Abstract

Since we began doing liposuction in 1989 we have had several diabetic patients whose insulin or oral diabetic needs have been substantially reduced following liposuction. When we reviewed the charts for these patients we found that they had improved diets, increased exercise and had lost weight. We were uncertain about the relationship between fat removal and metabolic modulation. We recently had patient whose fasting blood sugar went from 200mg to 100mg, following large volume liposuction, and have stayed that way for more than a year. In addition that patient lost 60 more pounds in the year following liposuction. It appears that removal of fat may improve several metabolic parameters and therefore we have started a multi-center study to evaluate this finding.

Background

When blunt liposuction was first introduced by Illouz and others in 1979 , it was advocated as a means of body sculpting and was not considered a means for weight reduction. Through the years we have noticed that many patients who had substantial amounts of liposuction (greater than four liters) not only lost the amount of weight that might be attributable to that of the fat removed but also continued to lose weight thereafter. There have been many reasons that we assumed may explain this event including: 1) the psychological benefits of being lighter 2) wearing more comfortable clothes and thus being more prone to physical activity and 3) more likely to pass on second servings of food after having gone through the procedure 4) the cost of liposuction, recovery, etc. may reinforce ones resolve to diet and exercise.


In 2001, Sharon Giese studied a number of patients that had large volume liposuction that upon follow up demonstrated lower levels of fasting insulin, lower systolic blood pressure, lower body fat mass and decreased body weight. A most dramatic finding is that her patients continued to lose weight even one year after liposuction. Every patient in her study lost weight. No other diet, exercise, behavior modification or surgery has such a record.


In our own experience, we had a nurse that had suffered from gestational diabetes with each of her three children and for the last five years had kept a chart of her weekly fasting glucose levels. She was consistently over 150 mg/dcl and more often than not was closer to 200 mg/dcl, thus classifying her as a diabetic (Fig. 1). She did not take medications or significantly change her diet. She chose to undergo large volume liposuction (about 10.6 Liters) thereafter noticing that her fasting blood glucose dropped to under 100mg/dcl and has stayed that way for over one year. In addition, she lost 60 pounds during that year. Thus, we have begun measuring HbA1c on all our overweight lipoplasty patients.


Obesity has been associated with type 2 diabetes (adult onset), heart disease, decreased longevity, increased cholesterol levels, higher LDL levels (“bad cholesterol), stroke and hypertension. Any improvement in metabolic modulation may add years to ones life.


Subcutaneous fat removal was first described by Teimourian in 1961 but was performed by sharp curettage. This form of fat removal proved to have many complications including bleeding, sloughing of skin and infection among others. In 1979 Illouz described blunt suction assisted lipectomy whereby fat could essentially be sucked through a blunt metal tube connected to a vacuum much in the same way that gelatin can be sucked through a straw. This idea was met with shock and disbelief by the majority of the medical community. However, once surgeons witnessed how safe and simple liposuction could be done if performed using the method developed by Dr. Illouz, a wave of patients with concerns about their shape and size made an appointment with a plastic surgeon and discussed having the procedure done.


One of the main qualifiers required of the patient wishing to be a candidate for liposuction was that they be within a few pounds of their ideal weight so as to maximize cosmetic improvement for the patient. The suction aspirate was limited to about two liters . This limit had been established due to the amount of blood that was suctioned with the fat, after two liters of fat aspirate, blood might need to be administered to the patient to replace the volume lost by the fat removal.


As techniques for suction assisted lipectomy (SAL) were improved, the amounts of fat that can safely be removed have increased. One of the main improvements that allow for larger amounts of fat removal include the super-wet technique developed by Fodor and Hunstad , , and the advent of intravenous sedation for out patient surgery as described by Charles Vinnick, MD and Robert Ersek, MD .

