Liposuction Case Studies by Dr Arthur Tjandra of L’Élixir de Vie

LIPOSUCTION CASE STUDIES

The advent of tumescent anesthesia in the 1980s by Dr Jeffrey Klein, a dermatogist, has revolutionalized the practice of liposuction. Liposuction which had to be performed under general anesthesia, could since then, be performed under local anesthesia with or without sedation. Over the past 2 decades, surgeons have moved away from traditional syringe liposuction to machine-assisted liposuction, namely: power-assisted liposuction, ultrasound-assisted liposuction (e.g. VASER), laser lipolysis (e.g. Smart Lipo), and water-jet liposuction. The question now is: "Does machine-assisted liposuction offer more advantages compared to traditional syringe liposuction?" The answer is "NO". Not only is there no real advantages, but by using machines a surgeon also increases the risk of complications. Dr Arthur Tjandra speaks from his own experience, as well as his mentors': Dr Pierre François Fournier (Paris) and Professor Fong Poh Him (Singapore), who are the fathers of modern liposuction. They are amongst the very few surgeons in the world who still stick to traditional syringe method using microcannulas. Almost no complication could ever possibly occur with manually-generated low suction with a plastic syringe and microcannulas measuring only 2-3 mm in diameter!. Dr Arthur Tjandra started performing liposuction surgeries in 2006. As of December 2016, he has performed close to 10,000 cases of liposuction surgeries on various areas of the body, from head to toes, in the last 10 years and has not seen a single case of complication! Not one single case from close to 10,000 cases of liposuction surgeries which he has performed! During this period of time he also performed many revision liposuction surgeries for patients who had undergone machine-assisted liposuction with other surgeons. One may view some of the cases below. As uploading raw videos takes significantly less time and also clears doubts on some prospective patients that photographs could be "Photoshopped", we have been uploading raw, unedited videos of our surgeries to our YouTube channel since end of 2014. We stopped uploading photographs to our website in 2010, after having published more than 5000 photographs of our surgery results from 2008 to 2010. The YouTube channel is named after our clinic, Elixir de Vie. Most of those complications could have been avoided, had syringe liposuction been used instead. Just like how the big pharmaceutical companies control doctors and the way they prescribe medicines, surgeons are also more attracted to the incentives they receive from using expensive liposuction devices. Besides, patients prefer surgeons who use the latest fancy machines and are also willing to pay more. There are more incentives for surgeons to use some fancy devices as patients are always attracted to fancy new technology. To them, syringe liposuction sounds too "out-dated". For liposuction devices manufacturers, there is no incentive trying to market syringes to be used in liposuction, as a plastic disposable syringe only costs a few dollars. It is more lucrative trying to invent new machines which sell for a few hundred thousand dollars each. What many patients and even surgeons fail to understand is that in liposuction surgery, we are not selling devices, but we are selling skill!

Using plastic syringe with micro-cannulas minimizes risk of complications during liposuction

As how Dr Arthur Tjandra puts it, "liposuction is a blind surgery", it is therefore very important for surgeons performing liposuction not to allow anything to impair his tactile sensation. Unlike other surgeries, in liposuction a surgeon cannot see what he is operating on. Once the cannula disappears under the skin, he has to rely completely on the tactile sensation of his hands and fingers. He must be able to feel with his fingers where the tip of his cannula is, as well as knowing exactly the anatomy he is going through as he pushes his liposuction cannula deep inside the body. With traditional syringe liposuction using micro-cannulas, there is no difficulty in knowing exactly where he is, as what he holds is just a light plastic syringe attached to a similarly light micro-cannula. Such light instruments do not weigh down the surgeon's hand, and as a result, does not interfere with his tactile sensation which is extremely important, as he cannot see what is happening under the skin. One of the lethal complications of liposuction is visceral perforations (puncturing internal organs). When a surgeon is holding such a light instrument, he can feel every single stroke of his cannula. It is akin to poking a hole on a sheet of paper with a pen. One can feel the resistance of the paper being poked through, even though the paper is less than 1 mm thick. However, once one attached various machines and devices to the liposuction cannula, disaster could occur. All those devices attached to a cannula tend to weigh the cannula down. Vibrations produced by the various machines tend to be conducted back to the cannula as well, which in turn is conducted to the surgeon's hand, interfering with his tactile sensation which is extremely important in liposuction as he relies mostly on his hand to perform the surgery rather than his eyes. In the early years of liposuction when it was still done with just syringes and micro-cannulas, there was no case of fatalities reported. However, as surgeons started to use more and more fanciful and powered devices to perform liposuction, deaths started to be reported. There have been numerous deaths from liposuction reported around the world. In Singapore alone, there have been 4 cases of fatalities:

1. CEO dies after liposuction; family sues clinic for $1M

2. CEO had laser op on tummy in 2006

3. Woman in intensive care after liposuction; undergoes surgery to remove part of damaged intestines

4. Liposuction GP faces disciplinary hearing: vascular surgeon found 15cm of blocked artery in post-liposuction patient's right forearm

5. GP suspended for 4 months for botched liposuction that burned patient

6. Mum, 44, second liposuction death in 4 years

The first two cases were caused by inadvertent puncturing of patients' intestines during VASER liposuction. The first case was performed by a general practitioner, while the second case was performed by a plastic surgeon. The fourth case is a case of burns of an artery which almost cost the patient his right hand! The fifth case is a case of severe 3rd degree burns caused by VASER liposuction, for which the patient required skin grafting. The sixth case, which resulted in another death, is still under investigation. The surgeon involved in the sixth case is also known to be using VASER as his liposuction method.

What do all these cases share in common? All were done with powered devices! All were done under heavy sedation or general anesthesia. These sad tragedies could have been avoided had surgeons used traditional syringe liposuction with micro-cannulas, instead. In liposuction, "back to basics" is still the way to go to ensure a safe surgery with predictable and controlled outcomes which are replicable at all times. ALL of the above fatalities occurred during machine-assisted liposuction. Back in the days when syringe liiposution was still performed in the 1990s, death during liposuction was unheard of. Using powered device means when something goes wrong, the effect is amplified! Putting patients under deep sedation or general anesthesia means that when something goes wrong and intestines are being punctured, for instance, the patients are too deeply sedated to be able to give any response which may have allerted the surgeon that something has gone wrong! Performing liposuction surgery under general anesthesia also increases the risk of pulmonary embolism, because blood clots may form during the long surgery where a patient is lying motionless and dehydrated. Pulmonary embolism may result in death! Unlike surgery done under general anesthesia, we ask our patients to move very frequently during their liposuction surgeries which is exactly how we perform our signature 3-dimensional liposculpting. Rather than using general anesthesia, we use solely local anesthesia (tumescent anesthesia) with or without mild sedation which the majority of patients tolerated very well. Moving around very frequently during surgery minimizes the risk of blood clot formation and eventual pulmonary embolism. If one reads the list of complications of liposuction on United States FDA website, one will realize that all those complications, such as visceral perforations, seroma, nerve compression and damage, skin necrosis, and burns, are caused because liposuction is performed with powered devices. If a plastic syringe attached to a micro-cannula is being used, it is almost impossible to cause such complications!

Unfortunately, health authorities cannot mandate liposuction surgeons to perform liposuction with any particular device or method in order to make the surgery safer. Surgeons are free to use whichever method they like. Health authorities cannot say, "Hey, why don't you perform the surgery the way Dr Arthur Tjandra does?" In order to circumvent this, and in order to make liposuction surgery safer, health authority in Singapore mandates all liposuction surgeries to be performed only in a hospital operating theater or surgical centre. The rationale is that if a surgeon makes a mistake and puncture a patient's intestines or liver, he can always shout out for help. Help is readily available from many surgeons who are present in the hospital. However, this makes the surgery costly, as patients will have to pay for operating theatre facilities. As operating theatres are under the jurisdiction of anesthesiologists, an anesthesiologist will have to be involved as well. No surgeon will be allowed to perform a surgery in an operating theatre in a hospital without the presence of an anesthesiologist. This is the rule. This automatically adds up to the cost of the surgery. As an anesthesiologist is involved, the surgery will almost certainly end up being performed under general anethesia, which makes it more unsafe, as is explained below.

