Highlights from Dutch Lipedema Day Conference – Part 2

By Tatjana van der Krabben

On May 30, 2015 I attended the 5^th Dutch Lipedema Day in the lovely southern part of the Netherlands. It’s impossible to cover everything I heard and learned that day. In this blog - part 2 - I will point out some interesting facts and figures I picked up that day.

We had a little bad luck: dr. Rapprich had had to cancel. Although famous for his liposuction treatments, he would have covered something entirely different: AquaCycling. He would have presented the first results of a study to include AquaCycling as part of the therapeutic concept for lipedema. I don’t know whether or not certain modifications were made to accommodate lipedema patients during the study, but this is aqua cycling. To be continued, then?

Ms. Smeets-Taubitz, a homeopath and health therapist (for lack of a better translation for ‘Heilpraktikerin’) delivered a very interesting lecture about infrared therapy. In this concept not to be mistaken for infrared sauna. Using specifically the infrared cabins of Physiotherm, lipedema patients were only exposed to temperatures between 27-37˚C (80.6-98.6˚F), therefore no higher than body temperature.

The warmth was directed at the back, to be absorbed by the bloodstream and to affect the lymph. The bloodstream is to spread the warmth over the entire body. It is to effect improved circulation, have a favorable effect on the organs, muscles, connective tissue and skin, potentially reduce pain, improve metabolism and have a favorable effect on the immune system. Afterwards either increased sweating or more frequent urination is reported, as well as weight loss by some over the course of 5 weeks.

Interesting detail was that Ms. Smeets-Taubitz referred to women sweating who were ‘normally practically unable to work up a sweat’. She had observed this more often in lipedema patients and this is something many of us have mentioned on forum, too.

Ms. Smeets-Taubitz may have only worked with a small group, but this has been applied as a therapy for lipedema patients in two German clinics already for some time.

Drs. Schift, cosmetic surgeon, went over the history of liposuction.
In 1974 Georgio Fischer started with fat removal in Italy.

In 1980 Yves Gerard Illouz and Pierre Fournier continued with fat removal in France, which drs. Schift described as still a bloody affair.

In 1987 dr. Jeffrey Klein, a dermatologist from the USA invented tumescent local anesthesia. This was a genuine breakthrough, reducing risks greatly. Dr. Klein’s Tumescent technique is still perceived as a handbook on the subject. Today’s irony being that American doctors now travel to Germany to learn the ropes.

In 1990 dr. Gerhard Sattler introduced tumescent liposuction in Germany. He perfected the technique and worked towards the extraction of larger amounts of fat. Along the way the cannulas have gotten significantly smaller as well.

With tumescent liposuction a fluid is being injected first. Tumescent fluid contains physiologic saline, lidocaine, adrenalin and bicarbonate.
The adrenalin helps the blood vessels contract to avoid a lot of blood loss. The bicarbonate reduces the acidity, making the infusing procedure less painful/stingy. The fat holds the lidocaine, releasing is slowly, which allows for the application of high doses.
However, the body being able to break it down is also very important. This can be hindered by medication like anti-depressants and certain pain killers.

Infusing of this tumescent fluid is not unlimited, but related to body weight: 35-50 mg per kilogram of body weight – if I noted correctly.

Upon infiltration the skin swells and becomes pale, from the contracted blood vessels. Then you need to wait for the anesthetic to take full effect. Drs. Schift described the infiltrated and therefore tense and swollen tissue as more easy to work with, providing clear definition.  

He also tackled the debate among patients on how much was extracted and how come it varies, when they compare their cases. Well, it depends on the person and how much tumescent solution can be used safely for that person. So you honestly can’t compare notes with other patients.

Tumescent liposuction comes in many variations. Initially it was done entirely manually, but this is tiring. Then came: UAL (ultrasound-assisted liposuction), PAL (power-assisted liposuction), WAL (water-assisted liposuction) and LAL (laser-assisted liposuction), not necessarily in that order.

All methods were designed to make the procedure easier, for both the surgeon and the patients and to improve results.
They all have their own quirks. Drs. Schift mentioned the risk of burns with UAL, although it helps loosen the fat, and the difficulty with anesthesia in WAL, the fluid being infused not prior but during the procedure and therefore not being able to put the anesthetic properties to full use and requiring additional anesthesia. Drs. Schift himself favors LAL, which he says is primarily used to burns through the connective tissue and helps the skin contract to avoid pleas and folds in the skin after liposuction.

