LIPOSUCTION CASE STUDIES

Case 1: Unhappy patient

This 25 year-old lady from Singapore came to us for liposuction of her thighs in January 2009. We performed liposuction on all 6 areas: hips, buttocks (banana rolls), outer/inner/front/back of thighs. She was not very happy afterwards as she said her thighs still looked the same although we have aspirated almost 2 L of fat. She emailed and called our clinic for the first 6 weeks complaining that her thighs were still big, although we advised her to be patient, as the post-liposuction swelling on the thighs may take up to 3 months to resolve. We never heard from her again until roughly 6 months post-op. She flew back from Singapore to show us her new thighs. And apparently she was very happy, even though the fat around her knees were not removed, as she opted so!

Take home message: Be patient, be patient, be patient! Swelling may take up to 3 months to disappear! When getting liposuction done on the thighs, it is important to get it done on all 7 areas: hips, buttocks, outer/inner/front/back of thighs and knees. If any of the area is not touched at all, it will result in disproportionate looking legs! As the case in this patient. Although her knees did not appear big at all pre-operatively, but when everywhere else slims down except the knees, the knees will definitely appear fatter!

Case 2: Revision liposuction/liposculpture and fat transfer

Another Singaporean in her early 20s, had VASER liposuction of her inner and outer thighs in Singapore 6 months earlier. She was not very happy, as she was left with funny looking thighs which appeared thick in front and at the back, as well as irregularity on the inner left thigh. On examination it was obvious that she has thick layer of fat on the front and back of the thighs, and denting on the left inner thigh due to uneven removal of fat, and possibility of overdoing it. We re-did liposculpting on all 7 areas: hips, buttocks (banana rolls), front/back/outer/inner thighs as well as knees. We also did fat transfer to the left inner thigh to correct the denting and irregularity. She was offered fat transfer to her hips to make them appear rounder, but she declined. She was very happy with the result.

Take home message: Do NOT just get liposuction done on outer and inner but not front and back of thighs. In fact liposuction of the lower limbs should include all 7 areas stated above to ensure excellent result!

Case 3: Revision liposuction of the abdomen

This 52 year-old Singaporean went to have VASER liposuction of her upper and lower abdomen in Shanghai a year ago, and was not too happy with her result. She came to us, asking for more curvature. We re-did liposuction on all 5 areas of her mid-section: upper and lower abdomen, waist, flanks, lower back, creating the hour-glass figure she has been dreaming of. We also cleared all the scarring tissue on her middle abdomen which made the skin stuck down to the muscles. At last, now at the age of 52, she has an hour-glass figure!

Take home message: When aiming to create an hour-glass figure, do NOT just perform liposuction on the frontal abdomen, without spending time on the other parts. The human body is a 3-dimensional configuration, not 2 dimensions, hence sculpting should be done in 3 dimensions, involving all areas!

Case 4: Revision liposuction of the arms

This 26 year-old Singaporean had liposuction of her arms done 9 months ago by a plastic surgeon in Singapore. However, she was not too happy with the result, because although her arms were smaller, she still could not wear her favourite tubes, as the fat from her shoulders, upper back and armpits were bulging from the tube dresses. She came to us for liposuction on those areas, as well as on her abdomen.

Take home message: Again, it is always very important to address fat in the shouders, armpits, and upper back when a patient asks for liposuction of the arms. After all, the whole idea of getting liposuction done on her arms is so that she can wear sleeveless and tube dresses.

Case 5: Liposuction may not be appropriate when skin tone and elasticity is poor

This 25 year-old Singaporean has had multiple pregnancies and deliveries. She presented to us for liposuction of the abdomen. On examination it was noted that she has significant stretch marks, and thinning of the abdominal skin, as well as poor skin tone and elasticity. Mild rectus diastasis was also noted. She was offered tummy tuck/abdominoplasty, but she declined. A liposuction was eventually performed, with suboptimal result. However, she was quite happy and willing to accept the result rather than undergoing abdominoplasty. Her goal was to look good with clothes on. Which could be achieved through liposuction alone.

Take home message: Liposuction is not always the solution for everything! When there is poor skin elasticity and a lot of excess skin, a tummy tuck may be more appropriate. A tummy tuck can always be combined with liposuction to sculpt the waist and flanks.

Case 6: Result is best when combined with exercise and diet

This 26 year-old Singaporean was completely out of shape when she presented to us. Although we were quite reluctant to perform liposuction for her initially, and asked her start on exercise and diet program, she was quite persistent. She promised to adopt healthy lifestyle after her first session of liposuction. She did! She started jogging barely 2 weeks after her liposuction and followed our nutritional and diet plans. She emailed us these photographs 6 weeks after her liposuction, obviously very happy with the result!

