Forum on Facial Wasting

Skinny legs on Combivir

Sun, 23 Oct 2016 21:48:44 -0400

Q: Been on antiretroviral therapy for 10 yrs(combivir and stocrin Iam okay not sick it's only that I lost body fats on my legs. Is there anything I can to gain body fats?Thembi (South Africa)

A: One thing that would be useful would be to have the Combivir changed to an alternative anti-retro viral medication. Combivir contains AZT, which is a medication that has been linked to loss of body fat.You can discuss this with your healthcare provider to see what other options are available.Good luck!

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facial wasting in Boston

Sun, 23 Oct 2016 21:42:19 -0400

Q: is there and coverage for people on medicare and mass health for people with facial wasting that want injections. if not what are the costs and how long do you wait till next treatment? thank You James Boston

A: Hello and thank you for posting.Massachusetts recently adopted regulations that mandate insurance coverage facial fillers for HIV related facial lipoatrophy. Medicare has covered facial fillers for lipoatrophy, but not many clinics offer this treatment because of insufficient reimbursement.I don't know of any clinics or doctors in Boston that provide access to facial fillers for people with facial wasting. I am looking into this and will update this post if I find an access point.

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Conflicting information about risk of lipo

Sun, 23 Oct 2016 21:35:57 -0400

Q: Hello, doctor. I bet plenty of us recently diagnosed keep hopping from one website to another looking for reassurance. Dr. Joel gallant says lipo is a thing of the past but Dr. Keith and yourself say sometimes that there is likelihood of that happening. I take Atripla, 24y.o., nadir cd4 of 600 and now UD. Like, am I safe? Should I fight for more modern therapies that don't take NRTIs, and are they the cause? Brazil will soon have dolutegravir in first line, so maybe that'll help.

A: Hello and thank you for posting.Lipodystrophy is much less likely to occur with current medications like Atripla. However, it still may develop, but it is likely that the degree of lipodystrophy not be as severe and it may take many more years to develop.There is much interest in NRTI-free regimens because they may be associated with less long-term toxicity.Dolutegravir has certainly emerged as a very potent and safe medication for treatment of HIV infection. Whether this medication will take th...

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Reversability of lipoatrophy?

Sun, 16 Oct 2016 17:09:45 -0400

Q: Hello,I was diagnosed in 2010. Since then, I have taken Norvir, Epivir, Isentress, and Prezista. In that time, the contours of my face have changed. My doctor has decided to prescribe one of the one pill a day medications. Will these side effects reverse with the change in medication?

A: Hello and thanks for posting. It is very difficult to answer this question without knowing what on the once a day pill is that you are being changed to. As a general rule, the regimen you were taking is not particularly known for causing lipoatrophy, so switching to a new simpler medication would be unlikely to reverse the changes.

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coolsculpting OK with HIV

Sun, 16 Oct 2016 17:02:40 -0400

Q: Hi Doctor Pierone,I am considering a Coolsculpting intervention. I often read in 'waivers' the mention that Coolsculpting is not suited for people with HIV. Why is that ? Are there any real risks ? I read in one of your previous contributions you helped an HIV patient through Coolsculpting. So I am a bit confused here. Can I proceed with such treatment or should I refrain from it ? in certain circumstances ? Thanks for your feedback.Alex from Brussels (Belgium)

A: I can't think of any reason that Cool Sculpting would not be an appropriate intervention for people living with HIV. I have treated patients with no problems. Good luck!

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Excess of PMMA. Need to remove/reduce

Sun, 16 Oct 2016 16:59:33 -0400

Q: Hello dr Pierone!Would you please let me know who are the best doctors/surgeons around the world for PMMA removal? Do you do removal? I have been overfilled with pmma. My cheeks look whey too big, puffed and asymmetrical. It's so frustrating and it's causing such a negative effect on my life. As I'm a lean guy, having big cheeks makes my face look not proportional to my body. And having one side bigger than the other is just making me look like a freak. I really want to remove the PMMA out of my...

