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Before we begin the discussion of liposuction in the obese, keep in mind that general anesthesia is usually the anesthesia of choice for megaliposuction. General anesthesia unfortunately reduces the allowable amount of tumescent (Klein) recipe solution. General anesthesia causes the body to more slowly (sometimes up to 50% more slowly) remove the lidocaine portion of the tumescent solution. Too much lidocaine (50% more in some cases) in the blood has killed many a patient. This is almost always the result of doctor error. No patients have ever been harmed or killed as a result of strict adherence to Klein’s original recipe and guidelines. Unfortunately, some doctors do not study, or review the guidelines, instead some try to modify the guidelines. Traditionally, liposuction has been considered a contouring treatment and not a treatment for obesity. Today there is much controversy between doctors as to whether or not liposuction should be used to control weight in obese patients. Some studies have shown improvement in insulin effects and weight control in the obese following megaliposuction. In the late 1990's a national nightly news television special showed doctors from Virginia who claim expertise in treating obesity with liposuction. In the United States, there are a far greater number of experienced surgeons who perform liposuction who disapprove of the use of "megasuction" as a means to control obesity than there are surgeons who approve. It is entirely possible to "megasuction" an obese patient. However, general anesthesia is usually needed; special monitoring is required at every moment of the procedure, because there is a very real and significant risk that something can go wrong. The Web site author has performed liposuctions on obese patients. However, these patients have been well coached as to the possible outcomes of liposuction and as to whether or not the fat can come back. This is a concern in an obese patient with a sedentary (inactive) lifestyle, one who does not exercise much or have the best of diets. Inactive obese patients’ bodies can be given the strictest of diets. Without exercise, their bodies will act as if in a state of starvation. Their bodies will hold onto every calorie; this simply means that they stay fat or get fatter. An obese patient who plans liposuction and who will definitely properly manage his/her diet and perform exercise has a chance for success with this procedure. Remember, although mature fat cells cannot divide, fat cells remaining after liposuction can grow extremely large in size in response to feeding the body more calories while the body is holding onto those calories. During liposuction in obese patients, a large amount of trauma occurs within the nearby unsuctioned body fat. Fortunately, the tumescent method reduces the amount of possible bleeding. Without the tumescent anesthetic method or adrenaline in the formula used, liposuction in the obese patient would be even more risky. An obese patient who is undergoing a "megasession" without the tumescent method could almost "bank" on the need for a blood transfusion following liposuction. Depending on what type of cannula is used and on whether or not the patient’s fat is fibrous, there may not be a greater tendency for blood loss. Obese patients should not expect the same type of result from liposuction that younger, thinner patients might expect. In obese patients, much larger cannulae must be used. Otherwise the surgery would take many, many hours, perhaps even days. Also, in obese patients, rippling can be the result of both properly performed and aggressive liposuction. This is because the surface tissues in obese patients have been greatly stretched. When fat is removed, tension is removed from the inside of the skin. Thus, there is a natural tendency for obese skin to allow ripples and ridges to be left behind following liposuction. These ridges are usually most prominent in the upper thigh and inner thigh region and may also be found around the folds of the arms. Ripples are usually found in the areas of obese skin that were the most tense before the liposuction. These areas include the protruding areas of the hips and the protruding areas of the thighs. The ripples can become bothersome if they are located in areas that experience friction during movement: for example, around the shoulders and where the legs meet the groin. It is to be noted in obese persons and those with larger fatty areas, liposuction (removal of fat) can result in constrictive bands or skin folds that may appear unsightly. These irregularities are more likely to occur in the highly lax zones of the inner upper thighs, groin, upper arms, and armpits. A groove or skin fold may not necessarily be caused by inappropriate technique, but may be expected in patients with poor skin tone, as is commonly seen in the obese, those with large fatty areas, and those with stretch marks. This occurs in part because the fatty deposits that are to be removed are covered by "stretched-out" or naturally tethered skin. Removing underlying fatty deposits may leave more "stretched-out" skin than is necessary to cover the now smaller areas. To achieve a smooth, natural-appearing result, one's skin must have the ability to contract (shrink) sufficiently to fit the smaller area (after the fat is removed). Depending upon the size of the patient, many patients may be best advised to undergo a "multistage" liposuction-having liposuction performed in two or more separate sessions. For some patients, multi-staging may allow further contraction, or reduction can be obtained in surrounding areas in order to reduce the band or skin fold. Surgical incision or excision (cutting with a scalpel) of the band may be necessary for correction. These surgical procedures are known as thigh- or arm-reductions. These corrective procedures remove the unwanted skin by cutting (with a scalpel) and stitching (suturing) specially in layers, to prevent the layers from coming apart. Whenever tissue is cut with a scalpel a scar must result. A scar is the natural glue