Liposuction has developed into one of the COSMETIC. Spontaneous Breast Enlargement following Liposuction of the Abdominal Wall: Does a Link Exist?

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1 COSMETIC Spontaneous Breast Enlargement following Liposuction of the Abdominal Wall: Does a Link Exist? Berend van der Lei, M.D., Ph.D. Gert-Jan Halbesma, M.D. Christianne A. van Nieuwenhoven, M.D. Jan J. van Wingerden, M.Med.(Plast. Chir.), F.C.S.(S.A.) Leeuwarden and Heerenveen, The Netherlands Background: A retrospective study was undertaken to determine the specific incidence of breast enlargement following liposuction of the abdomen (alone or in combination with the flanks), and to compare its effect with a control group of patients who had undergone abdominoplasty only and, where possible, identify corresponding variables. Methods: Forty-eight of 84 patients (57 percent) who had undergone a tumescent liposuction procedure of at least the abdominal wall and/or flanks and 53 of 104 patients (51 percent) who had undergone abdominoplasty met the entry criteria and formed the study group and the control group, respectively. The medical records were reviewed retrospectively, patient interviews were conducted and, where possible, the patients were examined. Patients who had undergone previous breast or abdominal wall surgery or who had a history of or were breast-feeding at the time of the study were excluded. Results: In the liposuction group, 23 of the 48 patients (48 percent) reported an increase in their breast size postoperatively. This could objectively be confirmed (by an actual increase of at least one bra cup size) in 19 patients (40 percent). Nine of 19 responders (47 percent) presented with a weight gain of as little as 4 percent of body mass index following liposuction, whereas this was observed in only one of 29 of the nonresponder group (3 percent) (p ). In the abdominoplasty group, 11 patients (21 percent) claimed to have perceived an increase in breast size, which was objectively confirmed by an increase in bra cup size in six (11 percent) only. Four of the six responders (with an increased cup size) reported a weight gain from as little as 4 percent of body mass index, compared with nine of the remaining 47 patients (19 percent) comprising the nonresponder group (p 0.01). Conclusions: Liposuction of the abdominal wall and/or flanks is followed by breast enlargement in a significant number of patients (40 percent), a risk that is significantly higher when compared with patients who have undergone abdominoplasty only. Patients should be informed about the possibility and risk of breast enlargement following liposuction of the abdominal wall in particular. (Plast. Reconstr. Surg. 119: 1584, 2007.) Liposuction has developed into one of the most popular methods of aesthetic body contouring; it is relatively safe and predictable, and satisfactory results can be obtained with minimal morbidity. Our attention was From the Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery, Medical Center Leeuwarden, and Private Clinic Heerenveen. Received for publication October 6, 2005; accepted December 29, Copyright 2007 by the American Society of Plastic Surgeons DOI: /01.prs b drawn to the possibility that breast enlargement may follow liposuction of, in particular, the abdominal wall as a largely unrecognized but not necessarily unpleasant side effect. In 1990, Bisaccia and Scarborough 1 reported on four women with breast enlargement following liposuction. Yun et al. 2 and Finzi 3 confirmed this observation more than 13 years later in two retrospective analyses of their patients. It was suggested that especially those women who had undergone liposuction of the abdominal wall and flanks were at risk. 2,3 This retrospective study was undertaken to determine the specific incidence of breast enlarge

