Title: Lifestyle Outcomes, Satisfaction, and Attitudesof Patients After Liposuction

Authors: George Broughton II, MD, PhD, Bauer Horton, BS, Avron Lipschitz, MD,

Jeffrey M. Kenkel, MD, Spencer A Brown, PhD, Rod J. Rohrich, MD,

Liposuction is the most commonly performed cosmetic procedure1. Liposuction has a well-documented safety record2, however there are few reports in the plastic surgery literature discussing patient satisfaction after their liposuction. From the available literature, 90% (n=159) of patients were “completely or mostly satisfied”3 with their surgery. A large questionnaire survey reported in 19934 that 76% (n=990) of responders were satisfied. In a more recent survey,5 74.8% (n=123) had an “increase in self-esteem”, 80.5% were “more confident”, and 83.7% thought that “they felt happier about their shape when looking the mirror.”To our knowledge, no report has examined patient’s attitudes and post-operative opinion, lifestyle changes, weight gain changes and satisfaction of their liposuction procedure in general and by specific site. We now report on data from a survey provided to patients from two plastic surgeons at University of Texas Southwestern Medical Center at Dallas.

Method:A self-assessment survey was mailed to 600 patients who had either SAL (suction-assisted liposuction) or SAL/UAL (ultrasound assisted liposuction) surgery performed by the authors (RJR and JMK) between January 1996 and January 2003. Four hundred (400) patients had liposuction procedures by RJR and two hundred (200) patients by JMK. The questionnaire was reviewed and approved by the Institutional Review Board, University of Texas Southwestern Medical Center, Dallas, Texas. Patients responded to the survey anonymously and were instructed to check their responses to the questions. The survey asked for general information about the procedure(s), area(s) of liposuction, lifestyle habits, and satisfaction. All but two of the questions were multiple-choice, closed-ended questions. Two questions at the end of the survey asked the reader to “Please comment on your overall satisfaction with your liposuction procedure” and “If you have any additional comments please list them here”. There were half-a-dozen responses that were compliments or “thank yous”. The questionnaire was divided into five general areas:

1. Time elapsed since liposuction and areas liposuctioned

2. Post-operative discomfort and analgesic use

3. Weight gain and fat return

4. Lifestyle Habits

5. Satisfaction and appearance

There were 108 undeliverable surveys and 209 completed surveys were returned (34.8% of 600 and 42.5% of 492 surveys). Data were analyzed by Chi Square and a probability value p of less than 0.05 was considered significant.

Results: The majority of patients (80%) of the patients were satisfied with their results. Fifty-three percent thought that their appearance was either “excellent” or “very good”. Satisfaction by site treated all had 60% or more of the responders “very satisfied” or “satisfied” with their results. Weight gain was reported in 43% of the responders with 56% of them gaining between 5 to 10 pounds after six months from their surgery. Fat return was reported in 65% of the responders. The abdomen was the most common location for fat return. Approximately 75% of responders described their post-operative discomfort as mild to moderate with 60% indicating that their discomfort lasted less than 7 days (39.8% indicated their pain lasted longer than 7 days); 83% indicated that they only needed to use narcotics for 7 days of less.

Appearance assessment and overall satisfaction opinions were not affected by post-liposuction fat return (Table 1). Among all those who reported having fat return after liposuction, only 12% rated their appearance as “excellent”, 39% as “very good”, 30% as “good”, 14% as “fair” and 5% as “poor”. However, when fat return is examined with each appearance group, 46.2% of those who reported their appearance was “excellent” had post-liposuction fat return; results in the other appearance groups are: 52.4% for “very good’, 43.3% for “good’, 75% for “fair” and 66.7% for “poor”. There was a strong correlation of patients having a “fair” or “poor” appearance assessment and also reporting post-liposuction fat return (analysis with a linear regression resulted in an r2=0.94 and p=0.007). When responders are examined by fat return and overall satisfaction (Table 1) among those reporting fat return 34% were overall “very unsatisfied”, 48% were “satisfied”, 14% “unsatisfied” and 4% were “very unsatisfied”. Looking within each satisfaction group and fat return, only 37.9% of all “very unsatisfied” responders also reported having post-surgical fat return. Surprisingly, those patients who were “very satisfied” or “satisfied” with their results had a higher percentage of reported fat return (49.2% and 53.2%, respectively) than those who were “unsatisfied” or “very unsatisfied” (37% and 37.9%, respectively). The reported distribution of fat return among all four satisfaction groups was statistically significant (r2=-0.99 and p<0.005) by linear regression- but in an unexpected direction! Those reporting being overall “very satisfied” or “satisfied” had a higher fat return group percentage!