Finally, the diameter of cannula used in machine-asssited liposuction is much bigger than the diameter of cannula which Dr Arthur Tjandra uses in his liposuction surgeries. This is because in a machine-assisted liposuction, gadgets, such as ultrasound device, need to be fitted inside the cannula. Dr Arthur Tjandra, on the other hand, performs liposuction with a naked cannula, which is a lot smaller in diameter. This is why other surgeons need to stitch up their incision wounds, while Dr Arthur Tjandra does not stitch liposuction incision wounds up, because they are extremely small, measuring only 2-3 mm. Performing liposuction with a big cannula increases the risk of scarring. Case study No. 47 below illustrates this point very well.

Powered vs syringe liposuction. Does the method of liposuction affect the safety of liposuction surgery?

As Singapore first liposuction death case went to court, an inquest revealed that poor technique and the use of very deep sedation up to the point of general anesthesia, as well as the use of powered device, have contributed to the inadvertent puncturing of the patient's instestines:

1. Doc says she did not cause liposuction death

2. Liposuction death caused by "poor technique"

3. Liposuction 'not performed safely'. CEO who died after procedure had wound caused by 'extremely poor technique'

4. The Court Room: Fatal Liposuction

5. Liposuction death case begins on Monday

6. Liposuction death: should doctor have taken toilet break?

7. Nurse grilled in court at liposuction inquest

8. Liposuction death: Forensic consultant agrees with autopsy findings. Property management firm boss died from multiple punctures to his intestines following a liposuction procedure

9. Liposuction death inquest enters last day

10. "Liposuction death" findings unveiled

11. Woman in 2nd liposuction death first saw doc over 'dents'

12. Surgeon in liposuction death rapped

13. Liposuction death: Doctor barred from practicing medicine

Had the doctor used traditional syringe method of liposuction, because there was no machine or whatsoever interfering with his hand's tactile sensation, he would have been able to feel it when he hit the intestines, no matter how poor his technique was. Likewise, had the surgery been done under just tumescent anesthesia without deep sedation or general anesthesia, the patient would have been screaming in pain had the doctor hit the intestines. This would have prompted the doctor to back off and not to proceed further. The fact that forensic pathologist found 13 punctures in the CEO's intestines, showed that the doctor could not feel it when he hit the intestines and other internal organs. If one understands human anatomy well, one will realize that intestines as well as all other visceral (internal) organs are located deep inside visceral cavities (which is why they are called visceral organs). They are separated, and in no way connected to the subcutaneous fat layer which surgeons perform liposuction on. As a matter of fact, it just does not make sense to even tell patients and make them sign surgery consent forms accepting the risk of visceral performation as one of the most common complications of liposuction as listed on United States FDA website. In order to puncture intestines or other visceral organs in the abdominal cavity, a surgeon has to first puncture through the abdominal muscles. How could a surgeon puncture through abdominal muscles, then puncture through intestines without knowing it? It lies in the type of device a surgeon uses. A powered device is powerful enough to do that. Moreover, heavy and vibrating devices impair a surgeon's tactile sensation. Powered device with impaired tactice sensation are perfect combination to create disaster!

Performing machine-assisted liposuction using either laser or ultrasound may also cause more scarring, as laser and ultrasound devices produce heat which burns the tissues. As a result of this injury, the burned skin and tissue heal with adhesions. This may pose a problem should liposuction is needed again in the future. As the doctor in this case said in his defense, there was a lot of adhesion scars encountered during the second liposuction on the CEO, which made it difficult for him to perform the second liposuction. Should a surgeon forcibly push his way through adhesions, the cannula could be diverted elsewhere by the scar tissues, and hence puncture unintended structures. The first liposuction this CEO received was performed using laser lipolysis, while the second one was performed using ultrasound-assisted liposuction.

More than 90% of surgeons and doctors offering liposuction in Singapore use ultrasound-assisted method. This must be the best method, right?

Wrong! As a matter of fact, most of the serious complications, such as infection, hematoma or seroma, permanent nerve damage, skin necrosis, and burns with resulting adhesion scars which cause the skin to appear stuck down or puckered, occur much more frequently with ultrasound-assisted liposuction, the most famous brand of which is VASER. Syringe liposuction with micro-cannulas can never produce the kind of insults and injuries which ultrasound energy and heat can produce! For this very same reason, it is extremely risky to perform Dr Arthur Tjandra's signature 3-dimensional liposculpting, which covers the entire length and entire circumference of a body segment, using powered device or machines, because it increases the risk of skin necrosis! This is why that none of the surgeons who offers machines-assisted liposuction performs the kind of circumferential liposuction like what Dr Arthur Tjandra shows on Elixir de Vie's YouTube channel. But, why don't they offer syringe liposuction instead of powered liposuction? As explained above, surgeons have no incentives to offer liposuction with a plastic syringe which may not appeal to most patients who believe that using the latest technology must be the best way which ensures best result. Moreover, none of the new generations of plastic surgery trainees is trained with syringe method anymore. The last batch of plastic surgery trainees who received training with syringe method graduated in the late 1990s! Try Google search for surgeons who offer syringe liposuction in the world and see how many you can find! Hence, syringe liposuction is losing its popularity and becomes almost extinct not because it is not a good technique of liposuction, but because no one is trained to perform it anymore! Only the old surgeons and the selected few trainees who are trained by the old surgeons who know how to perform this "obsolete" method of liposuction. It is also so much more time-consuming and extremely physically exhausting to perform liposuction using just a disposable plastic syringe and a cannula with a hole measuring just 2 mm! Can you imagine aspirating liters and liters of fat through a 2 mm hole, using suction power generated with your hand with a plastic syringe! Do you have an idea how painful and tiring it is for the hands to do that for hours? Try blowing balloons through a 2 mm straw. Not a normal straw, but a straw with a 2 mm hole and experience the fatigue after doing it continuously for 2, 3 or 4 hours! That is typically how long a liposuction surgery lasts. How many surgeons out there are prepared to spend so much more time and energy because of their passion in their works and do not mind losing out on potential extra incomes because they choose an obsolete method of performing liposuction with a plastic syringe and micro-cannula which is so time-consuming? How many surgeons out there who can produce consitently good results shown in thousands of videos on Dr Arthur Tjandra's YouTube channel? Such results can only be obtained if a 3-dimensional liposuction is performed However, 3-dimensional liposuction can only be performed safely using syringe and micro-cannulas method, not powered devices, which highly increase the risk of skin necrosis and burns!

Does it matter what liposuction technique is used if I would like to inject the fat into my breasts?

It does matter! Whether one would like to get autologous fat grafting to the face, hands, breasts, buttocks, hips, penis, vagina and virtually anywhere in the body, the fat cells obtained must be living cells! Dead fat cells are useless and may cause complications. When a surgeon performs liposuction in order to harvest fat cells using powered--suction, the fat cells are lysed (broken) during the suction process. Likewise, when a surgeon performs liposuction using laser or ultrasound energy, the heat produced by this energy may "kill" the fat cells. Hence, syringe liposuction using micro-cannula is the ONLY way to go if one intends to re-inject the fat cells into other parts of the body, also known as autologous fat grafting or fat transfer procedure. The suction power generated by hand using a plastic syringe is so low that it causes almost no or minimal trauma to the fat cells. There is also no energy or heat generated which may damage the fat cells.

General vs local anesthesia. Does the type of anesthesia affect the safety of liposuction surgery?