A: Hello and thanks for posting. I am sorry to hear about your experience with PMMA and being overfilled. The first step to reduce volume from PMMA injection would be a series of injections with triamcinolone and 5FU. This combination is usually sufficient to reduce the volume enough to avoid surgery. Another non-surgical approach to reduce PMMA volume is the use of Ultherapy micro-focused targeted ultrasound. If this does not work, then there are some surgeons who have experience with removal of ...

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Weight loss on isentress and kivexa

Sun, 10 Jul 2016 22:35:02 -0400

Q: Hello,I was diagnosed in August 2015 and was immediately starting with isentress and kivexa. A month later I was undetectable. About 3 months after starting of the treatment I started feeling like my facial tissue is a little looser. Now almost a year later I get comments about being losing drastic amount of weight from people who didn't meet me for months. As I'm naturally lean I always said I'm just always been thin but I know it must be the pills. I then read that kivexa can be causing "sunke...

A: Hello and thanks for posting. Kivexa is a combination of two nukes lamivudine and abacavir. This class of antiretroviral medications is most closely associated with lipoatrophy. Isentress is neutral from a metabolic perspective. It would be reasonable to try Isentress + Intelence as an alternative regimen. This would be a combination of a non-nucleoside reverse transcriptase inhibitor and integrase inhibitor. Another idea would be to use the combination of Norvir/Prezista and Isentress as a nuk...

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Radiesse Cost

Mon, 30 May 2016 00:29:32 -0400

Q: Hi Dr. Pierone,I have been receiving Radiesse injections for a couple of years, after problems with lumps from Sculptra. My insurance carrier actually has paid for about 80% of the cost. I have been very pleased with my provider, but the last time I saw him he came into the room with the Radiesse but then said he would not do the procedure because the insurance company would reimburse much less than 80% of the cost of the Radiesse, and he "Couldn't afford to lose money". I agreed with him, al...

A: Hello and thanks for posting.I don't think I can adequately answer your question because we have mostly failed in our attempts to get insurance coverage for lipoatrophy. But here goes. Most of my experience with Radiesse involves the patient access program. Our patients typically qualify for this program based on their limited income and they pay about $80 per syringe for the product. Then we charge a sliding scale for injecting the Radiesse (usually $100 to $200 per session). For patients...

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Lipohypertrophy - fat deposit under rib cage

Mon, 30 May 2016 00:17:25 -0400

Q: Hello Dr. Pierone: Briefly my story is that I contracted HIV in 1978, so have been poz now for 38 years. When meds that actually worked started coming on line in the late '90s, I thought the worst had passed. Then, around 2001 my weight dropped from 186 athletic pounds to 97 "walking death" pounds. Medi/Medi would not approve me for Serostim at that time. It took many months and all sorts of alternative treatments to strive back to around 150. Then I plummeted again, this time to 92 lbs. I final...

A: Thanks for sharing your story. I am sorry to hear about the latest challenge you are facing. Lipohypertrophy often involves the back of the neck, the so called "buffalo hump". But these odd fat deposits may occur in other sites as well. For example, I have seen them develop in the upper abdomen, sides of the chest, and just above the pubic bone. You mentioned liposuction and this approach should work. Liposuction involves using a cannula inserted through a hole in the skin to suction out the u...

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Aluvia -lipoatrophy???

Sun, 29 May 2016 23:59:15 -0400

Q: Hi. Ive been on aluvia and lamivudine tenofovir for almost a month now.Ive been noticing my legs and arms get thin as well as my face..Though ive been hitting the gym and trying to eat more. Is this because of the meds? Does lipoatrophy still happen today? Help pls.

A: Hello and thanks for posting. Aluvia is also known as Kaletra. Lipoatrophy still does occur, but not as often as it used to when AZT, d4T (Zerit), and ddI (Videx) were used. The nukes lamivudine and tenofovir are more closely linked to lipoatrophy than protease inhibitors like Aluvia. Have you lost weight or might there be another reason you might be getting thinner? Lipoatrophy is generally a very slowly progressive condition that plays out over years, not in the short time interval of a mont...

