Erik L. Goldman

MADRID — Angiotensin I receptor blockade with losartan improves insulin sensitivity independent of its effects on blood pressure in hypertensive individuals at risk for metabolic syndrome, reported Dr. Tonje Aksnes at the annual meeting of the European Society of Hypertension.

Previous studies have shown that blocking the renin-angiotensin system prevents new-onset diabetes to a far greater degree than does pressure control with calcium channel blockers, which suggests that angiotensin receptor blockers (ARBs) have direct effects on glucose metabolism. Calcium channel blockers probably do not have metabolic effects, said Dr. Aksnes of the cardiovascular and renal research centre at Ullevål University Hospital, Oslo.

To test this hypothesis, Dr. Aksnes and colleagues compared two regimens—10 mg/day amlodipine and 100 mg/day losartan plus 5 mg/day amlodipine—in a cohort of 21 subjects with essential hypertension. The patients had a mean age of 59 years and had baseline systolic pressures in the 160–180 mm Hg range and diastolic pressures of 95–110 mm Hg.

All had impaired glucose tolerance or impaired fasting glucose levels, and at least one of the following signs of metabolic syndrome: microalbuminuria, low HDL cholesterol level, elevated triglycerides, waist-to-hip ratio greater than 0.9 for men or 0.85 for women, or body mass index greater than 28 kg/m

After a 4-week run-in period during which all of the patients were given 5 mg/day amlodipine, they were randomised to receive, in addition to the 5 mg/day amlodipine, 100 mg/day losartan or an additional 5 mg/day of amlodipine for 8 weeks. This was followed by a 4-week washout during which all of the patients were again put on 5 mg/day amlodipine alone. For the final phase, the two patient groups were crossed over: Those who were on the ARB during the initial trial phase were switched to the 10-mg calcium channel blocker, and those who were initially on the calcium channel blocker switched to the ARB.

The two drug regimens gave comparable levels of blood pressure control. Amlodipine alone, at a 10 mg daily dosage, reduced mean pressure to 141/88 mm Hg from a baseline mean of 160/96 mm Hg. Losartan reduced pressure to 143/88 mm Hg.

The investigators assessed glucose metabolism by two separate hyperinsulinemic glucose clamp examinations. They found a consistent and significant difference between the two regimens. While the patients were on 10 mg amlodipine alone, they had a mean insulin sensitivity of 4.2 mg/mL per minute. This increased to 4.9 mg/mL per minute while they were on the ARB plus 5 mg amlodipine.

There was no significant difference in HbA_1c values between the two treatment regimens. Likewise, blood glucose levels were more or less consistent and unchanged by either treatment. The main impact, it seemed, was on the degree of insulin sensitivity.

“The present data suggest that angiotensin I receptor blockade improves glucose metabolism at the cellular level, beyond what can be expected by the vasodilatation and blood pressure reduction alone,” said Dr. Aksnes.

MADRID — Angiotensin I receptor blockade with losartan improves insulin sensitivity independent of its effects on blood pressure in hypertensive individuals at risk for metabolic syndrome, reported Dr. Tonje Aksnes at the annual meeting of the European Society of Hypertension.

Previous studies have shown that blocking the renin-angiotensin system prevents new-onset diabetes to a far greater degree than does pressure control with calcium channel blockers, which suggests that angiotensin receptor blockers (ARBs) have direct effects on glucose metabolism. Calcium channel blockers probably do not have metabolic effects, said Dr. Aksnes of the cardiovascular and renal research centre at Ullevål University Hospital, Oslo.

To test this hypothesis, Dr. Aksnes and colleagues compared two regimens—10 mg/day amlodipine and 100 mg/day losartan plus 5 mg/day amlodipine—in a cohort of 21 subjects with essential hypertension. The patients had a mean age of 59 years and had baseline systolic pressures in the 160–180 mm Hg range and diastolic pressures of 95–110 mm Hg.

All had impaired glucose tolerance or impaired fasting glucose levels, and at least one of the following signs of metabolic syndrome: microalbuminuria, low HDL cholesterol level, elevated triglycerides, waist-to-hip ratio greater than 0.9 for men or 0.85 for women, or body mass index greater than 28 kg/m

After a 4-week run-in period during which all of the patients were given 5 mg/day amlodipine, they were randomised to receive, in addition to the 5 mg/day amlodipine, 100 mg/day losartan or an additional 5 mg/day of amlodipine for 8 weeks. This was followed by a 4-week washout during which all of the patients were again put on 5 mg/day amlodipine alone. For the final phase, the two patient groups were crossed over: Those who were on the ARB during the initial trial phase were switched to the 10-mg calcium channel blocker, and those who were initially on the calcium channel blocker switched to the ARB.

