IT WAS FAT THAT brought Arnie to the Beverly Hills office of Dr. Lawrence Birnbaum; fat that laid him out on the operating table to get suctioned. Fat nestled in a stubborn little bundle at the "V" of his chin, tucked beneath the tough mouth that had been so helpful taking him from a middle-class life in New Jersey to an $800,000 house in West L.A. Fat lay on the belly that had heretofore been perfect, but now presented itself in such an arrangement that his stepson had taken to patting it for luck. (All patients' names have been changed in this story.)
How old are you, Arnie?
"Fifty, but I like to think I look 40. I'm 5-11, a size 42, and when I looked in the mirror I saw a very attractive guy, except I had this minuscule pot."
How much of a pot, Arnie?
"I'm telling you, it wasn't that bad, but like I'm a foodie and last year my wife and I went to Milan and they have the best food in all Italy. When I came back, I got lazy and I stopped running, and it just started coming on. When a skinny guy looks like he's in his fourth month, see what I mean, it's time."
Off to the lean and melancholy Birnbaum goes Arnie and his minuscule pot.
A stay in the hospital is not required: The doctor puts Arnie in an operating room at the back of the office. He gives him a powerful local anesthetic and makes an incision in Arnie's navel. He wheels in the P.S.I. Aspirator suction pump and penetrates Arnie's bellybutton with a 3.7-millimeter blunt-nosed cannula, a drainage tube that is attached to a three-foot, translucent plastic hose. Fifty-year-old Arnie, attached like a fetus to his mother the machine, except in this case the ancient process will be reversed and the nutrients drawn out. Fifty-year-old Arnie, self-made and feisty, dreamy now as a prenatal infant in his twilight sleep.
Birnbaum presses the pedal of the machine with his foot. There is a pause and then a gurgling sound. First, through the hose, there is nothing; then, in a sea of yellowish body fluids and blood, comes the fruit of Arnie's good life: the pasta with white truffle sauce from Pane Caldo Bistrot; the sublime French pastry from L'Ermitage. Fat cells, actual fat cells, noisily pulled through the hose and deposited in the clear plastic container of the vacuum pump; the suctioning continues and the proportion of blood rises to the proportion of fat. The doctor, sweating, shoves the cannula back and forth under the belly in a sawing motion, tearing fat from fiber, battering Arnie like a boxer.
And 20 minutes later, Arnie is on his feet again, and one week later, he's bragging about it to his business partner, and three weeks later, over at the Four Seasons Hotel, he's still glad to talk--on the shady side of the pool, which is so much less damaging to the skin, of course.
"I'm as value-driven as the next guy," Arnie says, in his soft, laid-back voice, "but why should I have bags under my eyes when for $1,500 I can get rid of them? Why should I walk around with a potbelly when for a few thousand dollars I can look good in my clothes?"
His voice rises, West L.A. momentarily supplanted by the street.
"I get disgusted--no, disgust is too strong a word, say, 'I lose respect'--for people that are mean to themselves, who have the money but don't live."
He pulls up his shirt.
The side of his waist is still black and blue from the internal bruising, but his waist is three inches smaller than it was before surgery, and his stomach--his stomach is a marvel. Smooth and flat, lean as a 17-year-old boy's. You see a belly like this on a Malibu lifeguard; you see a belly like this at the movies when Dennis Quaid takes off his clothes to do a love scene. He holds the shirt up proudly, for a long time, the sun filtering down.
Arnie has been reborn.
WAS IT inevitable, suction lipectomy? The Gratification Now ethos of the Yuppie '80s supplanting the grim, no-pain-no-gain spirit of the previous decade? A weary people, jogging home one final day, contemplating Cher's hard-body health-club campaign with a rancorous glance, as a single thought snaked through the national brain:
"Oh, forget it. I'll suck the fat out."
Or maybe it's just a question of technology catching up.
Whatever, this method of vacuuming out pockets of fat in the body has become a full-blown trend.
Formally introduced in this country seven years ago by French physician Yves-Gerard Illouz, endorsed by the American Society of Plastic and Reconstructive Surgeons, suction lipectomy has, according to a survey of that organization's 2,900 members, nudged aside breast augmentation to become the most popular cosmetic procedure in the United States, increasing from 1984 to 1986 by an astonishing 78%. And it's not just the Beverly Hills ladies who are climbing on the table at $3,000 to $4,000 a pop: Middle-aged businessmen are going in to trim their love handles; schoolteachers in the San Fernando Valley, wistfully eyeing high-cut swimsuits, use savings to reduce dimpled saddlebags.
