BEFORE AND AFTER PHOTOS
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What Is the Ideal Body?
In centuries past, the female form has been somewhat heavy in many cultures, a sign of health and nutrition. This full form has given way in the last few decades to a lean look, albeit with full breasts. This combination is unusual in nature. Few women are naturally endowed with an enviable lean physique and full breasts. Similarly, few men are endowed with the physique of Michelangelo’s David, who did not have “love handles”!
What Are Healthy Body Proportions?
Healthy premenopausal women have waist-to-hip ratios of 0.67 to 0.80. This means that their waist circumferences are seven to eight-tenths as large as their hips. A healthy man’s waist-to-hip ratio is between 0.85 and 0.95. Moderate weight gain does not alter these basic male and female shapes, and they are found all over the world among people who vary considerably in height and weight.
Men have an innate preference for female bodies with narrow waists and full hips, which signal high fertility, high estrogen, and low testosterone. Cartoon characters and virtual images of females like Jessica Rabbit (Who Framed Roger Rabbit, 1988) and Lara Croft typically have exaggerated proportions. Barbie (at least the original Barbie) has measurements of 36-18-33, with a 0.54 waist-to-hip ratio. Audrey Hepburn and Marilyn Monroe represented two different images of in the 1950s. Yet, the 36-24-34 Marilyn and the 31.5-22-31 Audrey both had versions of the hourglass shape and waist-to-hip ratios of 0.70. During the 20th century, Miss America and Playboy centerfolds’ waist-to-hip ratios measurements ranged from 0.68 to 0.72. By the end of the 20th century, the average supermodel measured 33-23-33, giving her a 0.70 waist-to-hip ratio.
The Miss Americas of the 1960s were 5'6" tall and weighed 120 pounds. Twenty years later they had gained 2 inches in height but remained the same weight. Playboy playmates also dropped several pounds and gained several inches in height during the same period, dipping from 11% below the national average to 17% below it. Even the Columbia Pictures logo, the torch-bearing woman, was slimmed in 1992.
Presently, 64% of American adults are overweight, defined as having a body mass index of 25 or greater, and 31% are obese, having a body mass index of 30 or greater.
Body Shape Is Hereditary
It comes as no surprise to most of us that our body shape resembles other family members. Women sometimes refer to the “apple shape” or “pear shape” to describe less than ideal proportions. Our body fat distribution and number of fat cells is determined genetically. By the time we are adults, the number and distribution of fat cells in our body is unchanging. The exception occurs only at extremes of weight. When we gain weight, our existing fat cells swell and when we lose weight they shrink. But, their number and distribution remain the same. This fact explains why we find that our dimensions are reduced after weight loss, and increased with weight gain, but our body proportions stay about the same. Women with a pear shape (also unfavorably compared to a bowling pin) may find that they can drop from a size 8 to a size 6, but jeans are still tight on the thighs and loose at the waist. No amount of exercise and fat burning can overcome genetics. As a consequence of this fact, even professional athletes, body builders, personal trainers and aerobics instructors have liposuction.
Pregnancy and Body Shape
Pregnancy does not permanently alter body fat proportions. The tummy is stretched out, of course, and the body swells during pregnancy, but there is no net gain or loss of fat cells. This fact explains why, after losing their weight after pregnancy, women find that their body shape is unchanged. The abdominal skin and muscles have been stretched, so the skin tone will not be as tight as it was, and there is likely to be some degree of abdominal “pooch” due to stretching of the muscles, but even in the tummy, there is no fat that was not there before.
Achieving Ideal Body Proportions
Our major tool to achieve optimal body proportions is liposuction. As you explore the procedures in this section, you will learn how you can take advantage of body contouring options to enhance your appearance beyond what is possible with a healthy diet and exercise alone.
Adults have a fixed number of fat cells, and the only way to remove these fat cells is by liposuction. This provides permanent correction of body disproportions. Contrary to rumor, any weight gain after surgery is evenly distributed all over the body—it does not return specifically to the treated areas or accumulate instead in untreated areas.