Take home message: Liposuction is not meant as a way to lose weight. Liposuction is meant to sculpt the body. To lose weight and to maintain a nice figure after liposuction, it is very important to adopt a healthy lifestyle, which includes exercise and healthy diet.

Case 7: Buttocks lift with liposuction

A lot of times, patients do not realize how important it is to get liposuction done on all 7 areas of the legs if they want to get excellent results. Not only will they have shapelier and more proportionate looking legs, but by getting liposuction done on the buttocks, they also get an immediate buttocks lift! The following cases illustrate this very important point. Please note that the final result will eventually look better when all the swelling and bruises have resolved. But, even on post-op day 1 as all these photos show, the results are simply amazing! The 7 areas are: hips, buttocks, outer, inner, front and back of thighs, as well as knees.

Take home message: No point getting liposuction done just on the outer and inner thighs, like what most clinics offer. Our bodies are 3-dimensional structure, which need to be respected and treated that way! When getting liposuction of the thighs, get it done on all 7 areas!

Case 8: Complication from VASER liposuction

This 30 year-old Indonesian lady had VASER liposuction done by a plastic surgeon in Indonesia 6 months ago for her inner thighs, and now presented to us, requesting for liposuction for her outer thighs. Apparently she was quite happy with the result of her inner thigh liposuction. Hence, we did not offer to perform revisional work nor did we perform outer thigh liposuction for her. She was subsequently discharged from follow up, and asked to return to her previous plastic surgeon. We suspect that she never realized that she had complication from liposuction, and she might have thought that it was the normal expected result of liposuction.

Take home message: new innovation and technology does not always equate better results. In fact, put in un-trained hands, it can create disaster! Sometimes, back to basic is better, as in the case of liposuction.

Case 9: One litre ain't enough!

Since liposuction is regulated in Singapore in 2008, the Singapore Medical Council and Ministry of Health have imposed strict ruling that all liposuction done as office-based procedure, regardless of who is performing it--experienced or non-experienced-is not allowed to exceed 1 litre. But most of the time, even for slim patients who are already within their ideal weight range, it is common to aspirate even more than 2 litres when performing liposuction from larger part of the bodies, such as the thighs alone! As a result of this, the procedure either has to be broken down into a few sessions, or done in hospital setting, with additional anesthetist, operating room and in-patient room charges.

Take home message: Imposing maximum limit of fat which may be taken out on each session is good to ensure that the procedure is safe for patients. However, it should be left for the surgeons' judgement call to decide intraoperatively how much to take out judging from the amount of bleeding. Otherwise, it will bring up the cost of liposuction, causes loss of productivity and loss of income as patients need to take more leave days, and unsatisfaction as patients are left with unproportionate-looking areas of the bodies.

Case 10: The hour-glass figure

Some researchers have found that the waist-hip ratio (WHR) is a significant measure of female attractiveness. Women with a 0.7 WHR are usually rated as more attractive by men from European cultures. Such diverse beauty icons as Audrey Hepburn, Marilyn Monroe, Sophia Loren and even the Venus de Milo all have or had ratios close to 0.7, even though they all have different weights and heights. According to a new study, men prefer a woman with curves, which showed that an hourglass figure is an intoxicant for the male brain.

To enhance their perception of attractiveness, some women may artificially alter their apparent WHR. The methods include the use of a corset to reduce the waist size and hip and buttock padding to increase the apparent size of the hips and buttocks. However, 3-dimensional liposculpture combined with fat transfer, is the only definitive way to achieve that hour-glass figure, as illustrated by the following cases.

Take home message: To achieve the kind of results we get, it is very important to treat the body like a 3-dimensional structure. Hence, when sculpting the abdomen, it is crucial to work on upper and lower abdomen, waist, flanks, as well as lower back. Think and work like an artist, and you will sculpt a masterpiece!

Case 11: Revision liposuction after Vaser liposuction

This 27 year-old Singaporean woman had Vaser liposuction done for her arms and abdomen in Kuala Lumpur before presenting to us for revision. She was unhappy because although her arms appeared slightly smaller after liposuction, her shoulders and upper back still appeared very broad and manly. The procedure also left a deep groove and tunneling which ran from her waist to flanks. On top of that, there were multiple areas on the abdomen where skin was stuck down to the underneath muscles. All these unwanted outcome resulted from: liposuction of the arms without involving shoulders, armpits, and upper back; over-aggressive removal of fat over waist and flank areas; and burns from Vaser underneath the skin on the abdomen causing it to heal with scarring, and eventually stuck down to the underlying muscles. We performed an overhaul liposculpture for her arms, armpits, shoulders, upper back and flanks to smoothen out the contour, as well as to remove the bulk on her upper body. We will be performing a revisional work on her abdomen when she returns for her second session in November 2009.

