The Positive Side

Summer 2012 

From Injection to Infection

A Canadian doctor advises people with HIV who have facial fillers to take extra care when having dental work done.


In the early 2000s, facial wasting—the loss of the fatty layer just under the skin on the face, particularly in the cheeks—was a real concern for people with HIV on anti-HIV therapy. With its signature sunken cheeks and resulting gaunt appearance, facial wasting can cause a lot of psychological and emotional distress. It can affect one’s self-esteem and it carries a huge social stigma because it pinpoints people as HIV positive. Needless to say, many people with HIV who were affected by it looked for ways to improve it.

Facial wasting has been linked to the anti-HIV drugs d4T (stavudine, Zerit) and, to a lesser extent, AZT (zidovudine, also in Combivir and Trizivir). Fortunately, these drugs, especially d4T, are no longer commonly used in Canada now that other meds are available. As a result, facial wasting is much less of a problem today. Changing drugs was a way to stop the wasting but it usually ­didn’t reverse it.

Facial fillers—synthetic polymers injected under the skin to replace the lost fat—was another option. One commonly used product was poly-L-lactic acid (Sculptra). However, Sculptra is absorbed into the body after a few years and new implants are then needed. Another product used was polyalkylimide gel (Bio-Alcamid). ­Initially, it seemed that Bio-Alcamid was advantageous because, unlike Sculptra, it was a permanent implant and would not degrade. However, reports began to emerge from Western Europe of inflammation and infections in both HIV-positive and -negative people with Bio-Alcamid implants. As a result, several plastic surgery societies now discourage the use of Bio-Alcamid and other permanent implants.

Finding infections

In 2005 Sculptra was not available in Canada—it would become available in late 2009—and Bio-Alcamid was still experimental. Dr. Mona Loutfy, an infectious disease specialist at the Maple Leaf Medical Clinic in Toronto, and her colleagues set up a study with 36 participants to assess the permanent filler. The study was designed to last only two years; ­however, Dr. Loutfy began to notice infections and other complications in study participants and in other people with facial fillers. The research team decided to extend the study to four years and now has plans to continue for a total of 10 years.

In late 2011, the research team reported on the four-year study. It confirmed that the use of Bio-Alcamid can be associated with complications over the long term. Infection was one of the most common complications seen in the study. After an average of three years following injection, about one in four people had a confirmed or suspected infection in the face. In some cases, these infections were troublesome and required long-term treatment with antibiotics and surgery.

The link to dental work

Interestingly, the researchers found that people with confirmed infections had had prior dental work. It is possible that this work, which included ­routine dental cleaning, may have damaged or contaminated the Bio-Alcamid implants with bacteria, leading to infections. As a result, Dr. Loutfy recommends: “HIV-positive people who have facial implants should always tell their dentists, hygienists and surgeons—any oral healthcare professional—about their implants prior to receiving any dental care.”

She also has recommendations for oral healthcare professionals: Avoid injections into the upper gums leading into the cheek area, because they might puncture the implant and lead to infection. As well, she suggests that dentists offer their patients with facial fillers a broad-spectrum antibiotic one hour before dental work, including routine cleaning, to reduce the risk of infection.