetic outcome. MATERIALS & METHODS: The study was conducted in the Department of Plastic Surgery, Rajiv Gandhi Government General Hospital, and Madras Medical College over a period of 26 months January 2012 to February 2014. The pro-forma for the collection of data was made. All the relevant details of the patients during preoperative, surgical, and postoperative and follow up periods were collected and analyzed. This study is a prospective and retrospective study, where 20 patients are included. Correction of facial contour deformity by fat injection by Modified Coleman’s Technique. Inclusion criteria: Those patients needing facial contouring 1. All facial contour deformities including Romberg‟s disease with no underlying gross bony deformities. 2. Post trauma and developmental facial soft tissue deformities. Exclusion criteria: 1. Post irradiation. 2. Scleroderma and other connective tissue disorders. 3. Patients diagnosed to have body dysmorphic disorder. 4. Those who are not willing to participate in my study will be excluded. OBSERVATION AND ANALYSIS OF RESULTS : In this case study of 20 patients ,with unilateral facial atrophy or contour deformity surgically managed by injecting autologous fat graft with results are good with minimal complication. Below is a chart depicting the Gender distribution, Deformity nature distribution, Donor site distribution, Average fat injected per deformity. CONCLUSION: This simplified fat injection approach with simple instrumentation, short learning curve; adherence to multi-level 3-D lattice pattern injection technique has resulted in lasting results in comparable to standard Coleman‟s technique after one time correction. This approach and our protocol is the favored method of correction for facial contour deformities with mild skeletal deformities or without skeletal deformities (Grade 1 & Grade 2 deformity). Procedure related complication are very minimal in our study and again is an encouraging aspect of our devised protocol. The problem of storing fat and reusing it for secondary correction doesn‟t even arise in our approach. Good motivated patients with expectation and desire within realistic aim, get satisfied with the goal oriented aesthetic facial contouring approaches. The number of dissatisfied patients, even with informed consent are less or nil in our study. This may be related to the time devoted with patient, explaining all possible complication in the vernacular language, with early effective remedy for complication explained and reiterated and strict to the procedure protocol to our patient in a considerate manner has brought this excellent result

Enhanced Liposuction

Liposuction began as a simple, minimally invasive method of reducing the amount of localized fat in a region. Today it is a sophisticated and complex process, with many variations in purpose and technique. In this book, a global slate of expert surgeons offers a detailed description of various minimally invasive and non-invasive options for contouring the face, neck, and body. Chapters detail the evolution and utilization of various energy-based devices and combination treatments. They also describe procedure limitations and treatment of complications. Finally, they discuss indications for various approaches with case study descriptions so readers might be assisted with treating patients in their everyday practice

Recent results of basic and clinical research in MEN1:opportunities to improve early detection and treatment

Due to the variable expression of multiple endocrine neoplasia type 1 (MEN1), it is difficult to predict the course of the disease. However, knowledge about the normal function of the MEN1 gene product, together with the effects of cellular derangement by subsequent genetic events, has increased considerably. At first, the possible existence of a genotype-phenotype correlation is discussed. Thus, mild-and late-onset phenotypes may be distinguished from more malignant phenotypes depending on the character of the primary MEN1 disease gene mutation. Subsequently, tumor-promoting factors such as gender, additional genetic mutations and ecogenetic factors may contribute to the course of the disease. New developments in management are based on the knowledge and experience of the multidisciplinary teams involved. Finally, the metabolic effects of MEN1 mutations in aged patients are discussed. Early identification of predisposition to the disease, together with knowledge about the natural history of specific mutations, risks of additional mutations and periodic clinical monitoring, allow early treatment and may improve life expectancy and quality of life

Metabolism, Morphology, and Effect of Fat Grafts - Studies on Fat Graft Browning and Therapeutic Use in the Prevention of Peritoneal Adhesions

BACKGROUND: Fat transfer is a basic technique in the field of plastic surgery, but so far, there is very little information about what happens to fat grafts after transfer. The aim of this dissertation was to determine whether the metabolically inactive white adipose tissue (WAT) used in fat grafts is transformed in the recipient area in the direction of thermogenic brown adipose tissue (BAT), referred to as beige adipose tissue (Study I and III). Adipose tissue has anti-inflammatory and pro-healing properties, which we used to determine whether fat transfer can prevent peritoneal adhesions after open abdominal surgery. METHODS: In Study I, we investigated changes in subcutaneous and intramuscular WAT grafts using PET/CT (18F-fluorodeoxyglucose(FDG) as a tracer), histology, and BAT-related Ucp1 gene expression in a mouse model. Using a mouse model, we also performed 18F-FDG-PET/CT imaging, clinical analysis, histology, and macrophage phenotyping to determine whether fat graft transfer to the injured area of the peritoneum can prevent the formation of adhesions (study II). In Study III, we used 18F-FDG-PET/MRI imaging (in cold and warm temperatures) to study the metabolic activity of the fat graft area and the histology of the tissue samples from patients who previously received fat grafts. RESULTS: In study I, we found that some intramuscular fat grafts had transformed in terms of morphology and gene expression in the direction of BAT, as a sign of browning of WAT. In study II, we found that fewer adhesions were formed in the fat graft group, and that they were looser in structure compared to the adhesion group without fat. In addition, inflammatory activity was lower. In Study III, a cold-induced increase in glucose metabolism, typical of BAT, was found in the fat graft areas. CONCLUSION: Fat grafts may transform into more metabolically active beige fat as a result of browning, which is indicated by both the tissue samples and the increase in Ucp1 gene expression (study I) and the metabolic changes after cold exposure detected by PET imaging (study III). Fat grafts can prevent the formation of peritoneal adhesions in a mouse model (Study II)

Textbook on Scar Management

This text book is open access under a CC BY 4.0 license. Written by a group of international experts in the field and the result of over ten years of collaboration, it allows students and readers to gain to gain a detailed understanding of scar and wound treatment – a topic still dispersed among various disciplines. The content is divided into three parts for easy reference. The first part focuses on the fundamentals of scar management, including assessment and evaluation procedures, classification, tools for accurate measurement of all scar-related elements (volume density, color, vascularization), descriptions of the different evaluation scales. It also features chapters on the best practices in electronic-file storage for clinical reevaluation and telemedicine procedures for safe remote evaluation. The second section offers a comprehensive review of treatment and evidence-based technologies, presenting a consensus of the various available guidelines (silicone, surgery, chemical injections, mechanical tools for scar stabilization, lasers). The third part evaluates the full range of emerging technologies offered to physicians as alternative or complementary solutions for wound healing (mechanical, chemical, anti-proliferation). Textbook on Scar Management will appeal to trainees, fellows, residents and physicians dealing with scar management in plastic surgery, dermatology, surgery and oncology, as well as to nurses and general practitioners ; Comprehensive reference covering the complete field of wounds and scar management: semiology, classifications and scoring Highly educational contents for trainees as well as professionals in plastic surgery, dermatology, surgery, oncology as well as nurses and general practitioners Fast access to information through key points, take home messages, highlights, and a wealth of clinical cases Book didactic contents enhanced by supplementary material and video