Planning To Look Flab-u-less? Know the Facts About Liposuction
by Alexandra Greeley
A self-described athlete,
thirty-year-old Jeanne Smith of Washington,
DC, is fit, active, and happy. But like many
young women, she has felt dissatisfied with
her looks. Because she works in the medical
field, Smith knows about its latest trends and
techniques. So when friends talked about their
satisfaction with liposuction, Smith already
knew about the procedure and readily considered
its pros and cons. She decided it suited her.
She wanted some body
sculpting and knew what she was getting into. "I had basically the
lower half of my body done, and it was pretty targeted surgery,"
she says. "I experienced drainage afterwards and that's normal. I
stayed out of work for about one week, though I was active during that
time. I went to movies, out to dinner ... but was not up to my 100-percent
best."
That was more than
one year ago, and Smith says she is happy with her new trimmer look.
Or consider the case
of Robert F. Jackson, M.D., board-certified cosmetic surgeon of Marion,
Ind., and chairman of the liposuction committee of the American Academy
of Cosmetic Surgery. Himself a liposuction patient, Jackson had excess
tummy fat--a potbelly, he calls it--removed. "The day after the surgery,
I felt sore," he says, "but the pain was minimal." His
surgery took place on Friday morning, and by Monday, Jackson was back
at work.
These cases represent
two of the many individuals who have helped make liposuction the most
popular form of cosmetic surgery today. An estimated 287,000 procedures
were performed in 1999, according to the American Society for Aesthetic
Plastic Surgery. Liposuction has become the technique of choice for people
who want an improved body shape, a body sculpted to reflect their own--and
society's--ideals of physical beauty. Moreover, liposuction may be used
in conjunction with facelifts, for chin and tummy tucks, and to reduce
the size of abdomens, hips, and thighs.
"Most liposuction
procedures are done for purely cosmetic reasons," says Lori Brown,
Ph.D., an epidemiologist in the Food and Drug Administration's Center
for Devices and Radiological Health. But she adds that some medical conditions,
such as large breasts in men; lipomas, or fatty lumps; or fatty deposits
like the buffalo hump--caused by hormonal imbalances that grow masses
of fat on and around the neck--may be treated with liposuction.
But the rise in its
popularity and changes in the techniques doctors use to perform liposuction
have raised concerns within FDA. There is growing evidence that the increased
aggressiveness with which the procedure is performed--especially the amount
of tissue sucked from the body, the venues in which the procedures are
performed, and the amount of anesthesia used to sedate patients during
increasingly lengthy procedures--may be increasing the risk of post-surgical
complications and even death.
How Liposuction
Works - Conceptually, liposuction (or lipoplasty) is a straightforward
technique in which excess fatty tissue is suctioned from beneath the skin.
Prior to surgery, doctors flush the targeted area or areas with a solution
composed of lidocaine (a local anesthetic similar in its numbing effects
to novocaine), saline, and epinephrine (a drug that constricts blood vessels
and thus reduces bleeding during surgery).
Then doctors insert
a hollow wand-like device called a cannula through incisions in the skin.
They push and pull the cannula around through fatty deposits, breaking
up the cells, which, along with other body fluids, are suctioned out by
an attached vacuuming device.
It's a simple system,
says Stephen Rhodes, chief of the plastic and reconstructive surgery devices
branch in FDA's CDRH. "It's essentially just a cannula and a vacuum."
However, these products have only been approved for body contouring, and
are not intended for large-scale fat removal, an increasingly popular
use of liposuction.
There are several
liposuction techniques available today. The amount of injected fluid determines
the technique used, explains Peter B. Fodor, M.D., chief of plastic surgery
at Century City Hospital in Los Angeles and spokesman for the American
Society for Aesthetic Plastic Surgery.
In the "dry"
technique, which few doctors use anymore, no fluid is injected into the
targeted area.
For "wet"
liposuction, the surgeon injects only a small amount of fluid, about six
to eight ounces and usually containing small amounts of ephinephrine,
regardless of how much tissue is subsequently removed.
The "superwet"
technique evolved, says Fodor, because doctors found that the more fluid
they injected--up to a point--the less blood was lost. "We found
that by injecting one cc of solution for each cc of aspirate [amount of
tissue and fluid removed], the blood loss was negligible." Although
lidocaine is sometimes added when performing wet or superwet liposuction,
patients will also receive general or epidural anesthesia.
In the tumescent technique,
doctors inject up to five times as much fluid as aspirate. Because the
injected fluid also contains large amounts of lidocaine, tumescent liposuction
is generally performed with only a local anesthetic.
Many doctors are offering
a modified version of the procedure that calls for using ultrasound in
addition to the injected solution and the suctioning. Rhodes and others
at the FDA are especially concerned about this practice, which calls for
using devices not approved for liposuction--that is, special cannulas
that vibrate at high rates and emulsify fat tissue before its removal.
