Purpose: Once considered to be associated with a high rate of mortality, infection with human immunodeficiency virus (HIV) now carries with it a much greater chance of asymptomatic long-term survival, in large part due to the increased use of highly active antiretroviral therapy (HAART). Prolonged use of antiretroviral medications has been shown to cause significant alterations in fat metabolism, characterized by regional lipoatrophy or excess fat deposition. Enlargement of the cervicodorsal fat pad—resulting in a “buffalo hump”—is among the most disfiguring of these disorders. Several studies have identified suction-assisted lipectomy (SAL) and ultrasound-assisted liposuction (UAL) as effective ways of removing the cervicodorsal fat pad. These methods, however, are associated with significant rates of recurrence or the need for multiple procedures to achieve desired results. We have utilized power-assisted liposuction (PAL) in the surgical management of HIV-associated cervicodorsal lipodystrophy and have found it to be a superior method of treating the buffalo hump compared to SAL and UAL.

Methods: We conducted a review of prospectively obtained data from the medical records of five HIV-positive patients who underwent PAL for treatment of a buffalo hump. Charts were reviewed and the following data points were studied: age at time of presentation, sex, duration since initial HIV diagnosis, CD4 count and quantitative viral load at presentation, HAART regimens received, medical comorbidities, volume of tumescent solution infiltrated, volume of lipoaspirate, estimated blood loss, and incidence of immediate or delayed surgical complications. Preoperative and postoperative photographs were reviewed. Patient and physician satisfaction with overall cosmetic and functional results were compared. Particular attention was paid to the rate of lipodystrophy recurrence and the need for secondary operations.

Results: Five patients underwent PAL for treatment of cervicodorsal lipodystrophy at our institution between 2003 and 2005. All patients were male. Patients ranged in age from 36 to 60 years, with a mean of 48 years. The mean duration of documented HIV infection was 15 years (range, 7-23 years) at the time of presentation. The duration of HAART therapy ranged from 3 years to 13 years with a mean of 6.4 total agents (range 2-9 total agents) over that time. All patients had been treated with combinations of Nucleoside Reverse Transcription Inhibitors and Protease Inhibitors. The mean tumescent solution infiltration was 597 cc (range, 300 -1000 cc), with a mean lipoaspirate volume of 554 cc (range, 250-900 cc), and an estimated blood loss (EBL) of 88cc (range, 25-150 cc). There were no post-operative complications and all patients were pleased with their final result. The mean follow-up was 7.3 months (range, 2.5- 16 months) with no recurrence of the lipodystrophy during this time.

Conclusions: Numerous authors have commented on the fibrous nature of the buffalo hump and have favored ultrasound-assisted liposuction (UAL) to treat cervicodorsal lipodystrophy. Potential downsides to the use of UAL include the risk of dermal burns and necrosis at the sites of suction and access, hyperpigmentation, sensory alteration, contour irregularities and seroma formation due to excessive cavitation, and a longer learning curve relative to other liposuction techniques. In this series we have found PAL to be particularly effective in the aspiration of the highly fibrous and septated fat of the buffalo hump, with less operator fatigue, shorter operative times, and fewer complications when compared to traditional SAL and UAL.
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