Take home message: To get excellent results, it is always good to view the whole upper body as a whole, rather than just focusing on the arms. New technology does not always guarantee good results!

Case 12: Liposuction can be performed to correct asymmetry due to scoliosis

This slim 20 year-old Singaporean woman was known to have scoliosis since teenager. She presented to us because she wanted to have slimmer thighs and bigger buttocks. We took the opportunity to sculpt her body into a more symmetrical figure. We also performed autologous fat transfer to her buttocks. She, as well as her boyfriend who came along with her, was ecstatic with the result. Upon discharge, she was referred to orthopaedic surgeon for follow up.

Case 13: Don't throw away the fat, please!

Autologous fat transfer is an excellent technique to augment facial anatomies, such as cheeks, chin and lips, as well as buttocks. Combined with liposuction, it gives excellent result to the lower body. Although it is possible to perform fat transfer to the breasts, we do not like to do it, as in the long run, it may create confusion, as fat cells may get calcified (surrounded by calcium). On mammogram x-ray, this looks exactly the same as an early breast cancer. When faced with many calcifications on x-ray, the physician is faced with dilemma of whether to take out every single lesion for biopsy, or just to leave them alone, assuming that those are just calcified fat. If the physician chose the latter, and it turned out that one of those calcifications was a real cancer 2 years later, it is too late to regret.

Now, picture this: one out of 11 American women will develop breast cancer. That is a HUGE number. Just look at your co-workers and imagine how many in that group will develop that disease. Next - the most commonly used method to TRY and pick breast cancer is a mammogram. Many breast cancers grow so quickly that portions of the tumor actually die and are replaced with small clumps of calcium surrounded by scar tissue. ONLY trained eyes of Radiologists can diagnose classic microcalcifications of the breast as cancerous. Other cancers apparently do not bother reading the books and may appear in other forms which are NOT "classic".

When fat dies, the process of healing and resorption often leads to scar tissue and calcifications which to some may appear similar to those of breast cancer. While some may protest and say that microcalcifications of cancer are quite different than other calcifications, that is NOT always the case. Moreover, if the prospect of multiple "false positive" scares and needless breast biopsies does not scare you, consider the importance and likelihood of benign, fat grafting calcifications potentially hiding those of "real" breast cancer calcifications in a cancer prone organ.

Personally, we would NOT recommend getting fat grafting to the breast!

To read the current recommendation on fat transfer for breast augmentation set out by the Royal Australasian College of Surgeons, please click here.

Case 14: WYSIWYG!

What You See Is What You Get! Yes, immediately after liposuction surgeries, you should be able to appreciate what the final results will look like 2 to 3 months down the road, especially on the abdomen and arms, when all the swelling has completely disappeared. The best time to get these pictures, is the very next day after surgeries, when most of the tumescent fluid has drained out, compression bandages or garments have helped shaped the body, and severe swelling hasn't really kicked in yet. If you don't like what you see the very next day after surgery, it is high chance that you will never like what you see even after all the swelling and bruises have subsided. The only exception, for some reasons, is on the legs, where final result may be much better than what you see the very next day after surgery.

Case 15: More cases where a combined liposuction and tummy tuck would have been more appropriate

Both Singaporean patients featured below are in their 30s, has had multiple pregnancies and poor abdominal skin quality. They were offered lipo-abdominoplasty, but declined. Their goal was to look good with clothes on, which was achieved through liposuction alone, without abdominoplasty (tummy tuck).

Case16: Liposuction is for fat people?

Wrong! Liposuction should ideally be done for people who are already within their ideal range of weight, and used as an adjunct to sculpt the body into an ideal shape rather than as a means to lose weight. After all, even after taking out 2 liters of fat, you are going to lose only 2 kgs! Aspirating out 2 liters of fat from someone who is 10-20 kgs overweight, is not going to make any difference at all. You will need multiple sessions of liposuction before you can even create a visible waistline!! These twins, who are in their mid-20s, weigh barely 48 kgs, standing at 160 cm. They are physically active and fit, running 3 times a week, swim twice weekly, and play badminton up to twice a week. However, they have some stubborn pockets of fat here and there which distort their figures. They also have unusually fatty calves, which responded very well to liposuction.

