THE METABOLIC CONNECTION Although the article portrays liposuction as a panacea for many things, including saving lives and having long-lasting effects on appetite suppression, these findings have not been published or studied to my knowledge. However, there are many published, peer-reviewed studies that show that weight loss is overwhelmingly accompanied by an increase in insulin sensitivity in overweight and obese women following large volume liposuction (lvl).1-14 An outstanding review article was recently published15 detailing possible scientific mechanisms for how liposuction produces beneficial effects on the overall weight loss process. I strongly urge surgeons to review these publications, which are listed at the end of this commentary.
ONCOLOGIC METAPHOR Early in my career, a prominent oncologist likened her excess fat to a tumor — the overgrowth of a normal cell, in this case fat. It appears we have a "fatty tumor" epidemic in this country (and around the world), with adult overweight and obesity rates approaching 66 percent of the population. An overgrowth of the subcutaneous adipose tissue (SAT) likely stresses other systems in the body, causing them to work less efficiently. The many diseases associated with obesity, from joint disease to cancer, confer these relationships. As not all disease processes are reversible at any time during their development, not all individuals will benefit from SAT debulking. Klein et al,14 in fact, showed no benefit from SAT debulking in very obese individuals (average body mass index [BMI] 35 to 39.9) with and without type 2 diabetes.ONCE IS NOT ENOUGH A single intervention appears not to be enough to impact the milieu of this very obese population. They may be too far along into the "disease" of obesity to achieve a benefit. I have always stated that LVL is most effective for overweight (BMI 25 to 29.9), pre-or nondiabetic women.
Studies have repeatedly shown that LVL for women with BMIs of 25 to 35 improves insulin sensitivity and weight loss.1-11 My study also shows weight maintenance at one and two years.2, 3 (Many of the studies below address changes in insulin sensitivity. I caution readers to scrutinize scientific methods for hormone level collection because if they are not made at like intervals in a woman's menstrual cycle, they are not as accurate. Insulin levels (and other hormones) fluctuate during different times of a woman's cycle. It is not stated that blood draws were taken in this fashion, at like intervals during the menstrual cycle, in the single article that does not find a change in insulin sensitivity.14
METHODOLOGY QUESTION Furthermore, in the same publication, subjects were included with type 2 diabetes mellitus on two or three hypoglycemic agents, which affects glucose and insulin levels. In this study "... hypoglycemic medications were regulated by the subject's physician." It is not clear if these subjects were off of the two to three hypoglycemic medications before and during the 10-week to 12-week study. If not, there's a problem because it is not valid to measure a change from liposuction when the variables (insulin and glucose) are being controlled by medication. Patients on such agents met with the exclusion criteria for my study.
Achieving weight maintenance is the most laudable goal, which clearly positions liposuction as the front runner (greatest inches lost per pound lost) when compared to other weight loss methods. Based on a clear trend emerging from several publications regarding weight loss and liposuction, women with BMI greater than 35 are not ideal candidates. A study by Talisman et al16 states that "... [for] patients who are obese with BMI over 38, the chance to maintain results are practically zero." The morbidity and mortality of the surgery are higher for these patients, their cosmetic benefit is diminished, they regain weight, and the Klein study14 showed no health benefit for this very obese group.
PATIENT PARAMETERS As cosmetic plastic surgeons, we are in a unique position to contribute to the treatment (ideally combined with diet and exercise) of one of today's most vexing epidemics. While appearance is a critical outcome, safety is paramount. Hopefully, future studies will yield results based on longer follow-up and show changes in vascular reactivity to more directly indicate cardiovascular benefits. Additionally, parameters for safe treatment groups should be established. My initial thoughts are that women with bmi greater than 35 should consider other forms of surgical or nonsurgical interventions save for lack of cosmetic and health benefits. I am concerned when i hear case reports of 37-liter liposuctions performed on morbidly obese patients followed by blood transfusions.17 Liposuction was, and still is, first a cosmetic operation.
Dr. Giese is a diplomate of the American Board of Plastic Surgery and is in private practice in New York City. Her earlier research received grant support from the American Society of Aesthetic Plastic Surgery, the Plastic Surgery Education Foundation, and the Lipoplasty Society, Inc.
For more information
1 Giese SY, Bulan EF, Commons GW, Spear S, Yanovski J. Improvements in cardiovascular risk profile with large-volume liposuction: a pilot study. Plast Reconstr Surg. 2001;108:510.
2 Giese S, Bulan EF, Spear S, Yanovski J, Neborsky R. Improvements in cardiovascular risk profile after large volume lipoplasty: a 1 year follow-up study. Aesthetic Surgery J. 2001;21:527.
3 Giese, S. Improvements in cardiovascular risk profile after large volume liposuction: a 2 year follow-up study. Unpublished.
4 Gonzalez-Ortiz M, Robles-Cervantes JA, Cardenas-Camerena L, et al. The effects of surgically removing subcutaneous fat on the metabolic profile and insulin sensitivity in obese women after large-volume liposuction treatment. Horm Metab Res. 2002;34:446.
5 D'Andrea F, Grella R, Rizzo MR, et al. Changing the metabolic profile by large-volume liposuction: a clinical study conducted with 123 obese women. Aesthetic Plast Surg. 2005;29:472-478.
6 Rizzo MR, Paolisso G, Grella R, et al. Is dermolipectomy effective in improving insulin action and lowering inflammatory markers in obese women? Clin Endocrinol (Oxf). 2005;63:253-258.
7 Nicoletti G, Giugliano G, Pontillo A, et al. Effect of a multidisciplinary program of weight reduction on endothelial functions in obese women. J Endocrinol Invest. 2003;26:RC5-8.
8 Davis DA, Pellowski DM, Davis DA, Danohoo WT. Acute and 1-month effect of small-volume suction lipectomy on insulin sensitivity and cardiovascular risk. Int J Obes. 2006;30:1217-1222.
9 Ersek RA, Salisbury M, Girling R. Metabolic modulation by lipoplasty: a case report and invitation for investigation. Aesthetic Plast Surg. 2004;28:120-122.
10 Talisman R, Belinson N, Modan-Moses D, el al. The effect of reduction of peripheral fat by liposuction-assisted lipectomy on serum leptin levels in the post-operative period: a prospective study. Aesthetic Plast Surg. 2001;25: 262-265.
11 Robles-Cervantes JA, Yaniz-Diaz S, Cardenas-Camarena L. Modification of insulin, glucose and cholesterol levels in nonobese women undergoing liposuction: is liposuction metabolically safe? Ann Plast Surg. 2004;52:64-67.
12 Tazi, El Hassane. Personal communication. Casablana, Morocco.
13 Zocchi, Michele. Personal communication. Turino, Italy,
14 Klein S, Fontana L, Young VL, et al. Absence of an effect of liposuction on insulin action and risk factors of coronary heart disease. N Engl J Med. 2004;350:2549.
15 Esposito K, Giugliano G, Scuderi, N, Giugliano D. Role of adipokines in the obesity-inflammation relationship: the effect of fat removal. Plast Reconstr Surg. 2006;118:1048.
16 Talisman R, BenMeir P, Weinberg A. Pre-operative weight is the single most important factor to anticipate the long term results of body contouring surgery procedures. Presented at: The American Society of Aesthetic Plastic Surgery; April 2006; Orlando, FL.
17 Boswell CB, Young VL, Engel SJ, Centeno RF. Complications associated with very large volume liposuction. Presented at: The American Society of Aesthetic Plastic Surgery; April 2006; Orlando, FL.