No Increase in Female Breast Size or Fat Redistribution to the Upper Body After Liposuction: A Prospective Controlled Photometric Study

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1 535801AESXXX / X Aesthetic Surgery JournalSwanson research-article2014 Body Contouring No Increase in Female Breast Size or Fat Redistribution to the Upper Body After Liposuction: A Prospective Controlled Photometric Study Eric Swanson, MD Many researchers have claimed that breasts enlarge after liposuction, 1-6 and van der Lei et al 6 recommend informing prospective patients about this possibility. However, this phenomenon has not been evaluated by comparing standardized breast measurements. In a widely publicized study in 2011, Hernandez et al 7 claimed that fat is redistributed from the lower body to the upper body after liposuction. In previous research, 8 the author of the current study challenged their conclusion, finding no evidence of fat redistribution to the upper body after liposuction alone or in combination with abdominoplasty, Aesthetic Surgery Journal 2014, Vol. 34(6) The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journalspermissions.nav DOI: / X Abstract Background: Some studies have indicated that liposuction may cause breast enlargement. Fat redistribution to the upper body as a compensatory mechanism after liposuction has also been reported. Objectives: To evaluate the possibility of secondary breast hypertrophy and fat redistribution after liposuction, breast size and upper body measurements were obtained and compared for women who did not gain weight postoperatively. Methods: Eighty-two women who underwent cosmetic surgery, not including breast surgery, were enrolled in this prospective controlled study. Participants represented 1 of 3 procedure groups: cosmetic surgery not including liposuction (n = 24), liposuction (n = 41), and liposuction combined with abdominoplasty (n = 17). Breast measurements were obtained from standardized lateral photographs matched for size and orientation. Results were compared among the study groups. Results: Postoperatively, there were no significant changes in mean body weight among the study groups. No significant increases in upper pole projection, breast projection, or breast area were found in patients treated with liposuction alone and those who received liposuction plus abdominoplasty. Upper body dimensions were unchanged except for a significant (P <.01) decrease in upper abdominal width in women treated with liposuction plus abdominoplasty. The findings were the same for a subset of 17 women with liposuction aspirate volumes >1500 ml. Conclusions: Results indicate that neither liposuction nor abdominoplasty produces secondary breast enlargement. Upper body dimensions are unchanged, consistent with findings of a previous study and contrary to the theory of fat redistribution. Level of Evidence: 2 Keywords liposuction, abdominoplasty, photometric study, fat redistribution, secondary breast hypertrophy Accepted for publication February 18, but did not specifically evaluate possible postsurgical changes in breast size. This study was undertaken to investigate whether liposuction causes breast enlargement. Possible Dr Swanson is a plastic surgeon in private practice in Leawood, Kansas. Corresponding Author: Dr Eric Swanson, Swanson Center, Ash St, Leawood, KS 66211, USA. eswanson@swansoncenter.com

2 Swanson 897 Figure 1. Patient 1. This 39-year-old woman s upper body was photographed before (left) and 4 months after (right) liposuction of the lower body (abdomen, flanks, thighs, and knees). The total liposuction volume was 3150 ml. Preoperative weight was 178 lb, and postoperative weight was 170 lb. The 8-lb weight loss was only slightly greater than the 6 lb expected from the fat removal (3150 ml; 1 L = 2 lb), essentially rendering her calorically neutral after surgery. The upper body measurements showed no evidence of fat redistribution. Photographs were matched for size and orientation. (Photographs of this patient s lateral breast and lower body are shown in Figures 2-4.) compensatory changes in upper body dimensions also were evaluated, as in the previous study. 