Contact: Louis DeLuca, MD: (561) Thomas Fiala, MD: Yehuda Handelsman, MD: Richard Baxter, MD:

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1 Contact: Louis DeLuca, MD: (561) Thomas Fiala, MD: Yehuda Handelsman, MD: Richard Baxter, MD: Headline: Metabolic syndrome: As American as Apple Pie Dek: When paired with behavior modification, it is possible that liposuction can have a positive impact on obesity, and perhaps even metabolic syndrome. Byline: Rochelle Nataloni Introduction: Excess abdominal fat has been linked to cardiovascular disease, diabetes and high blood pressure, and studies show that losing abdominal fat through diet and exercise improves these and other symptoms of metabolic syndrome. If lose of abdominal fat through diet and exercise reduces or reverses the ill effects of obesity, does that imply that removal of abdominal fat via liposuction could offer similar results? In last month s issue, Cosmetic Surgery Times offered a look at this hypothesis and related studies in a three-part series aimed at examining the ramifications for cosmetic surgeons, patients and society. In part one of our series we looked at studies that distinguished between visceral fat and subcutaneous fat and their connection to metabolic syndrome, and discussed the effect that health insurance coverage of liposuction would have on cosmetic surgery practices. Here, in part two, a comprehensive review of liposuction/metabolic syndrome clinical studies is offered; cosmetic surgeons talk about how liposuction can and cannot -- help their obese patients, and the endocrinology community weighs in on the good, the bad and the ugly of fat. Estimates indicate that one out of two 2 adults in the United States is either overweight or obese. Only about 20% of obese patients do not have metabolic syndrome, according to Yehuda Handelsman M.D, medical director of the Metabolic Institute of America and vice president of the American Association of Clinical Endocrinologists. With numbers like these, it s easy to see why metabolic syndrome is as American as apple pie. The state of America s waistline is as relevant if not more so to cosmetic surgeons as it is to any other healthcare practitioner according to Florida plastic surgeon Thomas Fiala, MD. Metabolic syndrome is probably even common among my patients than in the

2 general public, because the patients I see for liposuction and tummy tucks are self-selected; they are seeing me specifically because they have an increased waist size, which is the most obvious part of the syndrome. Dr. Fiala routinely evaluates these patients for other metabolic syndrome symptoms. Almost every month, we find men and women who never knew they had untreated diabetes or cholesterol abnormalities or the whole package -- metabolic syndrome -- and they are invariably thankful that we discovered the problem early, rather than after a heart attack, said Dr. Fiala. Large numbers of these self-selected patients across the country seek out abdominal liposuction in an effort to defend themselves from the welldocumented and highly publicized cardiovascular risks of an apple-shaped physique. It s a tricky issue [because clearly] the problem isn t so much the external fat that we can remove with liposuction, but internal fat that relates more to hormones, menopausal status and genetics, said Seattle-are plastic surgeon, Richard Baxter, MD. Having said that, there has been some research indicating that large-volume liposuction can improve certain metabolic parameters, but whether that is successful long-term is debatable and large volume liposuction is risky, says Dr. Baxter who is a member of the Emerging Trends Committee of the American Society of Plastic Surgeons. The knowledge that body fat distribution is directly linked to metabolic syndrome and that the study of it could lead to the development of more effective treatment strategies for people with, or at high risk for Type 2 diabetes and coronary artery disease adds fuel to an already explosive field of research. In The Handbook of Obesity, edited by George A. Bray, MD and Claude Bouchard, PhD, chapter authors Luigi Fontana, MD, PhD, and Samuel Klein, MD, report that the effect of liposuction on metabolic risk factors is not clear because of the heterogeneity in results among published studies. 1 Four studies