2 Volume 119, Number 5 Breast Enlargement after Liposuction ment following liposuction of those areas at risk (i.e., the abdomen and flanks), and to compare its effect with a control group of patients who had had abdominoplasty only performed, in an effort to identify corresponding variables associated with this phenomenon. PATIENTS AND METHODS Eighty-four medical records of patients who had undergone a tumescent liposuction procedure of at least the abdominal wall and/or flanks, performed during the previous 4 years, with a minimal follow-up of 6 months, were selected from our liposuction database. The average period of follow-up was 2 years, which was short enough to discount the effect of aging. For the control group, 104 medical records of a carefully matched group of patients who had undergone abdominoplasty during the same period were randomly selected. Patients were interviewed either by telephone or during a follow-up visit. Patients unwilling to participate in this study, those with a history of pregnancy or who were breast-feeding, those who had undergone breast reduction or augmentation, and those in whom the abdominoplasty was combined with liposuction were excluded. The following data were collected: age, current weight and length at initial surgery, sites of liposuction, amount of supernatant fat removed, amount of abdominal wall tissue removed, current bra size, onset of menopause before surgery (where applicable), and use of medication. Entry criteria were met by 48 of the 84 patients (57 percent) in the liposuction group and in 53 of the 104 patients (51 percent) in the abdominoplasty (control) group. Differences in proportions between the groups were analyzed statistically using the chisquare method. Group mean values were compared by means of the t test. RESULTS The baseline results of the liposuction and abdominoplasty groups are comparable (Table 1). Liposuction Group (n 48) The liposuction group consisted of 48 women with an average age of years, a mean preoperative weight of kg, and a length of cm. Concurrently, the preoperative body mass index was On average, cc of total volume had been aspirated from the areas treated. Twenty-three of the 48 patients (48 percent) reported that their breasts had enlarged Table 1. Comparative Characteristics of the Liposuction and Abdominoplasty Groups Characteristics Liposuction (n 48) Abdominoplasty (n 53) Age, years Volume removed, cc and mg Length, cm Preoperative values Cup size (European)* cm Weight, kg BMI Postoperative values Cup size (European) cm Weight, kg BMI More than 4% of BMI weight gain, no. of patients Increased cup size, no. of patients 19 6 BMI, body mass index. *Cup size is defined as A 1, B 2, C 3, D 4, DD 5, E 6, and F 7. p following liposuction (Fig. 1). Objectively (i.e., an actual increase of at least one bra cup size), this was found to be the case in 19 patients (40 percent) (Figs. 2 and 3). The overall amount of aspirated volume did not differ significantly between the responders (i.e., those with an increased bra cup size) ( cc) and nonresponders ( cc); only two patients of the responder group had had less than 1000 cc aspirated. The overall postoperative body mass index remained However, the postoperative body mass index was significantly higher in the responder group ( ) than in the nonresponder group ( ; p 0.05) (Fig. 3). Nine of 19 responders (47 percent) presented with a weight gain of more than 4 percent of body mass index following liposuction, whereas this was observed in only one of 29 of the nonresponder group (3 percent). This difference is statistically significant (p ) (Table 2 and Fig. 3). Abdominoplasty Group (n 53) The abdominoplasty group consisted of 53 women with an average age of years, a mean preoperative weight of kg, and a length of cm (Table 1). The body mass index was On average, g of abdominal wall tissue (skin, subcutaneous tissue, fat) was excised. In this group, 11 patients (

3 Plastic and Reconstructive Surgery April 15, 2007 Fig. 1. Effect of liposuction and abdominoplasty on breast enlargement *Significantly more breast enlargement after liposuction (p 0.001). Fig. 2. Bra cup size according to responders (R; actual increase in bra cup size) and nonresponders (N) in both the liposuction group (L) and the abdominoplasty group (A). Bra cup size was defined as A 1, B 2, C 3, D 4, DD 5, E 6, and F 7. percent) claimed to have perceived an increase in breast size, which was confirmed objectively by an increase in bra cup size in six (11 percent) only (Figs. 1 and 2). The overall postoperative body mass index of did not differ significantly from the preoperative body mass index (Table 1). However, the postoperative body mass index was significantly higher in the responder group ( ) than in the nonresponder group ( ) (p 0.05) (Fig. 3). Four of the six responders (with an increased cup size) reported a weight gain of more than 4 percent of body mass index (67 percent), compared with nine of the remaining 47 patients (19 percent) comprising the nonresponder group (p 0.01) (Table 3 and Fig. 3). Effect of Gaining Weight (Increase in Body Mass Index) Nine of 10 patients (90 percent) who presented with an increase of