Illustration of the effects of weight loss and gain on body shape (above) before and (below) after liposuction. The number of fat cells has been permanently reduced in the treated areas. After surgery, the patient is trimmer in the treated areas than she would have been without liposuction, whether she gains or loses weight. Fat cells enlarge and shrink with weight gain and loss, but do not change in number.
Liposuction and Body Weight
Patients often remark, “I heard that if you have liposuction on the hips and thighs, when you gain weight you’ll gain it in other areas, like your face and your arms.” This is not true. Think of it this way: the rest of the body does not know that their fat cell neighbors in the love handles have “left the building.” Their size is simply determined by how many calories get delivered to them. They will swell if the body consumes more calories than it burns, or shrink if the body burns more calories than it takes in.
Does the Fat Come Back?
An article that was published in the Obesity Journal in 2011 suggested that fat removed by liposuction of the lower body returns later to the upper body, making women look disproportionate. An illustration in the New York Times showed a drawing of a woman looking like the Incredible Hulk after liposuction. No woman wants to trade lower body fat for upper body fat. There were a number of problems with the study including weight gain by subjects, inaccurate measurement techniques, small patient numbers and nonsignificant findings. In addition, there is no known physiological basis for such a fat redistribution mechanism. Rigorous photometric analysis reveals no distribution of fat (Swanson E. Photographic measurements in 301 cases of liposuction and abdominoplasty reveal fat reduction without redistribution. Plast Reconstr Surg. 2012;130:311e–322e; discussion 323e–324e). Measurements showed long-term improvement in body proportions after liposuction and tummy tucks with no subsequent fat accumulation in treated or untreated areas.
So, how does a rumor like this get started? One possible explanation is that people rely on their clothes as a guide to when to cut back on calories. After liposuction, their clothes fit more loosely because fat cells in these areas have dearly departed. So it is possible that they may gain weight until they fit clothes like they did before. Only now they are fuller in other parts of the body that were not reduced with liposuction, like the face and arms.
These patients see me in follow-up and say, “Doctor, I’m disappointed. I really didn’t notice that big of a difference after liposuction.” Before any further discussion, these patients are asked to step on the scales. Invariably, they weigh more, sometimes 10 pounds more, than they did at the time of liposuction. Of course, they should weigh less, not more, because the fat that was removed at surgery weighed several pounds, and sometimes as much as 10 pounds. Patients are invariably surprised when they learn of this weight gain.
So the patient has actually gained weight since the surgery, compromising their reduction from liposuction. In fact, if they had not had liposuction, they would likely not be able to fit into their pants. Patients ask, how did I gain that weight? Likely they gained weight because they were less active, but continued eating the same way. More calories, less exercise equals weight gain. Plus, their usual “alarm”—tight fitting clothes—did not alert them to cut back.
Fortunately, the outcome can still be a favorable one. Because the number of fat cells is fixed, there is no permanent harm done by temporary swelling of the fat cells. But, the patient needs to return to full activity and proper diet. When the weight returns to normal (the same as at the time of surgery or less), the patient will better appreciate the results of liposuction. With good behavior, the result just gets better and better.
I usually take photographs at least 3 months after liposuction. This allows enough time for the swelling to go down fully. Ideally, the patient will weigh the same as what they did on the day of surgery, or even a little less, accounting for the volume of fat removed by liposuction. This is about 2 pounds per liter. So if a patient had 3 liters (3000 cc) of fat removed by liposuction, she should weigh 6 pounds less when the swelling has gone down. Therefore, to appreciate the results of liposuction without any compromise due to postoperative weight gain or loss, this patient should weigh 6 pounds less than on the day of surgery, when the postoperative photographs are taken.
Liposuction and Fat Cell Removal
Another popular misconception surrounding liposuction: “If I gain weight it will just come back and I will have wasted my time and money having liposuction.”
Certainly, if any benefit realized by liposuction was lost the next time we put on 5 pounds, there would be no point in having liposuction in the first place. But, the results are still there at the heavier weight. The patient will always fit into her clothes better than she would have without liposuction, regardless of how much she weighs, for the rest of her life because there are fewer fat cells in the treated areas. And when she loses the 5 pounds, her shape returns to what it was right after liposuction. In fact, it is impossible to lose the benefit of liposuction, even if she wanted to do so, barring extreme weight gain. (At extreme weight the fat cells reach the limit of their capacity to expand and will start making new fat cells to hold the additional fat.)