that binds the tissues together. Good deep scar will help reduce spreading of surface scares. Nonetheless, the surgical approach by cutting unwanted redundant skin folds that may remain following liposuction is an accepted technique that, in most cases, reveals the desired results. These procedures need to be entertained by patients who are extremely heavy in many areas (obese) or those patients who are excessive in the areas being treated by liposuction (isolated lipo-dysmorphia). Additionally, one needs understand that incisions (cuts) to remove excess tissue may involve the entire length of the skin fold, be directly over the fold, may be adjacent to the fold, or may be located in the natural creases. The simultaneous combination of abdominoplasty (tummy tuck) with any tummy liposuction is concerning and has been proven in medical studies to carry an increased risk of problems. The combination of high-volume liposuction and abdominoplasty in the obese is especially concerning. This combination has proven deadly in numerous medical reports, and it should be approached with extreme caution, if at all. Full "plain-English" information should be given to the patients long before the day they are scheduled to undergo this particular "combination" surgery, especially when one considers that the mere removal of large volumes of fat by liposuction (which may include eight to ten liters of fat or more, depending upon the size of the patient) puts the patient at even greater risk for severe problems during and after liposuction surgery. One of the most severe of these problems (risks, complications) is the condition called disseminated intravascular coagulation (DIC). With DIC, a patient's blood can congeal (clot) everywhere as the result of trauma or a large imbalance in the body's fluid. Unfortunately, DIC is frequently deadly. Megaliposuction in the obese patient not only requires a special and experienced surgeon, but it requires a very skilled anesthesiologist, since these patients have a much higher risk of developing a severe problem during surgery (i.e., heart attacks and the inability to breathe properly). Also, it must be considered that the proportion of true muscle mass and water mass to the total weight of an obese patient is much less than that of patients who are very lean. This calculation influences how drugs are given and how obese patients respond to drugs. The Web site author believes that the decision to undergo a single "megasession" liposuction surgery is a very critical event and must be the result of carefully weighing the risks. As well, an anesthesiologist is necessary in this setting so that the patient can be kept comfortable, thus reducing the chance for stress-related complications (stroke, heart attack). The period immediately following surgery is extremely important. Is skilled aftercare and nursing available? Also, in the period after surgery, if the patient is not perfectly monitored and cared for, bleeding or DIC or severe toxic fluid imbalance could threaten the patient's life. Why be so concerned about the "megasession?" Because the risks of having the "convenience" of bundling all of the fat removal into one single large procedure are so much greater than those associated with accomplishing the fat removal with two or three separate tumescent (outpatient) sessions; frequently, megasessions do not make good sense. Megaliposuction concerns this author as well as a number of other well-respected plastic and cosmetic surgeons across the USA. However, in medicine, we must consider each patient and each surgery on a case-by-case basis. If the balance of risk is not too great, grant some skilled surgeons and only their well-informed patients the right to judge the risks together and to have a surgical option. However, the philosophical problem in megasuction is that we are currently not aware of any studies that show an improvement in "health" following liposuction in obese patients. Keep in mind, megaliposuction is not a cancer surgery but an elective (can have or not have and still live the same) and cosmetic surgery. When we consider all of the potential "bad" things that can happen during a liposuction that is mega in nature, it must be appreciated that the risks are high, the short-term benefits seem obvious, and the long-term benefits are unproved. The Web site author believes that prospective megasuction patients should think long and hard about the following possibility: instead of undergoing one "megasession" of liposuction (>10 liters of fat removed), why not undergo two intermediate-volume liposuctions with a removal of greater than six liters of fat? Many times, this multiple-session procedure can be accomplished in the following manner. The use of two liposuctions to reduce the fat volume of an obese patient often works out quite well both economically and in terms of the return-to-work period. For example, if an obese patient undergoes a "megasession" liposuction (which virtually requires general anesthesia), there is a usually a much longer period during which the patient is inactive and is hopefully monitored in some type of high-grade certified center (hospital, surgicenter, certified care facility, etc.). This can be compared with two smaller, walk-in, wheelchair-out outpatient in-office liposuctions performed on Thursdays or Fridays, with the patients returning to work three or four days later (on Monday). With the single "megasession," not only is there likely a larger time lost from work (one week to two), but there is greater expense related to proper aftercare monitoring. Also, consider the potential uninsured expense if some severe complication occurs, which is not all that uncommon in "megasessions." If a severe problem were to occur following a "megasession," an extra month or two in the hospital may cost about $50,000. Also, the use of general anesthesia (a virtual must in megaliposuction) has its additional risks. The larger risks of "megaliposuction" should be compared with the much smaller risks associated with two intermediate-volume liposuctions, performed in the presence of a board-certified