The two drug regimens gave comparable levels of blood pressure control. Amlodipine alone, at a 10 mg daily dosage, reduced mean pressure to 141/88 mm Hg from a baseline mean of 160/96 mm Hg. Losartan reduced pressure to 143/88 mm Hg.

The investigators assessed glucose metabolism by two separate hyperinsulinemic glucose clamp examinations. They found a consistent and significant difference between the two regimens. While the patients were on 10 mg amlodipine alone, they had a mean insulin sensitivity of 4.2 mg/mL per minute. This increased to 4.9 mg/mL per minute while they were on the ARB plus 5 mg amlodipine.

There was no significant difference in HbA_1c values between the two treatment regimens. Likewise, blood glucose levels were more or less consistent and unchanged by either treatment. The main impact, it seemed, was on the degree of insulin sensitivity.

“The present data suggest that angiotensin I receptor blockade improves glucose metabolism at the cellular level, beyond what can be expected by the vasodilatation and blood pressure reduction alone,” said Dr. Aksnes.

MADRID — Angiotensin I receptor blockade with losartan improves insulin sensitivity independent of its effects on blood pressure in hypertensive individuals at risk for metabolic syndrome, reported Dr. Tonje Aksnes at the annual meeting of the European Society of Hypertension.

Previous studies have shown that blocking the renin-angiotensin system prevents new-onset diabetes to a far greater degree than does pressure control with calcium channel blockers, which suggests that angiotensin receptor blockers (ARBs) have direct effects on glucose metabolism. Calcium channel blockers probably do not have metabolic effects, said Dr. Aksnes of the cardiovascular and renal research centre at Ullevål University Hospital, Oslo.

To test this hypothesis, Dr. Aksnes and colleagues compared two regimens—10 mg/day amlodipine and 100 mg/day losartan plus 5 mg/day amlodipine—in a cohort of 21 subjects with essential hypertension. The patients had a mean age of 59 years and had baseline systolic pressures in the 160–180 mm Hg range and diastolic pressures of 95–110 mm Hg.

All had impaired glucose tolerance or impaired fasting glucose levels, and at least one of the following signs of metabolic syndrome: microalbuminuria, low HDL cholesterol level, elevated triglycerides, waist-to-hip ratio greater than 0.9 for men or 0.85 for women, or body mass index greater than 28 kg/m

After a 4-week run-in period during which all of the patients were given 5 mg/day amlodipine, they were randomised to receive, in addition to the 5 mg/day amlodipine, 100 mg/day losartan or an additional 5 mg/day of amlodipine for 8 weeks. This was followed by a 4-week washout during which all of the patients were again put on 5 mg/day amlodipine alone. For the final phase, the two patient groups were crossed over: Those who were on the ARB during the initial trial phase were switched to the 10-mg calcium channel blocker, and those who were initially on the calcium channel blocker switched to the ARB.

The two drug regimens gave comparable levels of blood pressure control. Amlodipine alone, at a 10 mg daily dosage, reduced mean pressure to 141/88 mm Hg from a baseline mean of 160/96 mm Hg. Losartan reduced pressure to 143/88 mm Hg.

The investigators assessed glucose metabolism by two separate hyperinsulinemic glucose clamp examinations. They found a consistent and significant difference between the two regimens. While the patients were on 10 mg amlodipine alone, they had a mean insulin sensitivity of 4.2 mg/mL per minute. This increased to 4.9 mg/mL per minute while they were on the ARB plus 5 mg amlodipine.

There was no significant difference in HbA_1c values between the two treatment regimens. Likewise, blood glucose levels were more or less consistent and unchanged by either treatment. The main impact, it seemed, was on the degree of insulin sensitivity.

“The present data suggest that angiotensin I receptor blockade improves glucose metabolism at the cellular level, beyond what can be expected by the vasodilatation and blood pressure reduction alone,” said Dr. Aksnes.

NEW YORK — Simple genetic tests aimed at predicting the risk of drug addiction are still a long way off. But the genomics revolution is slowly changing the way physicians look at their patients and the disorders they treat.