Patients sometimes look at me with a degree of skepticism when I explain this, but they need only look at long-term results to see that this is true. They understand the concept once they understand that fat cell numbers are genetically determined and do not change during weight gain or loss. The only way to change fat cell distribution is by physically removing them using liposuction (or adding by fat injection). Liposuction permanently improves body proportions. This capability is the reason liposuction has been the most popular cosmetic operation of the last couple of decades.
Most patients are attentive to diet and exercise after surgery and lose rather than gain weight. By correcting body disproportions, patients experience a psychological benefit, and find that they are better motivated to maintain their improved body form.
Although liposuction has been used to treat obesity, it is now recognized that this is not the best application of liposuction. In very obese patients, the volume of fat and fluid removed may be much larger (well over 5 liters), making fluid management more difficult, and increasing the risk. Furthermore, the difference in body contours is proportionately less, making the procedure less worthwhile. Also, these patients have not developed good eating habits and exercise regimens (obesity speaks for itself) so that they may be more likely to gain weight after surgery, particularly if they are even less active.
Patients with a “beer belly” are the worst candidates for liposuction. These patients have very protuberant abdomens, but there is minimal subcutaneous fat. There is not much surface fat to grab. Almost all the fat is on the inside the abdomen (“intraperitoneal”), wrapped around the organs and therefore inaccessible to liposuction. These patients are understandably disappointed, but are sorted out early in the consultation. They are glad to be told candidly that they are not good candidates so they do not waste their time and money having a procedure that is unlikely to help much. I recommend professional weight loss counseling. Dieting and weight loss is the only way to reduce a beer belly.
Health Benefits—Reduced Triglycerides and White Blood Cell Count
Patients sometimes ask if there are any long-term health risks associated with liposuction. For example, how does it affect cholesterol levels? Liposuction has no effect on cholesterol levels (Swanson E. Prospective clinical study reveals significant reduction in triglyceride level and white cell count after liposuction and abdominoplasty and no change in cholesterol levels. Plast Reconstr Surg. 2011;128:182e–197e). This finding is not surprising because fat cells do not manufacture cholesterol. However, they do contain triglycerides. People with high triglyceride levels experience a 43% drop in triglyceride levels, on average. A surprising and unexpected study finding was that white blood cell counts are reduced 11% on average after liposuction. Although there are no studies to indicate that these favorable changes are associated with health benefits, there is evidence that high triglyceride levels and high white blood cell counts are unhealthy, so the news is welcome.
Triglyceride levels in liposuction patients with preoperative levels greater than or equal to 150 mg/dl. Both 1-month and 3-month mean triglyceride levels are significantly lower than the mean preoperative level (p < 0.001). The mean decrease 3 months after liposuction is 43%.
How Effective Is Liposuction?
Liposuction has been used for over 35 years now. Surprisingly, its effect on the thickness of the fat layer was only recently determined (Swanson E. Assessment of reduction in subcutaneous fat thickness after liposuction using magnetic resonance imaging. J Plast Reconstr Aesthet Surg. 2012;65:128–130) using magnetic resonance imaging. See illustration below:
This 24-year-old study participant’s (above) photographs and (below) magnetic resonance imaging scans were taken (left) before and (right) 6 months after liposuction of her lower body and breast augmentation. The total aspirate volume was 3000 cc. The subcutaneous fat appears white in these coronal, T1-weighted images. Measurements are indicated at the level of the left flank and outer thigh. The thickness of the abdominal fat pad was also measured, using axial slices (not shown).
On average, the fat thickness is reduced about 45% after liposuction and two-thirds of the swelling is gone by the first month. It takes about three months for the swelling to completely resolve. Unlike, for example, breast augmentation and abdominoplasty, the results of liposuction are not immediately apparent after surgery and patience is needed to appreciate the full effect.
What About Coolsculpting?
