The Gravity of Weight

The daunting science of weight control.

Liposuction: The Most Unkindest Cut of All?

When to consider liposuction.

The technique of liposuction

Marc Antony, in Shakespeare's Julius Caesar, speaks of the extraordinary betrayal that Brutus inflicted on Caesar—"the most unkindest cut of all"—when Brutus joins the conspirators and assassinates Caesar. Sometimes, our bodies seem to betray us, as well, no matter how well we treat them, when we accumulate fat in places that seem immune to diet and exercise. It is then that some people may want consider liposuction.

Liposuction is one of the most common surgical procedures performed in the United States, with hundreds of thousands done yearly on both men and women (though much more commonly in women.) It is essentially "body contouring." The technique consists of making small holes in specific areas of the body, injecting a fluid, such as saline or epinephrine to constrict the blood vessels and minimize blood loss, and then removing subcutaneous fat (i.e., the fat beneath the skin as opposed to visceral, i.e., fat around internal organs.) The fat can be removed by various methods, including power suction or laser. Depending on the quantity of fat removed, it can be an office procedure, or if "large scale" liposuction (involving removal several pounds of fat) is performed, it may require a hospital setting and general anesthesia.

Joseph A. Rabson, M.D., Chief of Plastic Surgery at Montgomery Hospital in Plymouth Meeting, Pennsylvania, emphasizes that liposuction should definitely not be considered a procedure for weight loss per se. What he has seen, though, is that those who undergo liposuction are often more motivated to lead a healthy lifestyle and continue to diet and exercise after surgery, with subsequent weight loss and maintenance over time. Sometimes, surgeons will recommend weight loss prior to liposuction. But Dr. Rabson explains there is no such thing as "spot reducing," no matter how many sit-ups a person does. In other words, exercise can tighten and firm, but when someone loses weight, he or she loses weight all over the body, not just in certain areas. In some people, however, there are those problem areas that are just genetically predisposed to hold onto the fat and that's where liposuction can be most effective. Incidentally, liposuction alone will not be effective when a person has lost considerable weight because the skin has lost its elasticity; other surgical techniques may be required in addition.

Adipose tissue (fat), though, is a highly active endocrine organ that secretes hundreds of substances called adipokines (including leptin and adiponectin) that are involved in regulating fat accumulation. It is generally now believed that the number of fat cells (adipocytes) in the body remains constant and is not affected by the calories we eat. When fat cells are lost such as by liposuction removal, the body produces more. And the body can compensate, as well, by the enlargement of the remaining adipocytes. As a result, weight gain can, of course, occur after liposuction in other areas of the body so that diet and exercise must be considered essential after surgery. Obese people, especially those who have been heavier since childhood, incidentally, have many more and considerably larger fat cells than those who are lean.


Further, there is controversy regarding whether liposuction can benefit a person's metabolic profile, such as the abnormalities seen in the metabolic syndrome. Unlike liposuction, bariatric surgery (see my previous blog, An Unbearable Heaviness of Being: Considering Bariatric Surgery) clearly has been shown to have considerable benefits in reducing glucose levels (and even the need for medication for diabetes), hypertension, and abnormal lipid levels. But bariatric surgery deals with the more metabolically active (and dangerous) visceral fat accumulating around the waist and encasing internal organs whereas liposuction aims at decreasing subcutaneous fat accumulation. (For those who are interested in some references regarding this controversy, please see my book, The Gravity of Weight, pp. 438-455.)

The overwhelming majority of those who undergo liposuction, especially the majority who do not gain weight after the procedure, feel there are many positive psychological benefits, including increased self-esteem and confidence, and increased comfort in wearing their clothing.

Plastic surgery, though, has been called body image surgery by Bolton and colleagues. As a result, physicians must be sensitive to those patients who have serious misperceptions about their body and even overt psychopathology, such as body dysmorphic disorder, and distinguish them from those whose dissatisfaction is specific and realistic. Years ago, researchers Napoleon and Lewis suggested that one screening technique plastic surgeons can employ is to ask patients to list, in order of importance, the five major areas of body dissatisfaction that they would like to improve. If the surgeon's own list is substantially different from and does not even include areas on the patient's list, that is a red flag and cause for concern (and even possible need for a psychiatric consultation.)

Sylvia R. Karasu, M.D., is Clinical Professor of Psychiatry at Weill Cornell Medical College and senior author of The Gravity of Weight.

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