The wand generates a great deal of heat, and if doctors don't move it
constantly, it can cause severe burns. As Roxolana Horbowyj, M.D., senior
medical officer in CDRH, points out, a temperature increase of 20 degrees
Celsius (about 36 degrees Fahrenheit) may encourage cell death. And, as
FDA epidemiologist Brown notes, "We don't really know the long-term
effects of ultrasound on tissues."
Understanding the
Benefits vs. the Risks - In a society in which beauty is often measured
by slender bodies and youth, it is no wonder that thousands of Americans
chase the "perfect" look by means of liposuction. Portrayed
in upbeat tones and associated with Hollywood glamour, liposuction seems
to offer instant help for unsightly bulges. Consumers checking out liposuction
Web sites on the Internet are further assured by the positive information
they find.
"There are probably
hundreds of thousands of patients who have had body sculpting without
complications," says Ann Graham, senior nurse consultant in CDRH's
Office of Surveillance and Biometrics. "But we are concerned about
the published reports of patients who have not had a good outcome. They
have undergone liposuction for weight reduction, not just body sculpting.
Liposuction, in general, is a purely elective procedure. As such, our
tolerance for an unsafe or harmful outcome is extremely low."
Although many consumers
think of liposuction as a quick and permanent fix, it's likely that few
understand its risks and frequently temporary results. There is no national
group of consumers, nor one group representative of all clinicians, that
is organized to oversee liposuction procedures and results. Although FDA
is aware of problems published in medical literature and described by
other sources, "very few adverse event reports are coming into the
agency through its formal reporting channels" according to Anita
Kedas, a nurse consultant in CDRH's Office of Surveillance and Biometrics.
But the small number of reports may simply mean that negative outcomes
aren't being reported.
Office-based procedures
may present the greatest reporting problem. There's no requirement that
adverse events from office procedures be reported, and most procedures
are done in offices, according to Graham. Even if offices are well equipped,
she adds, patients often need days of continuous support such as rehydration,
pressure dressings, and good nursing care, while others actually need
resuscitation and hospitalization to recover. And if a patient goes to
the emergency room for care, FDA doesn't hear about it, adds Graham.
Whether reported or
not, liposuction problems are real enough--though some, such as wavy or
uneven skin after fat removal, are not medically serious.
But others are. Overworking
the heart can be a serious side effect of the tumescent technique. "Let's
say they plan to remove 5,000 cc's of aspirate," says plastic surgeon
Fodor, "so they inject a dangerously large amount of fluid. The patient
would be practically 'drowning' in fluids. The heart can't handle this
fluid overload."
Another potential
complication is infection, says Brown. Infections can occur after any
surgery. Sometimes, infections may be serious or life threatening such
as in cases of necrotizing fasciitis (when bacteria eat away at tissue)
or toxic shock syndrome, a serious infection which has been associated
with tampon use but may also be associated with surgery, says Brown.
Other possible problems
Brown lists are burns, embolisms, cardiac arrhythmia, edema, and nerve
compression, which are all reported in the medical literature. Often,
too, Graham notes, cannulas are inserted in several different locations,
resulting in puncture wounds that need to heal.
A condition called
seroma, or an oozing or pooling of serum, or body fluid, may be a problem
after the more aggressive ultrasound techniques during which some skin
is detached from underlying tissue and fluid accumulates in a subcutaneous
pocket.
Deaths and Liposuction
- According to a survey conducted by the American Society of Plastic Surgeons
(ASPS) of more than 1,500 plastic and reconstructive surgeons in January,
1999, the death rate of one in every 5,000 (or 20 out of 100,000) liposuction
patients between 1994 and 1998 was much higher than anyone anticipated--higher
even than death rates from traffic accidents. And higher than acceptable
death rates from other kinds of surgeries, admits Jack Bruner, M.D., associate
clinical professor of plastic surgery at the University of California,
Davis, and chairman of the task force on liposuction for ASPS. Although
the survey data are not considered scientific information, they are useful
when establishing practice guidelines, and they led ASPS to recommend
some practice changes when performing liposuction.
It is encouraging,
Bruner says, that more recent statistics from The Doctor's Company, an
insurance company located in California, show that no liposuction-related
deaths have been reported there in the last 18 months. However, he notes,
this survey only addresses what's happening among board-certified plastic
surgeons, not with other doctor groups performing liposuction.
Deaths among liposuction
patients can happen for a number of reasons, Bruner says, including thromboembolism,
or a blood clot that forms in the deep veins of the pelvis or legs. "That
can happen during any surgery," he adds, "and I wish I could
say that it is always preventable, but it is not." Next, he cites
perforation of the abdominal wall or bowels, the latter being especially
serious. "If you perforate the bowel, there's a high mortality rate
if it's not fixed in the first 24 to 48 hours," he says. Physicians
are essentially blind as they perform liposuction because they can't see
what is in front of the cannula, notes FDA's Horbowyj.
Finally, Bruner notes
that shock and hemodilution, or diluting of the blood, may lead to a patient's
death. This can occur when patients have had large amounts of fluids injected
and then both fat and fluids removed, about 11 pounds worth in all during
a larger-scale procedure.
