Since 1983, the most commonly performed cosmetic procedure in the United States has been liposuction. Breast augmentations are a little more popular some years, but over the long haul, fat removal leads the way.Sucking fat keeps operating rooms across the country busy every day. And that’s because it is safe and effective. Two words worth repeating…safe and effective, but with a big asterisk*. More on that later.COLUMN: Fighting Fat the Modern WayLiposuction burst onto the scene three decades ago after first being described in France. Through incisions smaller than a quarter inch, a hollow tube called a cannula is pushed under the skin and agitated back and forth to break up the fat. Using a very powerful vacuum cleaner (creatively called a “liposuction machine”), that fat is removed from your belly or thighs and delivered to a canister, where it is treated as medical waste.Sounds simple, doesn’t it? Deceptively simple, it turns out, inviting all sorts of doctors to put down their stethoscopes and pick up those cannulae. But more on that later, too.Safety ConcernsWhen the procedure was new, no more than four pounds of fat could safely be suctioned. That’s because you would lose about a half pint of blood for every pound suctioned. Then plastic surgeons started injecting dilute lidocaine anesthetic containing epinephrine into the fat just before it is suctioned. That drug numbs the tissue and scrunches down blood vessels so much that the skin turns ghostly white.Suctioning through that blood-starved fat cuts way down on blood loss. So much that 10 pounds or even more could now be safely suctioned. With this technique, by the end of the 1980s there seemed to be a race to see how much fat could be suctioned.  Publications appeared with 10, 15, 20, even 30 pounds of fat being removed in a single session. But then the problems started, from terrible cosmetic results to deaths. Not just occasional, but dozens, even hundreds of people died during and shortly after liposuction.COLUMN: DIY Plastic Surgery, Yes (Sadly) It ExistsThe culprit in many cases was lidocaine, the ubiquitous anesthetic. You’ve had it many times in the dentist’s office, but for your teeth, less than a teaspoon is used. With liposuction, pints of the stuff are needed. And those large amounts can be toxic.So plastic surgeons began to critically analyze the limitations of the procedure. Now, deaths are thankfully rare in patients of board certified plastic surgeons. Most of us have our patients “cleared” by a board certified internist prior to the procedure—you should only have cosmetic surgery if you are healthy. And most of us stick to the 10-pound limit. If more fat must be suctioned, it is safer to have the procedure in the hospital and stay overnight with an intravenous and a urinary catheter. But honestly, if you have more than 10 pounds that need to be suctioned, you really should spend your money on gym equipment and a good diet book, not on liposuction. Ethical plastic surgeons will steer you that way. When you close in on your ideal weight, then those last few pounds can be suctioned.New TechniquesThe operation I just mentioned uses the “tumescent” technique: inflating fat with the dilute epinephrine solution (“tumescing”). You might read about other techniques—ones that use ultrasound, laser, or other high tech machines. But the truth is that these methods have not proven to be better than the more traditional tumescent technique. Honest plastic surgeons concede that their main benefit is in marketing. Many people think that surgeons who use lasers are “high tech” and better than those who use “old fashioned” techniques.  Sadly, many people choose doctors that way. I change my technique if a new technique is either better or has lower risks. So far, the “techsuction” techniques don’t fit that bill. I’ll stick to the methods that give uniformly good results and have a proven safety record.QUIZ: How Do You Feel About Your Body?Most Common Areas SuctionedIn women, the most common areas suctioned are the thighs and hips. The belly, knees and neck are also common, but liposuction of other areas like the calves and arms is rare. The procedure is most safely done with you asleep under general anesthesia, because the potentially toxic lidocaine anesthetic doesn’t have to be used. Afterwards, it shouldn’t hurt much, and you should be able to go back to work just a few days later. Yes, your bruises will make your thighs resemble eggplants, but these can be hidden under clothing. The bruising settles in a few weeks but your final result won’t be visible for about three months. If your procedure was performed well and your skin is nice and tight, you will join the millions of women who are thrilled with their liposuction.COLUMN: The Most Popular Plastic Surgery ProceduresWho Should Be Doing Liposuction?On the other hand, and here’s the asterisk, there are a lot of unscrupulous people performing liposuction these days. It’s a real surgical procedure, with both cosmetic and medical risks. I’ve seen women who were maimed by non-plastic surgeons performing their liposuction. I spent 10 years on New Jersey’s Board of Medical Examiners and reviewed deaths of patients who had their surgery by a variety of doctors ranging from family doctors to pathologists.These non-surgeons operate in private offices, virtually free of outside scrutiny. One case that made headlines recently was that of a 51-year-old New York City woman who died after liposuction performed by an internal medicine doctor. That’s worth repeating. Internal medicine doctor! Not a plastic surgeon…not even any type of surgeon, and without formal surgical training in a real residency program. This woman had a prior heart transplant and I can’t imagine performing cosmetic surgery in a private office on anyone who was at such a high risk for problems. For the most part, only qualified plastic surgeons can perform surgery in hospitals, but in private offices, many states allow anyone with an “M.D.” or a “D.O.” after their names to do anything in their offices.Staying SafeDespite this discussion, liposuction is an incredibly safe, high satisfaction procedure. The results will let you wear clothing without unsightly bulges, and you may be able to throw your Spanks away. Naked, the incisions should be too small to see, and liposuction can allow you to have the body your genes denied you.To stay safe, make sure your surgeon is a real plastic surgeon, preferably one who is certified by the American Board of Plastic Surgery. And make sure your surgeon operates in an accredited facility—whether it is an office, surgicenter or hospital. And to be safe, even if your plastic surgeon doesn’t require it, see a board certified internal medicine doctor before surgery and have her look you over carefully in preparation for surgery.Having passed these hurdles, you could be on your way to a more beautiful body.QUIZ: Do You “Fat Talk”?