What Doctors Don't Tell YouQ-A friend of mine is thinking of having liposuction. I wonder if you or any of your readers have any experience of it as I understand some of the results are less than satisfactory. She wants to reduce her thighs and buttocks. She is 52, 6 foot tall and weighs about 16 stone plus. LW, Brighton…….
A-For an example of less than satisfactory results, your friend has to look no further than the recent headlines of the former male model who decided to have liposuction on his face to hollow out his cheekbones. The procedure went wrong, and he was left with a gaunt and bumpy face, a condition only alleviated by his putting on enough weight to add extra fat to his face. So, not only is he unable to model anymore, but he now has to remain permanently overweight just to look normal.
Liposuction, or ‘suction assisted lipectomy’, is an operation whereby a plastic surgeon makes a number of unobtrusive incisions, inserts a little suction device with a variety of metal tips and literally hoovers up your fat.
Plastic surgeons and dermatologists who perform this procedure, also called ‘liposculpture’, pride themselves on improving a patient’s contours, usually around the lower abdomen, the buttocks or the thighs. In this regard, your friend and her lower body make a typical customer.
In the US, the land of the quest for physical perfection, liposuction rates as the most popular form of plastic surgery, with some 400,000 procedures performed each year.
Recently, dermatologists have developed an outpatient procedure called ‘tumescent’ liposuction, which is considered a great advance over earlier techniques, which required a hospital operation, anaesthesia and blood transfusions (fat contains up to 3 per cent blood; the old style operations called for transfusions when more than 2500 cc of fat was suctioned). This new technique can be carried out in a doctor’s office, with the patient only consciously sedated. The unwanted fat cells are injected with several quarts of fluid containing lidocaine, a local anaesthetic, and epinephrine (adrenaline) to minimise the bleeding. The doctor then makes a few discreet keyhole incisions (say, behind a buttock fold) and sucks out the fluid drenched fat cells.
An even newer technique allows doctors to use high frequency sound waves to ‘liquify’ fat cells so that they can then be removed via a low pressure suction device.
Ironically, the fatter you are, the less likely you are to benefit from this procedure. Those with an extremely large abdomen or slack skin (say, after pregnancy) often look worse after the procedure as they are left with a large fold of excess skin. Older patients often find that their skin becomes loose and unsightly once the fat beneath it is removed. Another well known side effect is bumpiness where the contour is left irregular a side effect which often occurs, as it did with the male model, where there are fat deposits that adhere very closely. Plastic surgeons estimate that about 30 per cent of their patients will return for ‘touch ups’ to clean up bumpiness or uneven contours once the swelling and bruising have gone down, which can take several months.
But these are only the aesthetic mishaps. The graver issues surround the potential medical dangers of liposuction. In 1999, a New York team of researchers identified five deaths from liposuction among the 48,000 plus deaths reported to the Chief Medical Examiner between 1993 and 1998. All five involved the tumescent outpatient procedure. Three of the patients had experienced a sudden and drastic drop in blood pressure and heart rate, which was quickly followed by cardiac arrest. Of the two remaining deaths, one patient died due to fluid overload when the fluid filled her lungs. The other woman, who weighed 225 pounds, died 18 hours after surgery when a blood clot, which had developed in her leg, travelled to her lung (N Engl J Med, 1999; 340: 1471-5). As the researchers bluntly concluded: this procedure can “kill otherwise healthy persons”.
Although the cause of death may be unclear, the researchers suspect that the underlying problem is the anaesthetic. Patients undergoing the procedure receive up to eight times the doses of lidocaine normally used for local anaesthesia. The received wisdom on this procedure has been that the lidocaine, when injected into fat tissue, enters the bloodstream too slowly to do any harm. But once the liver is saturated a situation which can be brought on when other sedatives are also used blood levels can soon rise and lidocaine toxicity results.
Other doctors maintain that there have been no deaths from tumescent liposuction when local anaesthesia has been used (Dermatol Surg, 1995; 21: 459-62); the problems have occurred, according to Dr Darrell Rigel and Ronald Wheeland, two American dermatologists, when anaesthesia was combined with heavy sedation, when an excessive amount of fat was removed or when the doctor attempted other cosmetic surgery at the same time (N Engl J Med, 1999; 341: 1000).