Wade Berrettini, M.D., of the University of Pennsylvania, Philadelphia, said investigators have identified several single nucleotide polymorphisms (SNPs), small but meaningful allelic variants that result in changes to the shape or structure of a specific receptor or enzyme that relate directly to addiction problems.

Among these is a set of SNPs that influence the binding affinity of the mu β-endorphin receptors. Some of the SNPs in this set are proving to have some predictive value for alcohol and nicotine addiction, and for response to addiction treatment.

“The Human Genome Project is really only the beginning,” Dr. Berrettini said at annual conference of the Association for Research in Nervous and Mental Disease. “At this point, it is like knowing the alphabet, without knowing words.”

Dr. Berrettini's lab has been focused on SNPs in the gene that codes for the mu receptor protein, which plays a central role in generating the neurophysiologically rewarding and analgesic effects of morphine.

Endorphins and enkephalins also bind to the mu receptor. Given its place in mediating the brain's response to endogenous as well as exogenous opioids, the mu receptor also plays an important role in the process of addiction to opioids, as well as other substances, such as alcohol and nicotine.

To date, researchers have identified at least 25 SNP variants in the gene coding for the mu receptor. It is important to understand that none of these SNPs constitutes a “gene” for addiction, he said. However, some of them do seem to alter how the mu receptor functions. One such SNP, for example, tends to increase the receptor's binding affinity for β-endorphin.

Dr. Berrettini and his colleagues have been studying mu receptor SNPs in the context of heroin addiction. Though they have not yet identified any single variant that clearly shows an increased prevalence among addicts, compared with nonaddicts, they have found some interesting racial differences.

“In African Americans, we've found some alleles in 10% of the population that we simply have not found in people of European ancestry,” he said at the conference, cosponsored by the New York Academy of Medicine.

This underscores an important guiding principle for genomic research: When looking at the influence of small genetic variations on the risk of a given disease state, it is important to compare ill versus well people of the same racial and ethnic background.

Though Dr. Berrettini's team was unable to identify a specific mu receptor SNP that correlated with heroin addiction, Swedish researchers were able to do so. They found a variant called A118G that does seem to predict risk of heroin dependence. Approximately 18% of Swedish opioid addicts had disease that is caused in part by this SNP.

Some researchers have suggested that the mu receptor may play a role in alcohol dependence since ethanol triggers a release of β-endorphin, the key ligand for the mu receptor.

Available data correlating SNPs in the mu receptor gene and alcoholism are highly variable; there are as yet no studies showing a clear association. However, variants in this gene may predict an alcoholic's response to treatment with naltrexone.

Dr. Berrettini and his group have done a series of studies looking at multiple mu receptor SNPs in alcohol-dependent individuals treated with naltrexone. In the subgroup of patients who had either the A/G or G/G variants of the Asp40 allele, only 10% relapsed after nearly 3 months of posttreatment follow-up. Those with the A/A variant had very high relapse rates, and outcomes were no better for naltrexone than placebo.

What these data suggest is that response to this drug, which is a mu receptor blocker, may be largely determined by genetic variants in a specific receptor. Dr. Berrettini estimated that 25% of the alcoholic population is either homozygous or heterozygous for the G allele, and it predicts better response to naltrexone.

Those who are homozygous for the A allele do poorly on this drug. “We'd like to do a treatment study where we randomize based on mu allele genotype,” Dr. Berrettini said.

Though still in its early stages, this type of research is opening up the possibility of designing treatment protocols based on an individual's genetic predispositions and likelihood of responsiveness to specific medications. In other words, individualized therapy based on pharmacogenomics may soon become the standard of care.

The technology to screen for SNPs is very well developed, and the cost is rapidly decreasing. “It is definitely possible to do SNP testing in a community hospital setting, and insurance will even pay for some of this,” said Dr. Berrettini. “The biggest challenge right now is to make clinical sense of the massive amount of new information we have about the human genome.”

NEW YORK — Simple genetic tests aimed at predicting the risk of drug addiction are still a long way off. But the genomics revolution is slowly changing the way physicians look at their patients and the disorders they treat.

Wade Berrettini, M.D., of the University of Pennsylvania, Philadelphia, said investigators have identified several single nucleotide polymorphisms (SNPs), small but meaningful allelic variants that result in changes to the shape or structure of a specific receptor or enzyme that relate directly to addiction problems.