anesthesiologist with the patient merely under IV (intravenous) sedation. In this case, the split liposuctions usually produce about six to eight liters of fat each. Body fluid shifts are much smaller and are better tolerated by the obese body in this type of setting, and the risks of problems are greatly lowered as well, thanks to the tumescent method (invented by dermatologist Dr. Jeffrey Klein). Usually, the patient will return to the office or outpatient surgical center one to two months after the first split session for the second liposuction. The patient usually plans to return to work two to three days after each liposuction; this works out very conveniently for many patients if they have their liposuction performed on a Thursday or Friday. Sedentary or computer work can usually be done on Saturday. Returning to work by Monday is usually possible, resulting in very little lost work time. It is therefore the Web site author's suggestion that patients who are obese consider two intermediate, split liposuction sessions as opposed to one grand "megaliposuction" session. Patients who are obese should think twice (or more) about the same-day combination of a tummy tuck and a liposuction, as this markedly increases the chances of death and serious complications. Why should anyone risk a chance of death if he/she is simply having a cosmetic procedure? If the risk is significant (more than one in a thousand incidence likelihood), it just doesn't make sense. Currently, no accurate publications exist regarding the number of single liposuction "megasessions" being performed. However, serious outcomes have resulted form megaliposuction. Could the risk of death or a serious event be more than one in one thousand? Is the convenience of "wrapping it up in one sitting" really worth the one-in-one-thousand chance of death? Consider as well that the cost of two intermediate liposuction procedures will be much less (when priced with second and third opinions with reputable doctors) than the cost of one "megaliposuction" procedure, especially if the risk of attendant complications to taken into account. Say, for example (remember there are so few of these procedures done that it is impossible to have accurate numbers), that the risk level associated with a serious problem related to split liposuction for obesity is one in four or five thousand, and say the risk level of a serious problem connected with a "megasession" is one in a hundred or one in two hundred, then doing two split procedures with the low risk would be at least 10 times safer than doing the "megasession." Remember that liposuction is not heart surgery. To the Web site author, the risk of a serious complication in one in a hundred or one in two hundred patients is a big concern. It appears that the possible gains (one-shot deal, short-term weight loss that has not been proven to remain even two years after surgery) do not appear to justify the risks of the single giant, somewhat risky "megasession" procedure. The following analogy applies: by having a "megasession," a patient is assuming a risk somewhat similar to that associated with a triple coronary bypass heart operation. The big difference is that a "megasession" may give a dramatic short-term change, a doubtful three-year long-lasting effect, is a cosmetic surgery, and is not a medically necessary surgery. On the other hand, the triple bypass is proven to extend a life and is therefore worth the risk. Impatience and incomplete information (on the part of patients) may be responsible for the recent popularity of "megasessions." However, it is possible that in the future, just as the risks of triple bypass surgery have decreased dramatically with better surgical techniques and medicines, that the risks of "megasessions" may decrease. What is said in this Web site today may not be as accurate several years from now. This is because medical science is constantly advancing. Look in the medical literature for updates that have been confirmed with at least two years' worth of data and experience. No matter what, the Web site author believes that all patients considering megaliposuction should have diet and exercise evaluations performed by nutritionists and physical therapists. Surgeons should consider psychiatric and endocrine (thyroid, diabetes, etc.) checkups for these patients as well. Problems that have been reported by doctors to commonly occur following megaliposuction are seromas (balls of internal fluid), excessive fatigue, loss of appetite, skin loss, and lowered hemoglobin in blood (which may continue to fall). Other possible events that may occur include death due to general anesthesia, loss of blood or fluid volume in the body, and shock (failure of the heart and vessels) and organ injury. Megaliposuctions are the equivalent of a burn to 30% of the inside of the body. This is probably why management of megaliposuctions may end up resembling the management and guidelines for burn patients, without bandages or similar antibiotics, of course. Currently the only thing that megaliposuction has going for it, in the Web site author’s opinion, is that Dr. Fournier of France is becoming involved in the procedure. Dr. Fournier says his own experience with megaliposuction has resulted in cases of shock and pulmonary edema (fluid filling the lungs) as well as in some skin death, along with the scarring that results from skin death. The Web site author visited and "scrubbed" into liposuctions with Dr. Fournier in Paris in the 1980’s. The author respects Dr. Fournier as an honest, highly intelligent, and very capable surgeon and feels that if anyone can improve or give good credit to megaliposuction, it is Dr. Fournier. Often the Web site author will recommend obese patients who are interested in liposuction to consult a nutrition therapists, exercise therapist, and endocrinologists as well as surgeon who specialize in such procedures as "stomach staplings" and stomach-bypass operations. The results from these may be more predictable and long lasting depending upon the degree of obesity.
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