Case 17: Another case of revision liposuction

This Singaporean patient in her late 20s presented to us because she was extremely unhappy with the results of her previous liposuctions. She has had Vaser liposuction on her abdomen and thighs done in Singapore 1-2 years ago, and recently had arms liposuction done in Hatyai. We found out that apparently her flanks and lower back were not done, as she did not request for it. There was also a lot of waviness and irregulariy on her abdomen, but she did not request for revision. Despite recent liposuction of her arms, she still could not wear sleeveless dress, as her arms, shoulders and upper back were still huge, and there was fat bulging from her armpits. During surgery we found that most parts of her arms have been left untouched, with thick layers of fat almost everywhere. There was only one incision scar on each arm from her previous liposuction, which could not have allowed for optimal removal of fat. We managed to aspirate almost 1 L of fat from her arms alone, producing immediate dramatic effect!

Take home lesson: To get excellent result, always get all 4 areas of the upper body, all 5 areas of the mid-section, or all 7 areas of the thighs done at the same time! This is the only way to ensure excellent results. The bodies are segregated into so many areas in liposuction for the sake of "charging" purposes. However, performing liposuction on different areas within the same section of the body in separate sessions is not advisable, as it is almost impossible to ensure smooth outline and contiguity of the areas concerned! Communicate with your surgeon prior to surgery and make sure he truly understands what you are trying to achieve. Liposuction is meant to sculpt the body into a beautiful shape with smooth outline. It is not just aspirating out some fat, put it in a jug, show your patients and be done with it! What is important is what you leave behind for people to see. Always perform liposuction on all areas in one section of the body within the same session. If you split it up into separate sessions, you will get less than satisfactory result.

Case 18: Get all areas within the same section done at the same time!

This 31 year-old Singaporean had a BMI of 22, which was quite decent, but she accumulated most of her fat in the lower part of her body (pear-shaped body). Although ideally her thighs should be lipo-ed in stages, perhaps in 2-3 sessions to achieve an ideal shape, we decided to extend the surgery to 6.5 hours, aspirating out more than 4 liters of fat. Most of the time was spent sculpting all 7 areas of her thighs. Ultimately her result was simply unbelieavable! We could afford to spend 6.5 hours on just one patient, because our clinic is an exclusive clinic which caters to selected group of patients. We only perform ONE major surgery per day! Hence, we are not pressed for time, and we ALWAYS produce excellent results!

Take home message: Even when the part of the body is too huge, and needs to be lipo-ed in a few sessions, it is always imperative to perform liposuction on all areas within the same section, in the same session. This way there will be a smooth transition and outline of all areas concerned. By performing liposuction on separate areas on separate occassions, there will be irregularities, waviness and uneven surface and texture. So, remember: all 4 areas of the upper body, or 5 areas of the mid-section, and 7 areas of the thighs, MUST be done within the same session to ensure excellent result!

Case 19: Another case of revision liposuction

This 41 year-old Singaporean presented to us after having 2 sessions of "whole-body" liposuction which was performed by a plastic surgeon and completed within 1 hour each session in Johor Bahru. She was extremely unhappy with the result. On examination, we found that there was uneven removal of fat in many areas, resulting in "hills" and "valleys" on the tummy, thighs, as well as arms. We suspected that the surgeon had performed powered-suction liposuction and lost control of the suctioning, with over-suctioning in some areas, and under-suctioning in other areas. The short duration of time allocated to cover such huge areas of the body did not allow the surgeon enough time to sculpt the body. We spent 3.5 hours performing a revision to even out the contour of the abdomen, as well as create a new waist and lower back curvature for the patient. She was ecstatic with the result, and planned to return for revision liposuction for her thighs and arms.

Take home message: Time and time again, we keep stressing that liposuction is NOT just a matter of removing fat! How much you remove is not as important as what you leave behind for people to see! Anyone can perform liposuction, but only true artists are able to sculpt a masterpiece. Traditional manual liposuction using only syringe and cannula ultimately is the time-tested method to produce excellent results with very minimal risks and complications. The only drawback is it is extremely time-consuming, and hence, there is little financial incentive to perform traditional liposuction in today's context. We have learned and performed liposuctions in many centers around the world, and realized that there is only a handful of surgeons who are still advocating traditional liposuction; amongst them: Dr Pierre Fournier in Paris, A/Prof Fong Poh Him in Singapore, and Dr Arthur Tjandra in Medan/Singapore.

Case 20: Smart Lipo is never meant for large area of the body!

