Background: Lipodystrophy syndrome, including metabolic and body-fat abnormalities, is common among adults infected with HIV who are receiving highly active antiretroviral therapy (HAART). These abnormalities may manifest as facial lipoatrophy or central adiposity, including a dorsocervical fat pad (or "buffalo hump") and truncal fat. Along with fat redistribution, these drugs are associated with insulin resistance, hyperlipidemia, and cardiovascular complications. Therefore, elective plastic surgery in these patients necessitates a comprehensive pre-operative assessment and vigilant post-operative management.

Objectives: To provide practical strategies for safely facilitating elective cosmetic surgery in HIV-positive patients who are receiving HAART.

Study Design/Methods: Case report and review of the literature.

Results: A 49-year old, HIV-positive female receiving HAART underwent ultrasonic liposuction of a buffalo hump, micro-fat injections for facial lipoatrophy, and abdominoplasty. Postoperatively, the patient developed flash pulmonary edema secondary to a hypertensive crisis. The patient was successfully resuscitated in an ICU setting, with aggressive diuresis and anti-hypertensive management. Postoperative outcome measurements were otherwise similar to those reported in lipodystrophy patients.

Conclusions: With the advent and widespread use of HAART, HIV-positive patients are living longer, and in increasing numbers seeking elective, cosmetic surgery. Operative intervention in these patients can prove dangerous, if not deadly, as HAART increases the risk of systemic arterial hypertension, pulmonary hypertension, pericardial effusion, and coagulopathy. Ultimately, the atherogenic effects of HAART promote acceleration of coronary heart and cerebrovascular disease and enhance the risk of myocardial infarction and stroke. Pre-operatively, plastic surgeons caring for HIV-infected adults should assess important disease indicators such as cardiovascular risk factors, viral load, and CD4 T-lymphocyte counts. After evaluation, risk reduction should be targeted. Post-operatively, means such as continuous cardiovascular monitoring and strict management of hypertension may be employed to minimize morbidity. We present an algorithm for plastic surgeons to safely treat lipodystrophy in HIV-infected patients.
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