Smoothing body contours

By Katherine Nichols
Advertiser Staff Writer

From left, surgical nurse Donna Sasaki, anesthesiologist Elliot DeMello and Dr. Robert Schulz perform a liposuction on a patient at Straub. The procedure is popular among women and men alike. Richard Ambo • The Honolulu Advertiser

It's a scene acted out several times a day in Hawai'i. Liposuction — a surgical procedure in which fat is vacuumed from beneath the skin — is the most popular plastic surgery procedure in the United States among women and men.

The Plastic Surgery Information Service reports that 201,083 women had the procedure done in 1999, up from 41,074 in 1992. In 1992, about 6,138 men had liposuction. By 1999, that number had increased to 29,782, almost five times as many patients.

In the operating room at Dr. Robert Schulz's Straub Clinic and Hospital office, he checks photos of the patient on a nearby light board and examines markings he has drawn on her outer thighs, indicating target areas. Then he injects a saline solution with a local anesthetic into the area. At his signal, a nurse hands him a scalpel. He makes one small incision to create a portal into the area he will suction.

Schulz inserts the cannula —a long, thin suction probe — under the skin, into the fat. Using the probe, he tunnels into the area in several different directions, creating a "honeycomb" pattern to minimize bruising and the development of lines in the skin. Then he connects the cannula to the suction machine and inserts it in the same incision; the tunnels he has made enable the instrument to reach the entire upper thigh through one small opening. The physician makes multiple passes quickly, with the same movement one might use to scrub a floor, not only removing the fat but also damaging some remaining fat and fibrous cells.

Slowly, fat (shaded crimson by a small amount of blood) bubbles its way through the surgical tubing into a clear container that measures the amount taken. Occasionally, a sound similar to the end of a milkshake rising through a straw fills the room.

Liposuction was invented in the mid-1970s and gained popularity after it was introduced to U.S. surgeons at a conference in Honolulu in 1982. However, according to Dr. F. Don Parsa, a plastic surgeon for 20 years and chief of plastic surgery at The Queen's Medical Center, the public still misunderstands what liposuction can do.

"They think they will walk in (the office) and walk out looking like the models" they see on the liposuction Web sites, said Parsa, who is also chief of the Division of Plastic Surgery at the John A. Burns School of Medicine. "It doesn't work that way."

For most, he said, "the degree of improvement these patients will obtain definitely does not warrant the great risks they are taking."

Candidate for surgery

So who is a candidate for this surgery? "If they have generalized obesity, they should never consider liposuction," said Parsa, who estimates that he turns away 90 percent of the people who request the treatment. "It is absolutely not a solution."

Instead, he urges patients to lose weight through diet and exercise under the supervision of a physician.

"However, despite weight reduction, if they still maintain a fatty bulge in areas of concern (abdomen, thighs, chin, etc.), then they might consider liposuction," he said. "The procedure is intended to improve body contour — not to reduce weight. That's why it's only indicated in patients who have localized fatty deposits that create disharmony in body contour."

In fact, Parsa said, "generalized obesity is a very strong risk factor for any type of surgery." If high blood pressure, heart disease, smoking and heavy drinking are also involved and too much fat is removed at once, "you're multiplying the risks to a very dangerous level."

"It's not an operation for people who have too much weight on board everywhere," agreed Schulz, a plastic surgeon for more than 20 years who estimates that about 30 percent of his liposuction patients are male. "The ideal candidate is someone who has a difficult fat pad to mobilize, someone who doesn't lose or gain weight symmetrically," he said.

Schulz said that a doctor should first advise dietary counseling.

'In love with myself again'

A 56-year-old Honolulu woman (who didn't want her name used) spent $7,000 on liposuction and a "tummy tuck" when her metabolism shifted after menopause.

"I just didn't like the proportion," said the woman, who has always watched her weight. Five days after the procedure, she said, she had already noticed a significant difference.

"I know once the swelling goes down, I'm going to be in love with myself all over again. If I maintain my weight now, I'm going to be happy," she said.

Is a patient ever too thin for liposuction? Parsa and Schulz agreed that it depends on the individual.

"The specific area must be examined," Parsa said, "and if it can be realistically improved and will make a significant difference in body contour, and a physical examination based on height and weight determines that there is no generalized obesity, and there are no ... factors such as heavy drinking, smoking, asthma, high blood pressure, diabetes or heart disease, then liposuction may be performed."

Once again, realistic expectations, good communication between the physician and the patient, detailed pre-operative counseling and a thorough physical examination are essential, the doctors said.

Before surgery, Schulz draws a topographic map on the body while the patient is standing up, sketching out the areas to be suctioned, because when the body is lying on a table, all references change. Sedation may be local or general, depending on the area to be suctioned and duration of the procedure.

Before and during the procedure, he checks the photos posted on the light board in the operating room and monitors the progress by feel, sight and measured volume of the removed fat, relying especially on pinching the area between two fingers and visual balance.

Both physicians favor a small-diameter cannula, which Parsa said "requires more passes, but allows the fatty deposits to be removed more evenly and provides a smoother contour."

With a larger cannula, especially when the patient has minimal amounts of fat, Schulz said, one pass too many can cause dimpling or other defects. Oversuctioning can create large dents or scarred portions in the skin.

Recovery is often less difficult than with other cosmetic surgeries. In the operating room, doctors and nurses help dress the patient in a localized compression garment — otherwise known as a "zipper body girdle" — which must not be removed for three days and nights (there is an area cut out to facilitate restroom use). After that, the girdle should be worn for two to three weeks, day and night, but can be taken off for showers.

Depending on areas suctioned, patients can often resume low-level physical activity after about five days. "There will be some discomfort," Parsa said, "but it usually doesn't interfere with activities."

Recovery was quick

The Honolulu woman admitted discomfort, but returned to work four days after the operation.

"I feel like I could play tennis now (five days post-op)," she said.

More vigorous exercise can be resumed when the patient feels ready — often in a couple of weeks — though Schulz said patients sometimes report feeling small pulls and twinges for up to three or four months. Other possible side effects include bruising, swelling and temporary numbness.

The procedure is cosmetic and not covered by insurance. Depending on the extent of the procedure, cost ranges from $2,000 to $7,000.

The potential risks are severe. Before considering the procedure, patients should find a reputable plastic surgeon certified by the American Board of Plastic Surgery with experience performing liposuction. But well-selected patients, Parsa said, generally are extremely satisfied with the results.