Further, although
virtually no hard data exist, says Bruner, he and others worry that too
much lidocaine may also lead to death. Lidocaine use poses particular
hazards, especially since experts do not agree on safe injectable levels.
"If you get too much lidocaine for too long," says Bruner, "the
heart muscles become lazy. On the other hand, the brain becomes very agitated
at first, which may cause a seizure, before coma sets in."
At least one study
links possible lidocaine toxicity to liposuction deaths, says Horbowyj,
adding that people with less than normal liver function or those who have
been drinking alcohol may not be able to metabolize lidocaine well.
After Surgery
- Patients should expect discomfort post-surgery, says Graham. "Patients
are bloated, have wounds all over, and are feeling distended."
Surgeons, says Bruner,
should discuss such conditions with their patients beforehand. "We
talk about excessive bruising and chronic and prolonged swelling,"
he says. Anytime there's an injury--and liposuction surgery is really
a controlled injury--body fluid rushes to the site and the injured tissue
becomes like a sponge, he explains. With liposuction, doctors have gone
under the carpet of skin and have taken away the fat undercoating, so
the raw surface oozes serum on the inside.
To control the swelling,
Bruner has his patients wear a garment with elastic pressure, reaching
from below the breast area to mid-thigh. "This gives good compression,
and if we don't do that, the body swells up like the Michelin man,"
he says. The skin sticks to the undersurface, and as it starts to heal
the fluid stops oozing and the swelling goes away. "At the end of
three weeks, 90 percent of the swelling and bruising are gone," he
says, although patients may wear the elastic garment for up to six weeks.
Is Liposuction
for Everyone? - Many people develop stubborn fatty deposits--like
in the buttocks or upper thighs, or the so-called "love handles"--that
are resistant to dieting and exercise. And although most people would
admit to wanting to reshape their body in some way, not everyone makes
an ideal liposuction candidate, says Daniel Morello, M.D., president of
the American Society for Aesthetic Plastic Surgery. Morello stresses that
liposuction is for body contouring, not weight reduction. "It is
designed for removing localized areas of fatty tissues--not as a substitute
for proper dietary management and exercise."
But what happens to
the mildly to seriously overweight people who want and get liposuction?
Sometimes after the surgery, these people may face yet another unwanted--and
possibly unexpected--complication: the return of fatty deposits, but probably
in other areas of the body, says C. Wayne Callaway, M.D., an associate
clinical professor of medicine at George Washington University. Callaway,
who is also an internist, endocrinologist, and obesity specialist in Washington,
D.C., sees post-liposuction patients complaining of renewed accumulations
of fat.
Animal studies have
shown that if you remove significant amounts of fat from one area, body
fat increases elsewhere, according to Callaway. "The signal is leptin,
a hormone made in fat cells," he says. "The more fat you have,
the more leptin is made ... and if a large amount of fat is removed, there
is a drop in leptin levels." In animal studies, this drop in leptin
levels results in an increase in food intake and a decrease in activity
until the leptin levels are up again, according to Callaway.
Callaway says that
the people who have the most trouble after a liposuction procedure are
the really obese who have had large amounts of fat removed. "They
have a compensatory increase in new fat cells," Callaway says. "And
fat goes to areas where there are still a lot of fat cells. So that means
to the neck, above collar bones, and the upper abdomen." Besides,
he adds, abdominal obesity is controlled by a whole other set of signals,
so that even after liposuction, the underlying causes for obesity remain.
"Those causes are not addressed by taking out fat cells." He
points out that, contrary to recent theories, "One can keep making
new fat cells throughout life, so little can be gained by liposuction."
Liposuction for obese
patients is "a prescription for disaster," according to Gerald
Imber, M.D., a plastic surgeon in New York City and clinical assistant
professor of plastic surgery at Cornell-Weill Medical College. The greater
the volume of fat and tissue fluids, including plasma, that are sucked
out, the greater the chance of severe dehydration and electrolyte imbalances.
"When you remove six, eight, or ten liters of mixed fat and water,
you are courting disaster," he says. "Liposuction is not meant
to change a size 16 to a size 8."
According to a consensus
of the experts, the ideal liposuction candidate is a mature adult between
the ages of 30 and 50 years old, male or female, in good health, who has
dieted and exercised to lose unwanted pounds, with good skin tone, with
a set of realistic expectations, and who wants a limited procedure for
body contouring.
Fighting fat may be
the number one battle for many Americans, but liposuction may not be the
best weapon to win that slimmer, trimmer body.
Alexandra Greeley is a writer in Reston, Va.
Buyer Beware - Anyone considering liposuction should
consider all the options, and consumers need
to be very careful when selecting a doctor.
The saying "caveat emptor" (buyer
beware) has never been truer, says Morello.
Liposuction sounds so deceptively simple, but
in the hands of unskilled doctors, it poses
a real threat to people's health, he adds. To
complicate matters, anyone with a medical degree
can perform liposuction, even with only the
briefest weekend training period.
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