Aesthetic Plastic Surgery

, Volume 36, Issue 2, pp 438–442

Large-Volume Liposuction and Prevention of Type 2 Diabetes: A Preliminary Report

Authors

    • Personique Surgery Center
  • Michele Narsete
    • Personique Surgery Center
  • Randy Buckspan
    • Personique Surgery Center
  • Robert Ersek
    • Personique Surgery Center
Original Article

DOI: 10.1007/s00266-011-9798-5

Cite this article as:
Narsete, T., Narsete, M., Buckspan, R. et al. Aesth Plast Surg (2012) 36: 438. doi:10.1007/s00266-011-9798-5

Abstract

This report presents a preliminary study investigating the effects of large-volume liposuction on the parameters that determine type 2 diabetes. The study enrolled 31 patients with a body mass index (BMI) exceeding 30 kg/m2 over a 1-year period. All the liposuction procedures were performed with the patient under local anesthesia using ketamine/valium sedation. Pre- and postoperative blood pressure, fasting glucose, glycosylated hemoglobin (HbA1C), weight, and BMI were evaluated for 16 of the 30 patients who returned for a follow-up visit 3 to 12 months postoperatively. The average aspirate was 8,455 ml without dermolipectomy and 5,795 ml with dermolipectomy. The data reveal a trend of improvement in blood sugar levels associated with weight loss that helps the patients. The average blood sugar level dropped 18% in our return patients, and the average weight loss was 9.2%. The average drop in BMI was 6.2%, and HbA1C showed a decrease of 2.3%. The patients with the best weight loss had the best reduction in blood sugar level and blood pressure. No transfers to the hospital and no thromboebolism occurred for any of the 31 patients. One dehiscence, two wound infections, and three seromas were reported. The authors hypothesize that large-volume liposuction in their series may have motivated some to diet, which could be explored in a larger series with control groups. Liposuction alone did not improve obesity but helped to motivate some of the patients to lose weight. These patients had the best results.

Keywords

Large-volume liposuctionType 2 diabetesObesity

A recent paper from Australia [1] showed that reduction of body fat through surgical intervention by LAP-BAND® helped to cause substantially reduced body weight in 60 surgical patients. This surgery decreased insulin needs and actually helped to improve type 2 diabetes. The improvement in these patients was due to weight loss.

Several of our patients who underwent large-volume liposuction (>6 l) experienced a substantial reduction in weight. Large-volume liposuction may help to reduce body weight and promote dieting that helps to reduce the effects of type 2 diabetes.

One former patient (Fig. 2) demonstrates the effect of liposuction and weight loss on her glucose levels. This patient, who experienced gestational diabetes with each of her three children, kept a chart of her fasting glucose levels. She was classified as a diabetic, with glucose levels above 150 mg/ml. She decided to undergo large-volume liposuction (10.6 l). Her fasting blood glucose level went from 180 mg/ml preoperatively to less than 100 mg/ml over a 20-month period. It has remained normal since that time. She also lost 60 lb.

Background

After Illouz [2, 3] first described liposuction, it became widespread and was originally thought to be a treatment for figure faults and not a treatment for obesity. Large-volume liposuction for the obese population was dismissed as unsafe or unrealistic surgery. However, we noted that many patients had substantial improvement in their metabolism as a result of large-volume liposuction and weight loss. Several of our patients who had serial suction of 10 l or more experienced a substantial decrease in body fat. Many reported that their appetite decreased and that they continued to lose substantial weight after recovery.

Little emphasis has been placed on the metabolic benefits of liposuction for obese patients facing the consequences of type 2 diabetes. Giese et al. [4, 5] demonstrated a reduction in weight, body mass index (BMI), fasting insulin levels, and blood pressure in large-volume liposuction patients during a 1-year and 4-month study. Klein et al. [6] presented a study of large-volume abdominal liposuction with 15 patients. These authors concluded that the large-volume abdominal liposuction did not significantly reduce obesity-associated metabolic abnormalities during a 12-week follow-up period. Their large resection of fat was defined as 4 l. Because 60% was reported as fat removal, their average removal of fat was only 2.4 l, a very small amount.