In Beverly Hills, Birnbaum, whose clients include a good portion of the rich and famous, suctions the flanks of a television superstar four times; in Palm Springs, the outspoken Dr. Vincent Forshan, who co-authored a text on liposuction with Illouz and retains a public relations agent, suctions a Pasadena couple in their 60s who have decided it is a nifty way to celebrate their 40th anniversary. When the technique was introduced, the general wisdom was to avoid the procedure for persons over 40, but Forshan, half of whose clients are "geriatric," disdains tradition: His oldest patient, after all, was his grandmother, whose belly he suctioned at the age of 80 so she could look good in Bermuda shorts.
Whatever happened to the concept of age as beauty?
"Wait till you're 80," Forshan says.
As most doctors will tell you, you have a finite number of fat cells that expand and shrink as you gain and lose weight, and when you suction them out, they are gone forever, never to return. Which is not to say that, after surgery, you will not gain weight. Eat like a horse, after you have had your tummy sucked, and even if you tend to gain less in your stomach, your body will find a place to store that fat.
There are other problems with the technique.
It is, first of all, a method for removing localized fatty deposits, not for overall weight loss. If a surgeon takes out too much fat or removes the fat unevenly, he may leave "divots" or "waves": indentations in the skin. Though some doctors have had success grafting fat from one part of the body to the other, in many cases damage cannot be repaired. A 32-year-old psychologist and self-described perfectionist reports she went back into psychotherapy after a suction lipectomy left deep ridges in her stomach and legs. The operation cost her $4,000. She spent another $4,000 on more surgery to get herself fixed.
There are still other problems: If the skin is inelastic, from aging or from having been stretched by weight gain and loss or pregnancy, after liposuction the patient may have loose, baggy skin, correctable only with additional surgery--which leaves scars.
And then there's the clincher: When a doctor suctions out fat, he is removing blood and body fluids as well, and if too much is removed--most doctors put a limit of 2,000 cubic centimeters or 4.4 pounds total per procedure--without replacing the blood supply, it can lead to death. There have been 14 deaths nationwide, according to San Francisco surgeon Mark Gorney, a former president of the American Society of Plastic and Reconstructive Surgeons, which have led to an ongoing battle among doctors regarding who should be allowed to perform suction lipectomy. (See accompanying article, previous page.)
There are also those plastic surgeons, who--while they use the technique--take a skeptical view of its current popularity.
"I was there that day in 1983, at the meeting of the American Society of Plastic and Reconstructive Surgeons in Honolulu, when liposuction burst forth upon us fully formed like some strange, alien beast," says an eminent California plastic surgeon, who asked not to be named. "Actually, we'd heard rumors that this kind of thing had been going on in France with good results, so this fellow Illouz was invited to present to us. The last day of a five-day surgical meeting you barely have one-third of the room full. It's probably the worst slot, but this was different. It was standing room only in the main ballroom. He presented this paper in heavily accented English and talked about the little waves and we didn't know what the hell he was talking about."
"I was doing plastic surgery a lot," Illouz himself explains, "and I was obliged when I wanted to modify the contour to leave a big scar, and I did not find this very aesthetic. I don't think this makes a very good improvement, except for the people who are dressed, and now women want to be beautiful not only dressed but undressed. They go to the beach, they have short skirts, they want to be happy in their private life. Then, one day, it was 10 years ago exactly, a girl, young and pretty, comes to me with a lymphoma, a fat tumor, on the shoulder. She wanted that removed with a minimum of scar, and an idea comes to me and I say, 'I am going to try on you something that may be working.' So I remove the fat with the suction machine."
"He showed a lot of pictures," says the California surgeon. "Many had excellent results, some of them had poor results, some I couldn't see the difference. But it certainly made an impression on the specialty. We were coming out of a recession, and in a recession the volume of elective surgery goes down. All of a sudden here was a procedure that many regarded as exciting enough to bring a lot of patients into the office. Of course, traditionally, most operations are developed in the anatomical laboratory or with animals, and then we try it on human beings."
