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Ultrasound Assisted Liposuction Reduces Buffalo Hump
  “Use of Ultrasonography-Assisted Liposuction for the Treatment of HIV-Associated Enlargement of the Dorsocervical Fat Pad”
Clinical Infectious Diseases 2003;37:1374-1377
P. J. Piliero, M. Hubbard, J. King, and J. J. Faragon
Albany Medical College, Albany, New York

SUMMARY. Enlargement of the dorsocervical fat pad (i.e., "buffalo hump") is one manifestation of the lipodystrophy syndrome associated with human immunodeficiency virus. We report our experience with the use of ultrasonography-assisted liposuction in a cohort of 10 patients with this complication. For patients who experience the development of a BH associated with HIV infection, our experience suggests that UAL represents a well-tolerated and effective treatment modality. Although, in our cohort, recurrence was common, one-half of the patients achieved a sustained reduction in the size of the BH. In lieu of other treatment options, UAL appears to be a reasonable surgical procedure. Further evaluation of UAL in larger cohorts is warranted to substantiate long-term efficacy of this procedure.
UAL is the treatment of choice for patients with a buffalo hump, according to Dr. Rod Rohrich, chief of plastic surgery at University of Texas Southwestern in Dallas and president of the American Society of Plastic Surgeons, as told to Reuters Health
"I've treated about 15 patients this way, and only in one patient did a small amount come back." But even for this patient, re-treatment was not necessary. "The key is you have to treat it fairly aggressively, and have the patient wear a compression garment to maintain pressure on the treated area for 2 weeks after the procedure."
And by reserving UAL for "fairly healthy individuals," he added, adverse effects are no more likely to be encountered than in the general population.
Fat maldistribution, also known as "lipodystrophy," is becoming an increasingly prevalent problem among patients with HIV infection. This syndrome may manifest as fat gain (lipodystrophy), fat loss (lipoatrophy), or a mixture of the two and is sometimes associated with metabolic abnormalities. Enlargement of the dorsocervical fat padcommonly referred to as a "buffalo hump" (BH)is one such manifestation. BH can be disfiguring and is associated with the development of neck pain and sleep apnea. Although the pathogenesis of fat maldistribution has yet to be elucidated, an association with the use of HAART and with HIV infection itself has been reported. BH development has been strongly associated with the use of protease inhibitors, although reverse-transcriptase inhibitors also can contribute to its formation.
There is no standard recommendation for the treatment of BH, because no prospective studies have evaluated potential treatment modalities. Pharmacological approaches, such as removing the protease inhibitor(s) (PIs) from the HAART regimen or using recombinant human growth hormone, have yielded inconsistent results. Isolated case reports evaluating the use of traditional liposuction have indicated that this procedure may be useful for treating HIV-associated BH. In an attempt to better characterize the development and treatment of BHs, a retrospective review was conducted to evaluate the use of ultrasonography-assisted liposuction (UAL) for the treatment of BH.
The Albany Medical College AIDS Treatment Center is an urban HIV clinic in northeast New York that provides care to 1200 HIV-infected patients. Clinicians were asked to identify patients who had developed a BH between 1994 and 2002 and had undergone UAL. Clinical charts were then reviewed, and the following data were abstracted and analyzed: demographic data; HIV-related data, including antiretroviral therapy (ART) history, CD4 cell counts, and virus loads; and information associated with the development and treatment of BHs. The individual patients' health care providers evaluated BH size by measuring the largest length and width of the adipose tissue mass or by describing it as small, moderate sized, or large. Most of the UALs were performed by a single plastic surgeon who obtained pre- and postoperative photographs of the BH.
UAL is a surgical procedure that is used to treat superficial and deep deposits of subcutaneous fat. This procedure allows removal of large volumes of fat and is especially useful removal of fat from fibrous areas, such as the upper back and neck. UAL involves the application of ultrasonic energy through a cannula inserted into subcutaneous adipose tissue. After the cannula is inserted, fluid is injected into the operative field. The ultrasonic energy is then applied, which effectively liquefies the fat by cellular fragmentation. This releases cellular contents into the intracellular space. The combination of triglycerides, interstitial fluid, and the injected fluid forms a stable fatty emulsion that is extracted from the subcutaneous space using vacuum suction. The specificity of sound waves for low-density tissues such as fat allows selective targeting of fat cells, without affecting the intervening connective tissue and neurovascular structures.
Clinic providers identified 10 patients6 men and 4 women who underwent 12 UAL procedures for the treatment of BH between 1994 and 2002. Patients generally noticed the enlargement of their dorsocervical fat pads, and all cases were confirmed by the patients' primary care providers. Eight patients were white and 2 were African-American; the mean age of the patients was 46 years (range, 3760 years). Five patients had Centers for Disease Control and Prevention defined AIDS, with a mean duration of HIV infection of 8.1 years (range, 313 years), at the time they developed BH. Before developing BH, patients had received ART for a mean duration of 5.4 years (range, 211 years), with a mean of 5.6 agents (range, 311 agents). The mean nadir and CD4 cell counts at the time of data collection were 139 and 400 cells/mm3 (ranges, 8497 and 111044 cells/mm3, respectively), and the mean virus load at the time BH developed was 10,445 copies/mL (range, <5095,561 copies/mL).