8 Methods Patients This prospective study was conducted in consecutive patients who underwent plastic surgery between January 2012 and July 2013 at the Surgery Center of Leawood, a state-licensed ambulatory surgery center. Institutional review board approval was obtained from Institutional Review Board Services, accredited by the Association for the Accreditation of Human Research Protection Programs, Inc. Eligibility criteria were as follows: (1) women who underwent cosmetic surgery that did not involve breast surgery, (2) consent for breast photographs, (3) availability of postoperative photographs taken at least 3 months following surgery, (4) no breast surgery between surgery and the dates of any postoperative photographs, and (5) no pregnancy during the study period. Patients who underwent liposuction simultaneously with another procedure, such as abdominoplasty, were included. Also included were patients with existing breast implants. Each patient was weighed before and after surgery on the same hospital scales. Of the 102 consecutive women who underwent cosmetic surgery that did not involve a breast procedure, 12 declined to participate in the study. Seven others were unavailable for follow-up appointments at least 3 months after surgery. One patient had a breast procedure within 3 months of surgery, rendering her ineligible. Therefore, the study population comprised 82 patients (80.4% inclusion rate). These patients were categorized into 3 study groups: the control group of patients whose procedures did not include liposuction (n = 24), patients who had liposuction alone (n = 41), and those who had liposuction plus abdominoplasty (n = 17). Liposuction/abdominoplasty was defined as liposuction of the abdomen and flanks in combination with abdominoplasty. Most liposuction/ abdominoplasty patients also underwent liposuction of the thighs and medial knees. Surgery All liposuction procedures were performed with the Lysonix 3000 ultrasonic system (Mentor Corp, Santa Barbara, California) and a superwet technique. All surgery was performed by the author. Total intravenous anesthesia was administered by an anesthesiologist or certified nurse anesthetist. 9 All abdominoplasties were primary procedures and included plication of the rectus fascia. Photographs To ensure standardization, 10 all patients were photographed in the same room, with the same background and lighting. All photographs were digital images taken by the author with the same Nikon D80 digital camera and Nikon 60-mm fixed focal length lens (Nikon Corp, Tokyo, Japan), calibrated by having each patient hold a ruler in 1 of their photographs. All upper body photographs were obtained while patients were standing with arms resting at their sides (demonstrated in Figures 1 and 2). Lower body photographs were taken with

3 898 Aesthetic Surgery Journal 34(6) Figure 2. Patient 1. Lateral breast measurements for this 39-year-old woman, obtained before (A) and 4 months after (B) liposuction, showed no evidence of breast enlargement posttreament. Photographs were matched for size and orientation. MPost, maximum postoperative breast projection. the arms raised (demonstrated in Figures 3 and 4). Lower body measurements were not compared in this study but were evaluated previously. 8 Measurements Horizontal breast measurements and area calculations were obtained from standardized lateral photographs matched for size and orientation using the method previously published 11 and Canfield Mirror imaging software (Canfield Scientific, Inc, Fairfield, New Jersey) (Figure 2). Measurements were taken from frontal photographs to determine any possible changes in upper body dimensions after liposuction. 8 The areas measured included shoulder width, bihumeral width, and upper abdominal width at the same vertical level (Figure 1). Although not specific, these shoulder and mid-humeral measurements are expected to indicate an increase in subcutaneous fat volume of the arms, triceps, and midaxillary areas, 8 which are anatomic sites thought to be affected by fat redistribution. 7 To investigate the possibility of selection bias, excluded patients were compared with eligible participants. Statistical Analysis Statistical analyses were performed with SPSS for Windows (version 21.0; SPSS, Inc, an IBM Company, Chicago, Illinois). Mean differences between groups were determined by 1-way analysis of variance (ANOVA), and mean differences between matched pairs before and after surgery were assessed with paired t tests. Pearson correlations were computed. For multiple comparisons, statistical significance was defined as P <.01. A power analysis was performed to determine adequate sample sizes. To achieve 80% power at α =.05, sufficient to detect a moderate treatment effect (F = 0.40) across 3 groups, subjects were required. 13 Results There were no significant differences between treatment and control patients with respect to mean age, follow-up time, body mass index, and change in weight (Table 1). The mean follow-up period was 5.6 months (range, 3-19 months). The overall comparison of participants and nonparticipants showed no significant differences in these