This petite 38 year-old Singaporean patient, weighing just 42 kgs, has had 4 sessions of liposuction done in Singapore: 2 sessions of Smart Lipo on her abdomen a year ago, 1 session of Vaser on her abdomen 4 months ago, and another session of Smart Lipo of her thighs a year ago. Obviously she was not very happy with the result, even after a recent Vaser liposuction. There was a lot of waviness and irregularity on her abdomen. The waist and her back were not touched at all. As she has been longing for an hour-glass figure, she presented to us for a revision liposuction on her abdomen, as well as her arms, which have not been lipo-ed previously. On examination, we found that she had very lax abdominal skin, full of stretch marks from her previous pregnancy. We advised her to undergo a combined liposuction and abdominoplasty, but she declined abdominoplasty. During surgery, we found that there were many patches of skipped areas where fat was not removed in her abdomen, hence the appearance of irregularity. There were also a lot of scarring with fibrous tissue, presumably from burns from Vaser, preventing smooth passing of cannula in the fat layers. We spent 4.5 hours performing a revision resulting in exceptionally good result. There was, however, signficant loose hanging skin on her abdomen. But, she has been warned about that.

Take home message: Do your homework carefully before going for liposuction! Smart Lipo is good for double chin, but is never meant for large areas, such as abdomen or thighs! This patient has had 4 sessions of liposuction and spent more than SGD20,000 before coming to us for a revision. Everyone can perform liposuction. It is just a matter of sucking out fat. But, it needs a real artist to produce a masterpiece. Always look at a surgeon's track records and talk to his/her previous patients. This way you can be sure that you are in good hands.

Case 21: Another revision for a patient who was unsatisfied with her VASER liposuction result

This 29 year-old Singaporean patient contacted us a month after she had Vaser liposuction surgery on her thighs done in Singapore. She was completely unsatisfied as she could not see any significant result. We asked her to wait at least 3 months for all the swelling to resolve and before we could perform a revision liposuction on the same area. She presented to us 4 months after surgery. We found out that she had paid SGD4,000 just to have her inner thighs done. Her thighs were still very huge when we examined her. Although her inner thighs had been lipo-ed, we still managed to pinch a thick layer of fat! Surely enough, we managed to aspirate 1.4 L of fat from both her inner thighs alone, with a total amount of almost 2.6 L of fat from both thighs!

Take home message: We have stressed again and again the importance of getting all 7 areas of the thighs, or all 5 areas of the abdomen and lower back, or all 4 areas of the upper body done at the same time to ensure excellent result. If those areas are split up and done separately on separate sessions, it is very hard to ensure smooth contiguity between 2 adjacent areas. Less than satisfactory result will occur. Liposuction is essentially a very time-consuming work. In order to sculpt a beautiful piece of arts, it is important to spend a significant amount of time. However, it is unrealistic and financially non-viable for a surgeon to dedicate half a day just to sculpt one patient. Many, hence, take short cuts of just performing liposuction on a very small area of the body, when they should have covered the whole segment, in order to produce excellent result. A lot of time, it is also due to patients' financial constraint. If getting just one area done already costs $4,000, doesn't it mean that all 7 areas will cost $28,000? Elixir de Vie Indonesia prides itself in offering affordable cosmetic surgeries, without compromising quality. We are able to do that because cost of living is very low in Medan. Wages in Medan is only one-tenth of those in Singapore. Elixir de Vie Indonesia is one of the very few center of excellence for liposuction surgeries in the world. We only perform 1 liposuction surgery per day, as each surgery takes an average 4-6 hours. Almost 40% of the works we do are revision works on patients who have had liposuction surgeries done elsewhere.

Case 22: Another revision for a patient who has had VASER liposuction on her abdomen

This 28 year-old Singaporean has had multiple VASER liposuction done in Singapore on her abdomen, thighs, as well as arms. Unhappy with the result, she flew over to Medan to get a revision done. As her budget was restricted, we did revision for her upper and lower abdomen as well as inner thighs only. We sculpted her waist at the same time. Intra-operatively, we found there were significant scar tissues underneath the abdominal skin resulting in adhesion and appearance of "groove" on the skin, as well as uneven removal of fat, which resulted in waviness. We cleared all the scars with a special cannula, and removed fat evenly in both upper and lower abdomen, including the pubic area which was bulging and caused a lot of embarassment to the patient..

Case 23: Be realistic!

It is unrealistic to expect a model's slim figure if you are too big to begin with. There is a safe limit of how much fat and blood which can be taken out at any point of time. Death can occur because of too much blood loss! Our bodies need time to recover and to reproduce red blood cells. And this cannot be achieved overnight. Hence, it is completely unwise to get a few sessions of liposuction done over a few consecutive days hoping to remove more fat, as not only our bodies will not be able to replace all the blood loss so fast, but we are also subjecting our bodies to daily dosage of local anesthesia and sedative. Lidocaine needs time to be cleared from the body. High level may lead to toxicity, and eventually death! We never compromise on patients' safety. We follow international guidelines and will only perform liposuction on the same person at least one month apart for different areas of the body. If it was to be done on the same areas, it has to be 3 months apart. We also insist on having patients going for blood test to ensure that they are not anaemic, they do not have blood clotting problem, and their liver and kidneys function are perfectly normal, before undergoing liposuction. Any abnormality may jeopardize a patient's safety!

