Gluteal contour restoration in antiretroviral users and its quality-of-life related impacts : a historical cohort study

Introduction: Since the introduction of highly active antiretroviral therapy for the treatment of human immunodeficiency virus (HIV), disease mortality has been dramatically reduced worldwide. One related side effect from the use of these drugs is gluteal lipodystrophy. The aim of this study is to assess the quality-of-life impact of correcting this deformity in HIV patients. Methods: A historical cohort study was conducted between January 2010 and December 2014 with 23 patients, assessing the quality of their lives using the Nottingham Health Profile. A statistical analysis was performed using the McNemar test for related samples. Results: There was a significant difference between preoperative and postoperative response in 19 of the 38 questions. Conclusion: We may say that gluteal reconstruction plays a role in improving quality of life for HIV patients who have been affected by antiretroviral related gluteal lipodystrophy. ■ ABSTRACT


Original Article
internationally validated tool that consists of 38 yes-no questions categorized into six major areas.For comparison purposes, the test was given using two approaches: (1) to evoke respondent feelings during the preoperative period; (2) to record current respondent feelings.
Answers were compared (preoperative vs postoperative) using the McNemar test for related-samples with IBM SPSS 20 ® software.Results were considered significant at p<0.05.

RESULTS
The responses of 23 patients were analyzed.Nine of the 32 patients initially scheduled were not found by the research team through identification data obtained from hospital records.Table 1 shows a sample profile, with the patients' relative clinical features and the surgical technique used.Mean age was 45.8±8.72 years and 87% of the patients were women.The technique used was XYZ 9 in all cases, with a prosthesis median volume of 330 mL (interquartile range: 50).

INTRODUCTION
Since the introduction of highly active antiretroviral therapy for the treatment of human immunodeficiency virus (HIV), disease mortality has been reduced by about 50 to 80% worldwide 1 .One related side effect is disturbance of adipose tissue distribution, known as lipodystrophy 2 .Drugs more commonly associated with these effects are used widely in developing countries, such as Brazil 3 .
The prevalence of lipodystrophy has varied significantly in different international studies, ranging from 1% to 84% 4 .There are many risk factors associated with the development of fat distribution disorders, particularly in female patients 5 .The gender/syndrome relationship is important for plastic surgery because deformity resulting from antiretroviral treatment can become stigmatized, which will have negative impacts on the quality of life of HIV-positive women.
Evaluating quality of life in HIV patients has become crucial for clinical monitoring, as it assesses aspects which are often difficult to measure.Some protocols have been created with the aim of evaluating physical, social, emotional self-care and self-awareness 6 .Use of these instruments appears to be of fundamental importance for the evaluation of treatment in different areas of health care.
A major stigma caused by antiretroviral related lipodystrophy is the loss of gluteal contour.First performed in 1969 by Bartels 7 , gluteoplasty seeks to improve buttock contour by inserting prostheses.This technique has been improved over time by exponents, such as Mendieta 8 and Gonzalez 9 , with intramuscular and subfascial variations that optimize results and reduce complications 10 .

OBJECTIVE
The objective of this study is to assess the role of reconstructive plastic surgery in the treatment of HIV patients by evaluating gluteal reconstruction impacts on those patients' quality of life.

METHODS
A historical cohort study with HIV patients undergoing gluteal reconstruction from January 2010 to December 2014 in Hospital Nossa Senhora da Conceição, Porto Alegre/RS, Brazil, was conducted.According to hospital records, the total population included 32 patients, contacted by phone for personal interviews.
We collected data on the surgical technique, early and late complications, and postoperative evolution related issues.A quality of life survey was also conducted, using the Nottingham Health Profile questionnaire 11 , an Patients quality of life results are shown in Table 2.A significant difference was found in 19 of the 38 responses, with the following division by section: one in the energy level section, one in the pain section, nine in the emotional reaction section, four in the sleep section, two in the social isolation section, and two in the physical abilities section.

DISCUSSION
These findings support the important role reconstructive gluteoplasty plays for HIV patients with antiretroviral related lipodystrophy 12 .With nine questions presenting significant difference, the considerable impact on emotional reactions emphasizes the importance of reconstructive plastic surgery to improve the quality of life for these patients.The authors are currently unaware of any similar research published this far, and this is the first publication to scientifically prove gluteoplasty as a tool to improve quality of life for HIV patients.These data could be a stimulus to include plastic surgeons as members of the multidisciplinary team for the treatment of HIV infection.
The concept of health as complete physical, mental, and social well-being 13 reinforces the importance of humanized and comprehensive medical care.The focus on drug-related lipodystrophy patients body contour turns plastic surgery into an active element for the achievement of excellence in health care.
A study limitation here is that these data represent but a portion of the planned population, where only 23 of the 32 patients were included.This is a restricted sample, as this is a relatively uncommon procedure in the Public Health System of Brazil.We cannot say that these represent all HIV patients in the realm of those who undergo gluteal reconstruction; however, it seems illogical to consider that data with such high statistical significance could be a matter of chance.

CONCLUSION
HIV patients with drug-related gluteal lipodystrophy have achieved quality of life improvements with gluteoplasty.The restoration of body contours is effective to improve social integration, emotional balance, and other psychosocial aspects of this population.Therefore, plastic surgeons must become members of these patients' multidisciplinary health care team, intent on providing complete treatment and addressing their health with a global approach.

COLLABORATIONS GB
Analysis and/or interpretation of data; statistical analyses; final approval of the manuscript; conception and design of the study; completion of surgeries and/or experiments; writing the manuscript or critical review of its contents.

Table 2 .
Applied questions with preoperative and postoperative responses.