The current study aimed to examine these metabolic benefits with a preliminary investigation of our patient population during a 3- to 12-month follow-up period after an average larger volume of resection (i.e., 8,455 ml).

Materials and Methods

Patients undergoing large-volume liposuction with a BMI exceeding 30 kg/m2 were included in the study. Patients who had simultaneous dermolipectomy with a smaller volume of liposuction also were included. The study enrolled 31 patients in 1 year, 16 of whom returned for follow-up visits 3 to 12 months postoperatively.

No formal diet plans were used. Of the 31 patients, 18 underwent dermolipectomy with liposuction. None of the study patients were insulin dependent. All our procedures were performed with the patient under local anesthesia as well as valium and ketamine sedation. Sequential tourniquet devices were applied to the knees for deep vein thrombosis (DVT) prophylaxis. This type of anesthetic procedure avoids the pitfalls of general anesthesia and allows patient to maintain normal use of the leg muscles, consequently reducing the possible threat of embolic phenomena. Diazepam and ketamine dissociative sedation is relatively harmless and useful regardless of the length of surgery [7, 8].

Because of the numerous advantages, nearly all the surgery was done on an outpatient basis. Those who had risky medical conditions or excessive weight were treated at a hospital and remained overnight. A superwet technique was used, with tumescent fluid injected in the areas to be treated [9]. We used cannulas up to 45 cm long so that a single incision in the buttock’s crease allowed us to reach from the neck to the knees posteriorly and laterally. One or two incisions in the hair-bearing area of the groin gave us access from the chest to the knees anteriorly and to the thighs laterally.

Our postoperative patients were placed in compression garments for a total of 6 weeks. These were kept in place around the clock for the first week and then removed for bathing for the next 5 weeks. We waited a few months between serial suction episodes to allow complete healing and equilibration. A maximum of 8 l was removed in one sitting without a blood transfusion. We removed more than 15 l safely by administering 2 U of autologous blood. The safety of fluid replacement has been published previously [10].

We reviewed a number of parameters for our study to demonstrate how large-volume fat removal might help the patient improve type 2 diabetes. These parameters included pre- and postoperative blood pressure, BMI, fasting glucose, glycosylated hemoglobin (HbA1C), and weight loss (Table 1). Our results show the average preoperative values and the average lowest values 3 to 12 months postoperatively. Of the 31 patients enrolled in 1 year, only 16 returned for the postoperative study after 3 to 12 months. The average aspirate in our 31 patients was 8,455 ml without dermolipectomy and 5,795 ml with dermolipectomy. Our average infusion was 5,485 ml without dermolipectomy and 4,350 ml with dermolipectomy.
Table 1

Average results for 16 patients

 

Preop

Postop

Change (%)

FBS

119

97

18

BP

136/86

132/84

None

Weight

217

197

9.2

BMI

36.87

34.30

6.2

HbA1C

5.96

5.82

2.3

Preop preoperative, Postop postoperative, FBS fasting blood sugar, BP blood pressure, BMI body mass index, HbA1C glycosylated hemoglobin

Results

The data in Table 1 demonstrate a trend of improvement in blood sugar levels. The 18% drop in average blood sugar is the best benefit we can report from our study. This drop in blood sugar is beneficial to the patients and reduces their tendency to experience the development of type 2 diabetes. The five patients who had the largest drop in fasting blood sugar level (15–78 mg/ml) lost the most weight, 20 to 50 lb each (Table 2). Similarly, the two patients with the least weight loss had the least drop in their fasting blood sugar levels (0–6 mg/ml). The HbA1C levels in our patient population dropped by 2.3%. The average blood pressure readings did not change significantly, and the average weight loss was 9.2%.
Table 2

The patients with the largest weight loss had the best reduction in their blood sugar level

Patient

Preop weight (lb)

Postop weight (lb)

Reduction in FBS, mg/ml (%)

D.A.

266

233

30 (22.7)

P.S.

195

175

49 (36.8)

R.M.

200

180

19 (19)

A.A.

229

198

15 (14.85)

R.T.