The following 2 cases which were performed at almost the same time illustrate very well the message we are trying to convey. Both are patients from Singapore in their early 20s. Patient No.1 was already slim to begin with, with only some excess of fat here and there. After removal of 3.2 L of fat from her thighs and calves, we could see almost instantaneous result. Patient No.2 still has slightly bigger than average thighs, even after removal of almost 4 L of fat! She will most likely need a second session if she would like to have model's thighs. However, it is important to remember that the thighs were still very swollen. They will look better in months to come when all the swelling and bruises have resolved, as what Case No. 1 illustrates.

Case 24: Another revision case: A case of a combination of incomplete and over-removal

This 29 year-old Singaporean patient had gone to Hatyai 4 months ago for liposuction of her abdomen and arms. She was advised by her surgeon in Hatyai that there was no fat to be removed from her abdomen. At the end she had liposuction of her arms, flanks and inner thighs over 3 consecutive days. She was extremely unhappy with the result, as she is now left with "drumstick" arms as the fat over her shoulders and upper back was not aspirated at all! She also had deep grooves over her flanks, which was due to over-removal of fat, and bulging hips, due to inadequate removal. There was also sunken areas in the mid-buttocks, which she claimed were not present prior to her liposuction. We planned staged revision liposuction for her. For this session we aspirated fat from her arms, shoulders, and upper back, producing a smooth contour, as well as releasing adhesion in the grooves and re-inject fat into the grooves. The grooves were not completely gone, but became less visible. Her "drumstick" arms were successfully corrected. We will be performing fat transfer into her sunken mid-buttocks areas on her next visit when she is back for revision liposuction on her thighs. We also managed to flatten her abdomen completely.

Take home message: Traditional liposuction is still the safest method of liposuction which consistently produces excellent result. The likelihood of over-removal of fat causing dents and grooves is very little. From the description provided by our patient, it was likely that the surgeon was using powered-suction, which is notorious for causing dents and grooves from over-removal of fat. When getting liposuction done it is very important to get all areas within the same segment done at the same time. Otherwise, case like the "drumstick arms" above is likely to occur. It is also very important to take note that liposuction surgery should NEVER be performed on consecutive daily basis hoping to maximize fat removal. Liposuction causes bleeding regardless of the methods used. Bleeding may cause death! By getting liposuction done on daily basis, the body does not have enough time to reproduce red blood cells. Besides that, there is a potential lidocaine toxicity which may also lead to death, from daily administration of local anesthesia which consists of lidocaine. This is made worse if the liver function is already abnormal to begin with. Hence, it is very important to ensure liver and kidneys function are normal before getting liposuction surgery done.

Case 25: Revision liposuction post VASER liposuction

This is the same Singaporean patient who was featured in case No. 11. We performed revision liposuction using traditional method to correct all the damage done.

Case 26: Self-discipline is needed after liposuction

This is the same Singaporean girl who was featured in Case 6 above. She returned for arms and upper back liposuction 4 months after liposuction of her abdomen. We are extremely pleased to learn that she has picked up running as a hobby, and is going to gym regularly!

Take home message: To maintain your figure after liposuction, you really need to change your lifestyle and watch what you put inside your mouth, as well as embark on an exercise program. Otherwise, all efforts and money will be completely wasted!!

Case 27: Why do I still look fat after 4 sessions of liposuction?

This Singaporean patient in her 20s has had 4 sessions of liposuction done in Singapore, of which 2 sessions were done on her thighs alone, spending close to SGD 20,000 and was still unhappy with the result. We agree that after so many sessions of liposuction, her thighs are still considered pretty huge. She claimed that she has not gained any weight after liposuction, and that her thighs have always looked that way even after liposuction. We are, however, a little bit sceptical. Could she have gained back all the fat because she did not watch what she put into her mouth, and did not exercise? Or could she have hormone imbalance (e.g.. estrogen dominance or hypothyroidism) which causes someone to gain weight despite exercising and consuming healthy diet?