The following photographs taken during syringe liposuction using tumescent anesthesia and light sedation at Elixir de Vie Indonesia in Medan, illustrates the above points very well. Patients commonly chatted, sang along to their iPods or even sent text messages while Dr Arthur Tjandra performed liposuction on them. There is zero possiblity to force the liposuction cannula into any unintended structures causing damage, as patient who is under local anesthesia can scream out in pain when the cannula hits important structures. The anesthesia given is intended to numb the fat layers only, but not other internal organs. Patients who are deeply-sedated or worse, put under general anesthesia will not be able to do that. This was what had happened in the unfortunate event above. Besides that, as Dr Arthur Tjandra uses only a hollow tube to aspirate fat and nothing else; without the need of inserting laser or ultrasound devices into the cannula; the diameter of the cannulas used are normally between 1 to 3 mm only. With such a slim cannula, the cannula will be broken into two if one tried to force it through intestines, for instance. For this reason, syringe liposuction is the safest method of liposuction! Why is there hardly any surgeon who offers syringe liposuction? As we have mentioned above, patients always prefer the latest technology and gadget. They are also willing to pay more for fanciful gadgets. Surgeons who offer liposuction using fanciful gadgets tend to attract more business than those who still stick to the old-aged primitive method of syringe liposuction. There is also a very important downside of performing syringe liposuction, which is the length of time needed to slowly aspirate using syringe, and also the great physical effort and endurance needed to aspirate fat using just a syringe! That is why Dr Arthur Tjandra goes to gym every day and participates in marathons regularly to keep himself fit.

One can watch how syringe liposuction under local anesthesia is performed by visiting our YouTube channel: http://www.youtube.com/user/arthurtjandra/videos. Several examples of videos of awake syringe liposuction performed under local anesthesia by Dr Arthur Tjandra are:

(Note: You have to be of legal age and logon to YouTube in order to watch our videos.)

Update on 2 Dec 2016: All the links to YouTube videos posted above are no longer working as our account has been terminated by YouTube for posting videos showing breasts and buttocks. However, the above videos do not reveal any nudity at all. They show how liposuction can be performed with just a syringe under local anesthesia. Hence, there is clearly a hidden agenda, which is the result of very strong lobbying to prevent the public from learning about this method of liposuction! The industry does NOT want patients to know that there is such thing called syringe liposuction! They do not want patients to know that liposuction can be performed with just a syringe and it is so much safer to do so. YouTube's terms and conditions of usage clearly state that nudity is allowed as long as it is not sexually explicit. Many of our videos reveal breasts and buttocks. But, breasts and buttocks surgeries are what Dr Arthur Tjandra does for a living! None of our videos is sexually-explicit! In fact, Dr Arthur Tjandra is one of the pioneers of autologous fat grafting breasts and buttocks augmentation. He was the first surgeon to perform autologous fat grafting breasts and buttocks augmentation in South East Asia! He is possibly one of the most experienced surgeon in the world and has performed the most number of cases of autologous fat grafting breasts and buttocks augmentation. It is absurd to censor the breasts and buttocks when showing the results of breasts and buttocks surgeries. We started uploading live, unedited videos of our surgeries in mid-2013. In less than 3 year time, we have uploaded more than 2000 live, unedited videos showing the immediate results of our surgeries, with follow-up videos taken months and years later. While all other surgeons post "before" and "after" photos of their surgeries, which are often heavily-edited, we are the first and currently still the only one in the world who raise the bar higher by posting unedited, live videos taken during surgeries, until YouTube decides to take down all our videos today. Our decision to post live, unedited videos of our surgeries has caused an uproar in the medical community, especially cosmetic surgery, all around the world. A lot of major forces have been trying to shut us down in the last few years and they finally managed to do so. Firstly, Dr Arthur Tjandra's Facebook personal account was terminated 2 months ago as he posted some photographs of the results of his breasts augmentation surgeries, and today, his YouTube account is also terminated for allegedly violating the guidelines, while one can easily watch videos of people having sexual intercourse on YouTube. The truth is, the medical community, especially cosmetic surgery, prefers to remain in status quo, by showing prospective patients photos, which can be edited, rather than videos, which are harder to edit, especially when a surgeon has thousands of videos to showcase. That is why videos of people having sexual intercourse are allowed on YouTube, while videos of breasts and buttocks surgeries are not allowed on YouTube. As there is no other option of showcasing the result of our surgeries through videos anymore, as all other platforms have even stricter terms than YouTube regarding nudity, we will have to re-join the rest of the pack by posting photographs only. We stopped doing so back in 2010, as we figured out that there were too many surgeons out there who heavily-edited their surgical photos. However, those who had watched the 2000+ videos we had posted from 2013 to 2016, and also read first-hand accounts of patients who blogged about their experience and compared the photos they took themselves and the videos we posted on YouTube, would have realized that all our photos are genuine and unedited. We will soon be updating these 2 pages, which we have stopped updating in 2010: Liposuction Case Studies and Elixir de Vie Whole Body Transformation Series.

Update on 7 Dec 2016: We have launched our new video blog (Vlog), L'Elixir de Vie by Arthur Tjandra, to replace our YouTube channel. However, due to the huge numbers of videos we have, we are not going to re-publish videos which have previously been published on our YouTube channel, even though they have been removed by YouTube. This new blog will start with Case Study No. 399. We have, however, published new videos of patients having fun and "enjoying" their surgeries on "Awake Syringe Liposuction under Local Anesthesia". Enjoy!

Currently, many doctors still misrepresent facts about liposuction suggesting it is safer if performed under general anesthesia rather than local anesthesia when, in fact, the opposite is true. From the pioneering liposuction techniques introduced in Europe in the 1970s through the time it was introduced in the U.S. in the early 1980s, liposuction procedures were performed under general anesthesia. This changed in the mid-1980s when dermatologist, Jeffrey A. Klein, M.D., developed the tumescent technique. The tumescent technique, which involves local anesthesia, revolutionized liposuction and is much safer than liposuction under general anesthesia.

As confirmed in an article published in the Journal of Clinical Anesthesia (Liposuction: contemporary issues for the anesthesiologist), many physicians who perform liposuction have not made the effort to learn the new, safer procedure:

Unfortunately, many physicians and anesthesiologists, due to their limited training in tumescent anesthesia, still believe that modern general anesthesia is the safest route for liposuction. Consequently, many do not make the effort to learn the new technique that allows liposuction totally by local anesthesia. Although modern general anesthesia is considered safe, it may expose the patient to unnecessary risk given that a safer alternative is available. Now that liposuction can be performed totally by local anesthesia, it might be considered that general anesthesia is often abused in the world of cosmetic surgery. Kucera, M.D., Ian J., Liposuction: contemporary issues for the anesthesiologist. Journal of Clinical Anesthesia, 2006, 18: 380).

The type of anesthesia used for the liposuction surgery can influence the risk associated with liposuction. There have been no deaths reported with liposuction that is accomplished using the tumescent technique totally by local anesthesia. Virtually all deaths associated with liposuction are associated with the use of either general anesthesia or the use of intravenous (IV) sedation. A publication in the journal, Plastic and Reconstructive Surgery, reported 95 deaths associated with liposuction from 1994 to mid-1998, all of which occurred in the hands of surgeons who typically use general or systemic anesthesia. In the same period of time there were no reported deaths associated with liposuction when performed by surgeons who do tumescent liposuction totally by local anesthesia. (Reference: Grazer FM, de Jong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plastic and Reconstructive Surgery 105:436-446, 2000).

