Image: Before and after, Laser & Skin Surgery Center of NY
Dr. Lori Brightman  /  Laser & Skin Surgery Center of NY
A 20-year-old has a more defined jawline three months after LipoLite, a laser-assisted liposuction treatment for small areas, says Dr. Lori Brightman who performed the procedure.
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updated 8/20/2010 9:28:55 AM ET 2010-08-20T13:28:55

Fat.

Those three little letters are freighted with enough baggage to sink a cruise ship. The issue encompasses health and aesthetics, of course, but also self esteem, class, money, and politics. Then there is the moral component. After losing more than 40 pounds, Kelly Osbourne said, "I took more hell for being fat than I did for being an absolute raging drug addict — I will never understand that." On the flip side, for those with a conscience (and we know you're out there), the idea of obsessing over a problem that is often rooted in self-indulgence can make a person want to join the Sisters of Mercy and work off the guilt among people with real troubles. Yet even thin women are not exempt, as they may worry about a little roll at the waist, a hint of a double chin, jiggly arms, or chubby knees. No amount of Spinning or sit-ups can eliminate certain stubborn bulges or change the dictates of our genes.

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Enter the plastic surgeon. In 2009, more than 243,000 women had liposuction to remove fat from various body areas, and about 123,000 underwent stomach-firming abdominoplasties. In recent years, doctors have developed several new — and nonsurgical — methods to reduce fat and sculpt the body. To help make sense of all the options, Allure asked experts to weigh in on how (and whether) these procedures work. And don't be embarrassed about the tape measure. When it comes to fat, there are no silly questions.

What can getting liposuction do — and not do?
Liposuction treats fat deposits that are resistant to diet and exercise, such as saddlebags or the lower abdomen, which means it's not a substitute for traditional weight loss. In fact, diet and exercise are essential before and after the procedure to obtain the best results, says Jeffrey Kenkel, professor of plastic surgery at the University of Texas Southwestern Medical School. A doctor can suction out up to five quarts of fat, but there is usually little change in body weight — at most a pound or two. Liposuction can't eliminate stretch marks or cellulite, and it may even make cellulite more pronounced, Kenkel says. Once the fat is taken out, "we can't predict or control how much the overlying skin will contract," he says. "In general, patients with good skin tone will experience tightening as the skin redistributes itself. But others with thin, soft skin may develop sagging in the areas suctioned." Doctors are developing alternative and noninvasive ways to remove fat, but for now liposuction is considered the gold standard.

Adding padding

Does lipo ever need revision?
Yes — about 20 percent of patients request a redo, says Lori Brightman, director of dermatology at the New York Eye and Ear Infirmary. Common causes are unevenness (for example, one outer thigh not seeming symmetrical with the other) or a lumpy look, in which case the doctor can usually do a touch-up by removing more fat. Another potential complication is track marks, the result of fat taken too close to the skin's surface. "This is a lot harder to repair and in some cases may require transferring fat from somewhere else in the body," Brightman says.

Once the fat is removed, can it come back?
If you gain weight after the procedure, you may find it collecting in unlipo'd areas on the body. The redistribution is unpredictable, says Gerald H. Pitman, a plastic surgeon in New York City and clinical professor of plastic surgery at NYU School of Medicine. "Patients who gain weight after liposuction of the hips and thighs may say, 'My arms are bigger' or 'My bra is tighter.'"

People are talking about laser lipo. What is it?
In laser-assisted liposuction (LAL), fat is loosened with a laser before being suctioned out, which is why it can take twice as long to perform — for example, about 60 to 90 minutes for traditional liposuction of the abdomen versus 120 to 180 minutes for LAL, says Rhoda S. Narins, chief of liposuction in the dermatology department at NYU School of Medicine. The laser is said to stimulate collagen and elastin repair in the overlying skin and to result in less bruising than regular lipo, because it coagulates blood vessels. "You don't need laser lipo for someone with good-quality skin. It's for an older patient who has lost elasticity," says Barry DiBernardo, clinical associate professor of plastic and reconstructive surgery at the University of Medicine and Dentistry of New Jersey in Newark. LAL is best for relatively small areas without thick fat, such as under the chin, he says. (In ultrasound-assisted liposuction, fat is also liquefied before suctioning.)

Some doctors are skeptical of using lasers this way, pointing out that there currently isn't scientific data to support the claimed benefits. Also, "you are potentially heating the skin to dangerous levels in order to achieve skin tightening," Kenkel says (there have been some burns reported from LAL). And the tumescent anesthetic solution that's commonly used in regular liposuction results in little to no bruising anyway, Narins says.

There are several LAL devices, including SmartLipo, SlimLipo, ProLipo, and LipoLite. A new one, LipoEze, can remove large quantities of fat and presents no risk of burns, because the laser is positioned inside the suction tube away from the skin, Narins says.

For a jiggly belly, is a tummy tuck better than lipo?
"Liposuction and abdominoplasty treat different problems," says Al Aly, professor of plastic surgery at the University of California, Irvine. If the issue is simply extra fat, plastic surgeons generally recommend liposuction, but if there is very loose skin and muscle-wall weakness, which is not unusual in women who have given birth, then a tummy tuck may be preferable. This repositions muscles and skin, as well as removes fat; "it usually takes a couple of weeks before the patient can walk normally," he says. (A mini tummy tuck, which targets small amounts of excess skin and abdominal weakness, may involve a shorter recovery.)

What about all the spas that offer fat-melting injections?
These shots sound good — but not to the FDA, at least for now. The agency has threatened legal action against spas advertising fat-dissolving procedures called lipodissolve, lipozap, lipotherapy, injection lipolysis, or mesotherapy. None of the chemicals, drugs, vitamins, minerals, or herbal extracts in these injections are FDA-approved to eliminate fat, and the FDA cites "reports of permanent scarring, skin deformation, and deep, painful knots in the injected areas." Studies are under way to find out which ingredients, if any, might work, and some injectable drugs show promising, though modest, results. For example, a study of one formula found that after people got 71 shots on one side of the abdomen, over eight months, they lost about a centimeter (less than a half inch) of fat, according to V. Leroy Young, a plastic surgeon in St. Louis. Tests of a drug called ATX-101 — which contains deoxycholate, a bile that breaks down dietary fat in cows' digestive process — have shown that it can safely reduce very small fatty deposits in the back and under the chin.

What's the least invasive fat removal option?
Zeltiq, a device applied to the skin, is completely noninvasive: It chills fat cells, enabling the body to process and excrete the fat. Studies suggest that this treatment (also known as cryolipolysis) is for very fit people with isolated fat deposits, Brightman says. The procedure is slow, and the results take a long time — up to four months — to show. Zeltiq is cleared for localized fat reduction in Canada; here, it is FDA-approved only for skin cooling during dermatological treatments, and doctors are using it off-label. After trying it on one of his own love handles, Mathew M. Avram, director of the Massachusetts General Hospital Dermatology Laser & Cosmetic Center in Boston, reports, "It's boring, but it's not painful. There was a noticeable change on the treated side versus the untreated side, which I was happy with."

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