Super-wet technique

This is a method by which large amounts of dilute lidocaine and epinephrine is injected in to the subcutaneous fat so as to anesthetize the area and cause compression of the capillaries due to the volume of the injected fluid and the vasoconstriction effect of the epinephrine6. This technique also reduces the amount of blood lost, maximizes the amount of adipose tissue that can be removed and improves the precision with which fat is removed thereby providing better cosmetic results.

Intravenous Sedation

This is a method of injecting sedatives and other anesthetics that allow for normal regulatory functions of the nervous system thereby decreasing the risks associated with general anesthesia and liposuction that include: deep venous thrombosis and pulmonary embolism. Valium (20 mg) is given by mouth when the patient enters our facility. In the operating room, valium is given intravenously until speech is slurred (5-50 mg). Then, ketamine (75 mg) is added to the IV line and given over a 3-minute interval. The area is then infiltrated with local anesthesia 6,9,10, .


Using these methods we removed 10.6 liters of adipose tissue from our patient on 9/05/2001 and then 2.8 liters on 5/15/2002 (Fig. 1), her fasting glucose levels had a significant decrease after the fist session, they went from an average of 200mg to 100mg. She also had a subsequent decrease in weight of 60 lbs and has kept it off for over a year with no significant change in diet.

Conclusion


Large volume liposuction reduces insulin resistance and facilitates continued weight loss.

Discussion


Large volume liposuction has a definite effect upon insulin resistance and glucose levels as can be seen in this patient’s case. Previously, liposuction has been seen as a “cosmetic” procedure with no real therapeutic value, however, after discussing our experience with other colleagues we found that most have a patient that has experienced a similar effect. We have begun a new multi-center study to determine the effects of large volume liposuction and metabolic modulation. We monitor patients using hemoglobin A1c to determine past average glucose levels, current serum glucose, blood pressure, body weight and abdominal circumference. We hope to prove that the therapeutic impact of liposuction is long lasting and may decrease the rate and incidence of diabetes, heart disease and stroke and thus add years to our life.

Call for Investigators


In order for the results of this study to be statistically significant we are urgently calling on our colleagues to participate and to contact the Lipoplasty University at (877) 547-6362 or go to lipou.org to sign up and receive the protocol of investigation. This is a simple study that requires no doctor time, no added costs or procedures. It will combine our experiences in one important result.

1. Illouz, YG, De Villers, Y. T., “Body Sculpturing by Lipoplasty”, Churchill-Livingstone, New York, 1989


2. Giese, S.Y., Bulan, E.J., Commons, GW, Spear, SL, Yanovski, JA. “Improvements in Cardiovascular Risk Profile with Large Volume Liposuction: A Pilot Study”, Plast. Reconstr. Surg. 2001, Aug;108(2):510-9;Disscussion 520-1


3. Teimourian B, Fisher JB. “Suction curettage to remove excess fat for body contouring”, Plast Reconstr Surg. 1981.


4. Lipoplasty Society Guidelines, 1986


5. Fodor, PB. ‘Wetting solutions in aspirative lipoplasty: A plea for safety in liposuction.’ Aesth Plast Surg 19:379, 1995.


6. Hundstad, JP. “The Tumescent Technique: An Evolution”. Lipoplasty. 2(1):29, 1994


7. Hundstad, JP. “Tumescent and syringe liposuction: A logical partnership.” Aesth Plast Surg 19:321-333, 1995


8. Hundstad, JP. “Liposuction for obesity.” Operative Tech Plastic Reconstruct Surg 3(2,May):124-131, 1996


9. Vinnick, CA. “Intravenous Dissociaton Technique for Outpatient Plastic Surgery”: Tranquility in the Office Surgical Facitility, Plas. Reconstr. Surg. 67:799, 1981


10. Ersek, R.A. “A New Sedation Magnetic Monitor Board for Medication Monitoring During Outpatient Anesthesia”, Lipoplasty Newsletter, Vol. 6, No. 2, Spring 1989, pp.56-57


11. Ersek, R.A. “Disassociative Anesthesia for Safety’s Sake: Ketamine and Diazepam 35year Experience.” In Press