Drs. Schift also stated that despite large volumes are being extracted, this is, due to the subcutaneous friction, an active procedure for skin, stimulating the skin to retract. Whereas natural weight loss is more passive for the skin and will show sagging skin more readily.

And then…bring on the fireworks! Dr. Cornely, dermatologist and phlebologist, but more so known for his liposuction treatments, covered lipedema in the arms and ‘treated’ us to some graphic, but informational footage.

On forum most object to the claim that lipedema only sometimes occurs in the arms. Dr. Cornely argued 80-90% of the patients he saw have it in the arms as well. Other doctors have come up with percentages of around 30% of the patients, but he disagrees. He said the lower arms are often skipped with liposuction because of the concentration of lymph vessels in the lower arms. He, however, didn’t perceive this as a reason to not treat the lower arms and showed us footage of him doing so.

He also proposes to change the name of liposuction in lipedema to lymphologic liposculpture to take some distance from esthetic surgery, since liposuction for lipedema is not (necessarily) about esthetics.

Then there was an interesting debate on the long term effects of liposuction. Drs. Schift presented 2 cases with very good long term results, but said it was difficult to follow patients (time, cost, developing an objective standard to compare data), but that it would be useful in order to determine the long term effect. Dr. Cornely, however, spoke of ‘curing’ lipedema through liposuction, which statement was also welcomed by another liposuction doctor present.

Weeeeell, that sparked a lot debate and triggered many critical questions. Mind you – the physiotherapists present were for the better part trained in conservative treatment options. So watching liposuction of arms and fingers (!) in action was way out of the box for many, that, and the cure claim. As for the patients: we all fear false hope, don’t we?
I wouldn’t know about treating the lower arms myself. If that is possible, safely, it would be of use for many, since many do have lipedema in the arms. As for a cure? In case you’re not a regular reader of this blog: we’re open to liposuction as a treatment option (been there, done that, no regrets), but we don’t refer to it as a cure. Sadly, there is no known cure for lipedema at this point.

Those who attended the conference may miss 2 lectures in this overview, or three actually. Busted. One was on food/diet, by someone who admitted she had little or no specific knowledge of lipedema. Although touching upon relevant issues such as the quality of food and looking more so at nutrition and its effect on the body than calories, it was not lipedema-specific. Being flooded with (contradicting) information on this subject as it is, I thought it better to skip coverage on this one.
The other being about skin therapy and Ayurveda, more specifically a combination of endermology, Ayurvedic supplements, breathing techniques and exercise. I’m not saying it does nothing, but it described only one case of a lady who (also) had venous insufficiency and therefore had a strong edema component. The before and after pictures were great – she lost inches - but edema is easier to reduce than pure lipedema. At this point the person presenting the findings could not confirm whether or not it was (mostly) edema management and what did what in the treatment program. So, I’m giving it a mention, but am not getting into the details.

A third lecture not covered here did not address lipedema, but body language and therefore doesn’t fit the scope of this blog. Plus, I played hooky with that one – yes, bad me.

Will lipedema remain focused on treating symptoms?

By Tatjana van der Krabben

Lipedema is poorly understood. That much we know. We gain, we hurt, we swell and deal with inflammation. That we know, too. New research sometimes allows us to catch a glimpse of what is or could be behind the veil. Best examples I know of at this point is by Szél et al (2014) Pathophysiological dilemmas of lipedema (abstract) and by Bosman et al (pending) Prospective controlled study to determine the use of ultrasound in lipoedema patients compared to obesity, which reveals distinct characteristics in our connective tissue.*

But these glimpses are rare. Extremely rare. Most papers are still about liposuction or what lipedema looks like, including overviews of traditional treatment options. I know you can never get too sure about surgical intervention and within that area of expertise much is being learned still, about treating stage 3 lipedema, differences between types of cannulas and techniques etc. Most useful. Of course.

But still… With liposuction getting most attention and being presented in the media as a cure sometimes or the only effective treatment, a situation of supply and demand is being created, where patients place their money – literally – on liposuction. It’s becoming the thing to do and the thing to want. The next step, which is already becoming apparent, is that treatment becomes about liposuction.

I would like to see it as a tool in a toolbox that, like any toolbox, contains more useful tools with room for more and new tools. New tools, less invasive hopefully, and, dare I hope, even more effective, will not be found unless there’s a supply of data. But before there’s supply, there needs to be demand. We need to voice that demand. We need to be that demand. We need to strive for more insight into causes of lipedema.