Among these is a set of SNPs that influence the binding affinity of the mu β-endorphin receptors. Some of the SNPs in this set are proving to have some predictive value for alcohol and nicotine addiction, and for response to addiction treatment.

“The Human Genome Project is really only the beginning,” Dr. Berrettini said at annual conference of the Association for Research in Nervous and Mental Disease. “At this point, it is like knowing the alphabet, without knowing words.”

Dr. Berrettini's lab has been focused on SNPs in the gene that codes for the mu receptor protein, which plays a central role in generating the neurophysiologically rewarding and analgesic effects of morphine.

Endorphins and enkephalins also bind to the mu receptor. Given its place in mediating the brain's response to endogenous as well as exogenous opioids, the mu receptor also plays an important role in the process of addiction to opioids, as well as other substances, such as alcohol and nicotine.

To date, researchers have identified at least 25 SNP variants in the gene coding for the mu receptor. It is important to understand that none of these SNPs constitutes a “gene” for addiction, he said. However, some of them do seem to alter how the mu receptor functions. One such SNP, for example, tends to increase the receptor's binding affinity for β-endorphin.

Dr. Berrettini and his colleagues have been studying mu receptor SNPs in the context of heroin addiction. Though they have not yet identified any single variant that clearly shows an increased prevalence among addicts, compared with nonaddicts, they have found some interesting racial differences.

“In African Americans, we've found some alleles in 10% of the population that we simply have not found in people of European ancestry,” he said at the conference, cosponsored by the New York Academy of Medicine.

This underscores an important guiding principle for genomic research: When looking at the influence of small genetic variations on the risk of a given disease state, it is important to compare ill versus well people of the same racial and ethnic background.

Though Dr. Berrettini's team was unable to identify a specific mu receptor SNP that correlated with heroin addiction, Swedish researchers were able to do so. They found a variant called A118G that does seem to predict risk of heroin dependence. Approximately 18% of Swedish opioid addicts had disease that is caused in part by this SNP.

Some researchers have suggested that the mu receptor may play a role in alcohol dependence since ethanol triggers a release of β-endorphin, the key ligand for the mu receptor.

Available data correlating SNPs in the mu receptor gene and alcoholism are highly variable; there are as yet no studies showing a clear association. However, variants in this gene may predict an alcoholic's response to treatment with naltrexone.

Dr. Berrettini and his group have done a series of studies looking at multiple mu receptor SNPs in alcohol-dependent individuals treated with naltrexone. In the subgroup of patients who had either the A/G or G/G variants of the Asp40 allele, only 10% relapsed after nearly 3 months of posttreatment follow-up. Those with the A/A variant had very high relapse rates, and outcomes were no better for naltrexone than placebo.

What these data suggest is that response to this drug, which is a mu receptor blocker, may be largely determined by genetic variants in a specific receptor. Dr. Berrettini estimated that 25% of the alcoholic population is either homozygous or heterozygous for the G allele, and it predicts better response to naltrexone.

Those who are homozygous for the A allele do poorly on this drug. “We'd like to do a treatment study where we randomize based on mu allele genotype,” Dr. Berrettini said.

Though still in its early stages, this type of research is opening up the possibility of designing treatment protocols based on an individual's genetic predispositions and likelihood of responsiveness to specific medications. In other words, individualized therapy based on pharmacogenomics may soon become the standard of care.

The technology to screen for SNPs is very well developed, and the cost is rapidly decreasing. “It is definitely possible to do SNP testing in a community hospital setting, and insurance will even pay for some of this,” said Dr. Berrettini. “The biggest challenge right now is to make clinical sense of the massive amount of new information we have about the human genome.”

NEW YORK — Simple genetic tests aimed at predicting the risk of drug addiction are still a long way off. But the genomics revolution is slowly changing the way physicians look at their patients and the disorders they treat.

Wade Berrettini, M.D., of the University of Pennsylvania, Philadelphia, said investigators have identified several single nucleotide polymorphisms (SNPs), small but meaningful allelic variants that result in changes to the shape or structure of a specific receptor or enzyme that relate directly to addiction problems.

Among these is a set of SNPs that influence the binding affinity of the mu β-endorphin receptors. Some of the SNPs in this set are proving to have some predictive value for alcohol and nicotine addiction, and for response to addiction treatment.