The most common causes of death associated with liposuction are 1) Pulmonary Embolus (blood clot in the lung), 2) Infections, 3) Injury to Abdominal Organs (liver, intestines) or Lungs, and 4) Drug Reactions and Side Effects of Anesthesia. An article published in 2000 found 95 deaths among 475,000 liposuction patients who had liposuction by surgeons using general anesthesia or heavy IV sedation. In contrast, a 2002 study of surgeons who do liposuction by local anesthesia found no deaths among 65,000 liposuction patients.

A surgery which is performed under general anesthesia also costs a lot more than an office-based procedure done under local anesthesia. If a surgery is performed under general anesthesia, one has to take into account not only surgeon's fees, but also anesthetist's fees, operating room and recovery room charges, as well as possibly admission charges. One has to pay for only surgeon's fee if the procedure is done in a surgeon's clinic. If a surgery could be done completely under local anesthesia, why would you want to get it done under general anesthesia? Of course, there is very small percentage of patients who are hysterical or cannot tolerate even the slightest pain or the sight of needles or blood. This group of patients may need to have their liposuction surgery done under general anesthesia. However, they have to bear in mind that the result would not be the same as if the surgery was performed under local anesthesia. If performed under local anesthesia, a patient could be flipped over, sat up, or even stood up, in order for the surgeon to perform a through 3-dimensional sculpting of the body, as what we have shown in the thousands of videos we have uploaded to our YouTube Channel. It is impossible and even dangerous to flip over, sit up or stand up a patient who is intubated under general anesthesia.

How to make liposuction surgery as safe as possible?

We asked Dr Arthur Tjandra how to make liposuction as safe as possible. He replied, "Patient selection is of utmost importance. I select only the right patients. They have to pass through various stages of screening before they are allowed to come to Medan for liposuction. Besides that, try performing liposuction with just a syringe, without any machine if possible. This will significantly decrease the risk of puncturing important structures, creating dents from over-removal of fat, or burning the skin with ultrasound or laser devices. I always perform liposuction under just local anesthesia (tumescent anesthesia) and light sedation. This way, even if you hit some important structures, the patient will wake up and scream, hence avert a potential disaster. Even if you couldn't feel what you were poking because you were using machine, it's impossible to poke the intestines 13 times unless the patient was heavily-sedated or put under general anesthesia! We have also come across surgeons who would perform several sessions of liposuction on patients on a few consecutive days, and even perform such major surgery without getting proper blood tests done. They are just looking for trouble! The only disadvantages of traditional syringe method are it is physically very exhausting and takes much longer time to complete compared to machine-assisted method. This translates into less cases which can be done, hence less revenue. In our case, we can only perform one liposuction surgery per day."

Does machine-assisted liposuction with fanciful device guarantee better results?

"One more last question", we asked. "You have pointed out that using machines for liposuction may increase risks of complications. However, does using machine produce better result? We have heard doctors telling their patients that they are using the latest technology for liposuction, hence the result should be very good. So, if patients want better result, but willing to take the risks, machine-assisted liposuction should be a better option? Yes?" Dr Arthur Tjandra replied,"The world's greatest sculptors produced masterpieces of all times using the most primitive tools they had hundreds or even thousands of years ago. They didn't need the latest technology to produce masterpieces. What matters is not the tools used to sculpt a masterpiece. It's the hands behind the tools which matters. If I were to give you what Michelangelo used back in the 1490s, can you sculpt me another Statue of David? Likewise, with all the latest technology available right now, why isn't anyone able to produce another Statue of David or even a replica of it? By now, I guess everyone should understand that liposuction is not just about sucking out fat, but also to sculpt a true masterpiece! After all, ultimately the result of liposculpting/liposuction of a human body depends not on what device a surgeon uses, but largely on a surgeon's skill. If by purchasing a particular machine could ensure that my body sculpting skill be replicated, I would purchase 10 of those machines, so that I could have 10 Arthur Tjandras at Elixir de Vie!"

Prominent Singapore plastic surgeons interviewed by Straits Times agreed. Technology may matter less than skill, they said. An experienced surgeon using traditional liposuction may achieve as good a result as another using the latest tool, noted Dr Andrew Tay, a plastic surgeon at Novena Medical Centre. Another plastic surgeon at Novena, Dr Tan Ying Chien, said: "No matter how advanced the plane, it will still crash if it's not driven by a competent pilot!"

Why do you keep emphasizing 3-dimensional liposuction? Isn't all liposuction performed in 3D-manner?

No! As a matter of fact, almost all surgeons who perform liposuction will never offer 3D liposuction, unless you request for it! Why?

First of all, what does 3D liposuction mean? It means liposuction is performed on the entire circumference of that particular region, from top to bottom. For instance, instead of performing liposuction on just the inner and outer thighs, which are the standard areas, Dr Arthur Tjandra performs liposuction on the entire length of the thighs, from hips down to the knees, from frontal thighs, to outer thighs, to the back of thighs and the inner thighs.

There are 2 reasons why most surgeons will never offer a prospective patient 3D liposuction:

3D liposuction is too expensive! The average cost of liposuction in Singapore as of year 2015 is SGD 5000 per area. Some surgeons consider the right and left inner thighs as 2 areas, hence both inner and outer thighs liposuction will easily cost SGD 20,000. Most patients may still be able to afford this amount. However, if surgeons start offering 3D liposuction to patients who are requesting to have only inner and outer thighs liposuction done, it is going to cost them a staggering SGD 70,000! Most patients may not be able to afford it and run away! So, as a surgeon, would you offer a patient 3D liposuction and risk losing the business, or just do what the patient comes for in the first place, which is inner and outer thighs liposuction?
3D liposuction may cause excessive trauma, and if performed under general anesthesia, increases the risk of deep vein thrombosis (DVT), with resultant pulmonary embolism (PE) and potential death. This risk has been documented by Dr Jeffrey Klein, the father of modern liposuction, in his liposuction textbook: The Tumescent Technique of Liposuction. However, based on his experience after having performed more than 5,000 liposuction surgeries with syringe technique, Dr Arthur Tjandra finds that syringe liposuction with micro-cannula inflicts minimal trauma, and hence the risk of having DVT and PE after 3D or circumferential liposuction is non-existent. Liposuction with modern devices, as a matter of fact, inflict so much more trauma, as they use laser or ultrasound-generated heat to melt the fat, before aspirating it out with high power suction device. Morever, Dr Arthur Tjandra performs liposuction with micro-cannulas which measure only 2 to 3 mm in diameter, and all surgeries are performed under local anesthesia. This is another reason why Dr Arthur Tjandra only offers liposuction surgery under local anesthesia, not general anesthesia!

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 6-9 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 6-9 months to disappear! Final result is usually apparent after about 6 months, provided there is not new weight gain. 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. Fat transfer can also be done to the breasts for augmentation and reshaping of the breast to create a long-lasting and natural result. There have been debates amongst surgeons on the long-term implication of fat transfer to the breasts, as fat cells may die and get calcified. 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. In a 1987 position paper, the American Society of Plastic and Reconstructive Surgery stated: “The committee is unanimous in deploring the use of autologous fat injection in breast augmentation [underlined in position paper]. Much of the injected fat will not survive, and the known physiological response to necrosis of this tissue is scarring and calcification. As a result, detection of early breast carcinoma through xerography and mammography will become difficult and the presence of disease may go undiscovered.”

Ironically also in 1987, a retrospective study of the mammographic changes after breast reduction reported that calcifications were detectable in 50 percent of all mammograms more than 2 years from the time of surgery. Despite this documented high incidence of calcifications, there was no discussion of discontinuing reduction mammaplasties because the procedure might interfere with breast cancer detection. It was well recognized by 1987 that with all surgical breast procedures, there is a risk of causing lumps and/or mammographic changes. After discussion with experienced radiologists, we noted that a “confident differentiation between benign postoperative calcifications and carcinoma” could be made in most cases. Discussion had already begun in the literature concerning such problems after breast reduction and augmentation with silicone implants. Currently, radiologists can distinguish with a high level of confidence the calcifications that are a result of fat necrosis from calcifications that are related to breast cancers. In a most recent study published on the Journal of Plastic & Reconstructive Surgery in March 2011, researchers found that there was no statistically significant difference between breast density findings before and after fat injection, whether using the American College of Radiology classification or a personalized rating system. Similarly, no significant difference was observed using the American College of Radiology Breast Imaging Reporting and Data System categorization before and after fat grafting. In conclusion, radiographic follow-up of breasts treated with fat grafting is not problematic and should not be a hindrance to the procedure.

