This last week I saw a woman for liposuction. I was not the first doctor she had seen; she had tracked down a variety of liposuction doctors, in several different cities, sometimes in surroundings that made her a bit uncomfortable. I asked how she found me and she said friends sent her, and she'd seen my website. I asked what she thought about the website, and she said I should put in more information about liposuction, that the information on the internet is confusing, and that my website was not much help. So let's see if I can be more helpful.

The History of Le Lipo
My first recollection of liposuction is from one of the national plastic surgery meetings. A French doctor was presenting his cases. I don't speak French, and he didn't speak much English, but what came across to me was that he had done thousands of cases, had no complications, and worked with a little wand that he had on stage and gestured with throughout the presentation. His summation was "Ve suck zee fat."

Surgery is one of those things that is a zero defects proposition. You want to get it right every time. If someone has a great new idea he or she usually tries it out cautiously, perhaps tries it out in the lab, then on a few patients, then may present it at a meeting. Then we wait. The next year we look that doctor up again and ask about that great new idea. If I hear "Well, we don't do it that way anymore," then I have avoided a lot of problems in the intervening year by being a late adaptor.

So I waited a year. The next year the presentation that looked to me to be a format for a Saturday Night Live skit was all the news and liposuction was on its way around the world. Dr. Illouz of Paris had improved his English, although my French was no better, and lots of other presenters had had good results as well.

Will It Hurt?
In this country liposuction is performed by physicians. Liposuction may be done by any physician, but it is done in different ways according to the history of the doctor who is doing the liposuction. If liposuction is done by a surgeon, it is apt to be done in an operating room, because that's where surgeons work. It may be done under general anesthesia, meaning you come into the operation room, go to sleep, have the procedure, wake up and go home. It may be done under IV sedation, meaning you are sleepy but not asleep, or local anesthesia, where you may be very much aware. The equation changes a bit depending upon the physician and staff involved. Dermatologists, OBGYN, General surgeons, ENT surgeons, family practitioners, and plastic surgeons all may decide to perform liposuction, and each brings a slightly different skill set to the table.

Each of these options requires the administration of drugs and the monitoring of your response to those drugs. In the hospital and in most operating rooms the administration of these drugs is monitored by an anesthesiologist, a medical doctor who specializes in anesthesia. He has helpers. His best helper is a CRNA, a certified registered nurse anesthetist, who can also provide any of the levels of sedation that may be used during your procedure. In most hospitals the MD watches over several CRNAs and is available if there is a problem. Just like at the airport, the problems are usually at takeoff and landing, so the MD and/or CRNA are usually right at your side while you are going to sleep and waking up.

With liposuction the drugs may be given IV, or intravenously, just as they are with most general anesthesia. The advantage of IV administration is rapid onset of action and precise dosage. Drugs may also be given in the fluid used to distend and tense up the fat to make it easier to suction. In most cases the fluid used is saline with some additives. The most common additive is epinephrine in a dilute solution; it constricts the blood vessels in the area to be suctioned so that there will be less bleeding and hopefully less bruising.

Another possible additive is a local anesthesia such as xylocaine or lidocaine. At one level this is a great idea because it numbs the area to be treated, and general anesthesia becomes optional. On the other hand, too much xylocaine/lidocaine is toxic. For most procedures this toxic level is not approached, but if you rely on xylocaine/lidocaine as the only anesthesia, and the liposuction is widespread, toxic levels may be approached.

Some practitioners argue that since you are putting the xylocaine/lidocaine in and then suctioning it right out, it's safe. However, because the leftover fluid is not easily measured, and it is mixed with epinephrine in the leftover fat, it may not be reabsorbed by the patient until some hours later. This is at a time when the typical patient has been home for several hours and the levels of lidocaine are not being monitored. In cases where there have been problems, this is the time the problems occurred.

How to avoid these problems? Careful patient selection is one way. Not too much fat and not too much lidocaine. Another is to separate the anesthesia and the liposuction fluid. If you give general anesthesia with the usual techniques during the liposuction, the wounds and liposuctioned area may be treated with a small amount of a long-acting local anesthesia, such as marcaine, to achieve patient comfort while maximizing safety. The downside is that this approach takes the skills of the anesthesiologist and CRNA in a fully equipped operating room; all these skilled people add to the expense of the procedure.