4 Swanson 899 Figure 3. Patient 1. Lower body photograph of this 39-yearold woman before liposuction. parameters or in liposuction volume or flap resection weight (data not shown). No patient with existing breast implants developed a clinical capsular contracture or a known implant deflation during the study. The mean weight change for the control group was a gain of 0.73 lb after surgery. Liposuction patients lost an average of 0.66 lb, and liposuction/abdominoplasty patients lost an average of 3.91 lb (difference not statistically significant). Pre- and postoperative right breast measurements were compared among the 3 study groups (Figures 5-10). Right and left breast data appear in Tables 2 and 3. There were no significant changes in breast measurements among control patients, with the exception of a slight increase (0.23 cm) in mean postoperative right breast projection (P <.01). There were no significant changes in breast measurements after either liposuction or liposuction/abdominoplasty (Figures 5 and 6). Mean breast area measurements also remained unchanged (Figure 7, Table 2). Upper body dimensions did not change significantly for control patients after surgery (Figures 8-10). Upper abdominal width decreased significantly (P <.01) after surgery in Figure 4. Patient 1. Lower body photograph of this 39-yearold woman 4 months after liposuction. This image was taken simultaneously with the upper body and breast photographs (Figures 1 and 2). All lower body dimensions were reduced from preoperative measurements. This photograph was matched with Figure 3 for size and orientation. patients treated with liposuction/abdominoplasty (Figure 10, Table 3). A subset of 53 patients who did not have existing breast implants was evaluated separately (data not shown). Similar to the larger group that included women with breast implants, there were no significant changes in any measurements after liposuction alone and a significant (P <.01) decrease in upper abdominal width after liposuction/abdominoplasty. A subset of 17 women with liposuction volume >1500 ml (Figures 1-4) also had no significant changes in breast or upper body dimensions after liposuction; a reduction in upper abdominal width (P <.01) was recorded after liposuction/abdominoplasty. No significant correlations were observed for any of the following parameters: age, follow-up time, body mass index, and change in either breast or upper body dimensions.

5 900 Aesthetic Surgery Journal 34(6) Table 1. Patient Data Control (n = 24) Liposuction (n = 41) Liposuction/Abdominoplasty (n = 17) All Procedures (N = 82) P Value Age, y ± ( ) ± ( ) ± ( ) ± ( ) NS Follow-up time, mo 6.01 ± 3.66 (3-15) 5.48 ± 4.06 (3-19) 5.40 ± 1.92 (3-10) 5.62 ± 3.57 (3-19) NS Preoperative BMI, kg/m ± 3.83 ( ) ± 4.82 ( ) ± 4.21 ( ) ± 4.63 ( ) NS Preoperative weight, lb ± ( ) ± ( ) ± ( ) ± ( ) NS a Postoperative weight, lb ± ( ) ± ( ) ± ( ) ± ( ) NS a Change in weight, lb 0.73 ± 5.32 ( ) 0.66 ± 5.78 ( ) 3.91 ± 6.81 ( ) 0.93 ± 6.03 ( ) NS a Aspirate volume, ml NA ± ( ) ± ( ) ± ( ) NS Flap weight, lb NA NA 4.15 ± 1.46 ( ) 4.15 ± 1.46 ( ) NA Data are expressed as means ± standard deviation (range). BMI, body mass index; NA, not applicable; NS, not significant. a Patient weights were compared for the 2 test times using a paired t test. The comparison was not significant at P <.01 for any procedure group. Means across groups were compared by 1-way ANOVA; no comparisons were significant at P <.01. Figure 5. Right breast projection before (green) and after (blue) surgery in the control group (cosmetic surgery that did not include liposuction; n = 24), the liposuction group (n = 41), and the group with liposuction plus abdominoplasty (lipo/abdominoplasty; n = 17). The mean follow-up time was 5.6 months (range, 3-19 months). Data are presented as means ± standard deviation (bars). Discussion Theory of Fat Redistribution Proponents of fat redistribution theorize that the body forms new fat cells in untreated areas to compensate for fat cells lost after liposuction. 