THE PERFECT BODY: How Far ShouId You Go?

Liposuction is America's most popular cosmetic surgery - outnumbering face-lifts, tummy tucks, even nose jobs. Is it beautification? Or mutilation?
BY RANDI LONDER

The promise of Thin Thighs in 30 Days was enough to catapult that book straight to the top of the best-seller list. So it's little wonder that the possibility of "thin thighs in little more than 30 minutes" - without doing so much as a single leg lift - has turned liposuction into the No. 1 cosmetic operation in country. The catch: This anti-fat procedure works best on people who probably need it least. And liposuction is not without the potential for dangerous complications.

What Price a Better Body?

Last year 100,000 people - most of them women - paid impressive sums of money to doctors who literally vacuumed out the fat from their thighs, hips, buttocks, abdomens, chins, knees and ankles. And indeed, the principle behind liposuction - or fat-suction surgery, as the operation is popularly tagged - sounds deceptively simple: Through a small incision in the skin, the doctor inserts a thin tube called a cannula into a localized fatty deposit - say a saddlebag - and "saws" back and forth in order to tear the fat from its moorings, the connective tissue just under the skin but above the muscle layer. This back-and-forth motion creates tunnels or pockets in the fat, which can then be sucked out through the tube. According to Simon Fredricks, M.D., clinical professor of plastic surgery at the Baylor College of Medicine in Houston, Texas, once those fat cells are removed, they are gone forever. "Liposuction permanently changes the body's contour," says Dr. Fredricks, "so that even if you regain weight, you won't lay down much fat in those areas ever again."

Weighing the Risks

According to Dr. Fredricks, who was the chairman of the team of plastic surgeons that investigated these unfortunate incidents, each could have been avoided. Seven patients had had abdominoplasty - a tummy tuck - along with their liposuction operation; combining these two procedures poses an increased risk that fat clots will travel to other parts of the body.

The four other patients, on whom only liposuction was performed, could have been saved, says Dr. Fredricks, if the operating theater and surgical instruments had been properly sterilized, and if the doctors had not attempted to suction out too much fat.

"It's essential that the surgeon not try to remove more than five pounds of fat at one time," explains Peter Bela Fodor, M. D., northeastern regional director of the Lipoplasty Society of North America. When too much fat is removed, large quantities of fluids are lost as well. These fluids must be replaced intravenously or the patient can go into shock.

Still, the risk of death or complications from liposuction is minimal, though doctors point out that all surgery carries some risks. So each person must weigh the dangers against the possible benefits, bearing in mind that liposuction is performed strictly for cosmetic reasons; there are no health benefits.

Unrealistic Expectations

One non-medical "complication" that worries doctors is disappointment. The patient may expect liposuction to transform her life-by helping her find a new job or save a faltering marriage.

Mary Ruth Wright, Ph.D., a psychologist at Baylor College of Medicine, cautions that liposuction treats a specific symptom - fat - and not the problem of a poor self-image. "Some people will con-tinue to have negative feelings about their bodies, even after their body contours are improved through surgery," she says. So in addition to screening out candidates who are unsuitable medically - heavy smokers (because more post-surgical complications are associated with cigarette smok-ing) and those with a history of diabetes or heart disease - John E. Sherman, M.D., assistant clinical professor of surgery at Mount Sinai School of Medicine in New York, questions a prospective patient closely about what she hopes to accomplish by having cosmetic surgery performed.

"I look for patients with limited, realistic goals," he says. "If a woman tells me that her abdomen or saddlebags bother her, we can fix that." But there are some people who are cosmetic surgery "addicts," and doctors must make every attempt to recognize them. "I do not perform liposuction on about 50% of those who come to me and request it," he adds.

In Pursuit of Perfection

Still, no matter how conscientious doctors are about trying to discourage misguided patients, some manage to "slip through." Part of the blame rests with an individual's poor self-perception, but the pressure to be perfect is largely generated by our culture. According to clinical psychologist Rita Freedman, Ph.D., society dictates that females should be unnaturally lean, even though women are supposed to have more body fat than men.

Unfortunately, the culture is winning. In 1986 plastic surgeons performed more than 500,000 cosmetic operations - up 24% from 1984. Liposuction alone showed a 78% jump during those two years. These figures are even more astonishing when you consider the considerable expense involved - and insurance companies seldom reimburse for elective cosmetic operations. To critics of any operation performed strictly for aesthetic reasons, "self-improvement" surgery like liposuction is closer to self-mutilation than proponents may like to think. Until the practice was outlawed in 1949, the Chinese bound little girls' feet to inhibit their growth because a small foot was considered a symbol of beauty. No matter that the women were often permanently crippled. It's possible that as we leap into the world of high-tech plastic surgery, we're taking a giant step backward for womankind.

If You Decide to Go Ahead

Only after each patient fully understands exactly what the procedure involves, including the possible risks and potential complications, does Dr. Sherman accept a candidate for liposuction surgery.

"A good candidate ranges in age between her late teens and her late 40's," says Dr. Sherman. "We can certainly perform liposuction on older people, but often a 'skin-tightening' procedure must be performed as well because, after the late 40's, the skin loses its elasticity."