How Does It Work?
So that's how the anesthesia works in liposuction. What about the liposuction equipment itself? In addition to the wand that Dr. Illouz brandished with such flair, there is now a confusion of terms and descriptions of liposuction equipment, techniques, and proprietary skills. The wand is connected to a vacuum, fat collected in a jug. Nice additions have been smaller canulae for removal of thinner areas of fat, power-assisted handles to move the canulae back and forth, and canulae with multiple holes for faster removal of fat.

These new gadgets look great, but no matter how fancy your practitioner's laser guided, power assisted liposuction wand is, there's still a person at the other end of it. If I were looking for someone to do liposuction on me, I'd try not to get distracted by the tools, and instead ask the same old boring questions: How many times has this doctor done this? How many people are happy with his or her work? The internet can be useful for finding out if anybody is mad at your practitioner for doing a bad job; you might also ask if he or she can give you the names of some people who are happy with their results.

Where Does It Work?
What are the places that liposuction works the best and where is it a little shaky? It works great for a fairly lean person with tight skin and a relatively small fatty thick spot. Even better if the fat to be removed is deep and in a bulge, so that by removing the bulge you even the fat thickness out so that it approximates the thickness of surrounding areas. Iliac bulges, on the lower flanks, trochanteric bulges, on the hips, and what we in the medical community call �Campbell's Soup Kid Knees� all fit these happy circumstances.

Less successful are places where the skin is thinner and looser. If you remove the fat and not the extra skin the surface becomes slack and develops an irregular surface. Cellulite! Not a pretty sight. In these areas tightening the skin as you remove the fat avoids the problem. The fat under the chin can be successfully liposuctioned if the skin is elastic enough to take up the slack. More commonly, in older individuals, liposuction is combined with direct excisions in a facelift. The abdomen is another area that offers disappointing results unless the loose skin is tightened with a tummy tuck. The lateral thigh often has a thick area of fat that may be nicely treated in the trochanteric area, so named for the bump on the femur that lies beneath. The inner thigh more often has loose skin and requires an inner thigh lift. Upper arms can be treated if thicker areas of fat are beneath elastic skin in younger individuals. If the skin is loose a brachioplasty, or arm lift, is more apt to please.

Liposuction is not a good treatment for obesity. Weight loss and exercise are the keystones to the treatment of obesity, with liposuction and traditional resection techniques such as tummy tuck, breast lift, buttocks lift, and face lift taking up the slack after the obesity has been overcome.

How Should I Decide?
Look around the internet and at the advertisements. I hope reading this will help the various options and ads make a little more sense. Ask around. See what options are available. Who is doing the work? Could they do the same operation in their local hospital or are they limited to doing it only in their offices? Are the procedures trademarked? Why? What's so special about them? When you go in for a visit, does anyone find out about you and try to solve your problem? Do they look at the whole person and try to determine if you will be a good fit for what they have to offer? Is liposuction their only option, or just one of many options? Do they ask questions, listen to the answers and try to determine if this will be a safe and successful experience for you? Does anyone check your blood pressure, listen to your heart and lungs, look at your ears, your skin, feel your abdomen, do a reasonable physical exam, and discuss your history with you? Where would the operation be done? Is the OR accredited? What about the staff? What kind of anesthesia do they offer, and who does it?

Look at the depth on the bench. Just like high school basketball, if there are problems the staff should have some depth and options. Are you in a medical center with lots of help handy, or out in the sticks where 911 is your best option? How much does it cost and what does that cover? Will your bill pay for RN's, surgical techs, CRNA's, and a MD anesthesiologist? Your work will be done by a medical doctor, because liposuction practioners in this country have to have a medical degree. But what is your MD's field? What is your MD's training and experience? Nice plane, but who flies it, and who fixes it when it breaks?

Once you have finished the consultation go home and think it over. Talk it over with your own trusted sage advisors. That's what I would do.

Asheville Plastic Surgery's Dr. James McDonough discusses shopping for liposuction.

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