Cost starts at $2,000 when it is done by general practitioners and $4,000 when it is done by plastic surgeons. Patients also have to pay for pre-operative test, post-operative compression garments, antibiotics and other drugs. The use of operating theatre facilities and anaesthetists' fees add $3,500 on average.

There are at least four types of liposuction available.

Traditional suction-assisted liposuction
This involves a doctor using a cannula to poke the fat cells until the fat breaks into little modules that can be sucked out.

Vaser liposelection
This is currently the most popular form of liposuction here. The same ultrasound used to scan babies is used to dissolve the fat before sucking it out.

Smartlipo
This is a form of laser-assisted liposuction which melts the fat. It is normally used for smaller areas like the chin.

Waterjet liposuction
High water pressure is used to dislodge fat cells before they are sucked out. The water spray delivers anaesthesia directly to the targeted area.

Every year thousands of women - and increasingly men - subject themselves to liposuction at a clinic or hospital here in a bid to attain an enviable, svelte figure.

This surgical procedure to remove fat through suction is a burgeoning multimillion dollar industry but not one without risks as the recent death of property head honcho Franklin Heng has shown.

While details of what caused his death have not been revealed, it has nonetheless cast a pall on a controversial industry that has in the last few years been the subject of much heated debate that has split the medical fraternity and seen the Ministry of Health's (MOH) eventual intervention.

Once the exclusive domain of plastic surgeons, general practitioners (GPs) have been getting in on the act, lured by the good money to be made. Liposuction is part of a rapidly growing $200-million-a-year aesthetic industry here.

Demand for such quick fixes has been on the rise, doctors reported, fuelled by the media, advancements in medical technology and aggressive marketing by clinics and liposuction equipment distributors.
 
While there are no statistics on how many liposuction procedures are done here each year, it is estimated that the number could easily be 5,000 or more.

MOH's Accreditation Committee on Liposuction has licensed 57 doctors to perform liposuction, out of 77 doctors who applied. Of those given the green light, 36 are GPs and 12 are plastic surgeons.

These doctors say liposuction accounts for between 15 and 50 per cent of their total business, which includes other cosmetic procedures.

It is a competitive business, they concede. Prices have dropped since GPs began muscling in on the action.

A liposuction procedure can cost anything from $2,000 to more than $20,000, with GPs generally charging half the price of plastic surgeons.

The competition is not just confined to Singapore. More cost-conscious Singaporeans are also choosing to get their nip and tuck in cheaper countries like Thailand, Indonesia and South Korea.

But there is insufficient awareness of the risks and complications of liposuction, and this in turn is driving people to try it; in the hope of finding an easy solution, said Dr Andrew Tay, consultant plastic surgeon at The Plastic Surgery Practice.

Liposuction is not to be taken lightly, said liposuction doctors The Sunday Times spoke to.

"Liposuction might seem to be an easy procedure, but the reality is that complications can occur as a direct result of the procedure. Also, bear in mind there are risks related to the anaesthesia given too," said Dr Ivor Lim, chairman of the Chapter of Plastic Surgeons at the College of Surgeons, Academy of Medicine.

Indeed, several reports have emerged in recent years of patients who have died after liposuction.

In 2004, a 43-year-old woman in Kuala Lumpur died after removing abdominal fat by liposuction. A post-mortem revealed she died of extensive internal haemorrhaging.

In November last year, a 28-year-old woman in Washington state in the United States died after doing liposuction on her abdomen, love handles and upper arms.

She was found lying in a bed soaked with bloody fluid that leaked from 11 puncture wounds left by the liposuction tubes. The autopsy ruled that she died from acute lidocaine intoxication. Lidocaine is a nerve blocker which suppresses pain during liposuction.

New procedures
But not everyone is overly concerned, especially since new-generation methods like ultrasound-assisted and water jet liposuction have promised less invasive surgeries that are supposedly safer and come with less downtime.

Dr Kevin Teh, medical director at the Singapore Lipo Body and Face Centre, said his patients typically go back to work or do household chores within a day or two.

"I even had a young man do his lipo in the morning and by lunchtime was back on his computer working away," said the GP. He does treatments at an accredited day surgery centre where he can remove more than one litre of fat.

One of his happy clients is Ms Jelyn Yew, 25, who saved up for a liposuction on her upper and lower abdomen which she did recently.

