Changes to Your Face (Facial Lipoatrophy) : What are facial fillers?
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Generally speaking, facial fillers are injectable—or surgically inserted—products that can be used to fill hollows in the face, such as those caused by lipoatrophy. Both temporary and permanent facial fillers are available. Temporary fillers usually last from three to 12 months (sometimes longer) and usually require touch-ups to maintain their results. Permanent fillers provide long-lasting benefits, but generally cannot be removed in the event of unhappiness with the results.

Two temporary facial fillers have been approved by the U.S. Food and Drug Administration (FDA) for the correction of HIV-associated lipoatrophy: Dermik's Sculptra and BioForm Medical's Radiesse. Several other temporary and permanent facial fillers are available, both within the United States and internationally, but have not been specifically reviewed and approved by the FDA for this purpose.

Here's a look at some of the available facial fillers:

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Temporary Fillers
Radiesse: This product contains a synthetic version of calcium hydroxylapatite, a substance found in bones and teeth. Radiesse was approved for the correction of HIV-associated lipoatrophy in December 2006. It costs approximately $1,500 per office visit, depending on the amount of Radiesse needed and the treatment fee charged by the specialist. BioForm Medical, the manufacturer of Radiesse, has set up a patient assistance program (PAP) to provide the filler, at a reduced cost, to HIV-positive patients who meet certain eligibility requirements.
 
Sculptra: This filler contains poly-L-lactic acid, a synthetic product that has a long history of use in reconstructive surgery. Sculptra was approved for the correction of HIV-associated lipoatrophy in August 2004. It costs approximately $1,500 per office visit, depending on the amount of Sculptra needed and the treatment fee charged by the specialist. Dermik Laboratories, the manufacturer of Sculptra has set up a patient assistance program (PAP) to provide the filler, at a reduced cost, to HIV-positive patients who meet certain eligibility requirements.
 
Autologous fat transplant: This procedure involves taking fat from one part of the body (such as the butt, hips, inner thighs, or abdomen), cleaning and filtering it, and injecting it into another part of the body, such as the face. Considered to be the most natural of all the facial fillers, and harvested fat can be stored if touch-ups are needed in the future. However, fat can be difficult to harvest from other parts of the body, especially in HIV-positive people with advanced lipoatrophy lacking in subcutaneous fat. Injected fat can sometimes become abnormally enlarged (hypertrophy); this is more often seen in patients who have fat taken from existing "buffalo humps" to fill hollows in the face. Autologous fat transplants do not require FDA approval, but should be performed by a Board-certified plastic surgeon with experience correcting lipoatrophy using this approach. Autologous fat transplants cost approximately $3,000.
 
Collagen (Bovine: Zyderm and Zyblast; Human: CosmoDerm and CosmoPlast): Collagen has been used for more than 25 years for cosmetic purposes in the United States, most notably as a filler for facial wrinkles. Because it has long been approved by the FDA for this purpose, it was one of the first products evaluated and used in HIV-positive people with facial lipoatrophy. Bovine collagen is derived from calf skins; human collagen is grown in test tubes using human tissues. If bovine collagen is used, an allergy test is required before the product is injected into the face. While not specifically approved for HIV-associated lipoatrophy, bovine and human collagen is widely available and many cosmetic surgeons have experience using it. The average cost, per session, is approximately $600.
 
Hyaluronic Acid (Restylane, Perlane, Hylaform): Hyaluronic acid is naturally found in human connective tissues. These three brands are synthetic versions of hyaluronic acid and have been designed to prevent rapid breakdown by the body. Not specifically approved for the correction of HIV-associated lipoatrophy, but widely available. Restylane/Perlane costs approximately $1,500 per visit, depending on the brand and volume of hyaluronic acid needed and the treatment fee charged by the specialist.

 
Permanent Fillers
Polymethylmethacrylate (PMMA; Artefill, Precise, Metacrill): PMMA is best known for its use in manufacturing hard contact lenses and Plexiglas. These products contain small particles (microspheres) of PMMA. Artefill also contains bovine collagen; Precise and Metacrill do not. After it is injected, the body produces collagen that surrounds the PMMA microspheres. The PMMA molecules and the surrounding collagen persist indefinitely. The FDA has approved Artefill for the (non-HIV) correction of facial wrinkles, lines, and furrows. Precise and Metacrill have not yet been evaluated by the FDA; most HIV-positive people treated with either Precise or Metacrill accessed the drug in Mexico or Brazil. The cost varies, depending on the brand used, the amount of filler needed, and travel expenses (if choosing Precise or Metacrill).
 
Polyalkylimide (Bio-Alcamid): Bio-Alcamid is a synthetic product that can be injected using a high volume. There is very little experience testing or using Bio-Alcamid in the United States. However, it has been used in Europe, Canada and Mexico for cosmetic and reconstructive purposes. There have been reports of infections in the tissue cavity containing the Bio-Alcamid, sometimes years later, as well as reports that the Bio-Alcamid has migrated downward into the jowls. Removal of Bio-Alcamid is possible, if necessary. Total costs of approximately $4,500—including travel, the necessary amount of product, and injections—have been cited.
 

Polyacrylamide hydrogel (Aquamid): Aquamid is a synthetic product that is bound around water molecules and is has been used primarily for filling in smaller to moderately sized areas. It is said to be permanent, though the longest studies have only gone on for 11 years. Aquamid is not approved for use in the United States, but has been used primarily in Europe. Studies in people with HIV-related lipoatrophy showed good results in Italy and Spain. The product can be removed soon after application if required. It is available in Mexico, and the average cost for the volume of the product typically used to treat facial lipoatrophy is $2,000.

Silicone Oil (Silikon 1000, VitreSil 1000): Silicone comes in solid formulations and liquid formulations. Solid silicone is rarely used for facial lipoatrophy. Silicone oil is more commonly used, but its safety and effectiveness for cosmetic purposes are still controversial. At present, silicone oil is approved for eye repair only; it is still being investigated for facial augmentation. Once injected, it cannot be removed. The cost is highly variable, depending on the amount of silicone oil needed and the fee associated with the injections.
 
Expanded Polytetrafluoroethylene (ePTFE) Implants (Gore-Tex, Gore S.A.M., SoftForm): These solid implants require minor surgery, via a small incision, under local anesthesia. They have been used for many years to help restore deep facial defects and may be useful for HIV-associated lipoatrophy in terms of filling large, sunken areas. Some experts believe that ePTFE should be used in combination with other fillers, particularly those that spark collagen production. There is a risk of post-operative complications, including infection and scarring, and the procedure can be expensive—approximately $2,000 per cheek.

It is important to recognize that the product selected is only one factor in the success of treatment. Anyone undergoing restorative therapy for facial lipoatrophy should be treated by an expert, meaning a Board-certified plastic surgeon or dermatologist with experience using the product selected to treat the facial lipoatrophy. Just as it is important to make sure that a product has been documented to be safe and effective, it is also important to ensure that a qualified and experienced medical provider performs the procedure.


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