For more information on this topic, you may like to read a recent published study on autologous fat transfer for breasts augmentation: Fat Grafting to the Breast Revisited: Safety and Efficacy.

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 (laser lipolysis) is never meant for large area of the body! Or nose!

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.

Recently a doctor in Singapore had his licencse suspended for causing burns on a patient's nose while performing laser lipolysis.

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.

Due to the nature of tummy, which is quite a big area, there may be irregularity and unevenness as some of the fat cells may die, while some may still survive. One cannot predict which fat cells may or may not die. You may have delivered laser energy throughout the layer of fat, but no one can guarantee 100% that the fat cells will die. Some may and some may not! And the worse thing is you have to wait for a few weeks or even months before you can see the result!

Laser lipolysis may never be used to sculpt the body the way manual liposuction can do! To sculpt the abdominal and lower back areas into a nice hour-glass figure, the surgeon needs to be able to see the result of his sculpting process while he is doing it. Which means as he aspirates out the fat, the area will shrink gradually. That is how he can slowly sculpt an hour-glass figure. However, if he used laser beam to melt the fat, the result could be seen only weeks or months later. How is he going to sculpt?

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 accounts 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!

Case 36: To create a masterpiece with liposuction, a surgeon needs more than just skill!

These 2 Singaporean patients had liposuction done by one of the most prominent surgeons in Singapore. They were not too happy with the result and had to come to Medan for revision.

Take home lesson: Cosmetic surgeons, just like any other surgeons have their own areas of specialty. Some are exceptionally good at double eye lid surgery, some are good at rhinoplasty, some are good at liposuction. Liposuction is more than just suctioning out fat. Liposuction should be seen as a tool to sculpt the body into a perfect 3-dimensional shape. To sculpt a masterpiece, one needs great patience and plenty of time besides exceptional skill. Going to a very famous or busy cosmetic surgeon does not guarantee great result, because the busier the surgeon is, the more he is pressed for time, the faster he is trying to get over with the work! Imagine the state of mind of a surgeon who is operating, if he knows that there are still 10 more patients waiting outside for him. This will definitely result in less than satisfactory result. How long do you think Michelangelo took to finish the famous Statue of David? That is why, at Elixir de Vie Indonesia, we only schedule ONE liposuction surgery per day! In fact, when Dr Arthur Tjandra accepts a case of liposuction, that will be the only case he does for the whole day! This way his patient will have get his undivided attention in sculpting another masterpiece!

Case 37: Post-op care is as important as the surgery itself!

Your surgeon might have done all the best he could do during surgery, but if you did not get optimal post-op care, the result will be less than optimal. This Singaporean staff nurse in her early 20s knew very well what difference it could make. After getting daily post-liposuction massage during her stay in Medan, she continued with thrice weekly massage. When she returned a month later for arms liposuction, we were amazed at her recovery. Almost all the swelling was gone, and there were only a few hard lumps here and there.

Take home message: We always recommend our clients to stay for at least 2-3 nights post-liposuction surgery for a reason. We provide comprehensive post-operative care which include daily drainage, lymphatic drainage massage, and change of dressing as often as they need round the clock, as well as radiofrequency treatment if clients stay long enough. All these services are complimentary for the entire period of their stay! Which means if you stay 10 days in Medan, you will get 10 days of free post-op treatments! We have heard horrid stories of how post-liposuction patients have to deal with blood-soaked dressing which stain their clothes and bed linen. Imagine how you have to do all the dressing changes, then put on your tight compression garments yourself! The importance of post-operative care cannot be overlooked. It is also important to continue with regular firm massage on the areas which have been lipo-ed, as this will improve blood and lymphatic circulation, as well as break down scar tissues which appear as hard lumps underneath the skin. This is quite common post-liposuction. Left alone, they will disappear in 6-12 months time. But if you massage regularly, the recovery will be much faster. The staff nurse above, went to the extreme of spending more than SGD 200 on each session of massage. This is unnecessary if you can get your spouse, girlfriend, or boyfriend to do it for you. Our nurses will show you how to do it.

Case 38: Creating a masterpiece with your own fat!

This 24 year old Singaporean spent SGD 8,000 for Macrolane filler injection to the breasts (100 cc in each breast) only 6 months before she came to Medan. A typical Macrolane filler injection for breast augmentation costs SGD 8,000 to 12,000. Although she was advised that the filler would last at least a year, she noticed her breasts shrunk back to almost their original size barely 6 months later. Not only that, she also noticed several hard lumps which started to occur 6 months after her breast augmentation with Macrolane. A Google search on the internet revealed that complication of hard lumps forming after Macrolane injection is actually quite common. A journalist of The Sunday Times in UK wrote about her first-hand experience with Macrolane injection. It was not until she developed several hard lumps in her breasts, she realized that she didn't read the consent form which said that Macrolane use “for breast enhancement has not been established” and that in small studies adverse reactions had included “development of hardness of the breast, formation of palpable lumps and capsular contraction”. Another report on the Daily Mail, also in UK, stated that 16 out of 20 female clients injected with Macrolane complained of abnormal lumps and pain. UK Health Centre, a patients advisory group, advised against the use of Macrolane injection for breast augmentation. Similarly, Aqualift filler, has been banned in Singapore for use in breast enhancement because of the same problem.

This client eventually had whole body transformation by getting liposuction done on her abdomen, waist, flanks, lower back, hips, saddle bags, outer, inner, front and back of thighs, as well as knees over 3 sessions in 4 months time. She also had autologous fat grafting to her breasts and buttocks during all those 3 sessions.

Recently we received an email update from her, 9 months after her autologous fat transfer to breasts. Her breasts have remained the same as immediately after surgery, which means that all the transplanted fat cells are surviving. However, the hard lumps which resulted from Macrolane injection still persisted and did not seem to improve over time.

Take home message: Filler injection for breast augmentation does work, but it is extremely expensive! In a typical example given above, this patient increased only 1/2 cup size with 100 cc filler injection in each breast. And it already cost her $8,000! These fillers (for breast augmentation) typically last 1 year or so, but in her case, it was almost completely absorbed by the body in 6 months time. So, she was basically flushing down $8,000 down the drain! Even if it lasted for 1 year, who would be able to afford to pay $8,000 every year? As filler is slowly broken down by the body, patients will also have to face the agony of watching their breasts shrinking day after day before the filler completely disappears. Most will choose to top up before it does. Which means you will probably have to get filler injection every 6 months. That is an extremely expensive exercise! We charge only S$2,500 for autologous fat transfer for breast augmentation, which can last indefinitely if the fat cells survive. However, there is still a lot of on-going debate regarding the long term implications. The opponents of fat transfer to breasts fear that calcified fat cells may interfere with breast cancer detection when the patient undergoes mammography in the future. While the proponents say that experienced radiologists are able to differentiate calcified fat cells from early breast cancer on mammogram, as they have different characteristics. We are taking the middle path. We advise patients of the possible long term implication and leave the decision for them to make. However, we try to minimize the risk of fat cells dying and getting calcified, by using a special harvesting and injecting technique. Prospective clients will also have to undergo mammography prior to surgery to make sure there is no abnormalities, as well as follow-up mammography in the subsequent years. Please read Case No. 13 above, as well.

