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Letters to the Editor - Year2015 - Volume30 - Issue 2

An article by Dr. Dornelas, and colleagues published in this Journal (Rev Soc Bras Cir Plást. 2012;27(3):387-91) provide physicians with remarkable evidence-based data on the management of patients with HIV/AIDS lipoatrophy. However it shows an elevated nodules formation rate of 12%. This finding is in conflict with an awarded study published by Dr. Gonella1 showing a nodule formation rate of 0%. It is important to assert that both studies have similar design, and did not specifically state the average duration of time that their patients were monitored.

It must be considered that Life-expectancy increased in patients infected with HIV/AIDS with the advent of highly active antiretroviral therapy. Facial lipoatrophy is a common complication in these patients, eventually leading to stigma, segregation, and a negative impact in quality of life (QOL). An important study by the Division of Plastic Surgery, Federal University of Sao Paulo, detected improvement in the QOL of patients with HIV/AIDS and facial lipoatrophy when they were treated with PMMA2. Knowing this we must provide these patients with a safe and low-risk procedure.

Nodule formation is considered a serious dermal fillers complication, and it should be differentiated from foreign body granuloma. For nodules the treatment indicated by the literature is surgical removal, whereas for foreign body granuloma the indicated treatment is intralesional injection of corticosteroid crystals (triamcinolone, betamethasone, or prednisolone), which may be repeated in 4-week cycles until the right dose is found. This infiltration can be combined with antimitotic drugs (5-fluorouracil, or bleomycin), and antibiotics (xylitol, ceftriaxione, or ciprofloxacin) to treat the biofilm usually presented surrounding dermal fillers3,4.

Obviouslythe rate of irreversible complications using a permanent filler as PMMA is high. Because of this resorbable fillers have been studied to replace him. Hyaluronic acid has been shown to be a material with higher satisfaction on the part of patients, better predictability of results, and most importantly, with reversible complications5, and can be a safer treatment for HIV/AIDS lipoatrophy patients.

The Dr. Dornelas promising study and others like it will continue to expand our knowledge and enable physicians to safely modify practice strategies in a rational, evidence-based manner.


1. Gonella HA, Barbosa MAA, Marques BPA, Orgaes FAFS, Oliveira RR. Avaliação da utilização do polimetilmetacrilato na correção das lipodistrofias faciais associadas à terapia anti-retroviral em pacientes HIV positivos. Rev Soc Bras Cir Plást. 2007;22(1):24-9.

2. Warde M, Gragnani A, Gomes H, Hochman B, Ferreira LM. The impact of facial lipoatrophy treatment with polymethyl methacrylate in AIDS patients as measured by four quality-of-life questionnaires. Int J STD AIDS. 2011;22(10):596-9. DOI:

3. Lemperle G, Gauthier-Hazan N. Foreign body granulomas after all injectable dermal fillers: part 2. Treatment options. Plast Reconstr Surg. 2009;123(6):1864-73. PMID: 19483588 DOI:

4. Sadashivaiah AB, Mysore V. Biofilms: their role in dermal fillers. J Cutan Aesthet Surg. 2010;3(1):20-2. DOI:

5. Valente DS. Preenchedores intramusculares: qual a melhor opção, polimetilmetacrilato ou ácido hialurônico? Rev Bras Cir Plást. 2012;27(Supl 1):32.

1. Mãe de Deus Center Hospital, Porto Alegre, RS, Brazil
2. Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil

Institution: Clínica Dr. Denis Valente Serviço de Cirurgia Plástica do Hospital Mãe de Deus Center, Porto Alegre, RS, Brazil.

Corresponding author:
Denis Souto Valente
Rua Verissimo de Amaral, 580-1706, Jardim Europa
Porto Alegre, RS, Brazil Zip code 91360-470

Article received: March 24, 2013.
Article accepted: April 14, 2013.


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