Important note: Information in this article was accurate in 1998. The state of the art may have changed since the publication date.
The Bay Area Reporter - November 17, 1998
Don Howard, ACT UP/Golden Gate writers pool
In the interview below, Dr. Richard Glogau, a dermatologist at the University of California, San Francisco (UCSF) discuses cosmetic treatment options for patients with facial wasting. Glogau has worked with HIV patients with Kaposi Sarcoma (KS) since the start of the epidemic, and is part of the UCSF team seeking to identify HPV-8 as the causative agent of KS.
Q. How many patients have you seen with facial wasting? What's the cause?
A. Over the last two years, I have seen at least two dozen patients with facial wasting. I never saw it to this extent prior to the advent of protease inhibitors except in patients who had severe, end-stage AIDS wasting. I don't know whether it is secondary to the drugs or whether people simply live long enough with the disease to develop the wasting now.
What is happening to patients with facial wasting?
Facial wasting is characterized by the slow, steady loss of the subcutaneous fat, loss of submucosal fat (beneath the eyes, in the cheeks, in the chin and neck), and the submuscular fat in the temples. All the compartments are similarly affected and the end result is that the skin is lying directly on the muscle fascia with no deeper compartment of fat behind it.
What are the current cosmetic options for treatment of facial wasting?
The cosmetic options depend of the degree of wasting present. Milder cases can be successfully treated with Zyderm collagen and Dermalogen, which can be injected through a 30 gauge needle. Other injectable options, such as Hyalform gel and Restylane gel, are available in Europe but not yet in the U.S. (Injectable treatments need to be periodically repeated to maintain the effect.)
Implants can be used for more severe cases. AlloDerm is a cadaver acellular collagen implant that can be placed in the subcutaneous space left behind. Other implants, such as SoftForm and GoreTex, are also available.
What are the costs? Will insurance pay?
At the cheapest, Zyderm would run about $400 a treatment and needs to be repeated every three months. SoftForm implants would run in the $3,000-and-up range and might need additional implants as the wasting progressed. So far, insurance has not covered any of these treatments that I am aware of.
What's the recovery time?
The injectables are walk-in, walk-out. The GoreTex and SoftForm have four- to seven-day recovery times.
Are new options in the pipeline?
Restylane, Hyalform, and other injectables are a year or two away from being marketed. We are waiting for the technical production of newer (larger) sizes of SoftForm, which may be available in clinical trials as early as February of next year.
What do you recommend to your patients?
It is very difficult to generalize since each case must be evaluated for the location and degree of volume loss. I think the SoftForm may offer a permanent if removable fix and simply needs to be tailored to the individual needs of the HIV patients. The sizes we currently have are essentially too small to be economically practical. Larger pieces will permit greater correction with fewer procedures. I would be happy to speak with any patients with facial wasting. Hopefully we will be in a position to offer them something [better] in the first quarter of next year.
Some people think that cosmetic treatment for facial wasting is just a quick-fix for the vain. What do you think?
Having seen my friends and associates succumb over the years to uncontrolled HIV disease, and having seen the undetectable viral loads in my patients with some of the new anti-viral agents, I would prefer that people stick with their therapies and see if we can come up with something that would help them with their wasting. It seems a relatively minor price to pay for prolonged life.
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