A word of caution on the use of dermal filler for breast augmentation. There has been no long-term study to prove that is safe. With the effects of the Macrolane injections not being very long lasting with only an estimate of the enhancement lasting up to 12-18 months, many argue that Macrolane breast enhancement leaves the patient in a more vulnerable situation than that of a person who only has to go through one intrusive operation i.e. breast implants.

Anecdotal evidence in our clinic showed that with the right technique, autologous fat transfer to the breasts may last a lifetime, without the need to change breast implant every 10 years and without having to go through the risk of major surgery and general anesthesia, as in the case of breast augmentation using breast implants.

Note: This case has been further updated as Case No. 1 in our Whole Body Transformation series.

Case 39: Another masterpiece created by removing and transferring fat

This Singaporean woman who is a mother of 3 children weighed barely 45 kgs, but had pockets of stubborn fat here and there. On the other hand, she has shrunken breasts resulting from years of breast feeding 3 children as well as her hobby running. We performed a head to toes surgeries for her in 2 sessions. During the first session, we performed liposuction of double chin, arms, abdomen, and fat transfer to buttocks. Ten months later, she returned for augmentation rhinoplasty, liposuction of the whole thighs, saddle bags and jowls, as well as fat transfer to her breasts.

Note: This case has been further updated as Case No. 2 in our Whole Body Transformation series.

Case 40: Is that fat or muscle??

This Singaporean woman in her early 30s had liposuction done by a plastic surgeon in Singapore, but was not too pleased with the result. Although the lower part of her arms were quite slim already, the upper part of her arms still appeared very bulky and huge. She had the typical "drumstick arms", a term coined by Dr Arthur Tjandra, as a result of incomplete removal of fat by removing fat only on the lower part of the arms but not the upper part and shoulders. She went back to her surgeon, but was told that it was muscle hence the bulk could not be removed by liposuction. She was offered Botox injection instead!! She herself was very sure that it was fat, so she declined the offer and chose to fly to Medan instead for second opinion. We found that the bulk was indeed fat. Even if that was muscle and not fat, Botox injection is never indicated for use to reduce muscle bulk on arms!!

Case No. 41: Does a 46 kg marathon runner need liposuction?

This Singaporean young lady in her mid 20s is a serious marathon runner and scuba diver who weighed barely 46 kg when she came to us for liposuction. Her case best illustrates the role of liposuction as a sculpting tool rather than a weight loss tool. An ideal candidate for liposuction would be a fit person who is within his ideal range of weight and has some stubborn pockets of fat which never seems to go away even with exercise.

Case No. 42: Another revision liposuction for "drumstick arms"

This 30 year-old Singaporean lady had her arms liposuction done in Hatyai. Although the surgeon has aspirated all the fat and done a very good job for the lower 1/3 of her arms, the upper 2/3 of her arms, as well as shoulders, armpit fat and upper back were not taken care of. As a result of this, she had to live with "drumstick arms", a term coined by Dr Arthur Tjandra, thinking that it was muscle. It was not until when she came to Medan for abdominal liposuction, that she learned that what caused her drumstick arms was in reality thick chunk of fat which could be removed!

Case No. 43: Extreme Makeover Whole Body Transformation

When we launched our Extreme Makeover Whole Body Transformation in 2010 where clients got whole body liposuction and autologous fat transfer to either the breasts or buttocks for slightly more than SGD 10,000, only 2 women signed up. Those 2 were the luckiest persons on earth, as they would otherwise had to spend at least 5 times that amount if they were to get it done elsewhere. We are no longer offering that package anymore. One of those women, a Singaporean in her 20s, emailed us her pictures one month after the 3rd session of her whole body transformation, during which she also received autologous fat transfer to her breasts. The other client was featured in case No. 39.

Take home message: The whole intention of offering a whole body transformation package at a ridiculously low price is to create awareness that to sculpt a masterpiece, all areas of the body should be sculpted in a 3-dimensional form, instead of the current practice where surgeons only work on 1 or 2 areas within the same segment of the body. Of course the current biggest limitation for clients is the cost. Therefore, we have moved our practice to Medan where cost of doing business is pretty low, and pass this savings to our clients to enable them to afford whole body 3-dimensional sculpturing. Only by performing a 3-dimensional liposculpture, can a surgeon create a masterpiece!

Case No. 44: Get all 4 areas of the upper body done at the same time. Enough said!

This Singaporean woman in her late 20s had her arms liposuction done by a GP/aesthetic doctor in Singapore. However, it resulted in very funny-looking arms as her shoulders, armpits and upper back were done not at the same time. The doctor also used machine-assisted liposuction, although it was not clear what machine he used. Apparently he did not have full control of his machine, and over-removed in some parts while under-removed in other parts. This produced very uneven-looking arms. The doctor attempted but failed to correct the unevenness by performing fat transfer twice. After repeated attempts to correct the defect in Singapore which failed, she eventually had to fly over to Medan to get a revision done. The following photographs showed excellent result 6 months after her revision surgery.

Case No. 45: Another revision case for arms

This 28 year-old Singaporean had her first arms liposuction done in Hatyai. Thinking that for arms liposuction one can just get arms done without getting the other parts connected to the arms done at the same time, she realized that she had made a mistake only after the surgery was over. She came to Medan for revision where we performed another round of liposuction on the entire length of her arms, all the way to her shoulders and upper back, as well as the armpits. Because of her above average size of arms, and very thick layer of fat, we have advised that she might need another round of liposuction to make her arms look even smaller. Nevertheless, we managed to make her arms appear more proportionate with a 3-dimensional liposculpting involving all 4 areas of the upper body.

Case No. 46: Does a photo model need liposuction?

In fact, photo models, runway models and athletes are the best candidates for liposuction! This male model from one of the biggest modeling agencies in Singapore, came to us to remove some unsightly bulges from his abdomen as well as love handles. Liposuction is not meant for weight loss, it is meant to sculpt bodies into perfect shape! That is why we refrain from performing liposuction for clients who are grossly overweight. Such clients need to be started on weight loss regime using sensible and healty diet as well as exercise.

Case 47: Worried about incision scars?

Traditional syringe liposuction requires the smallest incisions because traditional method uses only a bare naked canunula, which does not require the use of any machine. When you need to fit devices into a cannula, naturally the cannula has to be bigger. A bigger cannula will need a bigger incision in order to be entered into the fat layer of the body. Moreover, ultrasound-assisted liposuction such as VASER often causes burns to the skin which produces bigger scars.

Please watch this video: https://www.youtube.com/watch?v=k2Moc-l9VKU . This patient had gone for ultrasound-asssisted liposuction before coming to us for revision surgery. We compare the incision scars from her previous surgeries with fresh incision wounds for syringe liposuction, side-by-side.

Case 48: Three-dimensional sculpting means just that....3-dimensional sculpting!

There is no way to achieve a 3-dimensional hour-glass figure unless you sculpt the whole abdomen in a 3-dimensional way. This Singaporean patient spent a fortune getting VASER liposuction done on her abdomen in Singapore, only to find that she did not get the result she wanted. By the time she came to us for another liposuction, she could not afford to pay for whole abdominal sculpting anymore.

Case 49: Another unhappy patient because 3-dimensional sculpting was not performed

This 34 year-old Singaporean mother of 2 children had liposuction with VASER Liposelection done in Singapore 5 months before coming to Medan for revision. She did not get what she wanted: an hour-glass figure, because the sculpting was never done 3-dimensionally! But again, with the high cost of liposuction in Singapore, most patients can afford to pay to get upper and lower abdomen done only, neglecting the rest of the trunk.

Take home message: It does not really matter what kind of machine a surgeon uses to perform liposuction. The end result depends on how the surgeon sculpts the body!

