Is it Fat or is it Flab?

One of the most important things for a patient (and doctor) to understand is the difference between fat and flab.  It is important to the patient because it is directly related to meeting expectations from liposuction surgery, understanding its limitations and whether they are doing surgery for the right reasons.

But understanding the difference between fat and flab is also important for the surgeon in determining who is a candidate, who is not and achieving the optimal surgical result.

Fat in the context of liposuction surgery should mean a layer of tissue (the subcutaneous) layer made up of fat cells (adipocytes) that lies between the skin (epidermis and dermis) and the muscle layer.  It is this layer of fat that is the target of liposuction surgery. The precise sculpting of this layer and how the skin is dealt with and respected by the liposuction surgeon is crucial to a perfect result.

However, when we look at an area of the body that is full or loose, it is important to determine whether this is fullness or looseness due to fat, specifically subcutaneous fat, or due to something else.

To me flab and fat are not the same. To me, flab is a nonmedical term that is, loose soft tissue that can be grabbed and shaken around. We love to grab big handfuls of this loose soft tissue and quickly call it fat. But this loose soft tissue (flab) is not only the fat layer but also loose muscle and skin. Liposuction reduces the fat layer and if it is done properly tightens the skin (which by the way may also contain fatty tissue – recall that steak has marbling). Firming the loose muscle layer is the patient’s responsibility by proper exercise and diet.  The responsibility of the liposuction surgeon is to precisely sculpt the subcutaneous fat layer and respect the skin from underneath.  Let me help to clarify this by the following example.  The abdomen is a common area for liposuction. But a patient with a full or loose abdomen may or may not be a candidate for liposuction surgery. It all depends on the thickness of the subcutaneous layer of fat. To begin with abdominal fullness specifically can be due to fullness within the abdominal cavity (behind the muscle layer). This is mostly what is known as visceral fat, around the abdominal organs and obviously cannot be targeted with liposuction surgery. Proper diet or other calorie restrictions such as lap band and exercise will affect visceral fat. But once outside the abdominal cavity itself the full loose “flabby” soft tissue we all love to grab consists of the same three layers – skin, subcutaneous fat and muscle.

To properly assess the thickness of the subcutaneous layer (that liposuction targets) one must know how to pinch. If you just grab a big hand full of tissue (especially if you are sitting bent over) and shake it around, you will never get an accurate assessment of the thickness of the subcutaneous fat layer. You will most likely be grabbing a handful of folded over loose muscle, fat and loose skin. Instead, to get a better idea you should stand straight up, put your arms over your head, lean back and reach down and pinch a smaller area between your thumb and index finger. This will give you a better idea of the thickness of the subcutaneous layer of fat.

In most other areas of the body other than the abdomen the same principles apply (other than there not being an abdominal cavity). The “flab” or fullness consists of muscle, fat and skin.  If there is fullness or looseness one must determine the thickness of the subcutaneous fat layer to understand the power of properly done liposuction but also to understand the role of proper diet and exercise. It is the responsibility of the liposuction surgeon to make this clear to the patient in order to meet their expectations and obtain a perfect result.

So next time you look at an area on your  body that is full and grab it and shake it around, before you call it fat, ask yourself, “ Is it fat or flab”?

by David Amron, MD.