Once the New York cases were publicised, other deaths from liposuction began to emerge. In San Diego, California, the Health and Human Services Agency identified six cases of cardiac arrest or severe hypoxaemia between 1992 and 1996, again associated with outpatient liposuction. Four of the patients had respiratory difficulty and cardiac arrest after the operation, and one had respiratory difficulty during the procedure. The sixth patient reacted to the anaesthetic, possibly in combination with the sedative, and went into cardiac arrest before the operation even got underway.
The San Diego Health Department concluded that the deaths from liposuction that get reported represent only a fraction of the total, since many are done in outpatient clinics or states other than those in which the patients reside (N Engl J Med, 1999; 341: 1000).
Besides reactions to the anaesthetic, another potentially life threatening complication is infectious cellulitis followed by necrotising fasciitis (skin death). Doctors from the H™pital Henri Mondor in Creteil, France, reported four cases in three years of women who were admitted to hospital with high fever and painful inflammation in the areas where they’d had liposuction performed. Three of the four had skin necrosis and one went into septic shock. Bacterial pathogens, such as group A streptococci, were isolated. Although antibiotics resolved some cases, others required surgical excision of the necrotic (dead) tissue and skin grafts (N Engl J Med, 1999; 341: 1000-1).
Serious infection and necrotising fasciitis is a recognised, though rare, side effect (Am J Surg, 1996; 64: 458-60) thought to affect 0.34 per cent of all liposuctions, although these figures could be conservative (Dermatol Surg, 1995; 21: 459-62). In two cases of massive necrotising fasciitis treated in a burns centre, one patient died and the other required skin grafts on 22 per cent of his total body surface area (Plast Reconstr Surg, 1989; 84: 628-31).
Accidential puncture of major organs by the suction device may result in haemorrhage. In one case,a patient sustained multiple injuries to the small intestine during the procedure (Ann Plast Surg, 1997; 38: 169-72); in another case, the patient went into shock and cardiac arrest after multiple lacerations to an artery caused peritoneal haemorrhage (N Engl J Med, 1999; 341: 1001). The risk of death from this type of internal bleeding is more than 50 per cent (Plast Reconstr Surg, 1993; 92: 1085-98).
According to one study, the complication rate for liposuction is 0.1 per cent, with 60 per cent of deaths caused by pulmonary thromboembolism. However, as these data came from a voluntary questionnaire sent to doctors (a fraction of whom responded), the true risk may be much higher (Ann Plast Surg, 1988; 20: 562-5).
Dermatologists would probably advise your friend not to undergo this procedure because of her age and size. As many dermatologists and surgeons point out, liposuction is not a substitute for weight loss nor is it appropriate for obese patients. (In fact, three of the five New York patients who died weighed more than 200 pounds). It is intended for patients with localised fat that stubbornly refuses to disappear through dieting or exercise.
Although the lower abdomen, thighs and buttocks have the best success rates, less predictable results occur with chins, ‘love handles’ and knees. Another issue is the state of her skin, since slack skin will only worsen if you remove the fat.
Finally, you may wish to try to talk her out of undergoing this potentially dangerous procedure as a first port of call. Besides diet and exercise, she should investigate any allergies she may have. Allergies cause tissues to become waterlogged and are a major cause of overweight.
If your friend is still determined to go ahead with the procedure, make sure that she seeks out the most experienced doctor with the best credentials. Any doctor can call himself a plastic surgeon; make sure that your doctor has full accreditation as a surgeon or dermatologist and that he has done hundreds of these procedures safely. Caution her to avoid anyone claiming miraculous transformations. And, finally, despite the claims of doctors that the tumescent outpatient procedure is safer, it may be prudent to have the procedure done in a hospital, which will have to hand all the emergency equipment needed should something go wrong.
A final caveat is to keep in mind that all plastic surgery is temporary. Even with liposuction, fat tends to redeposit in its favoured positions. As one American doctor put it: “Patients can eat faster than I can suck.” (Newsweek, August 16, 1999).
Maryon Stewart
Daniel Redwood DC
Tom Ferguson MD