"I tried it with animals, yes," says Illouz. "It was not working on pigs, because the fat of the pig was very tough, but it was working on muttons."
"Yes, mmm, muttons. I tried it with rats, but it is very difficult to suck a rat; with too-small animals it is difficult to suck out the fat. So I must have big animals."
It's an amusing idea, actually, contouring the body of a pig.
"No, no, not to contour," says Illouz.
ON LASKY DRIVE in Beverly Hills are the glazed lavender offices of Dr. Lawrence Birnbaum, suction lipectomist to the stars. Which stars, of course, he cannot reveal. But according to Birnbaum, when the Night of 100 Stars had a benefit, and 44 actresses modeled in a fashion show, 11 of the bodies sashaying across the floor had submitted to the knife and/or vacuum pump of Birnbaum of Beverly Hills. He was one of the first doctors in the country to do reconstructive work after mastectomies, and it is possible, he says, that he does more breast work than anyone in the western United States; but suction, these days, is rapidly changing that.
"It's a very popular procedure," says Birnbaum, a tall, low-key fellow with that slight Western accent that is so soothing in airline pilots and other fellows to whom you entrust your life. "First because it's relatively new and there's a big backlog of patients waiting to be done. Second because a lot of the population suffers from fatty deposits here and there, so I think it's always going to be a popular procedure.
"We know a lot more about it now," he continues. "We're selecting patients with better skin tone; we're getting less rippling because we're using smaller and smaller suctions. Fat, you know, can be densely inherent or loosely inherent; when you look at a chicken, some fat you can pull away real easy, and some is harder to pull.
"It's a totally blind procedure. You don't make an incision and look in and say, 'There's some fat.' It's done through a tiny incision, sometimes a moderate to great distance from the area you want to suck. If one wanted to, one could suck the knees out from an incision in the bathing-suit area. The basic limit is going around a corner."
Birnbaum of Beverly Hills: board-certified in plastic surgery; worked in East Africa with the Flying Doctors; 51 years of age. The rewards of being a Beverly Hills surgeon: a '63 Silver Cloud Rolls-Royce; a house in the hills; a live-in housekeeper; and until some unfortunate business advice, a hotel in Vegas and an office building in West Los Angeles.
Oh, but in the office, the lavender shellac office, the ladies and gentlemen take off their clothes before him, and he is a Solomon of the flesh: examining a rebellious pocket of fat jiggling insouciantly on a lady's outer thigh with the same single-mindedness that the lady has so often used to scrutinize her bete noire ; pronouncing the awful line between "fat" and "too fat"; soothing the fearful as they proceed upon the endless journey to the perfect body.
Sometimes he must turn some sorry folks away--ever pleasantly, ever the diplomat.
A fellow with an enormous beer belly comes for suction, and he tells him, as nicely as he can, that he must diet--the procedure is not for him.
"I don't charge for a consultation, unless it's a reconstructive procedure," he says. "One of the hardest things for a young surgeon to do is to turn a patient down, because you have a $5,000 or $10,000 bill sitting in front of your face. But you have to learn to do that because there's no amount of money that's worth an unhappy patient. If a patient has unrealistic expectations about their results, if they think the results are going to get them a new man or a new job, I won't do it. . . . There's not many people that get married because somebody has nice (breasts)."
Does he think his love for his former wife, speaking of that, was affected by her figure?
"No. She did happen to have a great body, though. First time I saw her was in a bathing suit."
CHILDREN ARE cruel: "Piano Legs," they called Eleanor, and all her life she wanted to change them, so that now, a 43-year-old Santa Clarita housewife, she lies naked and unconscious on Birnbaum's table to be suctioned, and while she is at it, to have her tummy tucked and her bosom fixed.
Birnbaum, when Eleanor was awake and standing, outlined in purple surgical ink the areas of her body where he will be working: The circles where the outer lines of her bosom will fall; the triangular piece of skin that will be severed from the belly; the pockets of fat about the thighs and ankles and knees. Not that Eleanor, 5 feet, 9 inches, 155 pounds, is fat: Her legs, while large and somewhat beefy, are firm; her belly, excepting a slackness that is not unusual after childbirth, seems flat.
I don't know, an observer tells the doctor, this lady's belly looks pretty good to me.