There’s still much work to be done in raising awareness. Don’t give up on learning about the cause(s) in this lifetime. Perhaps, as one of the members of Lipese Challenge (Facebook group) suggested, it could be a plan to take matters in our own hands and get new research topics on the table. Why not? Doctors tend to see those in need of diagnosis and at that point barely informed. Once that hurdle is taken and some additional reading and thinking is done, the vital questions start to sink in. Questions we usually only express among ourselves.

I don’t mean to be gloomy, but we are currently at risk to see research regarding causes being skipped altogether in favor of treating symptoms. And nothing but symptoms.  A course of action that happens to so many conditions out there. Finding the needle in the haystack may not be particularly marketable at the short term, but I for one would love to see it found. Because, if you ask me, prevention for generations to come still trumps surgery for damage control.

 

*Feel free to chime in and point out recent groundbreaking research towards causes, which I may have missed. Make my day!

Liposuction – short term or long term fix?

By Tatjana van der Krabben

Liposuction is not a cure for lipedema. Been there, done that. Buuuuut….how long will you be able to enjoy the benefits? Snaky question, which I don’t have an answer to. All I know is, that it could be much shorter than anticipated.

I’ve blogged about the fat sometimes returning fairly soon in individuals. This week an article from The New York Times from May 8, 2011 was brought under my attention again. It’s disturbing: in a year fat was regained. Be it elsewhere, but fat was regained. Oops. I also stubbornly insist you CAN regain at the locations where the fat was sucked away. You can. Many have.

Where does that sit with the (few) long term studies on liposuction in case of lipedema? Quite well, actually. It’s a story of give and take. A case of “yes, but”. The body appears to be fond of storing. In lipedema we took this to the next level. And some, if you look at patients in stage 3. With liposuction we “steal” fat from our body and the little hoarder that she is will work overtime to “fix” that. Bring on the inflammation. We’ll get you gaining at under 1000 cal. a day. Ha!  

Yes, but. Thankfully there’s a “but” in this. You can counteract inflammation. You can attempt to crack the code to your body and figure out an eating and exercise plan that works well for you. Balance the stress, tweak some here, tweak some there. More and more of us manage to trick our bodies out of hoarding. At least between hormonal highs and lows. When the hormones shuffle, we are, alas, riding shotgun. Screaming “stop!”, praying the hormones will listen and hit the brakes.

The cases in my mind, where fat came back at a cruel pace involved women who were close to hormonal changes or didn’t change their lifestyle. And perhaps it also is of importance how much is removed. It has been implied – not researched – that, in order to tip the scales and change the balance properly for the patient, a significant amount of fat needs to be extracted. I wouldn’t be surprised, although clueless how to define “enough” and “too little”. (Can I make another request for research? Put it on the list, please.)

So, when considering liposuction, it doesn’t hurt to ask yourself if it would still be worth it for you personally if you could only enjoy the new optimum for, say, 5 years. It can be. Like with me. My kids are small NOW. I wanted the extra energy to start a new career NOW. I have this new window of opportunity that I obviously want to last and last. Every year in my present state counts. I make it count. It will be disappointing when I get pushed over to the passenger seat and watch the hormones take hold for a while again, but that’s the risk. I was willing to take it.

I bring this up, because for you it could also be worth it, but you need to know to take a proper decision. Maybe you’ll decide to wait, until after you have a family. Or not. Maybe you secretly hoped lifestyle would be less of an issue after liposuction. Sorry, no. Essentially you’re buying time. Make it count.

What to consider when searching for a surgeon to perform liposuction

This blog could never cover everything relevant, but it's a start, coming from personal experience and what else I learned along the way. I do not recommend liposuction. This blog does not provide tools to assess whether you should have liposuction. However, I receive many questions on where to start when considering liposuction and in that context I offer this information as food for thought. Preferrably, in an ideal world, you would be going over these issues with your informed doctor, or better yet with a specialist in a multidisciplinary institute, where they could answer all your questions and offer the treatment when considered a good candidate.

Learn what exactly you are looking for.
Liposuction, liposculpture, WAL, PAL, tumescent: are you still with me? It's ALL liposuction. All of it. And it's all tumescent. I love this quote of dr. P. Aldea:

"Tumescent liposuction is nothing but the universally performed pre-liposuction infiltration of the fat to be suctioned with a dilute solution of a local anesthetic (lidocain, marcain etc.) and adrenaline (epinephrine) which increases the accuracy of fat removal, largely reduced blood losses AND increases patient comfort."