235

185

78 (35.9)

Preop preoperative, Postop postoperative, FBS fasting blood sugar

Discussion

All 16 patients who returned for longer follow-up evaluation in 3 to 12 months lost weight after the surgery, with an average loss of 20 lb (9.2%) (Table 1). Of the 16 patients, 6 lost more than 20 lb, and 4 of the 6 patients had additional dermolipectomy surgery, indicating a modest benefit of weight loss in these four cases. The remaining 10 patients lost less than 20 lb, suggesting that a large-volume liposuction alone did not significantly improve obesity.

We believe that the patients with the best weight loss results in our study were those who had the best postoperative diet. In addition, the patients with the most weight loss also showed the best improvement in their fasting blood sugar level (Figs. 1, 2).
https://static-content.springer.com/image/art%3A10.1007%2Fs00266-011-9798-5/MediaObjects/266_2011_9798_Fig1_HTML.gif
Fig. 1

A 42-year-old female nurse had diabetes and measured her blood sugar every week for many years. It was always between 150 and 200 mg/ml until she had a serial liposuction of 10.6 l. She also lost 60 lb

https://static-content.springer.com/image/art%3A10.1007%2Fs00266-011-9798-5/MediaObjects/266_2011_9798_Fig2_HTML.jpg
Fig. 2

Pre- and postoperative photos of a patient who lost 50 lb. Her blood pressure dropped from 151/103 to 137/84, and her fasting blood sugar dropped from 217 to 139

The largest single loss of weight was 50 lb (21%), and the average weight loss was 20 lb (9.2%). The BMI values were similar to the weight loss values except that the BMI reduction was only 6.9%. The same patients who lost the most weight also had the smallest drop in their BMI. Because BMI incorporates height and weight, we think this is a better statistic for future studies to use in following obese patients.

The HbA1C level dropped only 2.3% even though the fasting blood sugar levels dropped 18%. These storage levels of glucose in the red cells are used to help determine compliance with insulin management and to assess the risk of cardiovascular disease. Glucose sticks to protein if it is around long enough. The glucose binds to the protein of the red blood cell, and the HbA1C tells how long the glucose has been in the system. The glycated hemoglobin (A1C) level reflects the blood sugar concentration for the preceding 3 months, the normal survival rate of a red blood cell. Diabetics normally experience a rise in this level if they are not compliant with insulin management. Nondiabetic patients do not normally change their HbA1C levels.

In our study, the low A1C drop was consistent with the fact that the HbA1C levels measure a storage unit for glucose. The HbA1C does not test the same parameter as a fasting sugar, so the value change will not be the same. The fasting sugar in the morning can show a drop as a result of eating habits when blood sugar is tested, and the HbA1C may not be affected as much.

The HbA1C level reportedly dropped only 6% in a study of nondiabetic children and adolescents after a 12-week weight reduction program [11]. It takes a long time or a large change in blood glucose levels for the A1C level to change significantly. Mumme et al. [12] studied the effect of laparoscopic Roux-en-Y bypass surgery on HbA1C levels in diabetics compared with a control population that had no surgical intervention. The surgical patients showed more improvement in their HbA1C concentration compared with the nonsurgical group.

The systolic and diastolic pressures did not change significantly as an overall value in our study (Table 1). All blood pressure readings were performed by the same nursing staff with the same monitor. Only five patients showed any improvement, and they were those who lost the most weight after surgery (Table 3). The largest blood pressure drop (151/103 to 137/89) was in the one patient who lost 50 lb postoperatively.
Table 3

The patients with the largest reduction in their blood pressure (BP) also lost the most weight after their surgery

Patient

Preop BP

Postop BP

Reduction in weight (lb)

D.A.

150/83

128/80

33

R.M.

131/73

113/78

20

N.M.

135/91

119/89

19

R.P.

169/94

144/82

17

R.T.

151/103

137/84

50

Preop preoperative, Postop postoperative

We believe that the average blood pressure did not change significantly in our study because the patients were still obese (BMI > 30 kg/m2) and that their blood pressure will not drop until their BMI is much lower. Greater weight loss, however, did help lower blood pressure in our study (Table 3).