The customer service officer spent $2,900 - a steal compared to the $8,000 she would have had to pay a plastic surgeon, she said.

The 1.58m-tall woman who weighs 50.4kg, went through a four hour surgery and even went to a late lunch later.

She took painkillers twice a day, wore a compression garment for a month and thinks nothing of the small incisions - less than 1cm at her belly button on her hips and groin - made for the procedure.

"Liposuction is a safe procedure," she said.

But in 2008, in response to growing concern and pressure from plastic surgeons that GPs and specialists in other fields may not be equipped to handle the procedure, MOH set new guidelines which made it mandatory for doctors who want to perform liposuction to get accreditation from a new committee.

They also had to satisfy other regulations such as having at least one year of surgical training, following their housemanship plus train ing in the procedure.

Those who choose to do treatments in a clinic must also have medical staff to monitor sedated patients and can remove only up to one litre of fat per session. Anything more must be done at a hospital or a surgery centre.

Records of all cases also have to be kept and complications or complaints reported.

The Singapore Medical Association says it has received only three complaints related to aesthetics treatment since then, none of which was about liposuction.

The Singapore Medical Council received four complaints related to liposuction from 2007 to last year. It got 40 aesthetic related complaints in the same time - a relatively small number given the total number of complaints for all medical matters from 2007 to 2009 was 349.

No weight loss
Doctors interviewed say they do not treat anyone who walks through the door. Generally, patients have to be healthy and have a Body Mass Index of 28 or less.

One of the biggest misconceptions about liposuction is that it can help someone lose weight.

"It can't," said Dr David Loh, a GP who specialises in aesthetic treatments, including liposuction.

"Liposuction - any form - is purely a sculpting tool. And it is only best for small areas like love handles."

The invasive surgery involves sucking solid fats out of the body, mostly from the abdomen thighs buttocks and arms. Usually performed under general anaesthesia, it typically takes a few hours and recovery follows in one to three weeks.

The tummy is the most popular spot for a fix among Singaporeans.

But potential complications could arise from the anaesthesia given or the fat removal, including bleeding, infection, prolonged swelling and bruising, contour irregularities and even perforation of the abdominal or chest wall resulting in injury to internal organs.

All eyes will be on the outcome of the findings of Mr Heng's case and the industry is keeping a close watch before taking action.

Dr Vincent Yeow, president of the Singapore Association of Plastic Surgeons, which lobbied for restrictions on who could perform liposuction in 2008, said: "It's unfortunate there has been a death The industry per se is a contentious one. While there are many points of opinion this is not an appropriate time until details are clearer as to what course of action to pursue."

For now, all the doctors interviewed said they have not seen cancellations for liposuction procedures since Mr Heng's death, and are not worried that their business will be hit.

Doc got fats removed too
A day before news broke about Singapore's first liposuction related death, Dr Siew Tuck Wah was getting his fats sucked from his abdomen by his colleague, plastic surgeon Tan Ying Chien.

It was all in a day's work for both men. All physicians at The Sloane Clinic. where they both work have to undergo all treatments on offer at the aesthetic clinic so they have "a patient's perspective", said Dr Siew, a general practitioner who performs non-invasive and minimally invasive procedures such as injecting Botox and fillers.

"This ensures that our treatment protocols are fine-tuned to increase a patient's efficacy and comfort."

Since joining the aesthetic chain last year, he has undergone a facelift Botox for wrinkles and Smoothbeam laser to control his acne.

His liposuction - his first sounded like something of a non-event: He had 300ml of fat taken out in surgery that took two hours using Vaser ultrasound-assisted liposuction.

By afternoon, he was back at work, with some mild aches on his abdomen.

Exercise and dieting have not helped get rid of his love handles. The single doctor, who is in his mid-30s, works out at the gym up to four times a week; running and doing weight training for up to two hours each time.

"I think that because I am a physician, I am more cautious than most people as I am fully aware of all the possible risks," he said.

"Every surgical procedure will carry with it some amount of risk, but this can be minimised by choosing a qualified surgeon who is highly skilled yet takes into account patient safety and comfort."

Dr Tan, whose liposuction fees start from $4,500 sees an average of seven cases a week.

He said that he sees Mr Franklin Heng's death as a small setback for the industry.

"However, I hope we as doctors can all learn from it, fine-tune and improve our processes and techniques so that surgical procedures will be made safer for the good of all patients."

