Heavy cost of pursuing beauty

Soruce: The Straits Times, Jan 9, 2010

HUMANS have always sought to enhance their appearance. Excavations have uncovered prehistoric skeletons buried with ornaments. Wearing gems in pierced ears and noses is still common practice in many cultures.

With improvements in medical science, more invasive methods of enhancing physical appearance have been developed. The number of such procedures has increased exponentially over the past two decades. Some pose risks to patients.

Many Singaporeans appear to be trying these methods without, sometimes, full knowledge of the risks involved. I was shocked to read in The Straits Times on Wednesday of a 44-year-old man, the chief executive of a property firm, who died after a general practitioner allegedly performed liposuction on him.

Liposuction is a surgical procedure to remove fat from different parts of the human body – ranging from the abdomen, thighs and buttocks, to the neck and arms. The more fat is removed, the higher the risk. The procedure may be performed under either general or local anaesthesia. In a clinic setting – versus an operating theatre – the anaesthesia used is usually the local tumescent method.

It is ideal that the patient is as fit as possible before the procedure and has not smoked for several months. While almost all doctors know that general anaesthesia carries some risk, some may be unaware that local anaesthesia is also not without danger. If the injection of local anaesthesia into the fatty area gets into a blood vessel, there can be deleterious effects on both the heart and the brain.

Last year, the Ministry of Health issued guidelines for various aesthetic procedures. General practitioners are allowed to do liposuction if they have adequate training, and do not suction more than one litre of fat at any one sitting. I have often wondered how the ministry can check to ensure that only one litre is suctioned each time.

Even if liposuction is limited to one litre of fat per procedure, there is still the risk of being under anaesthesia – albeit low if the patient is in competent hands. Also, there can be other complications, such as perforation of the abdominal wall, which can be life-threatening.

Not everyone is a good candidate for liposuction. To be a good candidate, one should be over 18 years of age and in good health, have tried a diet and exercise regime, and have found that the last 10 or 15 pounds (4.5kg to 6.8kg) of excess fat persist in certain pockets on the body.

Diabetes, any infection, heart or circulation problems are contraindications for the procedure. In older people, the skin is usually less elastic, limiting its ability to readily tighten around a new shape. In this case, other procedures can be added to the liposuction, such as an abdominoplasty – or ‘tummy tuck’ as it is popularly known.

The irony of liposuction is that while the procedure has clear risks, it has no compensatory health benefits. The fat that is detrimental to health is the intra-abdominal fat, which can lead to Type 2 diabetes. This is the common type of diabetes associated with being overweight and not exercising. It used to affect adults mostly, but as the epidemic of obesity has extended to children, there are now children with Type 2 diabetes.

Diabetes can affect many organs. It may lead to an abnormal lipid profile, hypertension and vascular inflammation, all of which promote the development of atherosclerotic cardiovascular disease.

Liposuction can remove abdominal fat only from under the skin (subcutaneous fat). This does not reduce the risk of Type 2 diabetes or coronary heart disease. Those adverse health effects are mediated via intra-abdominal fat, which liposuction cannot reach.

Dieting and exercise are safer methods to reduce obesity. In addition, they have beneficial effects on health.

Exercise may be beneficial beyond its effect on weight loss by more selectively removing abdominal fat, at least in women. The standard exercise recommendation is a daily minimum of 30 minutes of moderate-intensity physical activity, such as a brisk walk.

The Government seems convinced, and the public has been repeatedly told, of the inadequate numbers of doctors in Singapore, given our population size. In fact, we have more than enough doctors. The problem is that not all our doctors are doing what we need them to be doing. And the way doctors are currently distributed, there are not enough doctors in certain specialities that are not lucrative.

However, there is an excess number of GPs. Often, people become GPs because they were not counselled properly on possible career paths after they had finished their one year as a house officer.

GPs who limit themselves to coughs and colds and writing medical certificates may not earn much, after having accounted for rental and the salaries of clinic assistants. Thus they dabble in aesthetic medicine, for that is more profitable than being a good family physician.

For example, a 20-minute session of intense pulsed light therapy, allegedly to beautify the skin, can bring in $400 in cash up front – and not many patients ask for a receipt. On the other hand, looking after a patient above the age of 65 with hypertension and/or diabetes and/or high cholesterol or a stroke patient for one year can earn a GP $300 – after he has submitted the necessary information via Internet to Medisave. This is a situation that can tempt many GPs to practise aesthetic medicine rather than look after the health of their patients.

Ideally, we should train our GPs to become competent family physicians, and allow them to charge a consultation fee that reflects their skill and effort. In that way, they can be good gatekeepers for the acute hospitals, and emergency departments need not be swamped with patients who don’t need to be seen there. Indeed, the Ministry of Health found itself apologising just a few days ago because Tan Tock Seng Hospital could not accept more patients, and ambulances and patients had to be diverted to other hospitals.

While the financial benefits of practising aesthetic medicine are clear, I wonder how many of these doctors can live with their conscience. It seems to me that many have become inured to guilt.

The message I wish to convey is simple: Never do any unnecessary medical procedure. Any attempt to alter the body’s function carries risk. Beauty – and health – is not a matter simply of surfaces.