more than 4 percent of body mass index following liposuction had an increase in bra cup size. Only 10 of the remaining 38 Fig. 3. Bra cup size according to responders ( ; actual increase in size) and nonresponders ( ) in both the liposuction group (L) and the abdominoplasty group (A) in relation to increase in body mass index (BMI; 4 percent). In both the liposuction and abdominoplasty groups, there was a significantly greater increase in 4 percent body mass index in the responder group than in the nonresponder group (**p ; *p 0.01). patients (26 percent) in the liposuction group had an increase in bra cup size (p 0.001) (Fig. 4). Four of 13 patients (30 percent) in the abdomi- 1586

4 Volume 119, Number 5 Breast Enlargement after Liposuction Table 2. Comparison of Variables between the Responders and Nonresponders in the Liposuction Group Variables Responders (n 19) Nonresponders (n 29) Mean age, years Volume removed, ml and mg Length, cm Preoperative values Cup size (European)* cm Weight, kg BMI Postoperative values Cup size (European) cm Weight, kg BMI More than 4% of BMI weight gain, no. of patients 9 1 BMI, body mass index. *Cup size is defined as A 1, B 2, C 3, D 4, DD 5, E 6, and F 7. p Table 3. Comparison of Variables between the Responders and Nonresponders in the Abdominoplasty Group Variables Responders (n 6) Nonresponders (n 46) Mean age, years Volume removed, ml and mg Length, cm Preoperative values Cup size (European)* cm Weight, kg BMI Postoperative values Cup size (European) cm Weight, kg BMI More than 4% of BMI weight gain, no. of patients 4 9 BMI, body mass index. *Cup size is defined as A 1, B 2, C 3, D 4, DD 5, E 6, and F 7. p noplasty group who had had a weight gain of more than 4 percent of body mass index had an increase in bra cup size. However, only two of the remaining 40 patients (5 percent) had an increase in bra cup size (p 0.01) (Fig. 4). Fig. 4. Analysis of gaining weight (, 4 percent of body mass index;, 4 percent of body mass index) in both the liposuction (L) and abdominoplasty (A) groups and an increased bra cup size. In both groups, a significantly higher percentage of responders (increased bra cup size) was found in the groups who had an increase of more than 4 percent of the body mass index (**p 0.001; *p 0.01). DISCUSSION Patients presenting for liposuction are usually quite specific about what they wish to have removed and where they would like to have it removed from. That something may be gained elsewhere is never taken into consideration by the patient and seldom by the surgeon. Enlargement of the breasts following liposuction may come as a surprise to many patients. It could easily be argued that the breasts of all patients undergoing an abdominal reduction would appear larger following liposuction: the ratio of the breasts to the rest of the body improves, 4 and so does the posture. Also, according to Pisacane and Continisio, 5 perceptions regarding an actual change in appearance of the female breast often change following a major physical event. It was therefore not unexpected that more patients perceived their breasts to have changed than the actual numbers bear out. These arguments could, however, easily be countered in our study: first, all of the above also holds true for the patient who has had an abdominal lipectomy (which, as the statistics have shown, is not the case); and second, we were able to demonstrate that liposuction of the abdominal wall and/or 1587

5 Plastic and Reconstructive Surgery April 15, 2007 flanks is followed by an actual (true) increase in breast size in a significant number of patients (40 percent). Actual breast enlargement was defined as an increase in bra cup size, unaccompanied by an increase in chest circumference. This study has furthermore shown that the risk of actual postoperative breast enlargement is significantly greater following liposuction of the abdominal wall (including or excluding the flanks) when compared with patients who have had only an abdominoplasty performed (40 percent versus 11 percent). Although the exact mechanism whereby liposuction induces breast enlargement is not yet fully understood, the group of Bruck et al. 2,6 presented, in two carefully argued articles, the following hypothesis: adipose tissue enzymatically converts androstenedione to estrogen and testosterone. 7 The ratio in the production thereof varies, depending on the anatomical location; in the adipose tissue of the abdominal wall, the production of dihydrotestosterone (a product of 5 -reductase on androgen) is more than 10-fold greater than the production of estrogen. 