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Bioalcamid removal

Mon, 25 Jan 2016 00:35:43 -0400

Q: I had the bioalcamid in one cheek inflame following dental work. Two attempts to aspirate failed. Left with 2 - 3 cysts, swollen just above jawline.Want product completely removed.Best method?Thanks

A: If aspiration with a needle did not work on two occasions, then it seems unlikely that a third attempt with be the charm. So the best approach would be to find a facial surgeon to perform a surgical procedure to remove the product. The method would likely entail having a skin incision over the cysts, removing them and the Bioalcamid and then closing up. Another possible approach might be to make an incision inside the mouth and remove the cysts and residual product in that manner. It would reall...

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What is the average cost of Sculptra?

Mon, 25 Jan 2016 00:28:06 -0400

Q: I found sites (docshop) that say Sculptra should cost about $600 per session and that the doc fees should be about 300-500 more per session (or $1,100 per session). I see higher quotes on another site (realself?). If, as I was told, I need 5-6 sessions, how much should I expect it to cost with just Sculptra? And how much more would some Radiesse for the orbital sockets typically run? Lastly, assuming best case scenario/outcome, how soon and then frequently would maintenance injections be neede...

A: Hello and thanks for posting. I think $1000 per session is a ballpark figure for Sculptra (for 2 vials). If you have severe lipoatrophy then 5 or 6 sessions could be necessary for optimal improvement. I do not think that Radiesse would be the best choice for orbital eye socket volume replacement. A product like Restylane or Bellafill would be more predictable and appropriate for that location. Typically Restylane is about $500 per syringe and Bellafill about $800 per syringe. In the best cas...

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substitute for AZT?

Mon, 25 Jan 2016 00:19:22 -0400

Q: I ve been taking nevirapina/ lamivudine/ zidovudina for 15 years and it had always worked well ,, what could I replace zidovidina with in order to avoid more facial waste?

A: Zidovudine is also known as AZT and Retrovir. It is also a component of Combivir and Trizivir. It is rarely used anymore because if increased side effects compared with newer medications. An easy switch would be to have the zidovudine stopped and tenofovir (Viread) used instead. I hope that this information helps and best of luck to you!

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Wipe that AIDS off my face?

Wed, 20 Jan 2016 11:33:47 -0400

Q: Do I have face lipodistrophia? You re the doctor who treated that guy that says " I wan to wipe out that aids off my face". Could I send you a picture of me?

A: Yes, I did treat Mark King, blogger and HIV activist. Here is a link to the Huffington Post articleI may be reached at gp@verobeachdoc.com if you would like to send a facial photo. Best, Dr. P

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PMMA facial fillers or check implants?

Wed, 20 Jan 2016 11:27:22 -0400

Q: Dr. Pierone, I would like to know if PMMA fillers are safer that checks implants, Thanks, Dr.O. Perez

A: Hello and thanks for posting. There are no studies that I am aware of that directly compare PMMA to cheek implants for restoring volume. Both procedures are effective in restoring long-term cheek volume and of course both have potential risks. There are a few risks associated with cheek implants (this is true for chin implants or temple implants as well) that I have seen. The first is that surgical operations carry risks of bleeding and anesthetic risks, although anesthesia has become much safe...

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PMMA for buttock volume

Wed, 20 Jan 2016 11:08:47 -0400

Q: I had PMMA injections done 4 shape my butt everything on fulness is great but lower part of butt is a Lil flat...could I fix it with my own fat 2 fix or would it cause me a health risk..I jst wanted 2 shape a Lil & lift

A: Hello and thanks for posting. There should not be significant health risks associated with having your own fat used for grafting to fill in buttock volume deficits. The persistent challenge with autologous fat grafting is the unpredictability of this treatment. Sometimes the transplanted fat stays long-term with great results. On other occasions, some of the fat stays in one area, but recedes in another with resultant lumpiness. Another outcome is that all the fat dies and the results last just...