3 found improvement in insulin sensitivity and an equal number found no change in that metabolic marker; and as far as inflammatory markers, two studies found improvement and three found no change, according to the team. The authors elaborate that the reason for the differences in metabolic outcomes between studies is not explained by the amount of fat removed, the timing of the postliposuction studies or the initial BMI of the subjects. They note that it is possible that beneficial effects were missed in the negative studies because of the small number of participants. The pair point out that the largest study that evaluated the effect of liposuction on metabolic risk factors for coronary heart disease and diabetes was conducted in 123 obese women, and detected just 4% improvement in metabolic outcomes. The review concludes that the data do not support the theory that liposuction results in important metabolic benefits but qualify their statement, with the additional observation that things could change depending on the results of future studies that monitor body weight and fat mass after liposuction. Therein lies the rub. While current science suggests that liposuction s reach is too limited to have a positive effect on obesity related symptoms and thereby reduce the risks of metabolic syndrome, both the science of liposuction and the study of metabolic syndrome are far too young to make any conclusive statements. In the meantime, cosmetic surgeons have their own ideas about liposuction s usefulness in patients who desire the procedure for more weighty issues than spot reduction of subcutaneous fatty deposits. Boca Raton plastic surgeon Louis Dr. DeLuca, MD, matter-of-factly states that, It is generally accepted that liposuction does not significantly improve the metabolic derangements associated with metabolic syndrome. He points out that some liposuction studies have shown no improvement in the metabolic issues, but have shown improvement with removal of visceral (omental) fat and traditional weight loss. 2, 3 This, he says, strongly suggests that removal of

4 subcutaneous fat as performed in liposuction has no real beneficial effect on obese individuals with metabolic syndrome issues. What should be particularly relevant to cosmetic surgeons, according to Dr. DeLuca, is that many of his patients have used liposuction as a stepping stone to behavior modification. Liposuction on obese individuals should be important to any aesthetic surgeon who truly believes that the treatment goal is to provide both an aesthetic and behavioral benefit, rather than simply the former, says Dr. DeLuca. I spend a great deal of time emphasizing to potential patients -- particularly those who are overweight -- the limitations of liposuction without behavioral modification, and remarkably I have had a number of patients who have gone on to lose additional weight through lifestyle changes after undergoing a liposuction procedure. He emphasizes his belief that the mantra that liposuction is not a weight loss procedure is a valid one, adding that, My patients are fully aware of this and those who choose to pursue liposuction as part of a long term lifestyle change have seen the greatest benefit. Dr. DeLuca says he has no doubt that liposuction performed on the right patient can stimulate a desire for behavior modification. Body image psychology can have a tremendous impact on the overall health of many individuals. The positive correlation between improved body image and alteration of lifestyle can be a very healthy relationship, he adds. Endocrinologist Yehuda Handelsman, MD, concurs with a twist. Not all fat is bad, but too much fat anywhere is not good., says Dr., Handelsman. The answer is diet and exercise because in this way the number of fat cells remains the same. If the body needs them at a later point in time they will still be there. Whereas with liposuction you take out the small fat cells from the subcutaneous fat, and free fatty acids which are stored in the sub cute cells will find someplace else to go, such as in the liver, if there are not enough fat cells remaining in the subcutaneous layer. Dr. Handelsman advises his patients to use liposuction only for body sculpting and only for small amounts. Subcutaneous fat is important for storing

5 energy. Free fatty acids go there and prevent people from having too much fat in the blood. Deep subcutaneous fat, especially in the upper body can be almost as bad a visceral fat, but in general subcute fat cells are usually metabolically active and helpful, he explains. Part three: Current outcomes and opinion suggest that liposuction is not capable of minimizing metabolic syndrome, however studies are still ongoing. Even if it turns out that researchers eventually prove that liposuction is a one trick pony designed and destined solely to reduce inconveniently located fat deposits, there s something new on the horizon that may be capable of doing everything that liposuction does -- plus ameliorating the effects of metabolic syndrome. The something new is lipomodeling, and it s what s new and exciting on the fat frontier. References 1. Bray, George A. and Bouchard. The Handbook of Obesity 2. Klein, S, et al. Absence of an Effect of Liposuction on Insulin Action and Risk Factors for Coronary Heart Disease. NEJM, 350, Thorne A, et al. A pilot study of long-term effects of a novel obesity treatment: omentectomy in connection with adjustable gastric banding. Int J Obes Relat Metab Disord, 26(2), )