7 Extensive liposuction of the abdominal wall may thus result in reduced production of circulating 5 -reduced androgens, which results in a relative increase in the estrogento-androgen ratio. 2,8 Breast tissue growth is said to be influenced by this ratio. Moreover, the decrease of enzymatic conversion of androstenedione in the abdominal wall adipose tissue will increase its availability in the circulating plasma 7 and in extragonadal sites, such as the mesenchymal cells of adipose tissue of the breast. 9 Extragonadal estrogen biosynthesis then will lead to a locally higher concentration of estrogen, which can then mediate breast tissue growth Thus, the observed breast enlargement after liposuction may be explained by a systemic change in the estrogen-toandrogen ratio and by higher concentrations of estrogen locally in the breast because of extragonadal estrogen biosynthesis. All our patients, albeit for liposuction or abdominoplasty, are encouraged (but not specifically instructed) to adopt healthy lifestyle habits (i.e., exercise and diet). It was therefore heartening to observe that no significant increase in overall body mass index was found in either the study group (liposuction) or the control group (abdominoplasty) at the time of the survey (on average, 2 years after either procedure). We deliberately selected a low entry level (an increase in body mass index from as little as 4 percent) in both the study and control groups to allow us to study the effect of the slightest increase in weight on the size of the breast. It is also important to realize that no one in either group of patients who did report an increase in weight postoperatively changed to the category obese when taking body mass index definitions into consideration. A unique finding of this study is that, despite the fact that the increase in body mass index (and therefore in weight) in the responder groups in both the study (liposuction) and control (abdominoplasty) groups is absolutely comparable, there are significantly more responders in the liposuction group. A possible explanation could be that an increase in weight (storage of energy by fat accumulation) will result in fat accumulation in adipose tissue that was not damaged by liposuction; areas such as the breast and buttock are then at risk. The effect might also be attributable to hormonal changes followed by extragonadal estrogen biosynthesis; weight gain seems to be associated with an increase in the waist-to-hip ratio, 13 which is positively associated with an increase in dehydroepiandrosterone sulfate and free testosterone. The increase in these hormones may then lead to an increase in extragonadal estrogen biosynthesis in breast tissue, with growth of breast tissue as a result. 14 However, an increase in breast size cannot be explained by weight gain alone, as den Tonkelaar et al. 15 found in their elegant study on, among others subjects, the effect of weight on the size of the postmenopausal breast (our patient groups were premenopausal). Not unexpectedly, as was found in other studies, 16 weight gain did not distract from overall patient satisfaction. The group of Bruck et al. 2,6 opined that the technique of liposuction used did not significantly influence the degree of breast enlargement following liposuction. 6 This conclusion was based on subjective findings reported by the patients (34 percent reported an increase in breast size after power liposuction and 37 percent after tumescent liposuction). Objectively, however, a definite difference was observed: only eight of the 73 patients (11 percent) had an actual increase in bra cup size after power liposuction, whereas this was observed in 17 of the 70 patients (24 percent) after tumescent liposuction. This seems to be statistically significant. We suggest that power liposuction is possibly less harmful to the remaining adipose tissue cells. In support of this, we found an even higher rate of breast enlargement after tumescent liposuction: 40 percent of patients reported an actual increase in bra cup size. Limiting our study to those patients who were treated with tumescent liposuction of the high-risk areas 1588