"When we're through with her, that belly is going to be so tight you're going to be able to bounce a sterile quarter off it," Birnbaum says.
Estimated time on the table: four hours. Estimated recovery time: two or three days in the hospital, a week to 10 days at home, and of course Eleanor will have to wear support hose and a girdle for perhaps six weeks. She had been nervous before the operation, though trying to appear relaxed: "I came home with a new haircut, and my husband freaked," she told the nurse. "I told him, 'Well, you better get used to it because next week I'm going to be back with a whole new body.' " She had some guilt about having the surgery; she kept telling herself, "You're a lucky woman, married to the same man 20 years, with three great kids," "You've got two good legs, they work." But finally she recited that credo of long-married women of the middle-class: "After 20 years I deserve something for myself."
She got her bosom done last spring to try to balance her sort of pear-shaped look, and it had been a good move, except that the placement of the implants had a strange effect in her case: when she moved her muscles the implants would flex and jump, so now Birnbaum will redo them, placing the implants on top of the pectorals.
How much is this going to cost?
Birnbaum, injecting adrenaline into the areas he'll cut in order to reduce the amount of bleeding, has to think.
"Eighty-five hundred for the abdomino-plasty and the suction. I'm not charging her for redoing the chest."
Soft rock on the radio; Eleanor's new implants, square silicone bags of clear gel, rest in a sterile solution in a steel dish. Birnbaum cuts into a breast, opening a hole that grows from the size of a quarter to that of a lemon.
"My memories of love will bring me through," sings John Denver.
Birnbaum pulls out the old implant and sails it, like a Frisbee, into the trash can across the room. Then he sutures the old wound, opens a new pocket and stuffs in the implant, kneading and pulling the breast like a baker kneads dough.
He moves on to the abdomen.
"Her umbilicus is slightly off the middle," says Birnbaum. "It's important you notice that, because if you don't, they will. I know a doctor in New York who got sued for quite a lot of money by somebody who swore he moved their bellybutton."
He slices the belly through the layer of skin and fat down to the abdominal fascia. Then he cuts an inverted "T" from the base of the ribs to just below the pubic hairline, carefully circling around the umbilicus.
You can see now, on the skin that has been partially cut from the belly, the clumps of fat: vivid yellow, two inches thick. It looks--as Birnbaum has said--just like the fat on a chicken. There is also remarkably little blood. Birnbaum clamps back a triangle of skin that stretches from below the ribs to the hips, pausing one dramatic moment before severing the skin from the body with a flourish and flipping it in the direction of the discarded implants.
"Baby sneezes," Carly Simon sings. "Mommy pleases. Daddy breezes in."
Birnbaum, seated on a stool, stitches together the abdominal muscles that three babies have pushed apart. Then he orders the top and bottom of the operating table raised, so that Eleanor's chest and hips come together in a "V." He stretches the skin down from the ribs, making a hole in it for the umbilicus, and basting what had been the skin at the base of the rib cage to the skin at the pubic line.
He works in tiny stitches, carefully suturing the outside of the navel to the new covering of skin.
The patient now no longer seems human: Her head hidden behind the surgical drape, sterile sheets covering her legs and arms, she is a headless, legless torso with a spidery red spray of stitches, a cross between Venus de Milo and Frankenstein--an unnaturally firm body, tight as marble.
It's noon: Eleanor has been on the table for three hours. The operating table is lowered flat again, in preparation for suctioning; an assisting doctor begins a drip of 450 cc's of Eleanor's own blood, which she had banked.
"We'll get a lot more bleeding here. It's a much more traumatic procedure, a lot of banging around," says Birnbaum. "If not for this, we wouldn't have to give her the blood."
The pump is positioned beside the surgeon, the legs of the patient washed with antiseptic. Birnbaum makes an incision less than half an inch long in an area of the outer thigh that's been outlined in purple ink, then slowly pushes the cannula beneath the skin and depresses the pedal of the pump.
It is clear, now, why Birnbaum calls this procedure traumatic and why the patients, afterward, are sore: Birnbaum is not simply pushing the cannula across the layer of fat beneath the skin, he is battering the leg with it; an audible slapping motion, as if someone were being punched from beneath the skin. The pump begins filling with the mixture of fat and blood; the scrub nurse, as instructed, calls out readings as the vacuum receptacle fills; the assisting doctor is moved to the traditional suctioning speech.