7 Such a mechanism would require a memory for the original allotment of adipocytes and an ongoing inventory of site-specific fat cell numbers, directing different anatomic areas to manufacture new fat cells as needed. Advocates of this theory concede that their findings have not been reproduced by other Figure 6. Right breast upper pole projection before (green) and after surgery (blue) in the control group (cosmetic surgery that did not include liposuction; n = 24), the liposuction group (n = 41), and the group with liposuction plus abdominoplasty (lipo/abdominoplasty; n = 17). The mean follow-up time was 5.6 months (range, 3-19 months). Data are presented as means ± standard deviation (bars). investigators, and such a mechanism has no known physical explanation. 7 A landmark study of carbon-14 isotope incorporation in genomic DNA demonstrated that a homeostatic mechanism maintains adipocyte numbers, with a constant 10% renewed annually, and that this rate does not vary by age or body mass index in adults. 14 This finding confirms earlier work indicating that adipocyte hypertrophy accounts for increased fat volume in conditions of moderate obesity With weight loss, fat cells shrink, but their absolute

6 Swanson 901 Figure 7. Right breast area before (green) and after surgery (blue) in the control group (cosmetic surgery that did not include liposuction; n = 24), the liposuction group (n = 41), and the group with liposuction plus abdominoplasty (lipo/abdominoplasty; n = 17). The mean follow-up time was 5.6 months (range, 3-19 months). Data are presented as means ± standard deviation (bars). Figure 8. Shoulder width before (green) and after surgery (blue) in the control group (cosmetic surgery that did not include liposuction; n = 24), the liposuction group (n = 41), and the group with liposuction plus abdominoplasty (lipo/abdominoplasty; n = 17). The mean follow-up time was 5.6 months (range, 3-19 months). Data are presented as means ± standard deviation (bars). Figure 9. Bihumeral width before (green) and after surgery (blue) in the control group (cosmetic surgery that did not include liposuction; n = 24), the liposuction group (n = 41), and the group with liposuction plus abdominoplasty (lipo/abdominoplasty; n = 17). The mean follow-up time was 5.6 months (range, 3-19 months). Data are presented as means ± standard deviation (bars). Figure 10. Upper abdominal width before (green) and after surgery (blue) in the control group (cosmetic surgery that did not include liposuction; n = 24), the liposuction group (n = 41), and the group with liposuction plus abdominoplasty (lipo/abdominoplasty; n = 17). The mean follow-up time was 5.6 months (range, 3-19 months). Data are presented as means ± standard deviation (bars). number does not change The quantity of fat cells is reduced only by liposuction or other fat resections (eg, abdominoplasty). 21 This adipocyte theory 21,22 is the basis for the efficacy of liposuction in permanently improving body proportions (Figures 11 and 12). If this concept were false, liposuction would represent an unattractive therapeutic option. Most women would be unwilling to trade fat from the thighs for fat in the arms, axillary areas, and

7 902 Aesthetic Surgery Journal 34(6) Table 2. Breast Dimensions Before and After Surgery (N = 82) Control (n = 24) Liposuction (n = 41) Liposuction/ Abdominoplasty (n = 17) All Procedures (N = 82) P Value Right breast projection, cm Before 7.82 (1.45) 8.17 (1.37) 7.86 (1.57) 8.00 (1.43) After 8.06 (1.32) 8.16 (1.30) 7.85 (1.63) 8.07 (1.37) Change 0.23 (0.39) a 0.01 (0.42) 0.01 (0.48) 0.06 (0.43) NS Left breast projection, cm Before 8.33 (1.42) 8.91 (1.45) 8.16 (2.07) 8.58 (1.60) After 8.18 (1.29) 8.91 (1.38) 8.12 (2.18) 8.53 (1.58) Change 0.15 (0.42) 0.00 (0.49) 0.03 (0.30) 0.05 (0.44) NS Right breast upper pole projection, cm Before 4.52 (1.08) 4.76 (0.90) 4.52 (1.07) 4.64 (0.98) After 4.65 (1.07) 4.85 (0.93) 4.55 (1.15) 4.73 (1.01) Change 0.13 (0.31) 0.09 (0.35) 0.03 (0.33) 0.09 (0.34) NS Left breast upper pole projection, cm Before 4.96 (1.07) 5.34 (1.13) 4.71 (1.27) 5.10 (1.16) After 4.97 (1.18) 5.39 (1.00) 4.71 (1.36) 5.13 (1.16) Change 0.01 (0.41) 0.05 (0.39) 0.00 (0.26) 0.02 (0.37) NS Right breast area, cm 2 Before (21.14) (20.06) (25.24) (21.27) After (20.59) (18.91) (24.96) (20.49) Change 1.02 (4.47) 0.37 (5.03) 1.67 (5.36) 0.23 (4.97) NS Left breast area, cm 2 Before (19.33) (20.45) (31.09) (22.67) After (19.13) (19.73) (31.05) (22.30) Change 1.33 (5.15) 0.90 (4.34) 0.89 (4.07) 1.02 (4.49) NS Data are expressed as means (standard deviation). Before and after measurements were compared by paired t tests. The change in right breast projection was significant at P <.01 for the control group. The mean change scores were compared among the 3 groups by 1-way analysis of variance; no comparisons were significant at P <.01. NS, not significant. a P <.01. shoulders, which might create an unfeminine linebacker appearance. 8 The conclusion by Hernandez et al 7 supporting fat redistribution is undermined by methodological deficiencies 8 that include a limited sample size of 14 surgical patients, imprecise measurement techniques, nonsignificant changes, and a cohort that gained weight after surgery. Weight Change After Liposuction Caloric neutrality is essential in any study of fat change after liposuction. 8 If weight increases postoperatively, it is not possible to distinguish a theoretic volume expansion caused by fat redistribution from an expected volume increase relating to additional fat deposition due to weight gain. In the present study, patient weight was recorded rigorously by nurses, and the same hospital scales were used for all patients. There was no reliance on patient estimates, which are known to be inaccurate. Postoperative changes in mean body weight among control patients and liposuction patients were <1 lb (not statistically significant). The mean reduction of 3.91 lb after abdominoplasty was similar to the average flap weight of 4.15 lb. Therefore, measurement data are not influenced by a significant postoperative weight change that might cause an

8 Swanson 903 Table 3. Upper Body Dimensions Before and After Surgery (N = 82) Control (n = 24) Liposuction (n = 41) Liposuction/ Abdominoplasty (n = 17) All Procedures (N = 82) P Value Shoulder width, cm Before (3.56) (2.62) (3.27) (3.03) After (3.45) (2.31) (3.18) (2.85) Change 0.22 (0.83) 0.22 (0.99) 0.37 (0.87) 0.12 (0.94) NS Bihumeral width, cm Before (4.16) (3.18) (3.33) (3.52) After (4.12) (2.94) (3.28) (3.38) Change 0.44 (0.78) 0.24 (0.97) 0.27 (1.17) 0.04 (1.00) NS Upper abdominal width, cm Before (3.08) (3.01) (2.67) (3.08) After (2.94) (3.04) (2.81) (3.02) Change 0.19 (0.38) 0.43 (1.01) 0.57 (0.63) a 0.28 (0.85) a <.01 Data are expressed as means (standard deviation). Before and after measurements were compared by paired t tests. The mean change scores were compared among the 3 groups by 1-way analysis of variance; only the change in upper abdominal width was significant at P <.01. Post hoc comparisons were significant at P <.05 for liposuction vs control and for liposuction/ abdominoplasty vs control. NS, not significant. a P <.01. overall increase or decrease in adipocyte size and fat volume. The significant (P <.01) reduction in upper abdominal width after liposuction/abdominoplasty may be explained by the more effective fat reduction achieved by combined modalities. In previous studies showing a postliposuction increase in breast size, patients gained weight after surgery. 1-3,5,6 A single study 4 showed an increase in breast size without documented weight gain; however, patients weight estimates were provided in person or by telephone. Direct weighing was not performed. Possible Hormonal Influence Although postoperative increases in breast size may be explained by weight gain, some investigators 1-3,5,6 postulate a hormonal mechanism for increased breast size after liposuction. Fat cells are known to produce estrogen. In postmenopausal women, adipocytes produce most of the circulating estrogen 5 ; they also produce androgens. Proponents of a hormonal influence reference site-specific differences in the production of estrone vs androgens from their precursor, androstenedione. 22 In their study of 4 women and 2 men, Killinger et al 22 reported that the conversion of androstenedione to estrone was greater in fat cells harvested by liposuction from the upper thigh, buttock, and flank than in abdominal fat cells. According to this hypothesis, if abdominal fat is preferentially removed by liposuction, the relative amount of circulating estrogen is increased, causing breast enlargement. 