“The Human Genome Project is really only the beginning,” Dr. Berrettini said at annual conference of the Association for Research in Nervous and Mental Disease. “At this point, it is like knowing the alphabet, without knowing words.”

Dr. Berrettini's lab has been focused on SNPs in the gene that codes for the mu receptor protein, which plays a central role in generating the neurophysiologically rewarding and analgesic effects of morphine.

Endorphins and enkephalins also bind to the mu receptor. Given its place in mediating the brain's response to endogenous as well as exogenous opioids, the mu receptor also plays an important role in the process of addiction to opioids, as well as other substances, such as alcohol and nicotine.

To date, researchers have identified at least 25 SNP variants in the gene coding for the mu receptor. It is important to understand that none of these SNPs constitutes a “gene” for addiction, he said. However, some of them do seem to alter how the mu receptor functions. One such SNP, for example, tends to increase the receptor's binding affinity for β-endorphin.

Dr. Berrettini and his colleagues have been studying mu receptor SNPs in the context of heroin addiction. Though they have not yet identified any single variant that clearly shows an increased prevalence among addicts, compared with nonaddicts, they have found some interesting racial differences.

“In African Americans, we've found some alleles in 10% of the population that we simply have not found in people of European ancestry,” he said at the conference, cosponsored by the New York Academy of Medicine.

This underscores an important guiding principle for genomic research: When looking at the influence of small genetic variations on the risk of a given disease state, it is important to compare ill versus well people of the same racial and ethnic background.

Though Dr. Berrettini's team was unable to identify a specific mu receptor SNP that correlated with heroin addiction, Swedish researchers were able to do so. They found a variant called A118G that does seem to predict risk of heroin dependence. Approximately 18% of Swedish opioid addicts had disease that is caused in part by this SNP.

Some researchers have suggested that the mu receptor may play a role in alcohol dependence since ethanol triggers a release of β-endorphin, the key ligand for the mu receptor.

Available data correlating SNPs in the mu receptor gene and alcoholism are highly variable; there are as yet no studies showing a clear association. However, variants in this gene may predict an alcoholic's response to treatment with naltrexone.

Dr. Berrettini and his group have done a series of studies looking at multiple mu receptor SNPs in alcohol-dependent individuals treated with naltrexone. In the subgroup of patients who had either the A/G or G/G variants of the Asp40 allele, only 10% relapsed after nearly 3 months of posttreatment follow-up. Those with the A/A variant had very high relapse rates, and outcomes were no better for naltrexone than placebo.

What these data suggest is that response to this drug, which is a mu receptor blocker, may be largely determined by genetic variants in a specific receptor. Dr. Berrettini estimated that 25% of the alcoholic population is either homozygous or heterozygous for the G allele, and it predicts better response to naltrexone.

Those who are homozygous for the A allele do poorly on this drug. “We'd like to do a treatment study where we randomize based on mu allele genotype,” Dr. Berrettini said.

Though still in its early stages, this type of research is opening up the possibility of designing treatment protocols based on an individual's genetic predispositions and likelihood of responsiveness to specific medications. In other words, individualized therapy based on pharmacogenomics may soon become the standard of care.

The technology to screen for SNPs is very well developed, and the cost is rapidly decreasing. “It is definitely possible to do SNP testing in a community hospital setting, and insurance will even pay for some of this,” said Dr. Berrettini. “The biggest challenge right now is to make clinical sense of the massive amount of new information we have about the human genome.”

NEW YORK — Tumescent liposuction is one of the safest office-based cosmetic procedures, and probably the most effective way to manage localized adipose deposits, said Naomi Lawrence, M.D., chief of procedural dermatology, Cooper University Hospital, Marlton, N.J.

Speaking at an update sponsored by the American Academy of Dermatology, Dr. Lawrence noted that tumescent liposuction now ranks as the most popular cosmetic procedure in the United States, and it has rendered traditional liposuction under general anesthesia virtually obsolete.

One of the major trends over the years has been a progressive reduction in the size of the cannulas. Today's cannulas give surgeons far greater precision and control, which lead to better cosmetic results with far less tissue injury than was possible in 1985 when the technique first went public.

Dr. Lawrence was part of a research team that in 2001 surveyed 517 members of the American Society for Dermatologic Surgery who had listed liposuction as a part of their practices regarding their experience with performing office-based tumescent liposuction. A total of 267 surgeons answered the survey, and provided complete data on 66,570 liposuction procedures.