"You crisscross back and forth underneath the skin so that the fat is removed evenly and you don't get a dimpling effect," he says.
"He's BSing you," Birnbaum interrupts. "It's nice to say you crisscross. But how do you crisscross from one incision?"
He takes 500 cc's from the patient's thighs and moves on to the more fibrous fat around her knees. This area is more resistant. He is pushing with his entire body now, back and forth, back and forth, with the force of a man sawing wood.
"Nice delicate surgery, huh?" he says. "I'm crisscrossing, see--I forgot to tell you I'm crisscrossing."
The patient, after she awakens, will be delighted with the results. Birnbaum, however, is not that content--at least not with the procedure.
He seems to loathe it, he is told after the operation.
"It's not finesse surgery," says Birnbaum. "It's not what I was trained to do."
EVENING, AND Birnbaum is dining in the flowery interior of Le Dome. He seems mildly depressed. Even discussion of a recent nose job, creative and challenging, does not cheer him up.
"Let me tell you something interesting about that nose job," he says. "The patient comes in today and by any measure she has a fantastic result. And yet she's an unhappy lady. I say to her, you know, it's hard for me to fathom your mind in this regard. Here you were living for years with this nose that anybody would say wasn't attractive and was a 'done' nose. And now you have a nose that not only looks natural but is much more attractive and yet you're seemingly unhappy.'
"She says, 'Yes, but I came to you to get a great nose.' "
The talk turns to suctioning.
"It's not a creative surgery," he says. "It's more akin to manual labor, OK? It's a procedure. A friend of mine, another plastic surgeon, calls it 'God's most recent gift to plastic surgery.' I asked him, 'What do you charge?' and he said, basically, 'Whatever the market can bear, because God gave us this procedure,' and it's true. Because nothing was happening in plastic surgery, and all of a sudden this procedure came along that supersedes all procedures in numbers.
"We get overpaid for most things we do, but we sure get overpaid for suctioning. You can suction a tummy in 15 minutes, which is a real no-brainer; some guys for that charge as much as $3,000, $3,500. I generally charge $1,500 depending on how much fat has to be suctioned out, but if somebody comes in like (he names a famous actress), I'll charge $2,500 because that's what the market will bear."
Fifteen hundred dollars for 15 minutes--that's $100 for each minute's work. It is a breakthrough: a medical procedure more expensive than analysis.
EARLY AFTERNOON at Birnbaum's clinic and an attractive 29-year-old woman from Pacific Pali sades is in pre-op holding, awaiting suction lipectomy on her stomach and thighs, the third cosmetic procedure in her life.
This is who is in the room: the patient; a middle-aged man, large-boned and confident, whom she resembles in body structure; an elegant, small-boned woman of uncertain age, who poses upright on the edge of her chair in a silk dress, wearing a straw hat. She speaks rarely, the sort of woman, perhaps, who has come to find words extraneous, her presence enough of a gift.
"The parents," says the man.
"This is our baby," the mother says.
"We're for this 100%," says the father.
"She loves clothes so much, and this makes dressing so much more fun," the mother says.
Their daughter is nervous, but she tries hard not to show it. Warm and friendly, with her blond hair and beautiful skin, she gives away her fear only with her detailed questions about the previous suctioning and talks easily about her bottom lift.
"I used to be very heavy, and then I lost a lot of weight, maybe 20 or 25 pounds, and my behind just dropped," she says. "I gave myself about a year to exercise, but my butt would just never shape up. It was like it was this dead flesh, hanging there."
"It was a very unusual case."
They come in and take her to surgery and lay her on the table and put her to sleep. Naked, she has a buttermilk body--not fat, but soft and pale. They roll her from side to side to wash her; they lift her legs in the air as you would to diaper a baby.
You can see, as they do, the scars that encircle the base of her buttocks, marring the otherwise lovely skin: large scars, dark pink, permanent, and, the visitor thinks, very ugly. But this is a view of an outsider, after all, and two weeks from now, when the surgery is over, the woman will be very happy.
"I'm really thrilled with the operation," she will say. "My hips have gone down so much, I'm really excited."
And, of the scars, "I don't regret it whatsoever."