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Would pmma go down a little, after a few years?

Thu, 05 Nov 2015 21:37:39 -0400

Q: Hi doctor Pierone! I had pmma injected on my cheeks about 1 year and a half ago (that time was the final touch up) and I have been overfilled. My cheeks look a bit uneven and I feel like they're too big, giving me an unnatural look. I'm aware that pmma is a permanent filler, but I'm hoping and wondering if it would go down or diminish after some time. I may consider having facial lipo suction in order to remove some of it, but I'm really afraid to do it. It hasn't changed at all since a year ago...

A: Hello and thanks for posting. PMMA is a permanent filler and typically would not diminish or increase in size over time once the implant is stable. Since your last treatment was over a year ago it is highly likely that your implant is stable. One approach that will diminish the size of a PMMA implant is to inject a corticosteroid directly into the implant. The corticosteroid has anti-inflammatory activity and will typically reduce the size of the implant by reducing the volume of the non-PMMA co...

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Facial and TOTAL body wasting

Wed, 04 Nov 2015 11:59:31 -0400

Q: My Partner has been Poz for over 30 years. After taking AZT for 6 years, and Zerit for 4, he lost almost all his body fat. He is 5'8" and only weighs 110 pounds. He has a lot of issues from having so little fat. Are there any experimental treatments for him that you know of? Can you suggest ANYBODY for him to talk to? Thanks for your time!

A: Unfortunately I don't know of any experimental treatments for total body fat restoration. Sometimes an inability to gain weight (and fat) may be due to other medical conditions that may occur along with HIV infection. Examples would include thyroid disorders, nutrient malabsorption, and loss of appetite from medication-related side effects. Sometimes agents to stimulate appetite may be useful Marinol, marijuana, cyproheptadine, and Megace may help with appetite. I wish we had a means to revers...

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PrEP and lipoatrophy

Tue, 03 Nov 2015 15:55:08 -0400

Q: I was able to get a script for PrEP and I think I figured out how to get it covered by insurance, but my PCP scared me when he said that lipoatrophy is a potential side effect of PrEP.I am finding very little credible information on the Internet to indicate if this is a realistic side effect. Is this a realistic side effect? If so, is there a test or something to detect it early before it becomes serious? I was considering making an appointment with an Infectious Disease specialist to get more i...

A: I have not seen any studies on the risk of lipoatrophy with PrEP. The risk of lipoatrophy is certainly lower with Truvada as compared with older antiretroviral medications, but it may still occur. I don't know of any medical practices that measure facial volume as a means to identify facial lipoatrophy at an early stage, this approach would be considered experimental. I suppose one could do scheduled periodic facial MRI scans or facial ultrasounds and measure tissue thickness. Another strategy w...

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Is PMMA buttock treatment no longer available in 2015?

Thu, 29 Oct 2015 01:50:17 -0400

Q: I was investigating PMMA injections for correction of buttock lipoatrophy, deciding that Dr. Casavantes was the one based on my history of following facialwasting.org and THE BODY. However Dr. Casavantes website only addresses facial wasting treatments. No mention of buttock treatment exists on his website. A Dr. Garza in Monterey, Mexico is mentioned on facialwasting.org's site, but his practices website is not confidence inspiring in the least. I do not think I will go to Dr. Serra in Rio...

A: Hello and thanks for posting. Although Dr. Casavantes does not perform buttock treatment at his clinic he has an associate physician Dr. Palmira Morales who does perform this procedure. http://www.drcasavantes.com/meet-our-team/Best, Dr. P

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Sculptra providers

Sun, 25 Oct 2015 22:12:26 -0400

Q: For the past 5 yrs or so I had a provider that accepted Medicare to treat my facial wasting. I qualified for two viles of sculptra every six months now they won't accept. Medicare anymore. Are there any providers in the Denver area that still accept Medicare? The sculptra assistance program will only approve two viles (one kit) every two years which is woefully inadequate to treat my condition.