As an entire group, most responders would have the procedure again (79.7%) and would recommend the procedure (86%) to family or friends. Among those patients who reported weight gain after the procedure, 72% would still have the procedure again; and 82% of responders who did not gain weight would have the procedure again. However, when asked if they would recommend the procedure to family or friends, 90% of responders who did not gain weight would recommend the procedure where as only 74% of responders who did gain weight would recommend the procedure (p <0.001). When responders are divided up into groups based on the number of areas liposuctioned, there was a direct correlation to be “more likely to have the procedure again” (r2=0.995) and “recommending the procedure to others” (r2=0.995) with increasing number of areas liposuctioned. Nearly ninety-four percent (93.9%) of patients who had 5 to 8 areas treated would recommend the procedure compared to 87.1% with 1 to 2 treated areas and 80.6% with 3 to 4 areas. When asked if they would have the procedure again, 86.5% among those who had 5 to 8 areas liposuctioned would have the procedure again, 80.3% would among those with 3 to 4 areas treated, and for those with 1 to 2 areas treated, 74.3% would have the procedure again. Chi-square analysis of the data revealed that the distribution did not meet statistical significance.

The most dependent factor on whether a patient would recommend the procedure to family or friends was the patient’s appearance assessment (Figure 1). Fifty-percent (50%) of patients who labeled their appearance as fair or poor would recommend liposuction to others- compared to 96.2% who thought their appearance was excellent or very good and 85.2% who thought their appearance was good. This distribution was statistically significant by Chi-Square (p=0.0001).

Conclusions: Plastic surgeons have very few tools to objectively measure the success of their aesthetic procedures. Pre- and post-surgical photographs document the changes made and allow a side-by-side comparison; however, the final analysis is still subjective. It is not uncommon for a post-surgical result to be labeled poor or fair by our own critical eye and high-standards only to have that opinion trumped by a very happy patient. The converse has also happened when a post-surgical result is deemed good or acceptable (and that assessment is shared by other reviewing surgeons) and the patient finds it very unacceptable. The latter scenario is most disturbing to patient and surgeon alike. The importance of preoperative counseling and a mutual understanding of expectations can not be underestimated. Surveys and questionnaires are common tools used by clinicians and other professionals to objectively explain a subjective assessment.

Despite postoperative pain, fat return, or weight gain, patients are willing to have the procedure again and recommend it to others. Those patients who are unsatisfied and are less likely to refer patients are those who have the lowest opinion of their appearance.

References

1. ASAPS 2002 Statistics on Cosmetic Surgery. New York, American Society for Aesthetic Plastic Surgery, 2003.

2. Hughes CE 3rd: Reduction of lioplasty risks and mortality: an ASAPS survey. Aesthetic Surg J. 21:120-127, 2001.

3. Augustin M, Zschocke I, Sommer B, et al. Sociodemographic profile and satisfaction with treatment of patients undergoing liposuction in tumescent local anesthesia. Dermatol Surg25: 480-483, 1999.

4. Dillerud E, Haheim LL. Long-term results of blunt suction lipectomy assessed by a patient questionnaire survey. Plast Reconstr Surg. 92:35-42, 1993.

5. Goyen MR. Lifestyle outcomes of tumescent liposuction surgery. Dermatol Surg 28:459-462, 2002.

Table 1. Relationships of Overall Satisfaction to Appearance and Any Post-Liposuction Fat Return
Fat Return / Fat Return by Appearance / Appearance / Overall Satisfaction‡
Very Satisfied / Satisfied / Unsatisfied / Very Unsatisfied
YES
65% / 12% / Excellent / 50% / 33.3% / 8.3% / 8.3%
39% / Very Good / 51.3% / 46.2% / 2.6%
30% / Good / 23% / 70% / 6.7%
14% / Fair / 7.1% / 35.7% / 57.1%
5% / Poor / 14.3% / 75.7%
Fat Return Group Overall Satisfaction / 34% / 48% / 14% / 4%
NO
35% / 17.7% / Excellent / 70.6% / 23.5% / 5.9%
33.3% / Very Good / 56.3% / 34.4% / 3.1% / 6.3%
33.3% / Good / 34.4% / 50.0% / 15.6%
6.3% / Fair / 50.0% / 50.0%
3.1% / Poor / 33.3% / 66.7%
No Fat Return Group Overall Satisfaction / 45.6% / 38.9% / 10.0% / 5.6%
TOTAL‡
(n=201) / 15.6% / Excellent / 64.5% / 25.8% / 6.5% / 3.2%
36.7% / Very Good / 54.8% / 39.7% / 2.7% / 2.7%
33.2% / Good / 30.3% / 59.1% / 10.6%
10.6% / Fair / 4.8% / 42.9% / 38.1% / 14.3%
4% / Poor / 12.5% / 50% / 37.5%
Overall Satisfaction / 40.7% / 43.4% / 11.6% / 4.5%
Table shows the distribution of responders to overall satisfaction, appearance, and fat return. To read the table, 65% of responders had fat return, among those 65%, 12% felt their appearance was excellent and 50% of those responders were very satisfied. The “Fat Return Group Overall Satisfaction” row shows that among those who report fat return, 34% are “very satisfied”. Values shown in the “TOTAL” row are a summary of all responders. Appearance was rated as “excellent” by 15.6% of responders and 40.7% of all responders were “very satisfied”.
‡Distribution of appearance and overall satisfaction is statistically significant by Chi-Square (p<0.0001) for all groups (total responders and whether there was any fat return).
Figure 1. Influence Appearance Has On Recommending Liposuction to Family or Friends.

*- statistically significant by Chi-Square (p=0.0001).