More painful than giving birth
When news broke that a man had died following a liposuction operation chills went down Ms J. P. Lee's spine.

The mother of two, in her mid-30s, had liposuction done on her abdomen recently at Reves Clinic, the same clinic that property honcho Franklin Heng went to.

"I felt that I was dying after the procedure, and had to be pushed in a wheelchair, in a semi-conscious state, to the car to be driven home," said Ms Lee, who spent $5,000 on Vaser ultrasound assisted liposelection.

It was more painful than giving birth, she said.

For the rest of the week, she had to get her family members to help her up and down the bed and resorted to wearing adult diapers since going to the toilet was a pain and a chore.

The first day after the surgery, she could not urinate and almost fainted in the toilet.

"I felt miserable," she said, adding that she went back to the clinic daily to change the dressing over the incisions.

Healing took a month. During her check-up her doctor asked if she wanted to do the same for other parts of her body, but she said no for fear of being unable to cope with the pain again.

"My advice is liposuction should be done in a hospital with after-care of at least three days in hospital."

Her husband did not want her to go for the surgery, but gave in.

She ended up taking a month of leave from her sales job and stayed home because she was conscious of wearing the compressed garment that "made me look pregnant".

The 1.6m-tall Ms Lee has since gone from 58kg to 52kg, but attributes it to her loss of appetite during her recovery.

Singaporeans go abroad for cheaper beauty fixes
Singaporeans are the driving force behind Indonesian doctor Arthur Tjandra's success: at his 18,000 sq ft Medan clinic Elixir de Vie, up to 90 per cent of those who come in for a nip and tuck are Singaporeans.

The rest are made up of Americans, Taiwanese, Malaysians, Australians and Indonesians.

And of all the Singaporeans - mostly women in their 20s and 30s - who fly there in the hope of coming home looking better, 90 per cent are there for liposuction.

So lucrative is this foreign market that he ran a promotion last year offering a 30 per cent discount on procedures to attract foreign patients.

Of the promotion, he said: "Our intention was to produce as many excellent results as possible and allow patients to spread it by word of mouth. We have never advertised up to now."

The lure for Singaporeans? A vanity fix at the fraction of the price back home.

Dr Tjandra charges $650 per area while prices in Singapore generally start from $2,000.

Since he opened his clinic in November 2008, around 180 Singaporeans have passed through his doors. He said he is already booked till the end of January.

He said that he makes it compulsory for all liposuction patients to stay as in-patients for at least two to three nights in the clinic after the procedure, whether or not he had removed more than 1 litre of fat.

"If they can't stay, we reject the case," said Dr Tjandra, who uses the traditional liposuction method of a syringe and cannula which he claims is the safest of all available methods.

An arts management student in LaSalle College of the Arts, who wanted to be known only as Denise, spent $20,000 on Vaser ultrasound-assisted liposuction in Singapore two years ago.
 
She had fats sucked from various parts of her body, but was upset when it resulted in dents because of uneven removal of fats.

Recently, she went to Dr Tjandra in Medan and had liposuction done on her tummy and thighs. It cost her $1,950 for the surgery, $180 on air tickets and another $120 on accommodation.

Also gunning for the Singaporean dollar is Dr Preecha Tiewtranon, chairman and chief executive officer of Preecha Aesthetic Institute, a sizeable plastic surgery outfit in Bangkok.

About 10 per cent of his patients come from Singapore, and of this, about 10 per cent are there for liposuction, he said.

Most are between the ages of 20 and 30 and pay between 100,000 and 150,000 baht (S$6,300) if the procedure is performed under general anaesthesia.

But Singaporean doctors are trying to beat the overseas competitors at their own game.

In August last year, Singaporean doctor Z Teo set up his own operating theatre in Manila and assembled a team of Filipino plastic surgeons.

While the set-up there caters to Filipinos, Singaporeans looking for some savings have been flying there, where his team performs the surgery while he supervises since he is not licensed to practise in the Philippines.

Out of the 20 Singaporeans who went for a cosmetic fix last year, about eight were for liposuction.

These patients pay 30 to 40 per cent less than what they pay here said Dr Teo, a general practitioner.

"Here, a patient has to pay surgical fees, plus the services of an an aesthesiologist and the use of an operating theatre," said Dr Teo, who runs Z Medical Aesthetics in Paragon and is married to a Filipino dermatologist.