A: I agree that the patient access program limit of 2 vials of Sculptra every 2 years is woefully inadequate. I do not know of any providers in Denver who accept Medicare. You will have to do some research on this question. You might check with the company, your medical provider, and local HIV support organizations. Good luck!

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What Works Fastest and Last longest?

Sun, 25 Oct 2015 22:09:51 -0400

Q: Hi, I've been HIV positive since 2003. I have been on several regimens which seem to have emaciated my cheeks and face. I don't have the money for expensive procedures. Can you tell me which procedures, fillers, etc. are usually covered by Medicare PPOs? Also, of those, which acts the fatest and last the longest? Thank You

A: Hello and thanks for posting. The two facial fillers that have been approved for treatment of facial lipoatrophy in the United States are Radiesse and Sculptra. Medicare does provide for payment for both of these fillers when there is depression related to the lipoatrophy. Medicare PPO's vary considerably, so I would suggest that you check with the plans that are available in your geographic location. I suspect that the first challenge would be to find a provider who has experience with Sculptr...

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Can Non-HIV Issues Contribute to Facial Wasting? (Editor's Pick)

Mon, 07 Sep 2015 22:47:13 -0400

Q: I was diagnosed HIV+ end of 2015, all my blood values were pretty good, until I learned just a few months ago that despite having good CD4 count and still way beyond 100.000 viral load (it was the first time I had a all time high of 25.000 since December 2015 where I almost stayed below 6.000) it is advised for everyone to start treatment.Which I just did this month August 20th, 2015 (keeping a diary at hivprogress.com).Now here comes my question: before I got diagnosed I experienced a very stre...

A: Thanks for posting. Your narrative is important because it highlights the fact that facial thinning occurs in other medical conditions. I have seen people lose facial fat during acute illness and also from a chronic condition like gluten hypersensitivity. The regimen that you are on confers a low risk of lipoatrophy. The risk is not zero, but there is no question that facial lipoatrophy is much less prevalent now compared with a decade ago. The only generic recommendations that I can offer are t...

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After 10 Years, Another Round of Sculptra? (Editor's Pick)

Mon, 07 Sep 2015 22:34:24 -0400

Q: Dear Doc: I was able to benefit from Sculptra a decade ago, receiving several rounds from Dr. Jon Jarman here in Atlanta. Very Thankful for the Patient Assistance Program! Actually, received my first treatment as a "Show and Tell demo-patient" before the PAP was rolled out. I'm totally sold on the results from previous treatment, and writing to ask if there is any danger, or if I'd still be of benefit some years later. (If I can come up with the physician's fee ) I'm a stroke survivor as well. ...

A: Hello and thanks for posting. The Sculptra patient access program is still active, but is in a state of flux since Galderma acquired the filler from Valeant. Sculptra remains a safe and effective treatment for lipoatrophy and there is no reason that you would not derive benefit from it. Good luck!

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How fast does Facial Wasting kick-in

Sun, 22 Feb 2015 23:51:45 -0400

Q: Dear Dr. Pierone,I was diagnosed positive in June and started in September my meds treatment: Prezista, Truvada, Norvir.In an effort to "stay healthy" I am training 4-5 hours of week - and really enjoying it keeping my spirits up. I take Whey protein as well. I am in good shape, but would like to loose a few kilos so I am watching what I eat. Especially cut down on Carbs - (though I dont hold back on the weekends :)I have lost about 1.5 kilos in the last month. This shows a lot on my face.....

A: I suspect that the facial volume loss that you are seeing is more related to the weight loss rather than exposure to your antiretroviral regimen because you are so new to the treatment course. There is a fairly low risk of lipoatrophy with this combination, but most of the time it takes at least several years before facial wasting becomes apparent. There is some suggestion in clinical trials, but not definitive proof, that avoiding nucleoside/nucleotide antiretroviral medication (like Truvada or...

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