Coolsculpting, or cryolipolysis, has recently entered the marketplace as a nonsurgical alternative to liposuction. This machine freezes the fat. Proponents concede that the effects are not as dramatic as liposuction. Studies using ultrasound have detected a small difference in the thickness of the fat layer after treatment—a reduction of 1/10 of an inch in 16 weeks. It is time-consuming, expensive, and provides only spot treatments (like LipoDissolve used to do). Investigators generally have financial conflicts. Many owners of these systems report underwhelming results. Unlike liposuction, there is a deficiency of published studies using MRI or photometric analysis to demonstrate its effectiveness (Swanson E. Cryolipolysis: The importance of scientific evaluation of a new technique. Aesthet Surg J. 2015;35:NP116–NP119).
History of Liposuction
Advances in liposuction include the evolution of instruments, energy source, wetting solutions used to pre-treat the areas, and anesthesia.
Traditional Liposuction (1982)
Instrument: Cannula, large bore
Solution: Either none (“dry liposuction”) or small volumes
Results: Small volumes of fat removed, spot treatments, irregularities and blood loss. Liposuction was refined and reintroduced by a French plastic surgeon, Dr. Illouz, in the 1970s. Liposuction started off as basically making an incision and suctioning fat. Sounds simple enough, but this was a big advance in body contouring!
Tumescent Technique (1990)
Instrument: Blunt cannulae, smaller caliber
Solutions: Tumescent: saline, lidocaine, epinephrine
Results: Larger volumes of fat removal, multiple areas, smoother borders, less blood loss.
In 1990, an American dermatologist, Dr. Klein, described the tumescent technique. This was a big step forward. The tissues were injected with a large volume of saline solution prior to performing liposuction. This saline solution contained epinephrine, to reduce blood loss, and lidocaine, a local anesthetic. The local anesthetic allowed the procedure to be performed using local anesthetic alone, in the doctor’s office, making it a tool for non-surgeons.
The fluid injected into the tissues served to hydrate the patient during surgery, so that little or no extra I.V. fluid administration was needed. The infusion of fluid into the tissues filled up the tissues, making them “tumescent.” This facilitated liposuction by magnifying the fat layer, helping to make the contours smoother because it was easier for the operator to avoid going too close to the skin or oversuctioning areas, which would cause irregularities.
The epinephrine contained in this fluid greatly reduced blood loss. This enabled the surgeon to treat multiple areas at one time and remove greater quantities of fat. The surgeon was no longer limited to spot treatments. All of the affected areas could be treated simultaneously. Patients could be treated at one setting instead of returning for multiple procedures. The technique had matured and could now deliver worthwhile results for the thousands of people with body contour problems. Its popularity grew and it quickly became the most popular cosmetic operation.
Ultrasonic Liposuction (1995)
Instrument: Ultrasonic generator
Energy: Ultrasound, physical
Solutions: Saline, lidocaine, epinephrine
Results: Selective fat cell removal, less tissue trauma, possibly better skin contraction.
Ultrasonic liposuction, also called ultrasonic-assisted liposuction, was developed by an Italian plastic surgeon, Dr. Michele Zocchi, in 1988. It was used extensively in Europe and South America for several years, before being introduced in the United States in 1995.
Ultrasonic energy has been used in many areas of medicine since the 1970s. One of its first applications was in eye surgery, to selectively dissolve cataracts. It was subsequently used to remove tumors in neurosurgery. The same principle is applied to fat removal. An ultrasonic probe produces a high frequency sound wave which causes fat cells to dissolve. The technique is used in combination with tumescent (called “superwet”) liposuction. The tissues are first injected with fluid, the ultrasonic probe is introduced to dissolve fat cells and the liquefied fat is then suctioned out.
Ultrasonic liposuction does not replace tumescent liposuction. It adds to the effectiveness of tumescent liposuction, allowing the plastic surgeon to remove large volumes of fat from multiple areas at one setting. It has improved results in fibrous areas that may be difficult to treat with traditional liposuction—the upper abdomen, flanks, back, and male breasts. The fat is liquefied before its removal, so that the resulting contours are smooth. Because ultrasonic energy is used to break up the fat cells, less physical force may be required from the plastic surgeon. It makes sense that the less physical force is used, the better the connective tissue under the skin is preserved, along with nerves and blood vessels. This may mean less bruising of the tissues, less discomfort, and a shorter recovery time. An added advantage of ultrasonic liposuction may be improved skin tone and appearance, due to preservation of the underlying connective tissue and possible collagen stimulation. It is important to recognize that these are theoretical advantages that have not been clinically proven.