3,5,6 No published studies include hormonal assays to support this theory. Moreover, most patients treated with abdominal liposuction also receive treatment of the flanks 1-6 (sometimes labeled the hip rolls ) 3,5 and thighs, which equalizes any possible differences in estrone production by aspirated fat cells. Liposuction/abdominoplasty removes a greater volume of fat from the abdomen than liposuction alone. 8 The lack of breast size increase in the present study provides additional evidence that preferential removal of abdominal subcutaneous fat does not create a hormonal imbalance leading to breast hypertrophy. In an evaluation of 15 women and 14 men, Anderson et al 23 demonstrated no effect of either estrone or dihydrotestosterone on adipocyte mass through proliferation of preadipocytes, suggesting that differences in plasma levels of these sex hormones are irrelevant with respect to fat deposition. In postmenopause, estrogen no longer has a major role as a circulating hormone but rather functions locally in tissue sites where it is formed. 24 Scarborough and Bisaccia 2 reported no correlation between subjective change in breast size and supplemental hormone replacement or menstruation. Finzi 4 found no effect of menopausal status on patient-reported breast enlargement after liposuction. Limitations of Existing Studies The studies demonstrating breast enlargement after liposuction 1-6 relied on subjective patient assessments of change in weight, breast size, and bra cup size. None included objective

9 904 Aesthetic Surgery Journal 34(6) Figure 11. Illustration of the effects of weight loss and gain on body shape before liposuction. Fat cells enlarge and shrink with weight gain and loss, but do not change in number. Body disproportion is not affected. measurement of the breasts. Of course, reducing abdominal girth improves the ratio of breast/abdominal projection, which may be interpreted by patients as an increase in breast size. 25 The Measuring Device Obtaining measurements of body and limb circumference seems appropriate when studying changes in body dimensions. 26 However, these physical measurements have wellknown limitations: they are affected by differences in the level of measurement on the trunk or limb, the tension applied to the measuring device, and how level the measuring device is held. These factors create variations in subsequent measurements as well. Moreover, interobserver error is introduced when measurements are obtained by different individuals. Photographic measurements are convenient; taking photographs requires only 1 to 2 minutes of the patient s time and is typically done as a matter of course to document results. Measurement software facilitates matching photographs for size and orientation (Figures 1-4) 8,11 and corrects for any differences in magnification or tilt in the before and after photographs. Measurements can be made using a cursor on a computer monitor at the investigator s convenience. These factors maximize compliance and, therefore, inclusion rates. In the present study, an inclusion rate of 80.4% was achieved, meeting the benchmark for evidence-based medicine 27 and ensuring that the reliability of the findings is not compromised by missing patient data. Sample Size The initial report of an increase in breast size after liposuction included 5 women who gained between 5 lb and 7 lb after surgery. 1 In a recent study that reported breast hypertrophy after application of aminophylline cream to the thighs, the investigators evaluated 7 weight-stable patients but did not include a control group. 28 The study by Hernandez et al 7 that reportedly showed fat redistribution included 14 nonconsecutive surgical patients. These small sample sizes increase the likelihood of capturing a cohort of patients who gain weight after surgery. Large sample sizes are essential to avoid type II (false-negative) statistical errors. 29 The number of exclusion criteria must be minimized to avoid selection bias. 27 Women who had existing breast implants (ie, inserted during a previous operation) were included in the present study because it is presumed that the size of breast implants will not change in the absence of a complication. Data analyses in which these patients were excluded produced the same findings.