Reputable plastic surgeons stress that liposuction cannot replace dieting, nor will they operate on a "too fat" patient - say someone 30 to 40 pounds overweight. What the surgeon looks for is an area that bulges out of proportion to the rest of the body.

Choose your plastic surgeon very carefully, advises Dr. Fredricks. It's wise to select one who is board certified in plastic surgery; that background enables the doctor to determine the best procedure for your particular case - which may or may not be liposuction. The doctor should have a background in general surgery because it's essential that the surgeon understand the implications of large shifts of body fluids, which can occur with this procedure. Special training in the technique will enable the doctor to "sculpt" the body properly and avoid lumpiness or uneven contours.

In 1987 the American Society of Plastic and Reconstructive Surgeons (ASPRS) - alarmed by disturbing reports of deaths, complications and misinformation associated with liposuction - issued a report outlining some of the "variations from the ideal" that can occur with the procedure:

Wavy or lumpy skin: The most common reason for patient dissatisfaction, although the smaller cannulas that are now available can reduce this problem.

Pigment problems: Rarely, permanent changes in the skin's pigmentation can result. Stay out of the sun until all signs of bruising (normal, following surgery) have disappeared.

Skin bagginess: Patients - generally over age 40 - with skin that has lost elasticity may find that their skin "bags" once the underlying fat has been removed. A face-lift following liposuction on the chin area, to cite one example, can correct this problem.

Edema: Although swelling usually subsides within six to eight weeks, it may persist for as long as six months.

Skin sloughing: Unusual, but possible when excessive amounts of fat are removed.

Nerve damage: Numbness or a burning sensation in the suctioned: area can linger for weeks or months after surgery.

In addition, patients who undergo liposuction in the doctor's office should make certain that the doctor has admitting privileges at a nearby hospital in the event of an emergency.

ONE WOMAN'S EXPERIENCE

Dr. Sherman and 26 year-old Debbie Fagan (her name has been changed) allowed FAMILY CIRCLE to follow Debbie's liposuction experience. Debbie, who stands 5' 5" and weighs 120 pounds, wanted to flatten her stomach and get rid of saddle-bags on her upper thighs. (Often, no amount of exercise will trim these fat deposits.)

Like many board-certified plastic surgeons, Dr. Sherman performs most of his liposuction procedures right in his office, using a local anesthesia with an anesthesiologist present to administer intravenous sedation. But Debbie opted to check into Doctors Hospital in Manhattan - where Dr. Sherman has admitting privileges - and "go to sleep" during her operation. "I was afraid of the pain," she says.

December 2

At 8:30 A.M. Debbie checks into Doctors Hospital with pre-surgery jitters. By 12:25 P. M. a hospital worker wheels Debbie into the operating room. With a special marking pen, Dr. Sherman draws bull's-eyes on Debbie's thighs and stomach, and swabs sterilizing soap on her skin. She closes her eyes as the anesthesiologist hooks her up to machines that monitor vital functions and administers anesthesia.

Dr. Sherman begins by injecting a dilute adrenaline solution into Debbie's abdomen to help cut down on bleeding. He cuts two half-inch incisions just above her pubic hair, then takes the 18-inch-long metal cannula and pushes it under the skin of Debbie's abdomen. He does his work by feel, because he cannot actually see where the cannula goes - something like working through a keyhole. With surprisingly energetic sawing movements, he slides the l/4-inch-thick tube in and out, creating tunnels in the fat layer. He will have to repeat these forceful motions many times in the next 90 minutes.

Dr. Sherman's nurse hooks the cannula to a clear plastic tube that leads to a suction pump. "On," Dr. Sherman orders. And a mixture of yellow fat tinged with blood starts to flow out. By 1:15 P.M. he has repeated the tunneling procedure through two other incisions at Debbie's waistline. Satisfied, he moves on to her thighs.

At 2:08 P.M. Dr. Sherman sews up each of Debbie's six incisions with nylon stitches and zips her into a tight-fitting, knee-length surgical girdle that will compress the area where the fat was removed. The anesthesiologist monitors Debbie as she comes to. The operation is over.

December 3

At 8:00 A.M. Debbie checks out of the hospital, in considerable pain. She fills a prescription for a strong painkiller but takes only one, "because it makes me feel like a vegetable." For the next five days she will take a milder painkiller.

December 4

"Right now, I regret it," Debbie says. It surprises her that she hurts so much. She takes sponge baths and skips work for the next two weeks.

December 10

In his office Dr. Sherman removes Debbie's stitches. For the first time she sees her "black-and-blue, bloated and lumpy" skin that has been hidden under the girdle. "I still have extreme pain in my thighs. But Dr. Sherman thinks everything is coming along fine."

December 28

The black-and-blue marks have faded replaced by a yellowish tinge.

January 7

"I ate a lot over the holidays, and the weight has not gone to my stomach and thighs as usual, but my waist thickened. Now I wear the girdle only occasionally during the day."

January 15

Debbie looks back at her secret expectations before the surgery: "I've always wanted to look like the models in the magazines, with their flat stomachs, long legs, wispy waists. But I know that I can never look like that. I guess I'll just have to wait for the Marilyn Monroe look to come back in style."