She's 37, and, at 5-feet-7 and 160 pounds, not as thin as she'd like. So when her new boyfriend suggested liposuction and agreed to foot the $6,500 bill, she agreed.

``I was slightly insulted,'' says the woman, a graphic artist from Roxbury. But her boyfriend had had the same surgery and she wanted to be able to tuck in her blouses again.

Besides, she figured, this was a gift she'd have forever, ``as long I don't die through this surgery, which is not likely.''

She's right. In the vast majority of cases, liposuction, in which fatty tissue is literally sucked out of the body through hollow tubes under anesthesia, isn't lethal.

But the procedure -- the fastest growing, most popular form of cosmetic surgery, now performed on 177,000 people a year -- isn't as benign as many people think, either.

It's especially risky if it's done in a doctor's office, if the doctor is not properly trained and certified, if he removes too much fat, or if he pumps in too much ``tumescent fluid'' to control bleeding and then fails to control for potentially fatal fluid overload.

Consider:

• On March 17, 1997, a 47-year-old California woman died at the Irvine Medical Center after a massive procedure: 10 1/2 hours of liposuction on her legs, hips, thighs, buttocks, knees, and arms, plus a face lift. Her plastic surgeon gave her too much tumescent fluid, an administrative law judge ruled.
• On June 22, 1996, a 43-year-old California woman went in for ``lunchtime lipo'' in Los Angeles and was ``dead soon after dinner,'' as one magazine put it. Her operation was done in an office by an obstetrician-gynecologist who hadn't even completed a two-weekend course, said the Medical Board of California.
• On Jan. 13, 1998, a 51-year-old Florida man died after a 10-hour office procedure that included liposuction and penile enlargement. Afterward, he was left in the care of a night nurse. He died of valvular heart disease due to diet drugs and ``complications of plastic surgery,'' the autopsy found.

These cases, while rare given how common liposuction is, are undoubtedly the tip of an iceberg, though how big an iceberg is tough to determine because death certificates may mention surgery or cardiac arrest, but usually not liposuction per se.

But concern is growing, both among doctors, who are in fierce competition for patients, and among consumers.

Dr. Mark Gorney, executive vice president for The Doctors Company in Napa, Calif., a large doctor-owned malpractice carrier, asked plastic surgeons across the country to report fatal outcomes following liposuction to him. Over an 18-month period in 1997 and 1998, 69 were reported, and he says others think the true figure may be closer to 100.

Dr. Jack Bruner, a California plastic surgeon, thinks those numbers are too high. He believes liposuction caused 60 to 100 fatalities over five years, not 18 months. Still, the California cases were ``pretty spectacular deaths, so we decided we'd better take a look,'' acknowledges Bruner, who is head of a liposuction task force organized by the American Society of Plastic and Reconstructive Surgeons in 1997.

The issue galvanized California Assemblyman Martin Gallegos, who filed a bill this month to require reporting of liposuction deaths and tighter controls on office procedures.

In Florida, too, the medical board is considering rule changes that would limit office-based liposuction to four hours or less and the amount of fat removed to 2 liters (about two quarts) or less per procedure.

Even in states like Massachusetts, where there have been no reported complaints, Alexander Fleming, executive director of the Board of Registration in Medicine, says there is growing concern as economic pressures nudge more doctors, some with minimal training, to do liposuction.

In the right hands, the procedure is straightforward. The doctor inserts a tube called a cannula through a tiny slit in the skin. He then moves the tube around, causing fat cells to ``explode and loosen up,'' says Dr. Leonard Miller, a Brookline plastic surgeon. Increasingly, doctors use ultrasound as well to break up the fat before it is suctioned out. Typically, doctors make several tiny incisions in the areas of the body to be liposuctioned.

Though the procedure is ``blind,'' Miller says, ``you can feel where you are.'' And as long as the cannula is kept away from major organs (including the intestines, which may be punctured if the patient has an undiagnosed hernia), it works.

To maintain the benefits, though, you have to watch your diet and exercise. You're unlikely to re-gain pounds in the areas that were liposuctioned because there are fewer fat cells there to store fat. But if you overeat, you will gain weight in areas of the body that were not liposuctioned.

In some ways, it's safer than it was a decade ago, thanks to refinement by dermatologists of the ``tumescent fluid'' or ``super-wet'' technique, which involves injecting liters of fluid into the area from which fat is to be removed.