Take home message: Liposuction may help you achieve the figure you have been dreaming of, but you need to work hard to maintain it! It is also important to go for thorough hormone tests to rule out hormonal problems if you seem to unable to shed pounds even after healthy dieting and exercising. Look for a board-certified endocrinologist or anti-aging and regenerative medicine physician. Dr Arthur Tjandra is a board-certified Anti-Aging and Regenerative Medicine physician who specializes in treating hormone imbalances and hormone replacement therapy.

Case 28: Revision liposuction post-VASER liposuction

This is the same patient who was featured on case 22 who came to us just 2 months ago. She is extremely happy with the result of revision liposuction we performed for her, now returning for revision liposuction for her arms.

Case 29: Revision liposuction of thighs and fat transfer to buttocks

This is the same Singaporean patient who was featured on case No.24. She returned 2 months after her previous revision liposuction session, feeling very happy. This time round we continued to perform liposuction on her thighs and calves and re-inject fat into the sunken areas of her buttocks. However, as her legs were rather big, she agreed to get it done on just the left one first. We removed almost 2 liters of fat. We will perform liposuction on the right thigh and calf 2 months later. This is done for safety reason. Liposuction causes bleeding, and bleeding may cause death. That is why there is always a limit of how much can be removed in one session. Daily liposuction done over a few consecutive days, although popular in some clinics, is a very dangerous practice which may cost your life!

Take home message: Liposuction must never be performed on consecutive daily basis. We learned that this has been the new trend in a few clinics in this region to maximize fat removal. Patients who travel away from their home countries hoping to get cheaper rates, welcome this approach as to get "everything done in just one visit", and "take out as much fat as possible", without realizing the potential disaster which may cost their lives. In Singapore, where the Ministry of Health limits removal of fat to just 1 liter for patients who are not being admitted as in-patient, a few clinics have also made this offer to patients. The ministry ruling limits the volume which can be removed in one session, but never mentions the time interval between each session. Potential death is usually caused by excessive bleeding and lidocaine toxicity, as the local anesthesia is being administered on daily basis, especially when no blood test is being done to make sure liver and kidneys function is normal before surgery. Our rules are very clear: no liposuction will be done less than 1 month apart between each session, preferably 3 months; and no revision liposuction on the same areas will be entertained if it is less than 3 months, preferably 6 months, after the previous liposuction. We will also not perform liposuction on any patient whose BMI is more than or equal to 27. Thirty to 35% of patients who requested for liposuction in our clinic got rejected. That is why this particular patient opted to get it all done with the left leg, and get her right leg done 1-2 months later. Otherwise she would have to wait 6 months to get a second session done on her thighs again to make them even slimmer. And/or split thighs and calves liposuction into different sessions.

Case 30: Visceral fat versus subcutaneous fat

This 50 year-old Norwegian came to us wanting to have a flat tummy. We suspected that it was high visceral fat content which contributed to the protruding stomach. This was made worse by the possibility of peri-umbilical hernia on physical examination. We performed computerized body composition analysis which confirmed our suspicion. His subcutaneous fat level was merely 19%, while his visceral fat level was 14 (normal limit: 0-5)!! We explained that he was not exactly an ideal candidate for liposuction and suggested exercise and diet program instead. Moreover, there is a high chance of poking his intestines with the liposuction cannula in the presence of hernia. As he has traveled all the way from Norway, he was quite adamant about getting the liposuction done, and willing to accept less than satisfactory result as he understood that visceral fat could not be removed through liposuction.. He promised to follow a strict exercise and diet regime.

Take home message: There are 3 locations of fat in our bodies: visceral (aka intra-abdominal fat, which is located inside the abdominal cavity, packed in between internal organs and torso), subcutaneous fat (found underneath the skin) and intramuscular fat (found interspersed in skeletal muscles). Subcutaneous fat is the one which can be removed through liposuction. It is therefore, important to understand what contribute to a protruding abdomen. If it is visceral fat, then liposuction alone will not make much difference. We provide free computerized body composition analysis to all our patients prior to and after liposuction. Performing liposuction on a patient who has a defect in the abdominal wall is a very tricky situation as the cannula may poke the intestines. We advise beginners not to attempt this, especially when machine-assisted liposuction is used. Due to vibration and movement produced by a machine no matter how subtle it is (whether it is powered suction, rotating tip cannula, ultrasound, laser, or water-jet), the operator's tactile sensation of the hand will be affected. Hence there is a chance of puncturing the intestinal wall without the operator even realizing it! This has been the case of a recent liposuction-related death in Singapore, where VASER, an ultrasound-assisted liposuction, was employed. We are amongst the very few clinics in the world which are still offering traditional liposuction using just a cannula and syringe. The operator's hand and the cannula become one in traditional method, enabling the operator to be 100% sure where the tip of the cannula is located at all times. Traditional method has become extinct, especially in developed countries like United States and Singapore, where manpower cost is extremely high, and time is precious.