Understanding the Different Types of Liposuction Procedures
Patients (and even surgeons!) may be forgiven if they confuse “tumescent”, “ultrasonic”, “laser”, “Vaser” and “power-assisted”—all words to describe types of liposuction.
Stated simply, most patients want the modern, up-to-date kind of liposuction that works better and is kinder than the old-fashioned technique, particularly that technique that was often seen on television, which showed a surgeon apparently pummeling a patient with a long metal instrument.
With ultrasonic liposuction, the traditional benefits of liposuction remain the same. Usually multiple sites are treated, using small incisions. This allows correction of body contour disproportions.
As discussed above, these disproportions, for example, “saddle bags” in women and “love handles” in men, are inherited and are not corrected by diet and exercise alone. In women, the lower body is usually the concern— the abdomen, hips, flanks, buttocks, thighs, and knees. In men, the abdomen, flanks, and breasts tend to be affected. Each of these areas is treated simultaneously, removing more fat where necessary to produce optimal body contours. Other commonly treated areas are the arms, calves, and under the chin (“submental fat”).
In the past, surgeons relied on physical energy alone to dislodge fat cells, which were then suctioned away. The surgeon literally pummeled the fat with a blunt instrument (“cannula”). The flimsy fat cells were dislodged from their attachments and suctioned away. This technique was effective, but it was nonselective. Other tissues were traumatized, too.
Surgeons prefer selective techniques because there is less “collateral damage” to other tissues. We’ve seen this principle applied to medical laser treatments which target skin pigments, such as laser treatment of birthmarks or laser hair removal.
In liposuction, a cell type is targeted—the lowly fat cell, which is like a flimsy balloon full of Jell-O. If you expose it to high frequency sound waves, micro-bubbles are generated from pressure changes. This is called “cavitation”. The flimsy cell membrane cannot contain these bubbles, and gives way, releasing its liquid fat contents (“emulsification”), which are then suctioned off. But the important tissues are left intact; the nerves, blood vessels, and connective tissue stay behind, like the branches of a tree that has lost its leaves. No question, they have still been traumatized, but not as much as they would have been without the benefit of ultrasound.
Ultrasonic vs. Non-Ultrasonic Liposuction
In the past, before I started using ultrasonic assistance, I would be exhausted after a day of liposuction. Surgeons sometimes called this their “liposuction workout”. Not anymore. After pre-treating an area with ultrasound, the “mop up” liposuction is physically much less demanding. Of course, I do not object to a workout if it means that my patient will have the best result, but if it is possible to achieve a better result with less physical trauma to the patient, so much the better! Surgeons do well to remember that the patient is on the receiving end. Less trauma to the tissues should mean an easier and less painful recovery. So, fortunately, it is a win-win situation—less
trauma, better result. One plastic surgeon is fond of remarking at meetings, “Remember, we enjoy surgery much more than our patients.” So anything we can do to lessen the trauma and discomfort is welcome news for our patients.
Today many patients are having fat injection of the buttocks. When I am collecting fat for transfer to the buttocks I do not use ultrasound so that the fat cells stay intact and are more likely to survive the transfer.
Burns may be avoided with proper skin protection and by moving the cannula continually while in use, similar to ironing clothing. Seromas (fluid collections) are very rare after liposuction when areas are not subjected to excessive trauma, and can be avoided almost entirely by using the appropriate amount of ultrasound. It is better to come back another day and retreat an area than overtreat it the first time.
Concerned about complications, some plastic surgeons reverted back to traditional liposuction, without ultrasonic assistance. However, with the prudent use of this tool, limiting ultrasound duration to a few minutes per area, and avoidance of overtreatment, the advantages may be realized without additional risks. Moderation is the key. Using the optimal ultrasound duration is like using the correct dose of medication.