Case 50: Decided to get revision only after going through 4 sessions of VASER liposuction

This Singaporean in her early 20s had 4 sessions of VASER liposuction done in Singapore before eventually coming to Medan for revision to be done. She had to get her 3 revision sessions stretched over almost 3 years as she saved up for the surgeries. Her bank accounts were depleted from her previous surgeries. But, it was money worth spent! The amount she spent for 3 sessions in Medan, could probably only pay for 1 session in Singapore. She eventually volunteered to be interviewed by Straits Times.

Case 51: Would you imagine that a girl weighing just 40 kgs (88 lbs) would ever need liposuction?

This petite Singaporean in her early 20s weighed slighly over 40 kgs but had heavy bottoms. She was the most ideal candidate for liposuction as she was not overweight to begin with. Always remember that liposuction is a tool to sculpt the body. It is not a method to lose weight! In fact, many patients realized that the numbers on their weighing scales did not change much although they appeared so much slimmer and shapelier!

Case 52: Another unsatisactory result caused by incomplete removal as well as oversuction

This Singaporean woman in her early 20s had VASER Liposelection liposuction done in Singapore on her thighs prior to coming to us for abdominal liposuction. Naturally, after seeing the result of her thighs liposuction, she chose Elixir de Vie in Medan as her next destination for liposuction. The following photographs speak for themselves.

Case 53: A case to illustrate why all 4 areas of the upper body needs to be sculpted at the same time

When we perform liposuction for the arms, we do not just perform it on the arms, but also perform on the armpits, shoulders and upper back. This is what we call 3-dimensional sculpting. The following photographs taken from different angles illustrate just how beautiful the result can be if only all 4 areas of the upper body are tackled at the same time. However, due to high cost of getting liposuction done in many countries, many patients can only afford to pay for arms but leave behind the other areas. Many of the previous case studies before this one have illustrated how bulging armpit fat, bulging bra fat, bulging shoulders creating the so-called "drumstick appearance" as well as thick upper back can spoil the appearance of even the slimmest arms. Moreover, in many clinics, right and left arms are considered 2 areas, while we always consider right and left sides of the limbs as one area. When you get the right side done, you definitely want to get the left side done as well, don't you? Hence, do not always trust the low liposuction charge per area which is always advertised. You need to ask, "Are right and left sides considered one or two areas?" Most of the time, you just have to double the amount stated!

Case 54: Staged liposuction of the thighs

Sometimes when the thighs are too big, Dr Arthur Tjandra prefers to perform liposuction on just one thigh first, followed by the other thigh 1-2 months later. The reason is that it is more likely to sculpt a perfect 3-dimensional structure if the whole circumference and length of the thigh is covered within the same session, rather than to perform a few areas only at a time.

Case 55: Liposuction gone wrong!

This athletic German student in her late 20s had gone to Bangkok for liposuction of her outer thighs and buttocks before coming to us for revision. She was left with ugly dents and tunnels. Many parts of her thighs were also not done. Dents and tunnels caused by over-suctioning is difficult to correct. We attempted to correct it by smoothing the surrounding areas by feathering technique of lipsouction, combined with autologous fat grafting. Immediate post-op result appeared excellent. However, the final result will depend on how much of the grafted fat actually survives.

Take home message: Always get it done right the first time round. Don't always get tempted to try out with a surgeon who offers the lowest charges first, thinking that if something went wrong, there would always be someone to look for to fix it. The problem may or may not be fixed!

Case 56: Would you even imagine that a marathon runner need liposuction?

As a matter of fact, even marathon runners and athletes find it hard to get rid of stubborn pockets of fat. Exercise burns fat away, however we can't instruct the body to burn fat from only certain areas and not other areas. Exercise helps burn overall body fat, but not in targeted areas. To achieve this, liposuction/liposculpture may still be needed. This famous Singaporean marathon runner knew just what to do when she realized that despite her hard training, her figure was far from what she really wanted. She flew to Medan to get liposuction done on her arms, abdomen, buttocks and saddle bags. Now she has the figure she has been dreaming of!

Case 57: VASER Liposelection liposuction went wrong!

This Singaporean flight attendant with a major airline in her early 20s had VASER liposuction done on her outer thighs and buttocks in Singapore. She was left with huge dents in her buttocks. Overall, her thighs still appeared big. She had actually read through our liposuction case studies and understood that to obtain excellent result, 3-dimensional liposuction involving all areas should be done. However, having read some malicious gossip on the internet which said that Medan and other places in Indonesia were very unsafe for ethnic Chinese to visit, she chose to have her liposuction done in Singapore. Completely unsatisfied with the result, she had no choice but to visit us in Medan to get a revision done 4 months later, during which we also performed autologous fat grafting to the dented areas which were caused by over-suctioning. This is one of the most frequent problems often observed with machine-assisted liposuction! Anyway, she was very surprised by what she saw in Medan. The Indonesians were very friendly. She went to Sun Plaza and observed that it was packed with ethnic Chinese people without being robbed or harassed by the Indonesians as what gossipers on the internet said!

Case 58: Does an athlete need liposuction?

Times and times again we have reiterated that the most ideal patients for liposuction are not those who are obese, but those who are fit and trim with some stubborn pockets of fat which refuse to go away despite exercising. This national football player from a neighbouring country in his early 20s came to us in Medan to get rid off stubborn pockets of fat around his abdomen.

Case 59: Does an army recruit need liposuction?

Apparently this 20-year-old army recruit who runs at least 80-100 Km per week and has won a gold medal in his IPPT (Individual Physical Proficiency Test), finds it hard to get rid of his love handles and "man boobs" despite rigorous in-camp training. He came to us in Medan to finally achieve the body he always dreamt of.

Case 60: Why do we sometimes perform liposuction on just one leg at a time?

In some patients who have very big thunder thighs, we sometimes recommend liposuction on just one leg at a time, followed by another session of liposuction on the other leg one month later, as in the case of this Singaporean college student in her early 20s. The reason is that if liposuction was to be performed on both legs at the same time, the total amount of fat aspirated might not be maximized because of safety reason. This means that the patient might have to return for a second session. However, in order to allow complete healing before the next session can be performed, the patient will have to wait at least 6 months. For those who can't wait that long, we would recommend doing one thigh during the first session, followed by the other thigh one month later.

Case 61: Doc, why are my thighs still big after liposuction?

This a good example of why we require every single patient to sign photographic consent and pre- and post-op photographs to be taken as part of medical records. Without agreeing to this condition we will not be performing any surgery! A lot of time people do not remember what they looked like before surgery. Most of the time, they do not even have any photographic records as well. After all, who will be taking naked photographs of themselves, especially when they are completely out-of-shape? This Singaporean patient in her 20s had been complaining of how big her thighs were after liposuction, and believed that there had not been much change at all. She changed her mind after we showed her the before and after photographs of herself barely 2 months after her surgery. It was not even the final result yet, as final result would be obvious only at least 6 months after surgery. In any cosmetic surgery, there has to be realistic expectation of the patients. One has to understand that liposuction has its own limitation together with limitation due to safety issue. There is a limit of the volume which can be aspirated. If this safety limit is breached, it may even cost one's life! One also has to have realistic expectation of the outcome. If the thighs were very big to begin with, as in this case, one cannot expect to have a supermodel's thighs after just one session of liposuction! This is one of the main reasons why we have been refusing to accept patients who are grossly overweight, simply because we want to avoid getting into unnecessary arguments and losing precious time conducting lengthy explanation when one realizes that one still cannot win the Miss Universe contest, or be selected as one of Victoria Secret's angels after getting one's liposuction done in our clinic. Lastly, our advice is: "Be patient, be patient, and be patient!" You will not see final result of liposuction until at least 6 months later! Especially in our case where we perform 3-dimensional liposuction/liposculpting which causes extensive swelling.