The fluid contains salt water plus epinephrine (adrenalin), which constricts blood vessels and reduces bleeding. It also contains lidocaine, an anesthetic, which produces enough pain control that a patient may not need general anesthesia.

Adding fluid has enabled doctors to increase the amount of fat they remove because there's less bleeding and the fat is more liquified. Some doctors now remove as much as 20 pounds of fat and fluid at a time.

But there are serious drawbacks, too. ``If you keep putting in liters and liters of lidocaine and epinephrine,'' says Miller, ``the drugs can cause toxic reactions, including respiratory arrest, cardiac arrhythmias, and convulsions.''

And while some fluid is suctioned back out with the fat, most is absorbed into blood vessels. The result, especially if patients are given intravenous fluids as well, can be congestive heart failure and pulmonary edema (fluid in the lungs), both of which can be fatal.

Last fall, Dr. Rod J. Rohrich, chairman of plastic surgery at Southwestern Medical Center in Dallas, told a national plastic surgery meeting that ``careful management of fluids is essential to avoid complications in liposuction.''

``This is real surgery,'' he says. ``That's why it's dangerous when doctors who aren't trained in large-volume fluid management do this procedure. That's also why patients should be healthy to start with.''

In general, the plastic surgeons' society says, patients ``should be aware that lipoplasty to remove more than five liters [about 11 pounds] of fat and fluid requires a high level of surgical skill and a provision for prolonged monitoring after the procedure.''

Translated, this means ``you probably shouldn't have more than five liters of fat and fluid removed unless you will be monitored by nurses post-operatively for 24 hours in an accredited health care facility or hospital,'' says Rohrich. It's probably also wise not to have more than 20 to 25 pounds of fat and fluid removed even in a hospital, he adds.

Dr. George Hruza, a dermatologist who runs the cutaneous surgery center at Barnes Jewish Hospital in St. Louis, agrees, especially for liposuction in a doctor's office. He suggests not removing more than nine pounds of fat and fluids in procedures done in an office or outpatient surgery center.

The Roxbury woman, who had her three-hour operation under general anesthesia at New England Baptist Hospital, had 5 1/2 liters of fat and fluid removed from her abdomen, inner and outer thighs, hips, love-handles, and back.

Three weeks later, she was feeling great. She misses the ``softness'' of her old belly, she says. But she's thrilled to be ready to wear a slinky dress.

Sidebar:

To obntain more information on cosmetic surgery:

Legally, anyone with an MD can do liposuction. It's usually done by plastic surgeons or dermatologists, though sometimes by gynecologists and ear-nose-and-throat surgeons.

What counts more than the doctor's specialty, though, is his or her training and certification -- and these vary widely.

Ask if your doctor is board certified, and if so, by which board. There are 24 boards recognized by the American Board of Medical Specialties, and only one (the American Board of Plastic Surgery) certifies doctors in plastic surgery. If your doctor isn't certified by one of these boards, though, it doesn't automatically mean he or she is poorly trained, but it's a reason to ask more questions. Even if you do use a plastic surgeon, it pays to ask about specific training because they do not all specialize in liposuction.

If your doctor is not a plastic surgeon, you should ask how much post-graduate training he or she has had in liposuction, and be wary of anyone who's only been trained at weekend workshops.

In general, ask your doctor how many liposuction procedures he or she has done, what the possible complications are, what kind of anesthesia you'll get, and where the surgery will be done. You probably shouldn't have more than five liters of fat and fluid removed unless you will be monitored by nurses post-operatively for 24 hours in an accredited health care facility or hospital. If you do have surgery outside a hosptial, ask what the procedures are if there's an emergency.

You should also call the board that licenses doctors in your state and ask if there have been any complaints or disciplinary actions against the doctor.

For more information:

There are several ways to verify your doctor's credentials and training.

Nationwide, you may telephone the American Board of Medical Specialties; 1-800-776-2378. You may also call your state doctor licensing board.

In Massachusetts, the Board of Registration in Medicine can be reached at 617-727-0773.

On the Web, you can visit: www.docboard.org  or www.certifieddoctor.org

Judy Foreman’s column runs every other week. Past columns are available on www.myhealthsense.com.

Listen to her live call-in webcast radio show every Wednesday night from 8:30 to 9:30 EST on http://www.healthtalk.com.