Source: http://www.realself.com/question/tumesecent-liposuction-general-local-anesthesia

As dr. Aldea puts it: the anesthesia is supplemented. Meaning: tumescent infiltration of the area to be suctioned is a given, but the type of anesthesia is a matter of choice. But mostly not the patient's choice. I'll get back on that.

PAL, WAL, UAL, LA etc.
Along with tumescent, there often are additional specifications regarding the technique a surgeon applies. They can use a specific suction device like Power Assisted (PAL) or apply a thin water beam to help losen the fat from the tissue: Water Assisted Liposuction (WAL). There are more flavors out there. I highlighted PAL and WAL, because lately these are frequently mentioned on patient forums. However, as you can read through the link, these are not the only options.

As you can read they all are presumed to have their merits and do something specific to spare the lymph, do minimal damage, minimize risk etc. Ask a surgeon which is best and you'll get an answer. Ask another surgeon and you'll get another answer.

As a layman I noticed the difference of opinion between professionals and let it be. A certain surgeon prefers a certain technique. Well, apparently that technique suits him/her best. My personal choice was to get over the various terms which I could only ever understand superficially and looked at the surgeon's track record instead: knowledge of lipedema and years of experience. After all: the tool doesn't define the result; it's the surgeon's skill in using the tool.

Note: there's more research out there now compared to the time I had my procedures. If you want to know more about a particular technique and how it works compared to an other or the "plain" technique, there's far more information to be found. Go straight for the "boring" stuff: formal publications, in order to avoid information designed as a scientific-looking piece of marketing. The quickest way to cut to the chase is to search through Google Scholar. It only contains scientific publications.

Plastic surgeon or cosmetic surgeon
A plastic surgeon is trained in hospitals by professionals and has completed related residencies. Cosmetic surgery is not taught through residency programs. Doctors seeking to learn cosmetic surgery typically get their training after their residencies. This pretty much means a doctor would need to organize his/her own training and has a certain freedom the raise the bar to his/her liking. Cosmetic surgery is practised by doctors from a variety of medical fields. Read more about the differences here.

However, deciding between a plastic surgeon or a cosmetic surgeon based on the title only is a trick question. Plastic surgery does NOT equal (knowledge of) liposuction. There are numerous specialties within plastic surgery. Plastic surgery is first and foremost focused on reconstruction of defects due to disorders you are born with, trauma, burns and disease. Lipedema qualifies as a 'disease'. Care to guess how many hospitals acknowledge the condition and offer liposuction as a treatment option? Few. Very few. As a consequence there are few well-trained and informed plastic surgeons out there. For reference: tumescent, which is raved about as a major improvement to liposuction surgery, is invented by an American dermatologist, dr. Klein.

When considering a surgeon you best look at expertise and experience. While you're at it, also look at client/patient reviews. In that context, beware of posers, pretending to be content patients. In the past some clinics have used this despicable method to lure clients. It may still occur...

To improve cosmetically or to improve mobility and reduce pain
This is not about starting a debate. Your body, your choice. It's just very important to find out where your priority is and whether that priority matches with the surgeon you're considering for the job. It's not either/or per se. It can be a little of both. But trust me: there are surgeons out there with a 100% focus on mobility and they will NOT be open to a post-op debate over looks. Even when the result is very uneven and/or irregular. There's also the patient who, in her heart, wants killer legs (back). Again, not judging. Just make sure you set out for a realistic goal with a surgeon who is able and willing to help you strive for that goal. Strive, yes. We're quite the canvas to work with. It's no exact science.

You want a good or even super cosmetic result?
Ask. Ask for pre-op and post-op pictures of women much like you: size, build, with lipedema. Don't let the surgeon just show you his/her best work ever on young ladies with little excess fat and lovely elastic skin. There's skin elasticity and the condition of your connective tissue to consider. Ask about your personal possibilities and impossibilities and, if needed, try to adjust your expectations. It's better to know before than after when there's no going back.

Look for a surgeon with knowledge of lipedema
Typically, those seeking liposuction for purely cosmetic reasons need to have little fat removed. It's not designed as weight loss surgery. Many surgeons even refuse to operate when the BMI is on the high end. Many of these surgeons commonly remove 1 liter, maybe 2 per surgery. A drop in the bucket for most of us. We need someone who can and will remove more.