Case 62: Vagina and female external genitalia rejuvenation with autologous fat grafting

These patients who were in their late and early 20s came to us for liposuction. The lipo-ed fat was put into good use for rejuvenation of their genitalia.

Case 63: You need tummy tuck!

This Singaporean mother of one child who was in her mid 30s, wanted to look the way she used to look again. As she has significant rectus diastasis as well as excessive stretch marks and loose skin on her abdominal skin, we decided that she needed abdominoplasty (tummy tuck). Liposuction alone would not be able to solve her problem.

Case 64: Another case of unrealistic expectation

This post-graduate student in her early 20s who just had thighs liposuction wrote us an email barely 2.5 weeks after her thighs liposuction:

Dear Dr Jennifer,

To refresh your memory, I am XXX from Singapore and I have done my 7-area thigh lipo with Dr Arthur on XXX. Although the thighs are smaller than before, I do have a couple of concerns:

1. The buttocks (which were one of my main areas of concern, if you see the appended email) was left untouched. The banana rolls are still as evident as before and they have not changed from the past.

2. The back thighs were left untouched as well. (If you look at the appended email, my back thighs were also a main area of concern)

There were no bruisings on these mentioned areas (anywhere near the buttocks and back thighs) and I could sit perfectly well, without pain, from day 2 of the surgery. I do have photos to document these if you require them. I have also sought the second opinions of post-lipo masseurs (the one recommended by the clinic) as well as local cosmetic surgeons, and they have confirmed that lipo has not been carried out in these areas. As I am really puzzled because I have not been turned around during the course of the surgery as well, could you please enlighten me on that? I would really appreciate your prompt and keen reply. Thank You!

Regards

What we can do is to post all the pre- as well as immediately post-op photographs so that anyone can see for himself whether our surgeon has done a good job or not. There is no need for us to argue whether or not our surgeon has performed a 3-dimensional liposculpting or not, as these photographs speak a thousand words. This is the main reason why we will never perform a surgery if a patient refuses to sign photographic consent and have his photographs taken. Many patients tend to forget how they looked like prior to surgery. They also tend to have unrealistic expectation of the surgery. It is therefore very important for any potential patient to read through all the information available on our website, as well as pre- and post-op information sheets which are also downloadable from our website. It is stated that post-liposuction swelling will usually peak at 1 to 2 weeks after surgery, and final result will not be appreciated until 3 to 6 months later. This patient had ignored information provided by us both written and oral, during pre-op consultation, and chose to complain to us barely 2.5 weeks after surgery.

Dr Arthur Tjandra has, in fact, considered this case as a potential masterpiece, and eager to perform whole body transformation for this patient. That is why he decided to aspirate more than 3 liters of fat within the same session. In normal circumstances, this amount would be aspirated in 2 sessions. This case has also proven why syringe liposuction is the least traumatic method of liposuction. Many patients who have undergone machine-assisted liposuction suffered a lot of pain post-operatively, that most become incapacitated for a few days. This patient, however, could sit perfectly well, without any pain. Because she had expected a lot of pain just like other methods of liposuction, ignorant that syringe method does not cause so much trauma and paoin, she suspected that nothing had actually been done to her! Our method of liposuction using only local anesthesia and sedation also proves to be safest and the most effective method of anesthesia. There is no risk like that of general anesthesia, and patient who undergoes surgery completely forgets about what happens during surgery, as this patient has testified. How could we possibly not flip her around when all her post-op photographs show her back side was bruised and blood dripping?

In summary, this case illustrates how important it is to have realistic expectation and to be patient. If you have thighs the size of an elephant's, it is not realistic to expect a super model thighs after just one session of liposuction. Likewise, it is not realistic to expect result within weeks after liposuction. Final result can only be appreciated at least 3-6 months after liposuction. This case also illustrates why syringe liposuction is the least traumatic and safest method of liposuction! Lastly, a masseuse is not qualified to give medical opinion. And it is best not to doctor hop. If you have decided to trust one doctor with your surgery, stick to your gun and have faith and confident in him. Doctors do look out for trouble-making patients and will avoid these patients at any cost. If you go around doing this, doctors will avoid you. You just lose yourself one great surgeon who could otherwise transform you into one of his masterpieces!

Update on 21 May 2013: This patient has decided to return to us 6 months after her initial procedure! She is ecstatic with the result of her thighs liposuction and she is currently getting other areas of her body done as well, including autologous fat grafting for breasts augmentation. We learnt from her that the masseuse to whom we had been referring our post-liposuction cases, banked-in on her agony as she watched her thighs swell up 1-2 weeks after liposuction. This was expected as printed out on the post-liposuction instruction which was given to her after her surgery. However, this masseuse managed to convince her that her surgeon has not aspirated fat from many areas, which prompted her to write an email to complain to us. The masseuse proceeded to urge her to get a revision surgery done by another doctor. This patient declined and chose to heed our advice to wait 6 months for the final result. Today, exactly 6 months later, she is back for liposuction of her arms, love handles and autologus fat grafting breasts augmentation! Had she gone under the knife with the other doctor, she would have spent more than SGD 15,000 unnecessarily. At the end she would still be ecstatic with the result, because it was our surgeon who has done a good job! The other doctor would, however, receive the credit, because he was the last person to "touch" this patient!

This patient decided to blog about her liposuction experience in Medan: A Brand New Body

Case 65: Can I achieve slim V-shaped face without jaw-bone shaving surgery?

Yes, you can! With a combination of liposuction and botulinum toxin injection! In fact jaw-bone shaving is not a permanent solution. Squarish jaws are often a result of well-developed masseter muscles, either due to genetics or teeth grinding while sleeping. By injecting botulinum toxin, the muscles are partially-weakened. Over the long run, these partially-weakened muscles will eventually shrink. This is similar to the case where muscles shrink due to long-term disuse (disuse atrophy) such as in people who are bed-bound or have a stroke. Jaw-shaving surgery without addressing the masseter muscles is actually quite futile, because over the years, strong un-opposed action of the masseter muscles, will stimulate bone growth. Hence, it will be back to square one. Bone is a living structure. A fractured bone can grow back to normal again. A shaved jaw bone can grow back to square one again. Even after a jaw-bone shaving surgery, botulinum toxin injection still needs to be given to maintain the result. Hence, if a slim V-shaped jaw line can be achieved with botulinum-toxin alone, why should we perform jaw-shaving plus botulinum toxin injection?

For most cases, square or round face is not just due to well-developed masseter muscles, but also fat accumulation in the jowls, as well as neck. Liposuction of the jowls and neck, combined with botulinum toxin injection every 4 months is going to give the desired V-line jaws, which are popular in Japan, Korea, Taiwan, Hong Kong and Singapore.

Case 66: Abdominal liposuction gone wrong! Doc, are you creating 6-packs for me? But, they ain't look like 6-packs!

This Medanese patient had VASER Hi-Definition liposuction done in Penang. Although she never asked for 6-packs, the surgeon presumably tried to create 6-packs for her......unsuccessfully! Ultrasound-assisted liposuction can be done to create the "illusion" of 6-packs by directing the heat generated from the ultrasound energy just underneath the skin, hence creating a controlled "burn" on the undersurface of the skin. When these burns heal, they will form adherent scar tissues which cause the skin to be stuck down to the underneath soft tissue and muscles, hence creating the "illusion" of 6-packs. However, this technique carries a very high risk of burn injury, as well as undesirable result as the one we feature here if the surgeon has no control over which area(s) he wants to create "burns". Is it possible to do a revision for cases like this? Very unlikely, as all those lines seen on the abdomen are actually adhererent scars which cause the skin to be stuck down to the underneath structure. It is very difficult to release the scars, often requiring a V-Toledo cannula, which increases the risk of skin necrosis if done on large area like the whole anterior abdomen. Unfortunately, this patientn may have to live with this scarred abdomen for the rest of her life.

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