Case 31: Don't throw away the fat, please! You can look younger with your own fat!

Case 13 above illustrates how fat cells extracted through liposuction can be used to augment buttocks. Over the years we have been advising our patients to apply their own fat directly on the face as moisturizer before they go to bed at night, and we have had 100% positive feedbacks. All patients reported significant improvement in their complexion! Recent studies showed that fat cells have very high concentration of stem cells which have "anti-aging" properties. This confirms our findings. Fat cells can also be injected back into the face for a non-surgical face lift. This new approach as an alternative to surgical facelift is very popular in the United States, UK and Australia, especially after it received special coverage on ABC News.

The cases below illustrate how fat cells can plump up sunken face and produce a tightened, lifted and rejuvenated look. The effect is even better when combined with liposuction of "double chin".

Case 32: Another case of high visceral fat level

This is another patient who presented with very high level of visceral fat of 17 (normal less than 6)! He has high subcutaneous fat level as well. We proceeded to perform liposuction to take out as much subcutaneous fat as possible, but the only way to get rid of visceral fat is through exercise.

Take home message: A lot of time, a bulging upper abdomen which is not proportionate to lower abdomen, suggests that the visceral fat level is high. Liposuction will not be able to address this issue. The solutions are still exercise and healthy diet.

Case 33: To get excellent result, get staged whole body liposuction!

This same Singaporean patient who was featured on case No. 24 and 29, returned for the 3rd time to complete the whole cycle of whole body liposuction. Having gone to Hatyai and unhappy with the result, she turned to us for revision works to be done. Ecstatic with the revison result, she ended up having whole body liposuction done over the period of 6 months.

Case 34: Another revision work!

This 20 year-old Singaporean went to Hatyai to get liposuction done on her arms, abdomen and thighs over 4 consecutive days! She actually had daily liposuction without realizing that she was putting her life in danger! Unhappy with the result, she flew to Medan to get revision done. We agreed to perform revision on her thighs, which has to be done in 2-3 sessions over 6 months period. It was because her thighs were very huge. We estimated that we could aspirate out 5-6 liters of fat from her thighs. This certainly cannot be done in one session, as it may lead to excessive bleeding, electrolyte and fluid imbalance, which may cause death! We went on to perform revision liposuction on her inner and front of thighs, aspirating 2 liters of fat during the process. We also educated the patient that it was unwise to try to get the most of liposuction by getting it done on as many areas as possible over a few consecutive days. Excessive bleeding may lead to death. Likewise, daily administration of tumescent anesthesia which contains lidocaine may lead to accumulation reaching toxic level, especially when no blood test was done to ascertain that her liver and kidneys function were normal before surgery. Liver and kidneys are the 2 main organs which metabolize drugs in our bodies. Pre-operative blood test is also needed to exclude many other conditions such as diabetes and abnormal blood coagulation which may cause complications in liposuction, if not detected earlier. In fact, in someone with abnormal blood clotting, liposuction should not be done in the first place! The person may simply bleed to death!

Case 35: Revision liposuction of the thighs with patient's own personal account

This Singaporean patient in her mid 40s went to a prominent surgeon in Singapore to have thighs Vaser liposuction (Lipo Selection) done. She was not too impressed with the result, as it left unproportionate-looking thighs with dents and waviness on her outer thighs. The reason was that the surgeon never advised her that she should be doing all parts of her thighs at the same time to achieve excellent result. Another reason was that the charges for one area were already $4000, hence she could afford to get liposuction done on only 1 area, which is the outer thigh. She came to Elixir de Vie Indonesia to get a revision done. We did touch-up for the whole thighs as well as performed liposuction on her calves. She was ecstatic with the result. She sent us an email with her personal accounts and some pictures. Her thighs looked fantastic even after only 2 weeks post-op, when there was still significant swelling. When the all swelling subsides in 3 months time, they are going to look even better! We have obtained her permission to post her email and personal account as it is, without any editing.

Take home message: Your body is a 3-dimensional structure. It doesn't make sense to just get liposuction done on 1 area. To get good result, it has to be done in 3 dimensions, 360 degrees, covering the whole circumference. However, financial constraint often holds back a patient from getting proper 3-dimensional liposuction done. That's why Elixir de Vie Indonesia was set up in the first place. It is located in Medan because the cost of doing business as well as man-power is so low, we could pass the savings back to our clients! This is without compromising quality of care, as all our gadgets are imported and our surgeons are originally trained in Singapore and United States with American-Board Certifications!

For more "Before and After" photos, please click here.