He/she would have to be aware of the fact that we need to be especially careful with our sluggish and sometimes already compromised lymphatic system. As well as: possible poor skin elasticity, weak connective tissue and possibly slower healing.

General anesthesia or local
General anesthesia in itself poses a (small) risk, on top of the risks inherent to liposuction. You can draw the line there or you can reason that didn't stop you in the past to, say, have your appendix removed.

General anesthesia burdens your body. When I insisted on general anesthesia myself in an entirely different procedure, my surgeon warned me it would take me more time to recuperate afterwards compared to undergoing the same procedure with an epidural. It simply adds to what your body needs to process when healing. Local anesthesia is also favored by some to have the patient able to move and, if need be, stand to assess the evenness of the result. On the other hand, the prospect of enduring the procedure wide awake can be stressfull. Maybe too stressfull for some.

If you are to opt for general anesthesia, you may need to look a little harder for a suitable surgeon. Many clinics can't or won't offer general anesthesia. It requires additional facilities, knowledge and assistance during the procedure. If not that, some surgeons truly want you awake to monitor your wellbeing themselves and have you participating by moving during the procedure.

Pre-op and post-op care
What is being checked and looked into to dertermine you are a suitable candidate? Is it thorough? Do you have a good feeling about this? Do you know the basics and were provided with information on how to prepare for the procedure, what to expect and how to arrange care post-op? How can you reach the clinic when you (feel) you need to? What if post-op complications arise? Who covers these expenses? Where can you turn to? This is particularly relevant if your surgeon is far from your home and you travel back soon after the procedure. At the same time: don't wait to be asked about specifics. Share your medical history and use of medication in detail.

Do inform your primary, even if he/she doesn't support the idea. Make sure they understand what you embark on so they can help in case of problems.
Obvious stuff? Sadly no. I still read about questions like: "Is it normal to still have swelling after a week" and "Is it normal the cuts ooze". That's basic stuff. You should be told about this sort of thing in advance.

Insurance
In rare cases the procedure is covered. Ask around on forum if someone from your country managed to get it covered and what they did. Even if the odds are slim, consider trying. Health Insurance companies need to become aware of lipedema and liposuction as a serious treatment option.

Also, think how far you want to take this. Going ahead with the surgery while still butting heads with your health insurance may ruin your chances of coverage. It may also lead to a road where you can't have the procedure done by your surgeon of your choice. Ask around. Patient forums on for instance Facebook are a wonderful source of practical information.

Liposuction – Please tread lightly

By Tatjana van der Krabben

Every time people inquire which surgeon I saw or compliment me on the visible progress I made since my liposuction, while sharing their own plans, hopes and dreams in that direction, I tell them to tread lightly. My answer often surprises them, considering the obvious progress I made, but there are several reasons to urge for caution. It’s not all rainbows and song. Here are a few misconceptions that I wish to address.

“Liposuction is a cure for lipedema.”
This claim doesn’t come from the medical field per se, but patients sometimes say this. Liposuction is not a cure. It couldn’t be a cure. You don’t need to be a doctor to come to that conclusion: fat is extracted. No more, no less. Current insights have revealed it’s at least in part genetic, in part responding to hormones and in part to lifestyle. That’s what’s known at this point. With your full genetic package intact post-op and the same old hormones, you’ll be anything but cured…

“The fat that was removed, will not return.”
Technically true and misleading. The very fat that was extracted was disposed of post-op, obviously, in those canisters. So that fat will not come back to haunt you. However, your remaining fat cells can continue to swell. There’s also speculation new fat cells can be formed. Not that farfetched, considering your adipose tissue also contains stem cells that can theoretically become any type of cell. When regaining it will likely start in arms, belly and/or back, but eventually adipose mass can also increase on your legs. I met people who experienced that…

“Only this or that doctor can perform liposuction safely.”
There are absolutely dozens of skilled doctors out there who can do this safely with lipedema patients. I hear of - for me - new names on a regular basis. And those doctors in turn train other doctors, who…. Etc. It’s getting a less exclusive area of expertise, although the geographic spread is very uneven, with Germany as the absolute hotspot. Most doctors work for private clinics and have very good use for this claim. Presenting yourself as the absolute top of the bill is good advertising. It’s also fuelled by patients, providing raving reviews of their surgeon, leaving the impression that that particular surgeon is the (only) person to go see.