Nine of the 10 patients were receiving ART at the time they developed initial or recurrent BH. The components of the regimens varied. One patient developed a BH while not receiving HAART, 1 while receiving 2 nucleoside reverse-transcriptase inhibitors, 3 while receiving efavirenz-based HAART, and 5 while receiving a PI-based regimen. Seven of the 10 patients were receiving stavudine as part of the HAART regimen. Concomitant metabolic complicationswhich included dyslipidemia and dysglycemia, as well as other manifestations of fat maldistribution, such as lipoatrophywere commonly seen in our cohort.
A total of 12 UAL procedures were performed, 2 of which were for the treatment of recurrent BH. The procedures were well tolerated, without any immediate adverse effects, although 2 patients developed pneumococcal bacteremia and pneumonia 13 months after undergoing UAL. All 12 procedures were associated with at least partial reduction of the BH size. BHs returned to pre-UAL size in 5 patients, and 2 of these patients underwent a second UAL.
Although the use of HAART has been associated with dramatic reductions in HIV-associated morbidity and mortality, long-term use has now been associated with metabolic complications that may lead to additional morbidities, including dyslipidemia, dysglycemia, and hyperlactatemia. In addition, lipodystrophy can cause socially stigmatizing changes in body morphology that lead to psychological distress. One such change in body habitus is the development of an enlarged dorsocervical fat pad, which is referred to as a "buffalo hump." Whereas hypercortisolism is classically associated with the development of a BH, in HIV-infected individuals, the use of a PIcontaining HAART regimen has been the most common association. The etiology of these changes remains elusive but is likely multifactorial and includes receipt of ART and HIV infection itself.
Patients in our study had been infected with HIV for a mean duration of 8.1 years and had had significant ART experience during the course of infection. Most of our patients were receiving HAART at the time they developed BH and had achieved significant immune reconstitution.
Several authors have reported success in treating BH with traditional tumescent liposuction. Ponce-de-Leon et al. described the development of BH in a 46-year-old HIV-infected man who was receiving zidovudine, zalcitabine, and saquinavir. At the time of BH onset, his ART regimen was modified to include nelfinavir, nevirapine, and didanosine, but BH still had not resolved 13 months later. Liposuction (not assisted by ultrasonography) was performed with success. Wolfort et al. described the use of suction-assisted lipectomy to treat BH in 3 HIV-infected males. The mean age of patients in this series was 42 years, with a mean duration of PI therapy of 9 months. The procedures were well tolerated, and researchers reported patient satisfaction with the results. One case report described the use of liposuction in a 44-year-old HIV-infected male receiving nelfinavir, stavudine, and didanosine. Over the course of a 3-year period, the patient developed swelling in the subcutaneous tissue of his upper back and anterior neck. The patient then underwent successful tumescent liposuction and had an uncomplicated postoperative course. The major limitation of these 3 reports is the lack of long-term follow-up and evaluation of BH recurrence.
UAL is a relatively new procedure that offers several safety advantages over traditional liposuction and allows body contouring of fibrous areas and other body areas not amenable to traditional liposuction. Data on the efficacy of this procedure in treating patients with HIV infection is limited; however, one recently presented case series evaluated UAL in 23 patients during a 2.5-year period. Good-to-excellent responses were achieved in all but 1 patient, although recurrence of BH occurred in 32% of patients 6 months after UAL was performed. Gervasoni et al. evaluated the use of traditional liposuction in 15 patients and reported efficacy results similar to those of DeWeese et al., with BH recurrence in 1 patient after a median follow-up of 12 months.
UAL is taught to residents who are studying plastic surgery and is widely available. Reimbursement is variable, with some private insurers providing coverage when there is a medical complication associated with the BH; however, state-funded programs (i.e., Medicaid) do not provide reimbursement for this procedure. When our patients began developing these disfiguring humps, UAL was chosen as a possible therapeutic modality. Review of our cohort showed that UAL for all patients was partially successful, although one-half had recurrence with BHs that were the same sizes as those preceding UAL. Of note, all patients continued to receive ART after the procedure, which may have influenced the recurrence of BH.
All patients tolerated UAL well. However, 2 patients developed pneumococcal bacteremia associated with pneumonia 1 and 3 months after undergoing UAL. Both had received 2 previous pneumococcal vaccinations, and 1 had a prior history of pneumococcal pneumonia. It is not clear whether these cases were incidental or whether they were associated with the recent performance of UAL. A review of infectious complications associated with liposuction procedures in HIV-uninfected patients yielded no other cases of pneumococcal bacteremia.
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