Safety is an issue in all surgery centers as well as in our study. For this reason, we followed all 31 patients for a minimum of 12 weeks postoperatively (Table 4). There were no DVTs or pulmonary emboli in any of the obese patients. None of the patients were transferred to the hospital because of an intraoperative emergency. The wound dehiscence and infection rates were 5.5 and 11%, respectively. These are reasonable safety statistics for a population of patients normally considered at high risk. Pulmonary emboli are rare with dissociative anesthesia [8], which is why we do not use general anesthesia.
Table 4

Complications in all 31 patients

18 Dermolipectomies

 

Emergency transfer to hospital

0

DVT

0

Pulmonary embolus

0

Wound dehiscence

1

Wound infection

2

Seroma

3

DVT deep vein thrombosis

Diabetes mellitus is a disease of carbohydrate metabolism with a hereditary disposition, causing hyperglycemia, ketosis, and protein breakdown. With rising blood sugar and insulin levels, a metabolic syndrome develops, with blood vessel damage causing cardiac ischemia, stroke, renal failure, and neuropathy.

Carbohydrates are normally ingested as mono- or polysaccharide sugars and then converted into fructose and glucose. Once inside a cell, glucose is phosphorylated with adenosine triphosphate (ATP) to provide cellular energy. The main derangement in diabetes is inadequate or ineffective insulin that allows the blood glucose level to rise. Polyuria ensues, with dehydration, and ketones form.

The excess glucose then is converted to fat by the liver and adipose tissue, making fat a target organ for type 1 and type 2 diabetics. The fat is assembled into triglycerides as storage. Fat then becomes a metabolic substrate for the body, at the expense of protein synthesis. The reduction in body fat after bariatric surgery results from a decrease in the size of each fat cell. Liposuction removes the fat cells, resulting in fewer cells.

Type 1 diabetes may be autoimmune or congenital in nature, but type 2 diabetes is an adult-onset condition related to obesity. Many patients who have dieted successfully show a reduced burden of type 2 diabetes on their body. Bariatric surgery patients show the same result. By a reduction in the mass of fat through diet or bariatric surgery, the target organ of diabetes is lessened, and thus the effect of diabetes itself. Our hypothesis is that the reduction in fat stores by large-volume liposuction can have the same effect with a good postoperative diet. This could be the subject of further studies with control groups.

Conclusion

This preliminary study aimed to determine the effect of large-volume liposuction on the parameters that determine type 2 diabetes. The study demonstrated a trend of improvement in blood sugar levels associated with weight loss that helped these patients considerably. The overall weight and BMI did change modestly as a result of the treatment, which consisted of large-volume liposuction and dietary weight loss.

Although we do not have absolute proof that the larger-volume liposuction reduces type 2 diabetes, our study demonstrates a trend of improvement in our patients and opens a door for further discussion about large-volume liposuction motivating patients to more successful medical weight loss and research with a more controlled series. Although we were able to get only 16 patients back for our analysis, which is the weakness of our study, we believe our data warrant further investigation.

We hypothesize that liposuction may motivate some patients to diet, which could be explored in another study. Large-volume liposuction alone was not an effective weight loss surgery in our hands, but it did motivate a selective group of our patients to diet after their surgery. These patients had the best results.

The average blood pressure did not change much in our population, but the readings did drop if significant weight loss occurred. The HbA1C level did drop modestly. More time and weight loss may be needed to see these values drop more. We also conclude that ketamine/valium sedation is safe for the obese patient population, and our complication rate was acceptable.

Acknowledgment

We thank the following members of our staff for their assistance and participation: Mark Salisbury, MD, Cynthia Peterson, RN, Cindy Lou Carracio, RN, Rebecca Lee, Priscilla Tambunga, Rachel Salas, Eugene Gonzalez, Rhonda Mattox, Inna Wilkerson, MD, and Cynthia Willman, RN. We also give Stephen Fehrenkamp, MD, a local endocrinologist, special thanks for his contributions.

Conflicts of interest

None.

Copyright information

© Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2011