Within this cohort, there were no deaths, and the overall serious adverse event rate was only 0.68 per 1,000 cases, a finding that underscores the overall safety of this procedure when performed by well-trained dermatologic surgeons. Adverse event rates were higher for hospitals and ambulatory surgery centers than for nonaccredited office settings. Serious adverse event rates also rose when tumescent liposuction was combined with intravenous or intramuscular sedation, compared with oral sedation or no sedation at all (Dermatol. Surg. 2002;28:971-8).

Elimination of localized adipose deposits is the most common indication for tumescent liposuction.

Although it is important to encourage patients to continue with diet and lifestyle changes to control weight, it is equally important to foster realistic expectations. "Contrary to what a lot of people believe, 'spot' exercise does not reduce localized fat deposits. For example, abdominal crunches will not necessarily get rid of abdominal fatty deposits. The best way to deal localized adiposity is by liposuction," she said.

Many women develop fat deposits on the posterior aspects of their waists and hips after menopause, and Dr. Lawrence has found liposuction to be effective. "This 'back fat' causes obvious and unattractive bumps and ripples underneath clothing, and many women have a hard time with this. We can successfully smooth them out with liposuction."

She says she believes that many women who seek abdominoplasties ("tummy tucks") would be better off with liposuction. Even if they have stretch marks and poor elasticity, most women with abdominal rolls can get good cosmetic results with liposuction, obviating the need for a more invasive surgical procedure.

"Liposuction can also cause the skin to retract, reducing the prominence of the stomach. Overall, it is a safer alternative," she said.

It is also a safer than open surgery for breast reduction, an area that Dr. Lawrence sees as one of the procedure's fastest-growing indications. "In the past, the only solution for a woman who wanted to reduce her breast size was to undergo a breast reduction procedure under general anesthesia, which usually caused a lot of discomfort and limited her activity for several weeks. Liposuction is much less invasive than traditional breast reduction surgery, and requires a lot less recovery time."

The technique works best when the patient is seeking a reduction of one to two cup sizes. Women with fattier, less fibrous breasts tend to have the best outcomes. As a general rule, Dr. Lawrence said, make sure the patient has had a recent mammogram before undertaking a liposuction procedure for breast reduction.

NEW YORK — Tumescent liposuction is one of the safest office-based cosmetic procedures, and probably the most effective way to manage localized adipose deposits, said Naomi Lawrence, M.D., chief of procedural dermatology, Cooper University Hospital, Marlton, N.J.

Speaking at an update sponsored by the American Academy of Dermatology, Dr. Lawrence noted that tumescent liposuction now ranks as the most popular cosmetic procedure in the United States, and it has rendered traditional liposuction under general anesthesia virtually obsolete.

One of the major trends over the years has been a progressive reduction in the size of the cannulas. Today's cannulas give surgeons far greater precision and control, which lead to better cosmetic results with far less tissue injury than was possible in 1985 when the technique first went public.

Dr. Lawrence was part of a research team that in 2001 surveyed 517 members of the American Society for Dermatologic Surgery who had listed liposuction as a part of their practices regarding their experience with performing office-based tumescent liposuction. A total of 267 surgeons answered the survey, and provided complete data on 66,570 liposuction procedures.

Within this cohort, there were no deaths, and the overall serious adverse event rate was only 0.68 per 1,000 cases, a finding that underscores the overall safety of this procedure when performed by well-trained dermatologic surgeons. Adverse event rates were higher for hospitals and ambulatory surgery centers than for nonaccredited office settings. Serious adverse event rates also rose when tumescent liposuction was combined with intravenous or intramuscular sedation, compared with oral sedation or no sedation at all (Dermatol. Surg. 2002;28:971-8).

Elimination of localized adipose deposits is the most common indication for tumescent liposuction.

Although it is important to encourage patients to continue with diet and lifestyle changes to control weight, it is equally important to foster realistic expectations. "Contrary to what a lot of people believe, 'spot' exercise does not reduce localized fat deposits. For example, abdominal crunches will not necessarily get rid of abdominal fatty deposits. The best way to deal localized adiposity is by liposuction," she said.

Many women develop fat deposits on the posterior aspects of their waists and hips after menopause, and Dr. Lawrence has found liposuction to be effective. "This 'back fat' causes obvious and unattractive bumps and ripples underneath clothing, and many women have a hard time with this. We can successfully smooth them out with liposuction."