There are exceptions: many doctors refuse to perform liposuction in case of advanced lipedema and/or combined health issues. For these people it can seriously be slim pickings when searching for a surgeon.

“It’s safe.”
As safe as any sur-ge-ry. Don’t ever forget it’s a surgical procedure. The fact you’ll most likely be treated as an outpatient, doesn’t mean it’s not a surgery. They worked on the procedure to minimize risks, yes, but any surgery has its risks. This one too.

Also, since your primary won’t be involved, most likely you’ll have to look around for a surgeon yourself. It’s costly. I see people looking at expenses before track record. Do they check your medical history? Do they explain what it entails, what you can expect? Or are they smooth talking you into doing this? And what if there are complications post-op? Will your primary help you or refer you back to your surgeon, even if that’s in another country or across the country? Ask questions. Come prepared.

“The surgery will provide cosmetic improvement.”
Yes – no – maybe. It takes skill to work on a large lady. A lot of skill. I’ve seen uneven results. Also, only so much fat can be extracted. Sometimes choices are made to bring as much relief as possible to one particular area. Think proportions: smaller legs will make your behind, hips, belly possibly look larger. Or the surgery will finally get the proportions right for you - that could also happen. It’s all very individual. Finally, you could be left with loose or even sagging skin. Some doctors will focus more so on providing relief, others take more interest in the cosmetic side. So even the approach varies.

Super cosmetic results are usually only achieved in stage 1 lipedema or early stage 2 with good skin elasticity. Meaning: I don’t have a superb cosmetic result either. I’m happy, but my expectations were realistic. So while someone recently said I should look into a tummy tuck, I accept the somewhat loose skin. Especially since it seems a bit crazy to have a special liposuction procedure to spare the lymphatic system and next risk lymph damage through skin surgery. No, thank you.

“I will never have to wear compression again.”
That remains to be seen. If you needed compression pre-op you could still be needing compression after the healing period. It’s a wait and see kind of thing. Maybe you could do with lighter compression or could afford some cheating. Maybe you’re so lucky you can give up compression completely, but don’t assume that’s ‘normal’.

“After liposuction you will need to wear compression 24/7 for the rest of your life, or else your legs will start ‘growing’ again.”
Thankfully that’s not true! The first few weeks post-op (exact recommended duration varies per clinic) you will have to do so. By then you’ll be very, very happy to toss them aside for the night. Seriously! After that it will be limited to the daytime and after your healing period it’s a question mark what you’ll need. That’s very personal.

Your legs could ‘grow’ again. True. That has to do with how stable your lipedema is. More likely causes would be hormones and lifestyle. Not pointing the finger here! If your doctor doesn’t know (much) about lipedema, you could be getting poor medical advice on your lifestyle. You could be under the impression you’re doing everything right, while another approach would be far better in your case. It’s a common problem, I’m afraid… There are many misconceptions on that as well and contradicting recommendations, even among doctors and therapists specialized in lipedema.

“How much weight can I expect to lose?”
Don’t expect the scales to show a plummeting number. One liter of fat weighs about a pound and only so much will be extracted. Substantial weight loss is sometimes reported. Post-op improved mobility can sometimes do that for you.

What can you realistically expect?
Literature on the benefits of liposuction is widely available nowadays. That means already many have been successfully operated on. Improved looks and/or contours and improved mobility are mostly reported, although not necessarily in that order. The average patient generally reports progress, or great progress, even. Perception does play a part here, of course. The other factor is your specific health status. Are you a stage 1, 2 or 3? How active are you? How stable is your weight currently? What’s your plan to maintain the surgically obtained result?

Liposuction can be a shortcut to potentially great improvement. All else is a matter of perseverance, trial and error. That doesn’t make the alternative or traditional route less valid or less important, or mean that we should all look at liposuction. Not everybody can afford liposuction, is willing to try a surgical solution or is a suitable candidate. Plus, if you want to hang on to your results, you better come up with a lifestyle plan you will be able to stick with, if you haven’t already. There’s your perseverance, trial and error again.

In short: you could get a lot out of it, but you’re not out of the woods post-op. So tread lightly, please. I did! My surgically obtained result is still intact. That’s 3 years since the first surgery and 1 year since the last. That’s all effort, not dumb luck or an incorporated effect from the surgery. Sorry…

PS. Please don’t shoot the messenger…