10 Swanson 905 Figure 12. After liposuction, the number of fat cells has been permanently reduced in treated areas. The patient is trimmer in those areas than she would have been without liposuction, whether she gains or loses weight. There is no effect on untreated areas. Follow-up Time The follow-up period must be long enough to ensure that the temporary effects of tissue swelling do not influence the data, but not so long as to jeopardize the inclusion rate. 30 It is well known that elective cosmetic surgery patients are not typically motivated to participate in long-term follow-up for research purposes. 31 Previous measurement studies have shown that swelling has subsided at 3 months and is unlikely to affect measurements. 30,32 The mean follow-up period (5.6 months) and range (3-19 months) in the present study correspond almost exactly to those of a study 3 in which breast size reportedly increased after liposuction. This range slightly exceeds the maximum 18-month follow-up periods of the 2 original studies in which breast hypertrophy was reported after liposuction. 1,2 The other 3 studies in which breast size increased after liposuction included longer maximum follow-up times, 4-6 up to 4 years. 6 The negative findings of the present study do not rule out a hypothetic fat redistribution mechanism that might occur over a longer period. No published study included weight-stable patients who were measured with a reliable device for longer follow-up periods (ie, >1.5 years). As noted by van der Lei et al, 6 longer follow-up times may introduce confounding effects of aging. Limitations of the Study Breast and upper body dimensions after liposuction were evaluated in women who were predominantly nonobese. The maximum liposuction volume was 4050 ml. Hormone levels were not evaluated. Strengths of the Study Strengths include the prospective study design with a control group, rigorous methodology, consecutively treated patients, a high inclusion rate, one individual recording measurements (ES), a single surgeon, and precise weight monitoring (which rules out weight change as a confounding factor). The measuring device was objective and quantitative. Conclusions There was no evidence of fat redistribution to the breasts or upper body after liposuction in this study. Changes in breast size after liposuction are likely caused by postoperative weight gain. Acknowledgment The author thanks Jane Zagorski, PhD, for statistical analyses; Lindsey Kroenke, BSN, for data collection; and Gwendolyn Godfrey for illustrations.

11 906 Aesthetic Surgery Journal 34(6) Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. References 1. Bisaccia E, Scarborough DA. Breast enlargement after liposuction. Am J Cosmetic Surg. 1990;7: Scarborough DA, Bisaccia E. The occurrence of breast enlargement in females following liposuction. Am J Cosmetic Surg. 1991;8: Yun PL, Bruck M, Felsenfeld L, Katz BE. Breast enlargement observed after power liposuction: a retrospective review. Dermatol Surg. 2003;29: Finzi E. Breast enlargement induced by liposuction. Dermatol Surg. 2003;29: Frew KE, Rossi A, Bruck MC, Katz BE, Narins RS. Breast enlargement after liposuction: comparison of incidence between power liposuction versus traditional liposuction. 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