She says she believes that many women who seek abdominoplasties ("tummy tucks") would be better off with liposuction. Even if they have stretch marks and poor elasticity, most women with abdominal rolls can get good cosmetic results with liposuction, obviating the need for a more invasive surgical procedure.

"Liposuction can also cause the skin to retract, reducing the prominence of the stomach. Overall, it is a safer alternative," she said.

It is also a safer than open surgery for breast reduction, an area that Dr. Lawrence sees as one of the procedure's fastest-growing indications. "In the past, the only solution for a woman who wanted to reduce her breast size was to undergo a breast reduction procedure under general anesthesia, which usually caused a lot of discomfort and limited her activity for several weeks. Liposuction is much less invasive than traditional breast reduction surgery, and requires a lot less recovery time."

The technique works best when the patient is seeking a reduction of one to two cup sizes. Women with fattier, less fibrous breasts tend to have the best outcomes. As a general rule, Dr. Lawrence said, make sure the patient has had a recent mammogram before undertaking a liposuction procedure for breast reduction.

NEW YORK — Tumescent liposuction is one of the safest office-based cosmetic procedures, and probably the most effective way to manage localized adipose deposits, said Naomi Lawrence, M.D., chief of procedural dermatology, Cooper University Hospital, Marlton, N.J.

Speaking at an update sponsored by the American Academy of Dermatology, Dr. Lawrence noted that tumescent liposuction now ranks as the most popular cosmetic procedure in the United States, and it has rendered traditional liposuction under general anesthesia virtually obsolete.

One of the major trends over the years has been a progressive reduction in the size of the cannulas. Today's cannulas give surgeons far greater precision and control, which lead to better cosmetic results with far less tissue injury than was possible in 1985 when the technique first went public.

Dr. Lawrence was part of a research team that in 2001 surveyed 517 members of the American Society for Dermatologic Surgery who had listed liposuction as a part of their practices regarding their experience with performing office-based tumescent liposuction. A total of 267 surgeons answered the survey, and provided complete data on 66,570 liposuction procedures.

Within this cohort, there were no deaths, and the overall serious adverse event rate was only 0.68 per 1,000 cases, a finding that underscores the overall safety of this procedure when performed by well-trained dermatologic surgeons. Adverse event rates were higher for hospitals and ambulatory surgery centers than for nonaccredited office settings. Serious adverse event rates also rose when tumescent liposuction was combined with intravenous or intramuscular sedation, compared with oral sedation or no sedation at all (Dermatol. Surg. 2002;28:971-8).

Elimination of localized adipose deposits is the most common indication for tumescent liposuction.

Although it is important to encourage patients to continue with diet and lifestyle changes to control weight, it is equally important to foster realistic expectations. "Contrary to what a lot of people believe, 'spot' exercise does not reduce localized fat deposits. For example, abdominal crunches will not necessarily get rid of abdominal fatty deposits. The best way to deal localized adiposity is by liposuction," she said.

Many women develop fat deposits on the posterior aspects of their waists and hips after menopause, and Dr. Lawrence has found liposuction to be effective. "This 'back fat' causes obvious and unattractive bumps and ripples underneath clothing, and many women have a hard time with this. We can successfully smooth them out with liposuction."

She says she believes that many women who seek abdominoplasties ("tummy tucks") would be better off with liposuction. Even if they have stretch marks and poor elasticity, most women with abdominal rolls can get good cosmetic results with liposuction, obviating the need for a more invasive surgical procedure.

"Liposuction can also cause the skin to retract, reducing the prominence of the stomach. Overall, it is a safer alternative," she said.

It is also a safer than open surgery for breast reduction, an area that Dr. Lawrence sees as one of the procedure's fastest-growing indications. "In the past, the only solution for a woman who wanted to reduce her breast size was to undergo a breast reduction procedure under general anesthesia, which usually caused a lot of discomfort and limited her activity for several weeks. Liposuction is much less invasive than traditional breast reduction surgery, and requires a lot less recovery time."

The technique works best when the patient is seeking a reduction of one to two cup sizes. Women with fattier, less fibrous breasts tend to have the best outcomes. As a general rule, Dr. Lawrence said, make sure the patient has had a recent mammogram before undertaking a liposuction procedure for breast reduction.