6 Volume 119, Number 5 Breast Enlargement after Liposuction only could explain this high incidence of breast enlargement. Our control group, consisting of patients who had undergone abdominoplasty only, allowed for comparison of the effect of tumescent liposuction of the abdominal wall and/or flanks with the effect of partial excision of the abdominal wall. In this latter group, an actual increase in bra cup size was found in 11 percent of the patients. This observation still supports the hypothesis as proposed by the Bruck et al. 2,6 : less actual fat cell damage occurs above the umbilicus during abdominoplasty because the plane of dissection lies on the muscle fascia, below the actual abdominal wall fat. This is not the case in liposuction, where the actual fat cell damage is much more extensive and involves a large area, especially when large amounts are removed. In our study, the difference in outcome, from a breast enlargement perspective, was statistically highly significant: more patients in the liposuction group reported actual breast enlargement (40 percent) than in the abdominoplasty group (11 percent, p 0.001). It has also been suggested that the abdominal wall tissue removed during abdominoplasty represents a different type of host response than the removal of a specific anatomical plane of fat. CONCLUSIONS We believe our study conclusively demonstrates that liposuction of the abdominal wall and/or flanks is followed by breast enlargement in a significant number of patients (40 percent), a risk that is significantly higher when compared with patients who have undergone abdominoplasty only. The risk is such, we feel, that patients should be informed about the possibility. Fortunately, a survey of our responder group of patients showed that most patients were not displeased with the unexpected breast enlargement. Further prospective studies analyzing the hormonal changes in adipose tissue and plasma of both liposuction and abdominoplasty patients may help to elucidate the mechanism of breast enlargement after these procedures. Berend van der Lei, M.D., Ph.D. Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery Medical Center Leeuwarden Henri Dunantweg AD Leeuwarden, The Netherlands b.van.der.lei@znb.nl DISCLOSURE None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article. REFERENCES 1. Bisaccia, E., and Scarborough, D. A. Breast enlargement after liposuction. Am. J. Cosmet. Surg. 7: 97, Yun, P. L., Bruck, M., Felsenfeld, L., and Katz, B. E. Breast enlargement after power liposuction: A retrospective review. Dermatol. Surg. 29: 165, Finzi, E. Breast enlargement induced by liposuction. Dermatol. Surg. 29: 928, Flynn, T. C. Breast enlargement observed after power liposuction: A retrospective review (Commentary). Dermatol. Surg. 29: 167, Pisacane, A., and Continisio, P. Breastfeeding and perceived changes in the appearance of the breasts: A retrospective study. Acta Paediatr. 93: 1346, Frew, K. E., Rossi, A., Bruck, M. C., Katz, B. E., and Narins, R. S. Breast enlargement after liposuction: Comparison of incidence between power liposuction versus traditional liposuction. Dermatol. Surg. 31: 292, Killinger, D. W., Perel, E., Danilescu, D., Kharlip, L., and Lindsay, W. R. N. Influence of adipose tissue distribution on the biological activity of androgens. Ann. N. Y. Acad. Sci. 595: 199, Wilson, J. Endocrine disorders of the breast. In T. Wilson, E. Braunwald, and M. Isselbacher (Eds.), Harrison s Principles of Internal Medicine. New York: McGraw-Hill, P Simpson, E. R. Aromatization of androgens in women: Current concepts and findings. Fertil. Steril. 77 (Suppl. 4): S6, Simpson, E. R. Sources of estrogen and their importance. J. Steroid Biochem. Mol. Biol. 86: 225, Simpson, E., Rubin, G., Clyne, C., et al. The role of local estrogen biosynthesis in males and females. Trends Endocrinol. Metab. 11: 184, Labrie, F., Belanger, A., Cusan, L., and Candas, B. Physiological changes in dehydroepiandrosterone are not reflected by serum levels of active androgens and estrogens but of their metabolites: Intracrinology. J. Clin. Endocrinol. Metab. 82: 2403, Caan, B., Armstrong, M. A., Selby, J. V., et al. Changes in measurements of body fat distribution accompanying weight change. J. Obes. 18: 397, Killinger, D. W., Strutt, B. J., Roncari, D. A., and Khalil, M. W. Estrone formation from dehydroepiandrosterone in cultured human breast adipose stromal cells. J. Steroid Biochem. 52: 195, Den Tonkelaar, I., Peeters, P. H. M., and van Noord, P. A. H. Increase in breast size after menopause: Prevalence and determinants. Maturitas 48: 51, Rohrich, R. J., Broughton, G., II, Horton, B., Lipschitz, A., Kenkel, J. M., and Brown, S. A. The key to long-term success in liposuction: A guide for plastic surgeons and patients. Plast. Reconstr. Surg. 114: 1945,